Contemporary 90-day mortality rates after radical cystectomy in the elderly

INTRODUCTION

Existing radical cystectomy (RC) perioperative mortality estimates may underestimate the contemporary rates due to more advanced age, more baseline comorbidities and potentially broader inclusion criteria for RC, relative to past criteria.

METHODS

Within the most recent Surveillance, Epidemiology, and End Results (SEER)-Medicare database we identified clinically non-metastatic, muscle-invasive (T2-T4a) urothelial carcinoma of the urinary bladder (UCUB) patients, who underwent RC between 1991 and 2009. Mortality at 30- and 90-day after RC was quantified. Multivariable logistic regression analyses tested predictors of 90-day mortality.

RESULTS

Within 5207 assessable RC patients 30- and 90-day mortality rates were 5.2 and 10.6%, respectively. According to age 65-69, 70-79 and ≥ 80 years, 90-day mortality rates were 6.4, 10.1 and 14.8% (p < 0.001). Additionally, 90-day mortality rates increased with increasing Charlson Comorbidity Index (CCI, 0, 1, 2 and ≥ 3): 6.3, 10.3, 12.6 and 15.9% (p < 0.001). 90-day mortality rate in unmarried patients was 13.0 vs. 9.3% in married individuals (p < 0.001). In multivariable logistic regression analyses, advanced age, higher CCI, low socioeconomic status, unmarried status and non organ-confined stage were independent predictors of 90-day mortality (all p < 0.05).

CONCLUSIONS

The contemporary SEER-Medicare derived 90-day mortality rates are substantially higher than previously reported estimates from centers of excellence, and even exceed previous SEER reports. More advanced age, higher CCI score, and other patient characteristics that distinguish the current population from others account for these differences.

Association between the EGF rs4444903 polymorphism and liver cancer susceptibility: a meta-analysis and meta-regression

Emerging evidence suggests that a common functional polymorphism, rs4444903 (A>G), in the EGF gene might impact an individual's susceptibility to liver cancer; however, individually published results are inconclusive. This meta-analysis aimed to derive a more precise estimation of the relationship between the EGF rs4444903 polymorphism and liver cancer risk. A literature search was conducted in the PubMed, Embase, Web of Science, and CBM databases from inception through May 1st, 2013. Seven case-control studies were included with a total of 1408 liver cancer cases and 1343 healthy controls. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Our meta-analysis results indicated that the G variant of the rs4444903 polymorphism might be associated with an increased risk of liver cancer (G allele vs A allele: OR = 1.25, 95%CI = 1.01-1.56, P = 0.040; GG + AG vs AA: OR = 1.65, 95%CI = 1.27-2.15, P < 0.001; GG vs AA: OR = 1.77, 95%CI = 1.34-2.35, P < 0.001). Further subgroup analysis by ethnicity also showed significant associations between the G variant of the rs4444903 polymorphism and an increased risk of liver cancer among Asian, Caucasian, and African populations. No publication bias was detected in this meta-analysis. In conclusion, the current meta-analysis suggests that the G variant of the rs4444903 polymorphism may increase the risk of liver cancer. The EGF rs4444903 (A>G) polymorphism can be useful as a biomarker in predicting the development of liver cancer.

Could pulmonary arterial hypertension be an active index of systemic lupus erythematosus? A successful case of SLE-PAH cured by methylprednisolone pulse therapy

A 35-year-old female patient was diagnosed with pulmonary arterial hypertension (PAH) by right heart catheterization (RHC) in the 3rd month of systemic lupus erythematosus (SLE) duration with high disease activity. Through methylprednisolone pulse therapy, she got total recovery from PAH proven by repeat catheterization and follow-ups. This is the first simultaneously diagnosed, totally recovered, gold standard-proved SLE-PAH case ever reported in the literature. We would like to share this successful case, and at the same time, we want to highlight the relationship between presentation of PAH and active disease manifestations of SLE patients, and to discuss how immune suppressive treatment could benefit this subset of patients.

Detection of fetal sex chromosome aneuploidy by massively parallel sequencing of maternal plasma DNA: initial experience in a Chinese hospital

OBJECTIVES

To evaluate the performance of a massively parallel sequencing (MPS)-based test in detecting fetal sex chromosome aneuploidy (SCA) and to present a comprehensive clinical counseling protocol for SCA-positive patients.

METHODS

This was a retrospective study in a large patient cohort of 5950 singleton pregnancies which underwent MPS-based testing as a prenatal screening test for trisomies 21, 18 and 13, with X and Y chromosomes as secondary findings, in Southwest Hospital in China. MPS-based SCA-positive women were offered the choice of knowing whether their SCA results were positive and those who did commenced a two-stage post-test clinical counseling protocol. In Stage 1, general information about SCA was given, and women were given the option of invasive testing for confirmation of findings; in Stage 2, those who had chosen to undergo invasive testing were informed about the specific SCA affecting their fetus and their management options.

RESULTS

Thirty-three cases were classified as SCA-positive by MPS-based testing. After Stage 1 of the two-stage post-test clinical counseling session, 33 (100%) of these pregnant women chose to know the screening test results, and 25 (75.76%) underwent an invasive diagnostic procedure and karyotype analysis, in one of whom karyotyping failed. In thirteen cases, karyotyping confirmed the MPS-based test results (two X0 cases, seven XXX cases, three XXY cases and one XYY case), giving a positive predictive value of 54.17% (13/24 cases confirmed by karyotyping). After post-test clinical counseling session Stage 2, seven women chose to terminate the pregnancy: one X0 case, two XXX cases, the three XXY cases and the single XYY case. Six women decided to continue with pregnancy: one X0 case and five XXX cases.

CONCLUSION

Our study showed the feasibility of clinical application of the MPS-based test in the non-invasive detection of fetal SCA. Together with a two-stage post-test clinical counseling protocol, it leads to a well-informed decision-making procedure.

Chinese SLE Treatment and Research group (CSTAR) registry: II. Prevalence and risk factors of pulmonary arterial hypertension in Chinese patients with systemic lupus erythematosus

Objectives

To estimate the prevalence of pulmonary arterial hypertension (PAH) and risk factors for PAH in patients registered in the Chinese SLE Treatment and Research group (CSTAR) database, the first online registry of Chinese patients with systemic lupus erythematosus (SLE).

Methods

A prospective cross-sectional study of patients with SLE was conducted using the CSTAR registry. Resting transthoracic echocardiography was used to estimate pulmonary artery pressure (PAP); PAH was defined as systolic PAP (PASP) ≥40 mmHg. Patients with interstitial lung disease, valvular disease or cardiomyopathy were excluded because of disease influence on PAP. We explored potential risk factors for PAH including patient characteristics, organ involvement, laboratory findings and SLE disease activity.

Results

Of 1934 patients with SLE, 74 had PASP with 54.2 ± 17.1 (40,106) mmHg and were diagnosed with probable PAH. The incidences of lupus nephritis, pleuritis, pericarditis, hypocomplementemia, anti-SSA, and anti-ribonucleoprotein (RNP) were significantly higher in patients with PAH than in those without ( p<0.05). SLE disease activity was significantly higher in patients with PAH than in unaffected patients ( p<0.05). Multivariate analysis indicated that pericarditis (odds ratio (OR) = 4.248), pleuritis (OR = 3.061) and anti-RNP (OR = 2.559) were independent risk factors for PAH in patients with SLE ( p<0.05).

Conclusions

The possible prevalence of PAH was 3.8% in Chinese patients with SLE in the CSTAR registry. The significant association of pericarditis, pleuritis and anti-RNP positivity with PAH suggests that higher disease activity and vasculopathy may both contribute to the development of PAH in SLE, which need be treated aggressively to improve prognosis.

A novel TLR-9 agonist C792 inhibits plasmacytoid dendritic cell-induced myeloma cell growth and enhance cytotoxicity of bortezomib

Our prior study in multiple myeloma (MM) patients showed increased numbers of plasmacytoid dendritic cells (pDCs) in the bone marrow (BM), which both contribute to immune dysfunction as well as promote tumor cell growth, survival and drug resistance. Here we show that a novel Toll-like receptor (TLR-9) agonist C792 restores the ability of MM patient-pDCs to stimulate T-cell proliferation. Coculture of pDCs with MM cells induces MM cell growth; and importantly, C792 inhibits pDC-induced MM cell growth and triggers apoptosis. In contrast, treatment of either MM cells or pDCs alone with C792 does not affect the viability of either cell type. In agreement with our in vitro data, C792 inhibits pDC-induced MM cell growth in vivo in a murine xenograft model of human MM. Mechanistic studies show that C792 triggers maturation of pDCs, enhances interferon-α and interferon-λ secretion and activates TLR-9/MyD88 signaling axis. Finally, C792 enhances the anti-MM activity of bortezomib, lenalidomide, SAHA or melphalan. Collectively, our preclinical studies provide the basis for clinical trials of C792, either alone or in combination, to both improve immune function and overcome drug resistance in MM.

A novel rapid-onset high-penetrance plasmacytoma mouse model driven by deregulation of cMYC cooperating with KRAS12V in BALB/c mice

Our goal is to develop a rapid and scalable system for functionally evaluating deregulated genes in multiple myeloma (MM). Here, we forcibly expressed human cMYC and KRAS12V in mouse T2 B cells (IgM(+)B220(+)CD38(+)IgD(+)) using retroviral transduction and transplanted these cells into lethally irradiated recipient mice. Recipients developed plasmacytomas with short onset (70 days) and high penetrance, whereas neither cMYC nor KRAS12V alone induced disease in recipient mice. Tumor cell morphology and cell surface biomarkers (CD138(+)B220(-)IgM(-)GFP(+)) indicate a plasma cell neoplasm. Gene set enrichment analysis further confirms that the tumor cells have a plasma cell gene expression signature. Plasmacytoma cells infiltrated multiple loci in the bone marrow, spleen and liver; secreted immunoglobulins; and caused glomerular damage. Our findings therefore demonstrate that deregulated expression of cMYC with KRAS12V in T2 B cells rapidly generates a plasma cell disease in mice, suggesting utility of this model both to elucidate molecular pathogenesis and to validate novel targeted therapies.

Nicotine induces alteration of H3K27 demethylase UTX in kidney cancer cell

Cigarette smoking is one of the most important risk factors for kidney cancer, but the molecular mechanism is poorly understood. To examine the expression change of histone H3 on lysine 27 trimethylase (H3K27me3) demethylases ubiquitously transcribed TPR gene on the X chromosome (UTX) in kidney cancer cell line 786-O after nicotine treatment, quantitative real-time-polymerase chain reaction and western blotting analysis were carried out. These results showed that nicotine can increase UTX messenger RNA and protein levels and also decrease the content of H3K27me3. The decreased content of H3K27me3 may activate specific gene expression and lead to kidney cancer. Future investigation on nicotine induced UTX expression and its epigenetic effect would deepen our understanding on nicotine toxicity and carcinogenicity.

hIFN-α gene modification augments human natural killer cell line anti-human hepatocellular carcinoma function

Natural killer (NK) cells are characterized by an efficient antitumor activity, and this activity has been exploited as the basis of cancer immunotherapy strategies. Interferon-α (IFN-α) is an important cytokine required for induction of the durable antitumor immune response and is an important stimulator of NK cells. In this study, to augment the efficiency of NK cell cytotoxicity to tumor cells, human IFN-α gene-modified natural killer cell line (NKL) (NKL-IFNα) cells, which could stably secrete IFN-α, were established. We investigated the natural cytotoxicity of NKL-IFNα cells against human hepatocarcinoma cells (HCCs) in vitro and in vivo. NKL-IFNα cells displayed a significantly stronger cytolytic activity against both human HCC cell lines and primary human hepatoma cancer cells compared with parental NKL cells. The increased cytolytic activity of NKL-IFNα cells was associated with the upregulation of cytotoxicity-related genes, such as perforin, granzyme B and Fas ligand, in the NK cells. Moreover, cytokines secreted by NKL-IFNα cells, such as tumor necrosis factor-α and IFN-γ, induced increased expression of Fas on the target HCC cells, and resulted in increased susceptibility of the HCC cells to NK-mediated cytolysis. Encouragingly, NKL-IFNα cells could significantly inhibit HCC tumor growth in a xenograft model and prolonged the survival of tumor-bearing nude mice. These results suggest that IFN-α gene-modified NKL cells could be suitable for the future development of cell-based immunotherapeutic strategies for hepatocellular carcinoma.

Estimation of birth population-based perinatal-neonatal mortality and preterm rate in China from a regional survey in 2010

Objective:

To estimate birth population-based perinatal-neonatal mortality and preterm rate in China from a regional survey in 2010.

Study design:

Data of total births in 2010 obtained from 151 level I–III hospitals in Huai’an, Jiangsu, were prospectively collected and analyzed.

Results:

From 61 227 birth registries (including 60 986 live births and 241 stillbirths), we derive a birth rate of 11.3‰ (of 5.4 million regional population), a male-to-female ratio of 116:100 and valid data from 60 615 newborns. Mean birth weight (BW) was 3441 ± 491 g with 13.6% macrosomia. Low BW was 2.8% (1691/60 372) with 8.83% mortality. Preterm rate was 3.72% (2239/60 264) with 7.61% mortality. Cesarean section rate was 52.9% (31 964/60 445), multiple pregnancy 1.8% (1088/60 567) and birth defects 6.7‰ (411/61 227). There were 97.4% healthy newborns and 2.2% (1298) requiring hospitalized after birth. The perinatal mortality was 7.7‰ (471/61 227, including 241 stillbirths, 230 early neonatal deaths). The neonatal mortality was 4.4‰ (269/60 986). The main causes of neonatal death were birth asphyxia (24.5%), respiratory diseases (21.5%), prematurity related organ dysfunction (18.5%) and congenital anomalies (7.7%), whereas incidence of congenital heart disease and respiratory distress syndrome was 8.6‰ and 6.1‰, respectively.

Conclusions:

This regional birth population-based data file contains low perinatal-neonatal mortality rates, associated with low proportion of LBW and preterm births, and incidences of major neonatal disease, by which we estimate, in a nationwide perspective, in 16 million annual births, preterm births should be around 800 000, perinatal and neonatal mortality may be 128 000–144 000 and 80 000–96 000, respectively, along with 100 000 respiratory distress syndrome.

Pulmonary outflow tract obstruction in fetuses with complex congenital heart disease: predicting the need for neonatal intervention

OBJECTIVE

To identify prenatal echocardiographic markers that could predict the need for neonatal intervention in fetuses with right ventricular outflow tract obstruction.

METHODS

This was a retrospective study of 52 fetuses with right ventricular outflow tract obstruction. Echocardiograms were evaluated for fetuses with either two-ventricle anatomy with a large ventricular septal defect or single-ventricle anatomy. Fetuses with pulmonary atresia were excluded. Parameters were compared between groups that did and did not require an intervention at age < 30 days.

RESULTS

Fifty-two fetuses were studied; 20 (38%) underwent neonatal intervention and 32 (62%) did not. The most common diagnosis was tetralogy of Fallot (n = 32). Fetuses with two ventricles that required an intervention had lower pulmonary valve diameter Z-score (PV-Z-score) (-4.8 ± 2.1 vs. -2.6 ± 1.1; P = 0.0002) and lower pulmonary valve to aortic valve annular diameter ratio (PV/AoV) (0.53 ± 0.15 vs. 0.66 ± 0.1; P = 0.003). Using a PV/AoV ratio of < 0.6 or a PV-Z-score of < -3 at final echocardiographic examination was highly sensitive (92%) but poorly specific (50%), whereas classifying direction of flow in the ductus arteriosus as either normal (all pulmonary-to-aorta) or abnormal (aorta-to-pulmonary or bidirectional) was both highly sensitive (100%) and specific (95%) for predicting the need for a neonatal intervention. Parameters for the single-ventricle cohort did not reach statistical significance.

CONCLUSIONS

Analysis of the pulmonary outflow tract and ductus arteriosus flow in the fetus with complex congenital heart disease can aid in identifying those that will require a neonatal intervention to augment pulmonary blood flow. This has important implications for the planning of delivery strategies.

Comparative analysis of cerebrovascular resistance in fetuses with single-ventricle congenital heart disease

OBJECTIVE

We sought to determine whether the presence or absence of aortic obstruction impacts cerebrovascular resistance in fetuses with single-ventricle (SV) congenital heart disease (CHD).

METHODS

Pulsatility indices (PIs) were recorded for the middle cerebral artery (MCA) and the umbilical artery (UA) from 18 to 40 weeks' gestation in 59 fetuses (163 examinations) with SV-CHD with unobstructed aortic flow, yet decreased pulmonary flow, in 72 fetuses (170 examinations) with obstructed aortic flow and hypoplastic left heart syndrome (HLHS) and in 92 normal fetuses (92 examinations). The cerebral-to-placental resistance (CPR) was calculated as the MCA-PI/UA-PI. Z-scores were generated for the MCA-PI and the UA-PI in order to make comparisons independent of gestational age. Statistical analyses were performed using one-way ANOVA with post-hoc testing. Trends in these variables over the course of gestation were assessed using linear regression and univariate ANOVA.

RESULTS

The MCA-PI and the CPR were significantly lower in SV fetuses with aortic obstruction compared with SV fetuses with pulmonary obstruction and with normal fetuses. Moreover, the MCA-PI decreased significantly for SV fetuses with aortic obstruction over the course of gestation. In contrast, the MCA-PI was higher over the course of gestation in SV fetuses with pulmonary obstruction compared with normal fetuses.

CONCLUSION

In fetuses with SV-CHD, cerebrovascular resistance varies substantially between fetuses with and without aortic obstruction. Compared with normal fetuses, cerebrovascular resistance is decreased in SV fetuses with aortic obstruction, yet increased in SV fetuses with pulmonary obstruction. In fetuses with SV physiology, inherent differences in cerebral blood flow may underlie postnatal neurodevelopmental outcomes.

Distinguishing octane grades in gasoline using terahertz metamaterials

Distinguishing octane numbers of commercial gasoline is experimentally demonstrated by use of single split-ring resonator metamaterials functioning at terahertz frequencies. The differences in frequency-dependent absorption coefficients and refractive indices of various grades of gasoline lead to a modification in the surrounding dielectric environment and consequently the resonance properties of the planar metamaterials. This consequently enables a distinct frequency shift in the inductive-capacitive electric dipolar resonances. This paper reveals that such metamaterial arrays, as highly sensitive chemical sensors, have promising potential in petroleum industrial applications.

WE-E-BRB-09: A GPU-Based Monte Carlo QA Tool for IMRT and VMAT

PURPOSE

To develop a GPU-based Monte Carlo (MC) 3D dosimetry quality assurance (QA) tool employing patient geometry and actual delivery information.

METHODS

First, we generate fluence maps at all beam angles from the initial treatment plan. A GPU-based MC dose engine, gDPM, is employed for the secondary dose calculation (SDC) on patient CT. This SDC is used to verify the TPS plan dose (PD) accuracy. Before the 1st treatment fraction, we deliver the treatment plan on a Linac without any phantom setup to obtain machine log files. With the log files, we extract actually delivered fluence maps at all beam angles and perform delivered dose calculation (DDC) using gDPM. The difference between DDC and SDC indicates possible errors in data transferring and machine delivery. Lastly, the comparison between DDC and PD shows the accumulative errors from all the possible sources. Moreover, a web application for this QA tool is developed for clinical use. We have tested this QA tool on 6 patients, 4 VMAT and 2 IMRT patients. We reported mean gamma values and passing rates inside the 20% isodose line; DVH plot and dose difference matrix are also documented.

RESULTS

For all six patients, the gamma passing rates within the 20% isodose line for SDC, DDC and PD comparisons are all higher than 95%. In the DVH plot, the three dose distributions were found to be very close. A typical IMRT or VMAT case takes less than one minute to run the whole QA tool.

CONCLUSIONS

We have developed a GPU-based MC QA tool which can be used for efficient and easy IMRT and VMAT QA.

Synovial chondromatosis of the temporomandibular joint: MRI findings with pathological comparison

OBJECTIVES

The aim of this retrospective study was to characterize MRI findings of synovial chondromatosis in the temporomandibular joint (TMJ) by correlation with their pathological findings.

METHODS

22 patients with synovial chondromatosis in unilateral TMJ were referred for plain MRI prior to surgical management and pathological examinations. Parasagittal and coronal proton density-weighted imaging and T₂ weighted imaging were performed for each case.

RESULTS

MRI demonstrated multiple chondroid nodules and joint effusion in all patients (100%) and amorphous iso-intensity signal tissues within expanded joint space and capsule in 19 patients (86.4%). On T₂ weighted imaging, signs of low signal nodules within amorphous iso-intensity signal tissues were used to determine the presence of attached cartilaginous nodules in pathology, resulting in 100% sensitivity, 60% specificity and 90.9% accuracy. Signs of low and intermediate signal nodules within joint fluids were used to detect loose cartilaginous nodules and resulted in 80% sensitivity, 42.9% specificity and 68.2% accuracy.

CONCLUSIONS

MRI of synovial chondromatosis in TMJ was characterized by multiple chondroid nodules, joint effusion and amorphous iso-intensity signal tissues within the expanded space and capsule. The attached cartilaginous nodules in pathology were better recognized than the loose ones on MRI. Plain MRI was useful for clinical diagnosis of the disorder.

Distribution of metastatic sites in renal cell carcinoma: a population-based analysis

BACKGROUND

We assessed the distribution of site-specific metastases in patients with renal cell carcinoma (RCC) according to age. Moreover, we evaluated recommendations proposed by guidelines and focused specifically on bone and brain metastases.

PATIENTS AND METHODS

Patients with metastatic RCC (mRCC) were abstracted from the Nationwide Inpatient Sample (1998-2007). Age was stratified into four groups: <55, 55-64, 65-74 and ≥ 75 years. Cochran-Armitage trend test and multivariable logistic regression analysis tested the relationship between age and the rate of multiple metastatic sites. Finally, we examined the rates of brain or bone metastases according to the presence of other metastatic sites.

RESULTS

In 11,157 mRCC patients, the rate of multiple metastatic sites decreased with increasing age (P < 0.001). This phenomenon was confirmed in patients with lung, bone, liver and brain metastases (all P ≤ 0.01). The rate of bone metastases was 10% in patients with exclusive abdominal metastases and 49% in patients with abdominal, thoracic and brain metastases. The rate of brain metastases was 2% in patients with exclusive abdominal metastases and 16% in patients with thoracic and bone metastases.

CONCLUSIONS

The proportion of patients with multiple metastatic sites is higher in young patients. The rates of bone (10%-49%) and brain (2%-16%) metastases are nonnegligible in mRCC patients.

Characterization of 236 novel alleles at the HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1 loci from China Marrow Donor Program

Two hundred and thirty-six novel human leukocyte antigen (HLA) alleles are described from volunteer donors of the China Marrow Donor Program: 71 HLA-A alleles, 79 HLA-B alleles, 43 HLA-C, 16 HLA-DRB1 alleles, 26 HLA-DQB1 and 1 HLA-DPB1. Two hundred and thirteen (90.3%) of the 236 novel alleles are single nucleotide substitution variants when compared with their most homologous allele. Seventy-eight of these single nucleotide variants are silent substitutions. The remaining novel alleles differ from their most similar allele by two to four nucleotide substitutions. Some of the novel alleles encode amino acid changes at positions not previously reported to be polymorphic, such as codons 57, 62, 67, 41 and 52 in HLA-A alleles; codons 133, 156, 201 and 215 in HLA-B alleles; codons 74, 208 and 225 in HLA-C; codons 25, 32 and 72 in HLA-DRB1; codons 20, 39 and 77 in HLA-DQB1.

Expression and hormonal regulation of E-cadherin in canine uterus during early pregnancy

E-cadherin, a Ca(2+)-dependent cell adhesion molecule, is necessary for endometrial receptivity to blastocyst implantation. The aim of this study was to investigate the differential expression of E-cadherin in canine uterus during early pregnancy and its regulation under different conditions by in situ hybridization. E-cadherin mRNA expression was at a low level in the glandular epithelium on days 6, 12 and 17 of pregnancy. On days 20 and 23 of pregnancy, E-cadherin mRNA was highly expressed in the glandular epithelium surrounding the embryo, but not in the luminal epithelium and declined in villi and placenta on day 28 of pregnancy. During oestrous cycle, a moderate level of E-cadherin mRNA expression was found in the luminal and glandular epithelium of canine uteri at oestrus stage. The same expression was also found at anoestrus stage. Progesterone slightly induced the expression of E-cadherin mRNA in the luminal and glandular epithelium of ovariectomized canine uterus. These results suggest that E-cadherin expression is closely related to canine implantation and can be up-regulated by progesterone.