Prognostic Information for Known Genetic Carriers of RB1 Pathogenic Variants (Germline and Mosaic)

OBJECTIVE: To compare the number of tumors per eye for mosaic carriers of RB1 pathogenic variants with full germline variants and the conversion from unilateral to bilateral disease. DESIGN: Retrospective cohort study comparing patients with retinoblastoma and different genetic subtypes (HP: high penetrant, LP: low penetrant & mosaicism). SUBJECTS: Data were analysed between 1992 and 2018 at the Retinoblastoma Unit, Royal London Hospital, London UK. All familial patients had a parent with a known pathogenic variant even if the parent did not manifest the disease. MAIN OUTCOME MEASURES: Number of tumors per eye in children who developed retinoblastoma in that eye. Other outcomes included total number of tumors per patient, age at diagnosis, laterality at presentation and later, sex and stage according to International Intraocular Retinoblastoma Classification RESULTS: 111 patients were included: 64 full germline, familial patients (53 HP and 11 LP) & 47 were mosaic patients. 12 (23%) of HP patients were unilateral and 8 of 12 (67%) developed tumors in their previously unaffected eye. 34 (72%) of mosaic patients were unilateral and only 2 (6%) developed tumors in their unaffected eye. Age at diagnosis was higher in mosaic patients (median 22 months) than HP patients (median 7) (p<0.00002). Number of tumors per eye was fewer in patients with mosaic alleles (median 1.0 range 1-6) compared to patients with HP alleles (median 3.0 range 1-8) (p<0.0003). All three children (4 eyes) with mosaicism and more than 2 tumors per eye had high levels of mosaicism. CONCLUSIONS: Children with mosaic alleles have fewer tumors per eye compared to those with known high penetrant pathogenic variants and are more likely to remain unilateral. The level of mosaicism has an impact on laterality and number of tumors

Number, frequency and time interval of examinations under anesthesia in bilateral retinoblastoma

PURPOSE: Current practice in retinoblastoma (Rb) has transformed this malignancy into a curable disease. More attention should therefore be given to quality of life considerations, including measures related to examinations under anesthesia (EUAs). We aimed to investigate EUA measures in bilateral Rb patients and compare the findings to EUAs in unilateral Rb. METHODS: A retrospective analysis of bilateral Rb patients that presented to the London Rb service from 2006 to 2013, were treated and had long-term follow-up. RESULTS: A total of 62 Rb patients, 15 (24.2%) of which had International Intraocular Retinoblastoma Classification (IIRC) group A/B/no Rb at presentation, 26 (41.9%) C/D, and 21 (33.9%) were E in at least one eye. The mean number of EUAs was 35.8 ± 21.5, mean time from first to last EUA was 50.6 ± 19.9 months, and mean EUA frequency was 0.715 ± 0.293 EUAs/month. IIRC group was found not to correlate with any of the EUA measures. Age at presentation inversely correlated with time interval from first to last EUA and to EUA frequency (p ≤ 0.029). Rb family history correlated with the latter measure (p = 0.005) and intraophthalmic artery chemotherapy and brachytherapy correlated with all EUA measures (p ≤ 0.029). Mean follow-up time was 80.1 ± 24.3 months. When compared with a previously reported cohort of unilateral Rb, the present group underwent 3× more EUAs (p < 0.001) over nearly double the time (p < 0.001). CONCLUSIONS: Families should be counselled on anticipated EUA burden associated with bilateral Rb. In this respect, age at presentation and family history were found to have a predictive role, whereas IIRC group did not

Statistical challenges in assessing potential efficacy of complex interventions in pilot or feasibility studies

Early phase trials of complex interventions currently focus on assessing the feasibility of a large RCT and on conducting pilot work. Assessing the efficacy of the proposed intervention is generally discouraged, due to concerns of underpowered hypothesis testing. In contrast, early assessment of efficacy is common for drug therapies, where phase II trials are often used as a screening mechanism to identify promising treatments. In this paper we outline the challenges encountered in extending ideas developed in the phase II drug trial literature to the complex intervention setting. The prevalence of multiple endpoints and clustering of outcome data are identified as important considerations, having implications for timely and robust determination of optimal trial design parameters. The potential for Bayesian methods to help to identify robust trial designs and optimal decision rules is also explored

Bayesian design and analysis of external pilot trials for complex interventions.

External pilot trials of complex interventions are used to help determine if and how a confirmatory trial should be undertaken, providing estimates of parameters such as recruitment, retention, and adherence rates. The decision to progress to the confirmatory trial is typically made by comparing these estimates to pre-specified thresholds known as progression criteria, although the statistical properties of such decision rules are rarely assessed. Such assessment is complicated by several methodological challenges, including the simultaneous evaluation of multiple endpoints, complex multi-level models, small sample sizes, and uncertainty in nuisance parameters. In response to these challenges, we describe a Bayesian approach to the design and analysis of external pilot trials. We show how progression decisions can be made by minimizing the expected value of a loss function, defined over the whole parameter space to allow for preferences and trade-offs between multiple parameters to be articulated and used in the decision-making process. The assessment of preferences is kept feasible by using a piecewise constant parametrization of the loss function, the parameters of which are chosen at the design stage to lead to desirable operating characteristics. We describe a flexible, yet computationally intensive, nested Monte Carlo algorithm for estimating operating characteristics. The method is used to revisit the design of an external pilot trial of a complex intervention designed to increase the physical activity of care home residents

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study

Background: Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts. Methods: We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or 3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start

Miscellaneous personal letters of Alex Lachlan Williams, 1894-1897

Miscellaneous personal letters from Geoffrey J. Judge of Zeehan in regard to repairs to T. Gibbins' shop, lack of mining jobs and mines "commencing to look up" dated 1 July and 19 August 1894. From James Duncan regarding the tenancy of Williams' property at Zeehan dated 12 September 1896. From Ada Proctor of Sandy Bay on hearing ALW was about to leave Hobart to thank him for all he did for her Aunt dated 29 August 1897. From E.A Lorkin of North Lyell regarding the lease, amalgamation, and section not complying with labour clause written on 18 October 1897. From J. McDonald of Strahan, correspondence regarding mill timber and accompanying list of measurements of logs dated 6 September 1897. These personal letters of Alex Lachlan Williams 1894-1897 are from the papers of Oscar Jones, solicitor of Murdoch & Jones Queenstown branch and his predecessor Alex Lachlan Williams, apparently found at Strathelie at Broadmarsh formerly the Jones family home. The Queenstown practice was established by Alex Lachlan Williams in 1896. Later Charles Page became a partner and established an office at Zeehan. George Murdoch of the Stone Buildings, Hobart, later Murdoch and Jones, acted as Hobart agent and early in 1898 the two firms merged as Williams and Page of Hobart, Queenstown and Zeehan. In April 1899, however, Williams sold out to Murdoch and Jones, Oscar Jones managed the Queenstown branch and by July the firm's name was changed to Murdoch & Jones. Williams & Page remained in Zeehan, under C.S. Page. Private Deposit Collection M14/13 1-

The Generation of Successive Unmarked Mutations and Chromosomal Insertion of Heterologous Genes in Actinobacillus pleuropneumoniae Using Natural Transformation

We have developed a simple method of generating scarless, unmarked mutations in Actinobacillus pleuropneumoniae by exploiting the ability of this bacterium to undergo natural transformation, and with no need to introduce plasmids encoding recombinases or resolvases. This method involves two successive rounds of natural transformation using linear DNA: the first introduces a cassette carrying cat (which allows selection by chloramphenicol) and sacB (which allows counter-selection using sucrose) flanked by sequences to either side of the target gene; the second transformation utilises the flanking sequences ligated directly to each other in order to remove the cat-sacB cassette. In order to ensure efficient uptake of the target DNA during transformation, A. pleuropneumoniae uptake sequences are added into the constructs used in both rounds of transformation. This method can be used to generate multiple successive deletions and can also be used to introduce targeted point mutations or insertions of heterologous genes into the A. pleuropneumoniae chromosome for development of live attenuated vaccine strains. So far, we have applied this method to highly transformable isolates of serovars 8 (MIDG2331), which is the most prevalent in the UK, and 15 (HS143). By screening clinical isolates of other serovars, it should be possible to identify other amenable strains

Clinicians' caseload management behaviours as explanatory factors in patients' length of time on caseloads : a predictive multilevel study in paediatric community occupational therapy

Peer reviewedPublisher PD