US physician perspective on the use of biomarker and ctDNA testing in patients with melanoma

New treatments have increased survival of patients with melanoma, and methods to monitor patients throughout the disease process are needed. Circulating tumor DNA (ctDNA) is a predictive and prognostic biomarker that may allow routine, real-time monitoring of disease status. We surveyed 44 US physicians to understand their preferences and practice patterns for biomarker and ctDNA testing in their patients with melanoma. Tumor biomarker testing was often ordered in stage IIIA-IV patients. Barriers to biomarker testing include insufficient tissue (60%) and lack of insurance coverage (54%). ctDNA testing was ordered by 16-18% of physicians for stages II-IV. Reasons for not using ctDNA testing included lack of prospective data (41%), ctDNA testing used for research only (18%), and others. Physicians (≥74%) believed that ctDNA assays could help with monitoring and treatment selection throughout the disease process. Physicians consider ctDNA testing potentially valuable for clinical decision-making but cited concerns that should be addressed.

Task Shifting and Task Sharing to Strengthen the Surgical Workforce in Sub-Saharan Africa: A Systematic Review of the Existing Literature

BACKGROUND

A major constraint to surgical care delivery in low-resource settings is inadequate workforce availability. Surgical task shifting (TShifting) and task sharing (TSharing), in which non-surgeon clinicians (NSCs) are trained to perform select surgical procedures, have been proposed as one solution. However, patterns of safety and efficacy of surgical TShifting/TSharing are not well-established. This study aims to summarize the current literature and assess clinical outcomes and impact of surgical TShifting/TSharing in sub-Saharan Africa.

METHODS

A two-tiered systematic, PRISMA-adherent literature review of surgical TShifting/TSharing in sub-Saharan Africa was conducted. Collected data included healthcare settings; types of surgeries performed; attitudes toward NSCs; and categories, training, capacity, clinical outcomes, safety, retention, cost-effectiveness, and supervision of NSCs. A random effects meta-analysis of morbidity and mortality rates between NSCs and surgeons was conducted.

RESULTS

Among the 659 abstracts screened, 31 studies met inclusion criteria and were integrated in the final analysis. Eighteen studies (58%) report on the capacity and aptitude of NSCs, 16 (52%) on clinical outcomes and safety, and seven (23%) on attitudes. NSCs performed 1999 (61%) of 3304 total surgical cases studied. The most common operations reported were hernia repair (n = 12, 57%), acute abdominal (n = 12, 57%), and orthopedic procedures (n = 6, 29%). No differences were found between NSC and surgeon case morbidity [315 (16%) vs. 224 (17%); p > 0.05] and mortality [44 (2.2%) vs. 33 (2.5%); p > 0.05] rates.

CONCLUSION

NSCs are increasingly performing surgical tasks in regions of sub-Saharan Africa deficient in trained surgeons and appear to have non-inferior safety outcomes in select programs.

Objective Comparison of FDA-Approved Breast Implant Products in the USA: 5-Year Update

BACKGROUND

There are currently four companies offering FDA-approved breast implants: Allergan, Sientra, Mentor, and Ideal Implant. In 2015, our paper "Objective Comparison of Commercially Available Breast Implant Devices" sought to provide a unique conceptual framework to better understand the similarities and differences between FDA-approved breast implant products and tissue expanders. This paper uses the same variables, such as fill material, shape, relative dimensions, and surface coating, to aid understanding of both the surgical trainee and the operating surgeon of what devices each company offers, with a focus on how the market has evolved over the ensuing 5 years.

METHODS

The product catalogs of each FDA-approved company were carefully explored to determine the current available breast implants and tissue expanders. Subsequently, flow charts were created to provide a clear and objective survey of each companies' offerings, highlighting where there are overlap and deficiencies, and where there has been contraction or growth.

RESULTS

Disruptions to the industry, including both technological innovation and the recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), have caused a significant shift in the details of the available permanent breast implants, breast tissue expanders, sizers, and warranty programs.

CONCLUSION

As it has been in 2015, company jargon and brand names continue to make it challenging to discern the similarities and differences between company devices and programs. This project remained independent of any company's funding, support, or input, making it a uniquely objective and informative survey of the current breast implant market that should assist surgeons in decision-making regarding the breast implant procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Skeletal height reconstruction from measurements of the skull in indigenous South Africans

Stature reconstruction is important as it provides a forensic anthropological estimate of the height of a person in the living state; playing a vital role in the identification of individuals from their skeletal remains. Regression formulae for stature estimation have been generated for indigenous South Africans based on measurements of long bones of upper and lower extremities and the calcaneus. Since these bones are not always available for forensic analysis, it became necessary to use other bones such as the skull for stature estimation. The aim of the present study was to investigate the usefulness of certain measurements of the skull of indigenous South Africans in the estimation of adult stature. Ninety-nine complete skeletons obtained from the Raymond A. Dart Collection, School of Anatomical Sciences of the University of the Witwatersrand, were used. Total skeletal height (TSH) was calculated for each skeleton using the Fully's (anatomical) method. Furthermore, six variables were measured on each skull. TSH was regressed onto these cranial measurements in order to obtain regression formulae. The correlation coefficients obtained ranged between 0.40 and 0.54. The range of the standard errors of estimate from the current study (4.37 and 6.24) is high in comparison to that obtained for stature estimation based on intact long bones and the calcaneus. Therefore, the equations presented in this study should be used with caution in forensic cases when only the skull is available for human identification.

Promegestone (R5020) and mifepristone (RU486) both function as progestational agonists of human glycodelin gene expression in isolated human epithelial cells

One of the most abundant protein products of human secretory endometrium is glycodelin, a glycoprotein previously referred to as PP14. Although the precise function of this protein is unknown, its unique glycosylation pattern is believed to affect immunomodulatory activity during human embryonic implantation and inhibition of sperm-egg binding after ovulation. Having confirmed the expression of glycodelin in secretory endometrial glands, we used purified endometrial epithelial cell cultures to demonstrate the hormonal regulation of glycodelin synthesis and secretion. The findings were corroborated by transiently transfecting glycodelin gene promoter-reporter constructs into human epithelioid HeLa and Ishikawa cells. Our results indicate that glycodelin protein production by endometrial epithelial cells is directly up-regulated 4- to 9-fold by progestins and antiprogestins in vitro. Transcriptional regulation of the glycodelin gene promoter expressed in HeLa cells is progesterone receptor-dependent. As observed in the primary endometrial cells, progestins and antiprogestins both act as agonists on the in vitro expression of this endometrial gene. Our findings provide insight into the regulation of this abundant endometrial protein and raise interesting questions about the physical nature of the interaction of agonist- and antagonist-bound progesterone receptors with the glycodelin gene promoter.

Effect of fasting on serum leptin in normal human subjects

We have studied the effect of fasting on serum leptin levels in normal volunteers. Five normal-weight (BMI < 28, 2 males/3 females) and five obese subjects (BMI > 28, 2 males/3 females) were fasted (0 Kcal) for 52 h. Mean plasma glucose decreased from 88 +/- 3 to 63 +/- 5 mg/dl, serum insulin from 16 +/- 1 to 10 +/- 1 microU/ml, plasma beta-hydroxybutyrate increased from 0.2 +/- 0.1 to 1.8 +/- 0.4 mumol/ml. Serum leptin levels were higher in the obese than in the normal-weight volunteers (31 +/- 12 vs 11 +/- 3 ng/ml, p < 0.01). In the obese, serum leptin decreased from 31 +/- 10 to 12 +/- 5 ng/ml aft552 h (-72%, p < 0.001); in the normal-weight it decreased from 11 +/- 3 to 4 +/- 0.5 ng/ml (-64%, p < 0.001). Serum leptin correlated positively with serum insulin (r = 0.51, p < 0.001) and with plasma glucose (r = 0.61, p < 0.001). To determine effects of fasting induced decreases in plasma glucose and insulin on serum leptin, four normal subjects (3 males/1 female) were fasted for 72 h while their plasma glucose was clamped at basal levels with a variable rate glucose infusion. In these volunteers, serum leptin and insulin concentrations remained unchanged. In summary, the rapid decrease in serum leptin levels during fasting indicated that leptin release was regulated by factors other than changes in body fat mass. The lack of leptin changes during fasting, when basal insulin and glucose levels were maintained at basal levels, suggested that insulin and/or glucose may play a role in the regulation of leptin release.

Increased human immunodeficiency virus type 1 replication in human peripheral blood mononuclear cells induced by ethanol: potential immunopathogenic mechanisms

Previous studies have shown that alcohol ingestion significantly increases human immunodeficiency virus type 1 (HIV-1) replication in peripheral blood mononuclear cells (PBMC) isolated and infected with HIV-1 in vitro. Whether the increased replication of HIV-1 observed after alcohol ingestion was due to unknown factors released from the gastrointestinal tract during alcohol ingestion or to certain metabolites produced by intestinal flora that degraded alcohol was investigated. In addition, cellular mechanisms involved in the increased replication of HIV-1 after alcohol exposure were evaluated. Twelve healthy HIV-1-seronegative subjects abstained from alcoholic beverages for >10 days. Nine were infused with 500 mg/kg ethanol (7.5% at 20 ml/kg/h) in saline, whereas 3 were infused with saline alone. Compared with saline-infused subjects, ethanol-infused subjects' PBMC exhibited significantly increased replication of HIV-1 when infected in vitro, which was associated with increased inhibition of CD8+ T lymphocytes' function by alcohol.

Metabolic effects of darglitazone, an insulin sensitizer, in NIDDM subjects

Insulin resistance is a significant pathogenetic factor in the development of non-insulin-dependent diabetes mellitus (NIDDM). A new class of drugs, the thiazolidinediones, have been shown to lower blood glucose levels without stimulating insulin secretion. We report the metabolic effect of the thiazolidinedione, darglitazone, in obese NIDDM subjects. Nineteen subjects were enrolled in a double-blind placebo-controlled study in which 25 mg of darglitazone was given once a day for 14 days. Nine subjects received the active drug and ten subjects received placebo. Darglitazone-treated subjects showed; 1) a decrease in 24-h plasma glucose area under the curve from 292.8 +/- 31.2 to 235.2 +/- 21.6 mmol.h-1.l-1 p = 0.002; 2) a decrease in 24-h serum insulin area under the curve from 1027.2 +/- 254.4 to 765.6 +/- 170.4 microU.h-1.l-1 p = 0.045; 3) a decrease in 24-h non-esterified fatty acid area under the curve from 1900 +/- 236 to 947 +/- 63 g.h-1.l-1 p = 0.002; 4) a decrease in mean 24-h serum triglyceride by 25.9 +/- 6.2% as compared to -3.9 +/- 4.8% for the placebo-treated group, p = 0.012. Placebo-treated subjects showed no change in their metabolic parameters after treatment. Thus, darglitazone is effective in increasing insulin effectiveness in obese NIDDM subjects. The potential for this and similar drugs to treat or prevent NIDDM as well as the insulin-resistance syndrome needs to be explored.