Medicine by Alexandros G. Sfakianakis: 09/27/17

Τετάρτη 27 Σεπτεμβρίου 2017

Molecular Tumor Boards: Current Practice and Future Needs

Abstract

Background

due to rapid technical advances, steeply declining sequencing costs, and the ever-increasing number of targeted therapies, it can be expected that extensive tumor sequencing such as Whole Exome- and -Genome Sequencing will soon be applied in standard care. Clinicians will thus be confronted with increasingly complex genetic information and multiple test-platforms to choose from. General medical training, meanwhile, can hardly keep up with the pace of innovation. Consequently, there is a rapidly growing gap between clinical knowledge and genetic potential in cancer care. Multidisciplinary Molecular Tumor Boards (MTBs) have been suggested as a means to address this disparity, but shared experiences are scarce in literature and no quality requirements or guidelines have been published to date.

Methods

based on literature review, a survey amongst hospitals in the Netherlands, and our own experience with the establishment of a nationally operating MTB, this paper evaluates current knowledge and unmet needs, and lays out a strategy for successful MTB implementation.

Results

having access to an MTB can improve and increase the application of genetics-guided cancer care. In our survey, however, less than 50% of hospitals and only 5% of non-academic hospitals had access to an MTB. In addition, current MTBs vary widely in terms of composition, tasks, tools and workflow. This may not only lead to variation in quality of care, but also hinders data sharing and thus creation of an effective learning community.

Conclusions

this paper acknowledges a leading role for MTBs to govern (extensive) tumor sequencing into daily practice, and proposes three basic necessities for successful MTB implementation: (i) global harmonization in cancer sequencing practices and procedures, (ii) minimal member- and operational requirements, and (iii) an appropriate unsolicited findings policy. Meeting these prerequisites would not only optimize MTB functioning, but also improve general interpretation and application of genomics-guided cancer care.

Earliest depiction of vitiligo in “Venus at a Mirror” (1615) by Peter Paul Rubens (1577–1640)

Summary

The 1615 painting of Venus at a Mirror by Peter Paul Rubens is considered a powerful example of the Flemish Baroque movement. Recently it has been identified that the Venus character in the image has a goitre, however on studying the image further, I note dermato-pathology in another of the painting's main characters; the dark-skinned female typically described as the Venus' maidservant who clearly demonstrates patches of skin pigment loss on her face and neck with a concurrent streak of white hair. Together these suggest the underlying diagnosis of vitiligo. There is also a goitre in this individual suggesting thyroid disease. This new finding may offer additional insight into the historical epidemiology of disease in northern Europe but also offers further understanding of the method, origin, and pathological associations of this prominent painting from a genius artist.

Impact of the US Maternal Tetanus, Diphtheria, and Acellular Pertussis Vaccination Program on Preventing Pertussis in Infants <2 Months of Age: A Case-Control Evaluation

Abstract

Background

Infants aged <1 year are at highest risk for pertussis-related morbidity and mortality. In 2012, Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine was recommended for women during each pregnancy to protect infants in the first months of life; data on effectiveness of this strategy are currently limited.

Methods

We conducted a case-control evaluation among pertussis cases <2 months old with cough onset between 1 January 2011 and 31 December 2014 from 6 US Emerging Infection Program Network states. Controls were hospital-matched and selected by birth certificate. Mothers were interviewed to collect information on demographics, household characteristics, and healthcare providers. Provider-verified immunization history was obtained on mothers and infants. Mothers were considered vaccinated during pregnancy if Tdap was received ≥14 days before delivery; trimester was calculated using Tdap date, infant's date of birth, and gestational age. Odds ratios were calculated using multivariable conditional logistic regression; vaccine effectiveness (VE) was estimated as (1 – odds ratio) × 100%.

Results

A total of 240 cases and 535 controls were included; 17 (7.1%) case mothers and 90 (16.8%) control mothers received Tdap during the third trimester of pregnancy. The multivariable VE estimate for Tdap administered during the third trimester of pregnancy was 77.7% (95% confidence interval [CI], 48.3%–90.4%); VE increased to 90.5% (95% CI, 65.2%–97.4%) against hospitalized cases.

Conclusions

Vaccination during pregnancy is an effective way to protect infants during the early months of life. With a continuing resurgence in pertussis, efforts should focus on maximizing Tdap uptake among pregnant women.

Evolving Understanding of the Causes of Pneumonia in Adults, With Special Attention to the Role of Pneumococcus

Abstract

Before 1945, Streptococcus pneumoniae caused more than 90% of cases of pneumonia in adults. After 1950, the proportion of pneumonia caused by pneumococcus began to decline. Pneumococcus has continued to decline; at present, this organism is identified in fewer than fewer10%–15% of cases. This proportion is higher in Europe, a finding likely related to differences in vaccination practices and smoking. Gram-negative bacilli, Staphylococcus aureus, Chlamydia, Mycoplasma, and Legionella are each identified in 2%–5% of patients with pneumonia who require hospitalization. Viruses are found in 25% of patients, up to one-third of these have bacterial coinfection. Recent studies fail to identify a causative organism in more than 50% of cases, which remains the most important challenge to understanding lower respiratory infection. Our findings have important implications for antibiotic stewardship and should be considered as new policies for empiric pneumonia management are developed.

Medicine by Alexandros G. Sfakianakis