Level of evidence used in recommendations by the National Comprehensive Cancer Network (NCCN) guidelines beyond Food and Drug Administration approvals.

BACKGROUND: A previous analysis of 113 National Comprehensive Cancer Network® (NCCN®) recommendations reported that NCCN frequently recommends beyond Food and Drug Administration (FDA)-approved indications (44 off-label recommendations) and claimed that the evidence for these recommendations was weak. METHODS: In order to determine the strength of the evidence, we carried out an in-depth re-analysis of the 44 off-label recommendations listed in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). RESULTS: Of the 44 off-label recommendations, 14 were later approved by the FDA and/or are supported by randomized controlled trial (RCT) data. In addition, 13 recommendations were either very minor extrapolations from the FDA label (n = 8) or were actually on-label (n = 5). Of the 17 remaining extrapolations, 8 were for mechanism-based agents applied in rare cancers or subsets with few available treatment options (median response rate = 43%), 7 were based on non-RCT data showing significant efficacy (>50% response rates), and 2 were later removed from the NCCN Guidelines because newer therapies with better activity and/or safety became available. CONCLUSION: Off-label drug use is a frequent component of care for patients with cancer in the United States. Our findings indicate that when the NCCN recommends beyond the FDA-approved indications, the strength of the evidence supporting such recommendations is robust, with a significant subset of these drugs later becoming FDA approved or supported by RCT. Recommendations without RCT data are often for mechanism-based drugs with high response rates in rare cancers or subsets without effective therapies.

Paediatric primary cutaneous marginal zone B-cell lymphoma: does it differ from its adult counterpart?

BACKGROUND: Primary cutaneous marginal zone B-cell lymphoma (PCMZL) has rarely been reported in patients younger than 20 years. OBJECTIVES: To report our experience with PCMZL in the paediatric/adolescent age group. METHODS: Medical records of patients diagnosed with PCMZL before age 20 years and managed at two cutaneous lymphoma clinics in the U.S.A. and Israel from 1992 to 2015 were reviewed. RESULTS: The study group included 11 patients (six girls; median age 16 years, range 6-19·5); 10 had generalized/multifocal (T3) and one had regional/localized (T2) disease. Lesions were located on the limbs in all patients and the trunk in six; two had facial lesions. Staging in all but one was based on whole-body computed tomography or positron emission tomography. Initial management in most patients included nonradiation modalities: one patient with localized disease received intralesional steroids; six patients with multifocal disease received the following: topical/intralesional steroids (n = 3); excision (n = 2); 'watch and wait' (n = 1). No extracutaneous progression was noted during a median follow-up of 5·5 years (mean 7·5, range 0·5-14). At present, five patients are in complete remission. CONCLUSIONS: Based on our data (largest series in the literature with the longest follow-up), the clinicopathological presentation and course of PCMZL in the paediatric/adolescent age group are similar to those in adults. Given the indolent course and the long life expectancy of these young patients, the cumulative risk of imaging studies and the age-related potential toxicity of treatment, especially radiation, should be taken into consideration.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis.

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

A stable reagent system for screening and identifying red blood cell irregular antibodies: application to commercial antibodies.

OBJECTIVE: Development of a new solid-phase system for screening and identifying irregular red cell antibodies. MATERIALS AND METHODS: Red blood cell membranes were prepared by a semi-automated procedure in which the hemolysate solution was passed through a hollow-fiber system. The membranes were fixed to the solid phase (microtiter plates) by centrifugation and incubated with 8% fat-free milk. Antibodies added to the microtiter plate were detected by anti-human antibodies adsorbed onto yellow latex particles. RESULTS: The system had good sensitivity (titer <1); 97% of anti-D samples were detected. The detection system was stable for 6 months at 4 degrees C. CONCLUSION: This stable-antigen solid-phase system readily detects and identifies red cell antibodies that are important in transfusion.

In vitro study of the protective effect of trehalose and dextran during freezing of human red blood cells in liquid nitrogen.

Two nonpermeant cryoprotectants, the disaccharide trehalose and the polymeric carbohydrate (dextran, 40 kDa), were assessed as substitutes for glycerol in the cryopreservation of human red blood cells (RBC). The agents were evaluated by measuring the percentage of RBC recovery (total of free hemoglobin after freezing) and by evaluating the erythrocyte state after freezing. Ninety percent of the red cells were recovered after freezing in 30% (w/v) dextran in liquid nitrogen, which is very close to the recovery obtained in 35. 5% (w/v) glycerol (92%). The activities of pyruvate kinase and glucose-6-phosphate dehydrogenase of RBCs frozen and thawed with dextran were not modified, and the 2,3-diphosphoglycerate was reduced by 26%, but remained within normal values. ATP was reduced by 56%. The erythrocyte membrane integrity, evaluated by its osmotic fragility, was not altered, and the RBCs protected by dextran retained their normal discoid shape without the formation of microvesicles. The 24-h hemolysis of the washed red cells after storage at 4 degrees C was 7%. These results suggest that dextran protects red blood cells during freezing in liquid nitrogen, but that some effort is still needed to limit the drop of ATP concentration. One of the main advantages of dextran is that it does not penetrate the RBCs and requires less washing than glycerol.

Effect of anaesthesia on the QT interval.

A prolonged electrocardiographic QT interval may be harmful during general anaesthesia. It may be prudent, therefore, to select anaesthetic agents which have the least effect on the QT interval. In a controlled study, propofol has been shown to have less effect on the QT interval than thiopentone (P less than 0.05). Our data suggest also that any effects which may be caused by enflurane and isoflurane are masked by the effects of the induction agent.

Lack of predictive value of HbA1 for impaired glucose tolerance in polycystic ovary syndrome.

Twenty-seven women with polycystic ovary syndrome (PCO) and 17 control women had a 75 g oral glucose tolerance test (oGTT) performed. Although glucose tolerance was impaired in the obese (body mass index greater than 25 kg/m2) women with PCO, glycosylated hemoglobin (HbA1) concentrations did not exceed the normal upper limit (7.2%). In all 44 women, there was no correlation between HbA1 and fasting glucose (r = 0.082, p = 0.63) but there was a significant correlation between HbA1 and summed glucose levels through the oGTT (r = 0.389, p = 0.02). HbA1 measurement does not predict the presence of impaired glucose tolerance in women with PCO.