Chronic liver allograft dysfunction

Approximately 90% of liver transplant patients are alive after 1 year and 75% after 5 years with the majority leading full and near-normal lives. However, although early mortality rates after transplantation have fallen dramatically over the last 2 decades, the rates of late graft loss and patient death have remained constant. Thus, understanding of the causes of graft and patient failure is essential to improve long-term outcomes. In the early days after liver transplantation, ischemia and reperfusion injuries predominate, with acute cellular rejection relatively common in first 3 months. Thereafter, the causes of graft dysfunction are variable with disease recurrence as a major cause of graft loss. In this review, we discuss causes of graft dysfunction after 6 months.

Age-related changes in sex steroid levels influence bone mineral density in healthy Indian men

SUMMARY

Age-related changes in sex steroid levels and its contribution to variations in rate of bone loss among men is unclear. Although, Bio-T and Bio-E(2) levels declined with age and depicted an association with BMD in healthy Indian men, Bio-E(2) was found to be an independent predictor of BMD.

INTRODUCTION

Ethnicity influences sex steroid levels, therefore, their role in pathogenesis of low bone mass needs to be established in various populations. We assessed the extent of changes in sex steroid levels with age and related these to bone mineral density (BMD) in healthy Indian men.

METHODS

Total testosterone (TT), estradiol (E(2)), sex hormone-binding globulin (SHBG), PTH, osteocalcin (OC), and c-terminal telopeptide (CTX) were measured in 330 men aged 20-55 years and correlated with BMD measured by DXA.

RESULTS

Both Bio-T (1% per year) and Bio-E(2) (0.8% per year) levels decreased significantly in ageing men, whereas TT (0.4% per year) and E(2) (0.3% per year) levels decreased only marginally with age. In contrast, SHBG (1.4% per year) and PTH (1% per year) levels increased significantly with age. Serum TT (r = 0.19, p = 0.01) and Bio-T (r = 0.2, p = 0.01) levels were associated positively with BMD at spine, whereas E(2) and Bio-E(2) levels were associated with BMD at spine [E (2) (r = 0.31, p < 0.0001); Bio-E(2) r = 0.37, p < 0.0001] and femur (E(2) r = 0.26, p = 0.001; Bio-E(2) r = 0.27, p = 0.001). Men in the lowest quartile of Bio-E(2) were associated with lower BMD and higher bone turnover.

CONCLUSIONS

Age-related decrease in bioavailable sex steroid levels is associated with BMD in healthy Indian men. Bio-E(2) was found to be an independent predictor of BMD.

Association of estimated glomerular filtration rate (eGFR) with odds of a renal lesion

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Background: Patients with ESRD on long term hemodialysis are known to be at an increased risk for renal cell carcinoma. We postulate that some component of chronic renal failure not corrected by dialysis might be the tumor-inducing factor. We sought to determine if chronic renal insufficiency is a risk factor for developing renal cell carcinoma. Methods: A case- control study was used to determine a relationship between renal carcinoma and glomerular filtration rate (MDRD) (eGFR) and using patients with prostate cancer as controls. 1,298 patients from the Columbia University Urologic Oncology Database were identified with either prostate or kidney cancer who had sufficient information to predict eGFR. eGFR calculations were performed for both groups. eGFR was divided into two groups based upon the cut-off value of ≥90. eGFR was also categorized according to the MDRD definitions of chronic kidney disease (CKD), CKD1–4 (values≥90, 60≤values<90, 30≤values<60, and values<30, respectively). Logistic regression techniques were used to quantify the association between pre-operative glomerular filtration rate and the presence of renal or prostate cancer. Results: The mean age of the prostate (n=713) and kidney (n=585) group was 59.9 and 61 years, respectively (p=0.041). The mean weight was 83.9 and 87 kg, respectively (p=0.005). The mean serum creatinine was 1.01 and 1.29 mg/dL, respectively (p<0.001). The mean eGFR was 85 and 73.8, respectively (p<0.001). Two models were fit to analyze the association of eGFR. The first model found eGFR <90 was significantly associated with the presence of a renal carcinoma when controlling for age and race (OR=1.93, CI=1.49–2.49). The second model investigated the eGFR-CKD categories while controlling for age and race and was able to predict the presence of renal cancer (p < 0.001). Patients with an eGFR value of 60≤X<90 had an OR of 1.47 (CI= 1.13–1.92) for renal cancer when compared to patients with normal eGFR levels. Patients with an eGFR value of 30≤X<60 and <30 had an OR of 6.26 (CI=4.10–9.55) and 21.11 (CI=4.87–91.42), respectively. Conclusions: Diminished renal function showed a significant association with the presence of renal cancer. Chronic renal insufficiency may be a risk factor for the development of renal carcinoma.

No significant financial relationships to disclose.

A combined phase I/II trial of intravesical nanoparticle albumin-bound paclitaxel in the treatment of refractory non–muscle- invasive transitional cell bladder cancer

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Background: Up to 50% of patients treated with intravesical agents for non-muscle-invasive bladder cancer will recur. Response rates to current second line intravesical therapies average less than 20%. For these high risk patients, novel agents are necessary. Our previously completed phase I trial showed docetaxel to be a safe and efficacious agent for intravesical therapy. Nanoparticle albumin-bound (nab-) paclitaxel has been shown to have increased solubility and lower toxicity compared to docetaxel in systemic therapy and is therefore an appropriate candidate for further investigation as an intravesical agent. Methods: The ongoing phase I component of this combined phase I/II trial began enrollment on 1/1/08 and has reached 72% accrual as of 1/1/09. Inclusion criteria include recurrent high grade (HG) Ta, T1 and Tis transitional cell carcinoma failing at least one prior regimen with any intravesical agent. In phase I, 6 weekly instillations of nab-paclitaxel were administered beginning at a dose of 150 mg with a dose escalation model used until a maximal tolerated dose (MTD) was achieved. The primary endpoints were dose- limiting toxicity (DLT) and MTD; the secondary endpoint was response rate. Efficacy was evaluated by cystoscopy with biopsy, cytology, and CT imaging. Results: 13/18 patients have enrolled in this phase I trial to date, and the distribution of stages included 5 patients with Tis, 4 patients with HGTa, and 4 patients with HGT1. No patient has had any systemic absorption of nab-paclitaxel as measured by HPLC assays, and no grade 3 or 4 DLT has been encountered. Fifty-four percent (7/13) patients were noted to experience grade 1 toxicities, with dysuria being the most common. Forty-two percent (5/12) of completed patients had no evidence of disease at their post-treatment cystoscopy. None of the patients who developed recurrent disease have had disease progression. Conclusions: Intravesical nab-paclitaxel has exhibited minimal toxicity and no systemic absorption in the first ever human intravesical dose escalation trial. Upon completion of this ongoing phase I trial, we plan to evaluate this agent in a larger phase II efficacy study.

No significant financial relationships to disclose.

Interaction of obesity and race in predicting recurrence rates after radical prostatectomy

5070

Background: Black men are twice as likely to die from prostate cancer compared to white men. Obese men are known to have higher mortality rates and recurrence rates, and blacks are 1.4 times as likely to be obese than white Americans. However, the relative contribution of BMI and race to biochemical failure (BCF) after radical prostatectomy (RP) has not been well-characterized. We examined the interaction of BMI and race in predicting BCF after RP. Methods: A retrospective analysis of the Columbia Urologic Oncology Database found that 3,736 consecutive men underwent RP between 1988 and 2008. 1,461 men had BMI and race data available. 213 (14.6%) were black men, 1,004 (68.7%) were white, 162 (11.1%) were Hispanic, and 82 (5.6%) were Asian. Overweight and obese men were defined as having a BMI > 25 kg/m2 and a BMI > 30 kg/m2, respectively. BCF was defined as a post-surgery PSA level >0.2 ng/mL on > 2 measurements. Cox regression methods were used to model the relationship between race, BMI and BCF. Results: The 1,461 men had a median age of 60 years, and median pre-operative PSA of 5.5. There was no significant difference in BMI among the four races (p = 0.58). The 5 year disease-free survival for black obese men was the lowest at 69%, compared to non-obese black (71%), obese white (80%), and non-obese white men (80%, p < 0.001). BMI did not have a significant impact on BCF. After adjusting for preoperative PSA level, tumor stage, and Gleason sum, race remained an independent predictor of BCF (HR = 1.65, p = 0.04). An analysis assessing the effect of an interaction between race and BMI demonstrated that hazard ratios for increased BMI did not differ significantly by race. Black men who were normal, overweight and obese were 2.0, 3.0 and 2.5 times more likely than white men to have BCF in the respective weight categories, but the differences were not significant. Conclusions: Black race is an independent predictor of biochemical failure after adjusting for pathologic factors. The impact of BMI on BCF did not vary among different races. However, BMI does contribute to the accurate estimation of the risk of BCF. These findings suggest that elevated BMI does not affect the BCF rates of black men more than in other races, and that other factors may influence the racial variability in disease-free survival and BCF risk.

No significant financial relationships to disclose.

Role of obesity and race in predicting recurrence rates and survival in renal cell carcinoma

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Background: Two in three Americans are obese or overweight, and African-Americans are 1.4 times as likely to be obese than whites. However, the relationship between obesity, race, and renal cell carcinoma (RCC) is highly debated. We sought to explore the relationship between BMI and race, and determine the predictors for survival and recurrence after nephrectomy (Nx) for RCC. Methods: A retrospective analysis of the Columbia Urologic Oncology Database found that 1118 consecutive patients underwent partial or radical Nx for RCC between 1988 and 2008. Of these, 499 patients had BMI and race data available. 379 (76%) were white, 51 (10.2%) were black, 37 (7.4%) were Hispanic, and 32 (6.4%) were Asian. 341 (68.3%) were male compared to 158 (31.7%) females; 215 (50.3%) had partial Nx while 284 (56.9%) had a radical Nx. Overweight and obesity were defined as having a BMI > 25 kg/m2 and a BMI > 30 kg/m2, respectively. Cox proportional hazards models were used to assess the relationship between BMI, race, and recurrence- free survival (RFS). Results: The 499 patients had a median age of 63 years were followed for a mean of 25 months. Asians had significantly lower BMI than the other races (p=0.02), but the other ethnicities had similar BMI distributions. The two year cancer-specific survival was 89.6%, 92.7%, and 96.1% for normal weight, overweight, and obese patients, respectively (p=0.036). Race did not have a significant impact on predicting RFS. A multivariate Cox regression found that male sex, BMI, size of tumor removed, tumor stage, and margin were independent predictors of RFS. Overweight and obese patients were more likely to survive from RCC without recurrence than normal weight patients (p=0.04). An analysis assessing the effect of an interaction between race and BMI demonstrated that hazard ratios for increased BMI did not differ significantly by race. Conclusions: BMI is an independent predictor of RFS in patients undergoing partial or radical Nx for RCC. Recurrence free-survival did not differ significantly among the different ethnicities, and the impact of race on recurrence-free survival did not vary among different BMI classes. The importance of these findings needs to be addressed in large multi- institutional analyses.

No significant financial relationships to disclose.

Cancer in pregnancy: Trends and research

e20720

Background: Treatment advances for some cancers have allowed reproductive opportunities that would not have otherwise been possible. Optimal cancer treatment in pregnancy balances maternal needs with concerns for the developing fetus, often relying upon case report and retrospective study data which are subject to confounding factors. Study objectives were to estimate trends in cancer incidence during pregnancy and to describe current research methodology. Methods: The number and rate of pregnancies affected by cancer in 1990 and 2004 were estimated by applying age-specific incidence data from the Surveillance, Epidemiology, and End Results Program to pregnancy data from the National Center for Health Statistics for women 15–44 years. In addition, public trials registries were searched for actively enrolling studies related to “cancer in pregnancy.” Investigators were contacted for detail regarding methodology and descriptive statistics tabulated. Results: The incidence of cancer complicated pregnancies has increased overall between 1990 and 2004 from 1/1,560 to 1/1,180 pregnancies, and individually for breast, melanoma, and thyroid cancers. Seven studies actively enrolling pregnant patients with cancer were identified. Six studies are observational registries, two of which prospectively study specific drug therapies. Three enroll patients receiving care at single institutions whereas the others allow open-enrollment. Three studies focus on breast cancer during pregnancy including the only interventional study. Both maternal and pediatric outcomes are of interest. Conclusions: The shift in the distribution of pregnancies towards older women coupled with an overall increased incidence of cancer puts more women at risk of having a pregnancy complicated by cancer. Current studies are few and dominated by observational registries which maximize the eligible study population through open enrollment. Registries can efficiently provide outcome and follow-up data for this special population but have limited ability to assess effectiveness of specific treatment regimens. Oncologists must recognize the trend in the incidence of cancer in pregnancy and become stakeholders in the process of contributing to ongoing research by engaging their patients in existing studies and initiating new projects.

[Table: see text]

In-vivo efficacy of amodiaquine-artesunate in children with uncomplicated Plasmodium falciparum malaria in western Kenya

OBJECTIVES

To assess the efficacy of amodiaquine-artesunate in an area with high chloroquine resistance in western Kenya.

METHODS

Twenty-eight day in-vivo efficacy trial of amodiaquine-artesunate in 103 children aged 6-59 months in western Kenya with smear-confirmed uncomplicated Plasmodium falciparum malaria.

RESULTS

The 28-day uncorrected adequate clinical and parasitological response (ACPR) was 69.0%, with 15.5% Late Clinical Failure and 15.5% Late Parasitologic Failure rates. The PCR-corrected 28-day ACPR was 90.2%. Clinical risk factors for recurrent infection (recrudescences and reinfections) were lower axillary temperature at enrollment and low weight-for-age Z-score. The presence of single nucleotide polymorphisms pfcrt 76T and pfmdr1 86Y at baseline was associated with increased risk of recurrent infections, both reinfections and recrudescences.

CONCLUSION

Although artemether-lumefantrine (Coartem) is the first line ACT in Kenya, amodiaquine-artesunate is registered as an option for treatment of uncomplicated P. falciparum and remains an effective alternative to Coartem in western Kenya. Continued amodiaquine monotherapy in the private sector may jeopardize the future use of amodiaquine-artesunate as an alternative artemisinin-based combination therapy.

Urinary incontinence in 9-16 year olds with cystic fibrosis compared to other respiratory conditions and a normal group

BACKGROUND

Individuals with cystic fibrosis (CF) are deemed at risk of developing urinary incontinence (UI) due to repeated coughing and other factors causing increased pressure on the pelvic floor. Increased incidence of UI is recognised in women and increasingly in men and children. However, there is little comparison with normal controls and other respiratory conditions with chronic cough. Our aim was to report the incidence, degree and impact of UI in 9-16 year olds related to clinical status in CF, compared to these.

METHODS

9-16 year olds were invited to fill in a self-administered anonymous/confidential questionnaire at clinic. Data recorded were sex, age, height, weight, spirometry expressed as percentage predicted. Normal controls - age and sex only recorded.

RESULTS

No significant differences were found between incidence of UI (21% CF; 22% respiratory; and 17% normal controls, P=0.43). No relationship found between respiratory or nutritional status and UI. Laughing, exercise and cough were the most common causes of UI. No difference between groups for age range, physiotherapy, breathlessness, antibiotics, urinary tract infections and menarche. Only 6% reported more than a few drops of UI.

CONCLUSION

Incidence of urinary incontinence is no different between 9-16 year old girls and boys with CF, and controls.

Sensitive biomarker of polycyclic aromatic hydrocarbons (PAHs): urinary 1-hydroxyprene glucuronide in relation to smoking and low ambient levels of exposure

The study was conducted in a Chinese population with occupational or environmental exposures to polycyclic aromatic hydrocarbons (PAHs). A total of 106 subjects were recruited from coke-oven workers (workers), residents in a metropolitan area (residents) and suburban gardeners (gardeners). All subjects were monitored twice for their personal exposures to PAHs. The biological samples were collected for measurements of 1-hydroxypyrene (1-OHP) and cotinine in urine. The geometric means of personal exposure levels of pyrene, benz(a)anthracene (BaA) and benzo(a)pyrene (BaP) in workers were 1.470, 0.978 and 0.805 microg m-3, respectively. The corresponding levels in residents were 0.050, 0.034 and 0.025 microg m-3; and those in gardeners were 0.011, 0.020 and 0.008 microg m-3, respectively. The conjugate of 1-OHP with glucuronide (1-OHP-G) is the predominant form of pyrene metabolite in urine and it showed strong associations with exposures not only to pyrene, but also to BaA, BaP and total PAHs. Most importantly, a significant difference in 1-OHP-G was even detected between the subgroups with exposures to BaP at < 0.010 and > 0.010 but < 0.020 microg m-3, suggesting that 1-OHP-G is a good marker that can be used for the risk assessment of BaP exposure at levels currently encountered in ambient air. Furthermore, multiple regression analyses of 1-OHP-G on PAHs exposure indicated that cigarette smoke was a major confounding factor and should be considered and adjusted for while using 1-OHP to estimate PAHs exposure.

Autoimmune diabetes in adults: lessons from the UKPDS

Latent autoimmune diabetes in adults (LADA) is characterised by a relatively mild diabetes onset, autoantibody positivity and eventual requirement for insulin therapy. Twelve per cent of newly diagnosed, UK Prospective Diabetes Study (UKPDS) patients were positive for autoantibodies to GAD65 (GADA) and/or insulinoma-associated antigen-2A (IA-2A) and managed as if they had Type 2 diabetes according to the UKPDS protocol. Here, we compare data from UKPDS LADA patients with that from other cohorts. In common with other groups, UKPDS LADA patients required insulin therapy earlier post-diagnosis than non-LADA patients. Reduction of islet function was similar in UKPDS LADA groups randomised to oral glucose-lowering agents or insulin replacement therapy, contesting the current hypothesis of reduced decline of insulin secretion in LADA by immediate insulin therapy. Disease progression was not predicted by post-diagnosis GADA levels or epitope specificities as has been suggested. Slowly progressing insulitis and pancreatic beta-cell loss at post-mortem are consistent with sustained retention of residual C-peptide secretion in LADA. Genetic association patterns at the human leucocyte antigen (HLA) and insulin gene (INS) regions are similar in UKPDS LADA patients and individuals with adult and childhood-onset Type 1 diabetes. The combined evidence suggests that LADA is an adult-onset form of Type 1 diabetes, rather than a separate condition or an intermediate state in a continuum of phenotype from Type 1 to Type 2 diabetes.

Botulinum toxin vs glyceryltrinitrate for the medical management of chronic anal fissure: a meta-analysis

OBJECTIVE

The objective of this review was to analyse systematically the prospective randomized controlled trials on the effectiveness of botulinum toxin (BTX) and glyceryltrinitrate (GTN) for the pharmacological management of chronic anal fissure (CAF).

METHOD

A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of BTX and GTN for the management of CAF were selected according to specific criteria and analysed to generate summative data.

RESULTS

Six studies encompassing 355 patients with CAF were retrieved from electronic databases. Only three randomized controlled trials on 180 patients qualified for the meta-analysis according to inclusion criteria. There were 90 patients in BTX and 90 in the GTN group. BTX and GTN were equally effective in healing/improving the CAF. There was no statistically significant difference between the two pharmacotherapies [RR 1.29 (0.98-1.70) 95% CI, z = -1.83, P = 1.93, Fig. 1]. However, there was statistically significant heterogeneity among the trials (Q = 4.03, df = 1, P = 0.042). On fixed effect model, GTN was associated with higher incidence of total side effects [fixed effect model RR 0.14 (0.05-0.40) 95% CI, z = -3.71, P = 0.0002] and headache [RR 0.07 (0.02-0.20) 95% CI, z = -5.05, P = 0.0007] among patients of CAF.

CONCLUSION

Botulinum toxin is as effective as GTN for the management of CAF but it is associated with a lower complication rate. BTX can be recommended as a first-line therapy for chemical sphincterotomy in patients of CAF. However, a major and multi-centre randomized controlled trial is required to support this treatment approach in order to establish stronger evidence.

Prevalence of type-specific HPV infection by age and grade of cervical cytology: data from the ARTISTIC trial

Human papillomavirus (HPV) infection causes cervical cancer and premalignant dysplasia. Type-specific HPV prevalence data provide a basis for assessing the impact of HPV vaccination programmes on cervical cytology. We report high-risk HPV (HR-HPV) type-specific prevalence data in relation to cervical cytology for 24 510 women (age range: 20–64; mean age 40.2 years) recruited into the ARTISTIC trial, which is being conducted within the routine NHS Cervical Screening Programme in Greater Manchester. The most common HR-HPV types were HPV16, 18, 31, 51 and 52, which accounted for 60% of all HR-HPV types detected. There was a marked decline in the prevalence of HR-HPV infection with age, but the proportion due to each HPV type did not vary greatly with age. Multiple infections were common below the age of 30 years but less so between age 30 and 64 years. Catch-up vaccination of this sexually active cohort would be expected to reduce the number of women with moderate or worse cytology by 45%, but the number with borderline or mild cytology would fall by only 7%, giving an overall reduction of 12% in the number of women with abnormal cytology and 27% in the number with any HR-HPV infection. In the absence of broader cross-protection, the large majority of low-grade and many high-grade abnormalities may still occur in sexually active vaccinated women.

Bacterial examination of endodontic infections by clonal analysis in concert with denaturing high-performance liquid chromatography

BACKGROUND/AIMS

The aim of this study was to examine the diversity of bacterial species in the infected root canals of teeth associated with endodontic abscesses by cloning and sequencing techniques in concert with denaturing high-performance liquid chromatography.

METHODS

Samples collected from five infected root canals were subjected to polymerase chain reaction (PCR) with universal 16S ribosomal DNA primers. Products of these PCRs were cloned and sequenced. Denaturing high-performance liquid chromatography (DHPLC) was used as a screening method to reduce the number of clones necessary for DNA sequencing.

RESULTS

All samples were positive for the presence of bacteria and a range of 7-13 different bacteria were found per root canal sample. In total, 48 different oral clones were detected among the five root canal samples. Olsenella profusa was the only species present in all samples. Porphyromonas gingivalis, Dialister pneumosintes, Dialister invisus, Lachnospiraceae oral clone, Staphylococcus aureus, Pseudoramibacter alactolyticus, Peptostreptococcus micros and Enterococcus faecalis were found in two of the five samples. The majority of the taxa were present in only one sample, for example Tannerella forsythia, Shuttleworthia satelles and Filifactor alocis. Some facultative anaerobes that are frequently isolated from endodontic infections such as E. faecalis, Streptococcus anginosus and Lactobacillus spp. were also found in this study.

CONCLUSION

Clonal analysis of the microflora associated with endodontic infections revealed a wide diversity of oral species.

GAD autoantibodies and epitope reactivities persist after diagnosis in latent autoimmune diabetes in adults but do not predict disease progression: UKPDS 77

AIMS/HYPOTHESIS

Latent autoimmune diabetes in adults (LADA) is a slowly progressive form of autoimmune diabetes, with autoantibodies to islet proteins developing in older patients who have no immediate requirement for insulin therapy. Markers of its clinical course are uncharacterised. The aim of this study was to determine whether persistence of, or changes in, GAD65 autoantibodies (GADAs) in the LADA patients who participated in the United Kingdom Prospective Diabetes Study (UKPDS) were associated with disease progression or insulin requirement.

METHODS

GADA levels and their relative epitope reactivities to N-terminal, middle and C-terminal regions of human GAD65 were determined in 242 UKPDS patients who were GADA-positive at diagnosis; samples taken after 0.5, 3 and 6 years of follow-up were tested using a radiobinding assay. Comparisons were made of GADA status with clinical details and disease progression assessed by the requirement for intensified glucose-lowering therapy.

RESULTS

GADA levels fluctuated between 0.5 and 6 years but persisted in 225 of 242 patients. No association of GADA levels with disease progression or insulin requirement was observed. Antibody reactivity was directed to C-terminal and middle epitopes of GAD65 in >70% patients, and the N-terminal in <9%. There were no changes in epitope reactivity pattern over the 6 year follow-up period, nor any association between epitope reactivity and insulin requirement.

CONCLUSIONS/INTERPRETATION

GADAs persist for 6 years after diagnosis of LADA, but levels and reactivity to different GAD65 epitopes are not associated with disease progression.