Cost Analysis of R-CHOP Versus Dose-Adjusted R-EPOCH in Treatment of Diffuse Large B-Cell Lymphoma with High-Risk Features

Dose-adjusted rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (DA.R-EPOCH) is used for upfront treatment of high-risk diffuse large B cell lymphoma (DLBCL). In this study, we compared the outcomes in patients with high-risk DLBCL who received frontline rituximab, cycophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) or DA.R-EPOCH immunochemotherapy. Outcomes and treatment-related cost were analyzed. DLBCL with one of the following features were included in the study: MYC ± BCL2 or BCL6 rearrangement by FISH or MYC overexpression by immunohistochemistry, Ki67 index ≥ 80% or nongerminal center immunophenotype, tumor measuring ≥5 cm and NCCN- IPI score ≥4. A total of 80 patients were treated with R-CHOP (n = 52, 65%) or DA.R-EPOCH (n = 28, 35%), with a median follow-up of 11.2 months (range: 0.7–151.3 months). The hazard ratios (HRs) for progression-free survival and overall survival were 0.79 [95% confidence interval (CI) 0.28%–2.29%, p = 0.67] and 0.86 (95% CI 0.26%–2.78%, p = 0.80), respectively for DA.R-EPOCH compared to R-CHOP. The total mean cost was USD106,940 ± USD39,351 and USD58,509 ± 24,588 for DA.R-EPOCH and R-CHOP respectively (p < 0.001). In our analysis, DA.R-EPOCH resulted comparable clinical outcomes and increased treatment-related expenses compared to R-CHOP in high-risk DLBCL.

Peripheral blood biomarkers correlate with outcomes in advanced non-small cell lung Cancer patients treated with anti-PD-1 antibodies

Background

Anti-programmed cell death 1 (PD-1) antibodies have demonstrated improved overall survival (OS) and progression-free survival (PFS) in a subset of patients with metastatic or locally advanced non-small cell lung cancer (NSCLC). To date, no blood biomarkers have been identified in NSCLC to predict clinical outcomes of treatment with anti-PD-1 antibodies.

Patient and methods

We performed an analysis of retrospectively registered data of 157 patients with advanced NSCLC treated with anti-PD-1 antibodies at Mayo Clinic in Florida and Rochester. White blood cell count, absolute neutrophil count (ANC), absolute lymphocyte count (ALC), ANC to ALC (ANC: ALC) ratio, absolute eosinophil count, absolute monocyte count (AMC), platelet counts, and myeloid to lymphoid (M:L) ratio at baseline and throughout treatment were assessed. Kaplan-Meier method and Cox proportional hazards model were performed.

Results

We treated 146 patients with nivolumab and 11 with pembrolizumab between January 1, 2015 and April 15, 2017. At median follow-up of 20 months, median OS and PFS were 6.0 and 2.6 months, respectively. Higher baseline ANC, AMC, ANC: ALC ratio and M: L ratio correlated with worse clinical outcomes in patients who underwent anti-PD-1 treatment. A baseline ANC: ALC ratio of 5.9 or higher had a significantly increased risk of death (hazard ratio [HR] =1.94; 95% confidence interval [CI], 1.24–3.03; P = 0.004) and disease progression (HR, 1.65; 95% CI, 1.17–2.34; P = 0.005) compared with patients with lower ratio. Similarly, a baseline M: L ratio of 11.3 or higher had significantly increased risk of death (HR, 2.5; 95% CI, 1.54–4.05; P < 0.001), even after a multivariate analysis (HR, 2.31; P = 0.002), compared to those with lower ratio.

Conclusions

Increased baseline ANC: ALC ratio and M: L ratio before initiation of anti-PD1 antibodies were associated with poor PFS and OS in advanced NSCLC patients. The potential predictive value of these readily available biomarkers might help with risk stratification and treatment strategies. These findings warrant further investigation in a larger, prospective study.

Electronic supplementary material

The online version of this article (10.1186/s40425-018-0447-2) contains supplementary material, which is available to authorized users.

Comparing morbidity rates between wise pattern and standard horizontal elliptical mastectomy incisions in patients undergoing immediate breast reconstruction

BACKGROUND

Breast cancer patients with ptotic breasts pursuing mastectomy with immediate reconstruction can present challenges. A wise pattern (inverted-T) mastectomy incision (WPM) has been suggested as an alternative to the standard horizontal elliptical mastectomy (EM) to reduce redundant skin and correct ptosis. Herein, we sought to examine the differences in morbidity between the two techniques.

METHODS

We performed a retrospective review of women undergoing mastectomy with immediate reconstruction at our institution from June 2007 to January 2016. We compared those undergoing WPM to a control population undergoing EM. Statistical analysis was performed evaluating clinical, pathological, and surgical outcome variables according to patient and per breast. All tests were two-sided with alpha level set at 0.05 for statistical significance.

RESULTS

A total of 241 women underwent mastectomy and reconstruction in 421 breasts; 78/241 (32%) had WPM (149 breasts), 163/241 (68%) had EM (272 breasts). Both groups were similar in age, smoking status, diabetes, race, tumor type, and pathologic stage (all P > 0.07). Skin flap necrosis was the most frequently encountered complication, occurring in 58/149 (38.9%) of WPM breasts and in 24/272 (8.9%) of EM breasts (P < 0.0001). There was no difference in the need for revisional procedures between the groups (WPM: 24.1% vs EM: 17.6%, P = 0.207).

CONCLUSION

Patients should be counseled WPM is associated with higher rates of skin flap necrosis. However, this does not translate into higher rates of revisional procedures or return to OR.

Behavioral Interventions to Prevent or Delay Dementia: Protocol for a Randomized Comparative Effectiveness Study

Background

Currently, people at risk for dementia and their caregivers are confronted with confusing choices about what behavioral interventions are most effective.

Objective

The objective of this study is to determine which empirically supported behavioral interventions most impact the outcomes highly valued by patients with mild cognitive impairment and their partners.

Methods

This protocol describes a comparative effectiveness trial targeting 300 participants with mild cognitive impairment and their study partners. The trial is being conducted at the Mayo Clinic campuses in Arizona, Florida, Minnesota, and the University of Washington in Seattle. The study examines the contribution of five behavioral interventions (yoga, memory compensation training, computerized cognitive training, support groups, and wellness education) on primary outcomes of participant and partner quality of life and self-efficacy. In this unique 10-day multicomponent intervention, groups of couples were randomized to have one of the five interventions withheld while receiving the other four. Although the longitudinal follow-up is still under way, enrollment results are available and reported.

Results

In total, 272 couples have been enrolled in the trial and follow-up visits continue. Outcomes will be assessed at the end-of-intervention and 6-, 12-, and 18-month follow-ups. We anticipate reporting on our primary and secondary outcomes across time points in the next 2 years.

Conclusions

This paper describes the protocol for a randomized comparative effectiveness study of behavioral interventions to prevent or delay dementia. We describe of the rationale, design, power analysis, and analysis plan. Also because enrollment is complete and we are in follow-up phases of the study, we have included enrollment data from the trial.

Trial Registration

 ClinicalTrials.gov NCT02265757; http://clinicaltrials.gov/ctsshow/ NCT02265757 (Archived by WebCite at http://www.webcitation.org/6ueRfwSYv)

Study of LRRK2 variation in tauopathy: Progressive supranuclear palsy and corticobasal degeneration

BACKGROUND

Mutations in the leucine-rich repeat kinase 2 gene (LRRK2) are the most common genetic cause of Parkinson's disease (PD). Unexpectedly, tau pathology has been reported in a subset of LRRK2 mutation carriers.

METHODS

To estimate the frequency of pathogenic LRRK2 mutations and to evaluate the association of common LRRK2 variants with risk of primary tauopathies, we studied 1039 progressive supranuclear palsy (PSP) and 145 corticobasal degeneration patients from the Mayo Clinic Florida brain bank and 1790 controls ascertained at Mayo Clinic. Sanger sequencing of LRRK2 exons 30, 31, 35, and 41 was performed in all patients, and genotyping of all 17 known exonic variants with minor allele frequency >0.5% was performed in patients and controls.

RESULTS

LRRK2 mutational screening identified 2 known pathogenic mutations (p.G2019S and p.R1441C), each in 1 PSP patient, the novel p.A1413T mutation in a PSP patient and the rare p.R1707K mutation in a corticobasal degeneration patient. Both p.A1413T and p.R1707K mutations were predicted damaging by at least 2 of 3 prediction programs and affect evolutionary conserved sites of LRRK2. Association analysis using common LRRK2 variants only showed nominal association of the p.L153L variant with PSP.

CONCLUSIONS

Our study confirms the presence of pathogenic and potentially pathogenic LRRK2 mutations in pathologically confirmed primary tauopathies, albeit with low frequency. In contrast to PD, common LRRK2 variants do not appear to play a major role in determining PSP and corticobasal degeneration risk. © 2016 International Parkinson and Movement Disorder Society.

Comparison of patient-reported quality of life outcome questionnaire response rates between patients treated surgically for renal cell carcinoma and prostate carcinoma

Background

We sought to examine differences in response rates to quality of life (QoL) surveys in patients treated surgically for renal cell carcinoma (RCC) and prostate cancer (PCa) and to analyze factors associated with non-response of the surveys.

Methods

Patients who underwent surgery for RCC or PCa between 2006 and 2012 were offered enrollment in respective prospective cancer registries that included baseline and annual QoL assessments. We identified 201 RCC patients and 616 PCa patients who completed a baseline QoL survey and were mailed annual QoL surveys [RCC: SF-36, FACT–G (73 questions), PCa: EPIC, IIEF, Max-PC (80 questions)]. We compared patient characteristics between responders and non-responders using a Wilcoxon rank-sum test for continuous variables and a Fisher’s Exact test for categorical variables.

Results

The overall response rates for the PCa and RCC groups were 63 and 48 % (p < 0.001), respectively. This difference in response rates remained when we limited analysis to only those with early stage disease (pT2 for PCa and pT1 RCC, 62 % vs. 52 %; p = 0.03). PCa characteristics associated with response included older age (64.1 vs 62.6 years, p = 0.032) and robotic versus open surgery (56 % vs 44 %; p = 0.009). There were no characteristics that were associated with response in RCC patients.

Conclusions

Surgically treated PCa patients have higher QoL mail-based survey response rates compared to patients treated surgically for RCC. This difference holds true for clinically localized cancers as well.

Nutcracker esophagus: demographic, clinical features, and esophageal tests in 115 patients

Nutcracker esophagus (NE) is a common esophageal motility disorder chacterized by high amplitude peristaltic contractions in the distal esophagus. While previous studies have examined selected aspects of this condition (e.g. pathogenesis and treatment), there is a paucity of data regarding demographic and clinical features in large cohorts of patients. The aim of this study was to describe demographics, clinical features, comorbidities, time to diagnosis, source of patient referral by specialty, and medication use in a large cohort of patients with NE. We retrospectively analyzed consecutive cases of NE diagnosed from 2008-2010. The electronic medical records of these patients were reviewed, and relevant information was extracted. We identified 115 patients with NE. The median age was 62 years (range 25-87 years), and 63% were female. The median time patients experienced symptoms prior to diagnosis was 24 months (0-480 months). Most patients presented to an internal medicine consultant (42%) or to a gastroenterologist (35%). Presenting symptoms were chest pain (31%) and dysphagia (21%). Gastroesophageal reflux disease (GERD) symptoms were common: heartburn occurred in 51% of patients, 77% had a prior history of GERD, and 78% were receiving acid suppressive medications. GERD was confirmed by testing in at least 35%. Psychiatric comorbidity occurred in 24% with half the patients receiving psychotropic medications. Irritable bowel syndrome (IBS) and fibromyalgia co-existed in 15% and 12% of patients, respectively. Surprisingly, opioids were prescribed to 26% of patients. No statistically significant correlation was found between esophageal motility parameters and symptoms. In this study, NE patients were more commonly middle-aged females experiencing a considerable amount of time between symptom onset and diagnosis. Many were initially evaluated by internists for dysphagia or chest pain and had a history of GERD. Medication prescribed prior to diagnoses frequently involved acid suppression, but narcotic and psychotropic prescriptions were also commonly used. Central sensitization syndromes (fibromyalgia and IBS), psychiatric comorbidity, and reflux commonly coexisted. Our study suggests that future investigations should address the role and interaction of GERD and psychiatric disorders in NE.

Abstract B61: Evaluation of the prevalence of hypovitaminosis D and vitamin D awareness in African Americans living in a metropolitan southern community

Background: The health benefits associated with maintaining adequate circulating levels of vitamin D are well known. More recently, data have emerged supporting an inverse association between vitamin D levels and risk of several human cancers. Related to this, African Americans (AAs) are at increased risk of hypovitaminosis D due to elevated levels of melanin in the skin that reduce the conversion of cholesterol to vitamin D3 (cholecalciferol). Herein, we simultaneously assess levels of awareness regarding the health benefits of vitamin D and the prevalence of hypovitaminosis D in a metropolitan African American community.

Methods: From January 2012 through August 2013, we partnered with African American churches and community organizations in the metropolitan Jacksonville, FL area to provide nine education programs focused on vitamin D and the evidence linking poor vitamin D levels with increased risk of chronic disease, including cancer. Participants were offered free vitamin D testing to estimate the prevalence of vitamin D insufficiency (&lt;25 ng/mL) and deficiency (&lt; 15 ng/mL) in this population. Moreover, participants also completed surveys prior to the events to assess their awareness of issues related to vitamin D, including the emerging link with cancer risk.

Results: Out of 305 attendees, 285 agreed to provide blood samples for vitamin D screening. Of these, 262 (92%) self-identified as African American (75% female, 25% male). The median age of the AA participants was 59 years. Laboratory testing for 25(OH) vit D revealed 43% of the AA participants had normal levels of vitamin D (&gt;25 ng/mL), 35% had insufficient levels (15-24 ng/mL) and 22% had deficient levels (&lt; 15 ng/mL). Of interest, despite the high level of hypovitaminosis D (insufficient + deficient) in this population, participants reported high levels of awareness regarding vitamin D prior to the education program. For example, 82% of AA respondents correctly answered that the main source of vitamin D came from sunlight and 76% correctly answered that AAs are at risk of lower levels of vitamin D because of the amount of melanin in the skin. Moreover, 83% of AA respondents answered that maintaining proper vitamin D levels could potentially decrease risk for various chronic health conditions, including certain cancers. Finally, 75% of the AA participants reported never having had a vitamin D test discussed with them by their doctor.

Conclusions: We report a high prevalence of hypovitaminosis D in a large AA community in Jacksonville, FL. Moreover, we report that despite this high prevalence, awareness of the health benefits of vitamin D are high, yet regular vitamin D testing levels appear to be very low. These data provide the foundation for developing targeted interventions to raise vitamin D levels in this community.

Citation Format: Alexander Parker, Monica Albertie, Nancy Diehl, Matthew Drake. Evaluation of the prevalence of hypovitaminosis D and vitamin D awareness in African Americans living in a metropolitan southern community. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B61. doi:10.1158/1538-7755.DISP13-B61

Practice trends in patients with persistent detectable thyroglobulin and negative diagnostic radioiodine whole body scans: a survey of American Thyroid Association members

BACKGROUND

Management of patients with thyroglobulin (Tg)-positive/scan-negative thyroid cancer remains challenging. American Thyroid Association (ATA) guidelines recommend potential use of empiric (131)I therapy and various scanning modalities, but no standard for managing such cases exists.

METHODS

We surveyed ATA members to assess current practice in management of patients with Tg-positive/scan-negative disease. Members participated in a web-based survey of six case scenarios of Tg elevations but iodine scan negativity.

RESULTS

A total of 288 ATA members (80% male) participated. Patient age, sex, and basal and stimulated Tg varied between the cases. Respondents were asked their opinion regarding empiric (131)I therapy use, including (131)I dose, use and duration of low-iodine diet, thyroxine withdrawal or recombinant human thyrotropin (rhTSH), and utilization of additional imaging (neck ultrasound (US) or positron emission tomography/computed tomography (PET/CT)) and reconsideration of (131)I therapy. Between 16% and 51% recommended initial use of empiric (131)I for the various scenarios. The majority chose a (131)I dose between 75 and 150 mCi, and 73% employed a low-iodine diet for two or more weeks. Preference between thyroxine withdrawal versus rhTSH was evenly split. More than 98% obtained a neck US if empiric (131)I was not given; 52-89% would proceed to PET/CT if US was negative. Only 44% used rhTSH stimulation in PET scan preparation. (131)I use was more common with stimulated Tg significantly >10 ng/mL. (131)I therapy was slightly more likely with PET-positive (56%) than PET-negative status (45%). Respondents were split regarding empiric (131)I if basal and stimulated Tg increased ≥150% over two years. Providers in North America less commonly utilized (131)I treatment than those from other areas. In the face of possible heterophilic antibody interference in the Tg assay, the majority did not recommend (131)I therapy.

CONCLUSIONS

Empiric (131)I therapy is still utilized for patients with Tg-positive/scan-negative disease. Neck US is frequently used to further evaluate such cases as (18)FDG-PET/CT, albeit the latter is used somewhat less often. Use of (131)I therapy correlated with the degree of Tg elevation or development of Tg antibodies, and was recommended more commonly with PET-positive than PET-negative status in patients with lower Tg levels. (131)I was less commonly used by providers within North America.

Surgical site infections after liver retransplantation: incidence and risk factors

Surgical site infections (SSIs) after liver transplantation (LT) are associated with an increased risk of graft loss and death. The incidence of SSIs after LT and their risk factors have been determined for first LT but not for second LT. The importance of reporting the incidence of SSIs risk-stratified by first LT versus second LT is not known. All patients undergoing second LT at a single institution between 2003 and 2011 (n = 152) were reviewed. The Kaplan-Meier method was used to estimate the cumulative SSI incidence. Relative risks (RRs) and 95% confidence intervals (CIs) from Cox proportional hazards regression models were used to evaluate associations of potential risk factors with SSIs after second LT. Thirty-one patients developed SSIs (6 superficial SSIs, 1 deep SSI, and 24 organ/space SSIs). The cumulative incidence of SSIs 30 days after LT was 20.8% (95% CI = 14%-27%), which was slightly but not significantly higher than the previously reported incidence of SSIs after first LT at our institution between 2003 and 2008 (16%, RR = 1.32, 95% CI = 0.90-1.93, P = .16). Units of transfused red blood cells [RR (doubling) = 1.38, 95% CI = 1.02-1.86, P = .04] and hepaticojejunostomy (RR = 2.22, 95% CI = 1.05-4.72, P = .04) were the only factors associated with SSIs after second LT in single-variable analysis. The associations weakened in a multivariate analysis (P = .07 and P = .07, respectively), potentially because of the correlation of red blood cell transfusions and hepaticojejunostomy (P = .08). In conclusion, the incidence of SSIs after second LT was slightly higher but not significantly different than the published incidence of SSIs (16%) after first LT at the same institution. Significant independent risk factors for SSIs after second LT were not identified. Risk stratification for retransplantation may not be necessary when the incidence of SSIs after LT is being reported.

Abstract A62: Alcohol consumption, genetic variation in alcohol dehydrogenase genes, and risk of clear cell renal cell carcinoma

Introduction: An inverse association between alcohol consumption and risk of renal cell carcinoma (RCC) is well reported in the literature. Despite this, no investigators have explored the potential for effect modification of this association by genetic variations in enzymes that metabolize alcohol. Motivated by this, we conducted a pilot investigation of the role of genetic variation in the alcohol dehydrogenase genes (ADH) as an effect modifier of the association of alcohol and RCC risk.

Methods: We analyzed data on 121 RCC cases and 121 controls. Cases were prospectively collected as part of our Renal Registry in the Department of Urology. Controls were recruited through the Family Medicine and frequency matched to cases on age, gender and state of residence. We collected detailed risk factor data (self-report questionnaire) as well as a DNA sample on cases and controls. We utilized Sequenome analysis to determine presence of published SNPs in the ADH gene cluster (ADH1-7). We employed logistic regression with interaction terms as well as stratified analyses to evaluate effect modification by genetic variants in the ADH gene cluster on the association of alcohol consumption and RCC risk.

Results: Compared to non-drinkers, those that consumed alcohol above the median experienced a lowering in RCC risk (OR=0.80; 95% CI 0.5 to 1.43). We observed evidence of interactions with 6 SNPs in the ADH gene (p-values from 0.05-0.2). As an example, in stratified analysis, the inverse association strengthened in those without the minor allele present at rs1154454 in ADH7 (OR=0.56; 95% CI 0.3 to 1.0; p=0.08) while evidence of an increased in RCC risk was noted among those with the minor allele (OR=2.14; 95CI 0.8 – 5.7; p=0.1). Adjustment for age and gender did not alter our results.

Conclusion: Our pilot data suggest that specific variants in the ADH gene cluster may modify the reported protective effect of alcohol consumption on RCC risk. Given the possible implications for improving our understanding of the biology of this association and informing prevention, future investigations that analyze a larger sample size and examine additional variants are warranted.

Citation Format: Alexander Scott Parker, Nancy Diehl, Michelle L. Arnold, Shauna Rivera, Ashley Cannon, Kaitlynn Custer, Bradley Leibovich. Alcohol consumption, genetic variation in alcohol dehydrogenase genes, and risk of clear cell renal cell carcinoma. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr A62.

Incidence and associated endocrine and neurologic abnormalities of optic nerve hypoplasia

IMPORTANCE

Optic nerve hypoplasia (ONH) is an increasingly recognized cause of congenital blindness in children; however, there is significant discord regarding its incidence and the rate of associated conditions.

OBJECTIVE

To determine the incidence of ONH and the rate of associated endocrine, neurologic, and developmental abnormalities among a population-based cohort of pediatric patients.

DESIGN

Retrospective, population-based study.

SETTING

Olmsted County, Minnesota (95.7% white in 1990).

PARTICIPANTS

All pediatric residents (aged <19 years) of Olmstead County, diagnosed as having ONH from January 1, 1984, through December 31, 2008.

MAIN OUTCOMES AND MEASURES

Incidence of ONH and the rate of associated endocrine, neurologic, and developmental abnormalities.

RESULTS

Optic nerve hypoplasia was diagnosed in 19 pediatric patients during the 25-year study period, for an annual incidence of 2.4 (95% CI, 1.2-3.5) per 100,000 residents younger than 19 years or 1 in 2287 live births. The mean age at diagnosis was 2.1 years, and 10 (53%) patients were male. Commonly associated perinatal conditions included primiparity in 8 patients (42%), premature birth in 6 (32%), and maternal diabetes mellitus in 3 (16%). Of the 19 study patients, 16 (84%) had bilateral involvement at initial examination, 9 (47%) had decreased visual acuity, 8 (42%) had strabismus, and 5 (26%) had nystagmus. Systemic conditions included developmental delay in 12 (63%), neurologic deficits in 10 (53%), and endocrine dysfunction in 5 (26%).

CONCLUSIONS AND RELEVANCE

This population-based study demonstrated an incidence of ONH of 1 in 2287 live births. More than half of the patients had developmental and neurologic deficits, and one-fourth had a diagnosis of endocrine dysfunction.

Comparison of baseline quality of life measures between renal cell carcinoma patients undergoing partial versus radical nephrectomy

Background

To compare demographics, pathologic features, performance scores, comorbidities, symptoms and responses to quality of life (QoL) surveys between nephron-sparing surgery (NSS) and radical nephrectomy (RN) patients prior to surgical intervention. Previous investigators have compared QoL outcomes for patients undergoing RN and NSS; however, there are limited data comparing QoL-related characteristics at baseline between these groups.

Methods

We identified 144 patients with localized RCC who underwent either NSS (n = 71) or RN (n = 73) between May ‘07-November ‘12. We abstracted baseline data on demographic and clinic-pathologic variables as well as responses to the SF-36 and FACT-G surveys from our prospective registry. We amended the FACT-G with 8 additional questions designed to address RCC-specific QoL. For comparisons between the two groups, we employed Wilcoxon rank-sum and Fisher's Exact tests where appropriate.

Results

We observed RN patients to have more aggressive pathology. We noted no difference in performance scores between the two groups; however, RN patients were more likely to have higher Charlson scores (p = 0.022) and various symptoms at presentation (all p <0.001). For the QoL surveys, we did not observe differences on the FACT-G; however, we noted evidence of differential scores between the two groups on specific domains of the SF-36 (e.g. Mental Health; p 0.022) and the RCC-specific QoL questions added to the FACT-G.

Conclusions

We report baseline differences between RN and NSS patients on clinico-pathologic as well as QoL-related metrics. As issues of survivorship become increasingly important, our results underscore the need to consider baseline status in evaluations of QoL-related outcomes for patients undergoing surgery for RCC.

Amblyopia in childhood eyelid ptosis

PURPOSE

To report the prevalence and causes of amblyopia among children with ptosis diagnosed in a well-defined population over a 40-year period.

DESIGN

Retrospective, population-based cohort study.

METHODS

We retrospectively reviewed the charts of 107 patients younger than 19 years for the prevalence and causes of amblyopia who were diagnosed with childhood ptosis and were residents of Olmsted County, Minnesota, from January 1, 1965, through December 31, 2004.

RESULTS

Amblyopia was diagnosed in 16 (14.9%) of the 107 patients with childhood ptosis. Fourteen (14.6%) of 96 patients diagnosed with a congenital form of ptosis demonstrated amblyopia. Twelve (14.8%) of the 81 patients diagnosed with simple congenital ptosis had amblyopia, 7 (8.6%) cases of which solely were the result of eyelid occlusion of the visual axis. The causes of amblyopia in the remaining 5 patients were significant refractive error in 3 patients and strabismus in 2 patients.

CONCLUSIONS

Amblyopia occurred in 1 in 7 children diagnosed with ptosis in this population-based cohort. In approximately half of those with amblyopia, or less than 10% of all patients, the disease solely was the result of eyelid occlusion of the visual axis.

Impact of fellowship training on one-year outcomes of robotic-assisted prostatectomy

BACKGROUND AND OBJECTIVES

We examined 1-year functional and oncologic outcomes for robotic-assisted laparoscopic prostatectomy (RALP) from a single surgeon entering practice directly from fellowship training.

METHODS

We prospectively analyzed the first 100 RALPs performed by one fellowship-trained robotic surgeon. Data included resident involvement during the procedure, perioperative data, and surgical complications (scored using the Clavien grading system). Health-related quality of life (HRQOL) data were captured using the EPIC questionnaire at baseline (prior to surgery) and at 1-year follow-up.

RESULTS

Eighty-two patients (82%) had hospital stays of 2 days or less without any postoperative complications, urethral catheter removal was within 14 days of surgery, and none required readmission to the hospital. The overall positive margin rate was 21% (19% for patients with T2 disease). Clavien grades 1 through 4 complication rates, respectively, were 4%, 10%, 1%, and 1%. There were no deaths, reoperations, or bladder neck contractures. One patient (1%) required a blood transfusion within the 90-day perioperative period. At 1-year follow-up, 78% of patients reported wearing no pads; 41.3% of patients with baseline and 1-year follow-up data reported having intercourse.

CONCLUSIONS

We provide baseline data pertaining to the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing RALP.

Changes in efficiency and resource utilization after increasing experience with double balloon enteroscopy

AIM: To investigate changes in efficiency and resource utilization as a single endoscopist’s experience increased with each subsequent 100 double balloon enteroscopy (DBE) procedures.

METHODS: We reviewed consecutive DBE procedures performed by a single endoscopist at our center over 4 years. DBE was employed when the clinician deemed the procedure was needed for disease management. The approach (oral, anal or both) was chosen based on suspected location of the target lesion. All DBE was performed in a standard endoscopy room with a portable fluoroscopy unit. Fluoroscopy was used to aid in shortening the small intestine and reducing bowel loops. For oral DBE, measurements were taken from the incisors. For anal DBE, measurements were taken from the anal verge. Enteroscopy continued until the target lesion was reached, until the entire small intestine was examined, or until no further progress was deemed possible. The length of small intestine examined (cm), procedure duration (min), and fluoroscopy time (s) were analyzed for sequential groups of 100 DBE. Sub-groups of diagnostic and therapeutic procedures were analyzed using multivariable linear regression.

RESULTS: 802 consecutive DBE procedures were analyzed. For oral DBE, median [interquartile range (IQR)] length of small bowel examined was 230.8 cm (range: 210-248 cm) and for anal DBE was 143.5 cm (range: 100-180 cm). No significant increase in length examined was noted for either the oral or anal approach with advancing position in series. In terms of duration of procedure, the median (IQR) for oral DBE was 86 min (range: 71-105 min) and for anal DBE was 81.3 min (range: 67-105 min). When comparing by the position in series, there was a significant (P value < 0.001) decrease in procedure duration for both upper and lower procedures with increasing experience. Median (IQR) time of exposure to fluoroscopy for oral DBE was 190 s (114-275) compared to anal DBE which was 196.4 s (312-128). This represented a significant (P value < 0.001) decrease in the amount of fluoroscopy used with increasing position in series. For both oral and anal DBE, fluoroscopy time was reduced by greater than 50% over the course of 802 total procedures performed. Sub-group analysis was conducted on therapeutic and diagnostic groups. Out of 802 procedures, a total of 434 were considered therapeutic. Argon plasma coagulation was by far the most common therapeutic intervention performed. There was no evidence of a difference in length examined or fluoroscopy exposure among oral DBE for diagnostic and therapeutic procedures, P = 0.91 and P = 0.32 respectively. The median (IQR) for length was 235 cm (range: 178-280 cm) for diagnostic vs 230 cm (range: 180-275 cm) for therapeutic procedures; additionally, fluoroscopy time median (IQR) was 180 s (range: 110-295 s) and 162 s (range: 102-263 s) for no intervention and intervention. However, there was a significant difference in procedure duration among oral DBE (P < 0.001). The median (IQR) was 80 min (range: 60-97 min) and 94 min (range: 77-110 min) for diagnostic and therapeutic interventions respectively.

CONCLUSION: For a single endoscopist, increased DBE experience with number of performed procedures is associated with increased efficiency and decreased resource utilization.

Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery

BACKGROUND

Lymphedema is a feared complication of breast cancer surgery. We evaluated the trends in lymphedema development, patient worry, and risk reduction behaviors.

STUDY DESIGN

We prospectively enrolled 120 women undergoing sentinel node biopsy (SLNB) or axillary node dissection (ALND) for breast cancer and assessed lymphedema by upper extremity volume preoperatively and at 6 and 12 months postoperatively. We defined lymphedema as a >10% volume change from baseline relative to the contralateral upper extremity. Patients completed a validated instrument evaluating lymphedema worry and risk reducing behaviors. Associations were determined by Fisher's exact and signed rank tests.

RESULTS

At 6 months, lymphedema was similar between ALND and SLNB patients (p = 0.22), but was higher in ALND women at 12 months (19% vs 3%, p = 0.005). A clear relationship exists between relative change in upper extremity volume at 6 and 12 months (Kendall tau coefficient 0.504, p < 0.001). Among the women with 0 to 9% volume change at 6 months, 22% had progressive swelling, and 18% resolved their volume changes at 12 months. Overall, 75% of ALND and 50% of SLNB patients had persistent worry about lymphedema at follow-up, and no difference existed in the number of risk reducing behaviors practiced among the 2 groups (p > 0.34).

CONCLUSIONS

Upper extremity volumes fluctuate, and there is a period of latency before development of lymphedema. Despite the low risk of lymphedema after SLNB, most women worry about lymphedema and practice risk reducing behaviors. Additional study into early upper extremity volume changes is warranted to allay the fears of most women and better predict which women will progress to lymphedema.

Incidence and clinical characteristics of periocular infantile hemangiomas

OBJECTIVE

To report the incidence, demographics, and clinical findings among a population-based cohort of children with periocular infantile hemangiomas.

METHODS

The medical records of all patients (<19 years of age) diagnosed as having periocular infantile hemangiomas while residing in Olmsted County, Minnesota, from January 1, 1965, through December 31, 2004, were retrospectively reviewed.

RESULTS

Forty-three children were diagnosed as having periocular infantile hemangiomas during the 40-year period, yielding an incidence of 5.4 per 100,000 individuals younger than 19 years (95% CI, 3.8-7.1) or a birth prevalence of 1 in 1586 live births. Thirty children (70%) were female (P<.001). There was a history of maternal infertility in approximately 1 in 5 children and premature birth in 1 in 8 children. Twenty-six children (61%) had other abnormalities, including secondary hemangiomas in 9 (21%). Forty-one patients (95%) had unilateral disease, and 37 hemangiomas (86%) were located on the upper eyelid.

CONCLUSIONS

In this population-based study, periocular infantile hemangiomas occurred in 1 in 1586 live births and were most prevalent on the unilateral upper eyelid of white female patients. Prevalent associations included maternal infertility and premature birth. Other abnormalities, including secondary hemangiomas in 1 in 5 children, were common in this cohort.

Prevalence of hyponatremia, renal dysfunction, and other electrolyte abnormalities among runners before and after completing a marathon or half marathon

Background:

Prior reports on metabolic derangements observed in distance running frequently have small sample sizes, lack prerace laboratory measures, and report sodium as the sole measure.

Hypothesis:

Metabolic abnormalities—hyponatremia, hypokalemia, renal dysfunction, hemoconcentration—are frequent after completing a full or half marathon. Clinically significant changes occur in these laboratory values after race completion.

Study Design:

Observational, cross-sectional study.

Methods:

Consenting marathon and half marathon racers completed a survey as well as finger stick blood sampling on race day of the National Marathon to Fight Breast Cancer (Jacksonville, Florida, February 2008). Parallel blood measures were obtained before and after race completion (prerace, n = 161; postrace, n = 195).

Results:

The prevalence of prerace and postrace hyponatremia was 8 of 161 (5.0%) and 16 of 195 (8.2%), respectively. Hypokalemia was not present prerace but was present in 1 runner postrace (1 of 195). Renal dysfunction occurred prerace in 14 of 161 (8.7%) and postrace in 83 of 195 (42.6%). Among those with postrace renal dysfunction, 45.8% (38 of 83) were classified as moderate or severe. Hemoconcentration was present in 2 of 161 (1.2%) prerace and 6 of 195 (3.1%) postrace. The mean changes in laboratory values were (postrace minus prerace): sodium, 1.6 mmol/L; potassium, −0.2 mmol/L; blood urea nitrogen, 2.8 mg/dL; creatinine, 0.2 mg/dL; and hemoglobin, 0.3 g/dL for 149 pairs (except blood urea nitrogen, n = 147 pairs). Changes were significant for all comparisons (P < 0.01) except potassium (P = 0.08) and hemoglobin (P = 0.01).

Conclusions:

Metabolic abnormalities are common among endurance racers, and they may be present prerace, including hyponatremia. The clinical significance of these findings is unknown.

Clinical relevance:

It is unclear which runners are at risk for developing clinically important metabolic derangements. Participating in prolonged endurance exercise appears to be safe in the majority of racers.

Quality in colonoscopy reporting: an assessment of compliance and performance improvement

BACKGROUND

An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined.

AIMS

To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention.

METHODS

300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance.

RESULTS

Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16).

CONCLUSION

This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.

Medical and surgical outcomes in childhood glaucoma: a population-based study

INTRODUCTION

To describe the clinical and surgical outcomes among patients younger than 20 years of age diagnosed with glaucoma in a defined population during a 40-year period.

METHODS

The medical records of all patients (<20 years) diagnosed with glaucoma in Olmsted County, Minnesota, from January 1, 1965, through December 31, 2004, were retrospectively reviewed.

RESULTS

Thirty children (45 eyes) were diagnosed with various forms of glaucoma during the 40-year study period. During a mean follow-up of 12.5 years (range, 7 days to 32 years), 18 (60%) of the 30 children underwent a mean of 2.7 surgeries (range, 1 to 10), including 6 (20%) patients whose sole surgery consisted of enucleation or evisceration for a blind, painful eye. Twenty-eight (93%) of the 30 children required medical management during the follow-up period, including 14 (47%) treated before their first surgery. At the final follow-up examination, 11 (37%) had a visual acuity of 20/200 or worse. The 10-year Kaplan-Meier risk of vision decreasing less than 20/200 in all glaucoma patients was 22.7% (95% CI, 0-40.9), and patients requiring any glaucoma surgery was 68.3% (95% CI, 42.4-82.6).

CONCLUSIONS

In this population-based study of children diagnosed with glaucoma during a 40-year period, most patients required surgery, with few being successfully controlled by medications alone. A poor visual outcome or the loss of an eye was relatively common.

Incidence and clinical characteristics of childhood glaucoma: a population-based study

OBJECTIVE

To describe the incidence and clinical characteristics of childhood glaucoma in a defined population of the United States.

METHODS

The medical records of all pediatric patients younger than 20 years living in Olmstead County, Minnesota, from January 1, 1965, through December 31, 2004, who met diagnostic criteria for glaucoma or glaucoma suspect were reviewed.

RESULTS

Thirty children were diagnosed as having glaucoma during the 40-year study period. The incidence of childhood glaucoma was 2.29 (95% confidence interval, 1.47-3.12) per 100,000 residents younger than 20 years, with the following types and incidences: 19 acquired (1.46/100,000; 0.80-2.12), 6 secondary (0.45/100,000; 0.08-0.82), and 5 primary glaucoma (0.38/100,000; 0.05-0.72). The birth prevalence of primary congenital glaucoma during the 40-year period was 1 per 68 254 residents younger than 20 years or 1.46 per 100,000 (95% confidence interval, 0.03-8.16). Twenty-four individuals with glaucoma suspect were also identified, yielding an incidence of 1.9 per 100,000 residents younger than 20 years (95% confidence interval, 1.14-2.66).

CONCLUSION

The incidence of childhood glaucoma in this population was 2.29 per 100,000 residents younger than 20 years or 1 per 43 575 residents younger than 20 years. Acquired and secondary forms of glaucoma were the most common, whereas congenital and juvenile glaucoma were rare.

Incidence of pediatric Horner syndrome and the risk of neuroblastoma: a population-based study

OBJECTIVE

To describe the incidence of pediatric Horner syndrome and the risk of occult malignancy in a population-based cohort.

METHODS

The medical records of all pediatric patients (aged <19 years) residing in Olmsted County, Minnesota, who received diagnoses of Horner syndrome from January 1, 1969, through December 31, 2008, were retrospectively reviewed.

RESULTS

Horner syndrome was diagnosed in 20 pediatric patients during the 40-year period, yielding an age- and sex-adjusted incidence of 1.42 per 100 000 patients younger than 19 years of age (95% confidence interval [CI], 0.80-2.04). Eleven of the 20 patients (55%) had a congenital onset, for a birth prevalence of 1 in 6250 (95% CI, 3333-10 000), while the remaining 9 (45%) had acquired syndromes. Seven of the 11 (63.6%) patients with congenital cases had a history of birth trauma, while the remaining 4 (36.4%) had no identifiable cause. Six of the 9 (66%) acquired cases occurred following surgery or trauma, while the remaining 3 (33%) had no known etiology. None of the 20 patients (95% CI, 0.0%-16.8%) were found to have a neuroblastoma or other malignancy during a mean follow-up of 56.5 months (range, 0-256.9 months).

CONCLUSIONS

The incidence of pediatric Horner syndrome in this population was 1.42 per 100 000 patients younger than 19 years, with a birth prevalence of 1 in 6250 for those with a congenital onset. Birth, surgical, or other trauma occurred in 13 (65%) of the patients, while none were found to have an underlying mass lesion, suggesting a need for reappraising current recommendations for extensive evaluations in these patients.

Survival in stage III colon cancer is independent of the total number of lymph nodes retrieved

BACKGROUND

Retrieval of >/= 12 lymph nodes has been set as a marker of quality for surgical resection for colon cancer. The aim of our study was to determine if increasing the number of lymph nodes recovered in stage III colon cancer results in improved survival and if it does represent a reasonable quality metric.

STUDY DESIGN

Data from patients with stage III colon cancer from 1996 to 2001 were analyzed. Outcomes after operation (cancer-specific survival, disease-free survival, and overall survival) with or without adjuvant therapy were evaluated in 3 categories: the entire cohort, patients with N1, and patients with N2 disease. These categories were then classified into subgroups by the number of nodes (</= 12 versus >12) retrieved per specimen and whether they had 5-FU-based chemotherapy or not.

RESULTS

Three hundred twenty-nine patients, with a median followup of 5 years with stage III colon cancer, were identified. Five-year cancer-specific and disease-free survival was 67.2% and 59.7%, respectively. A positive correlation between number of positive lymph nodes and overall survival was found (p < 0.05). No significant association was observed between the total number (> 12 versus </= 12) of lymph nodes removed either in the entire cohort or in patients with N1 (249 patients) and N2 (80 patients) disease.

CONCLUSION

Accurate staging requires an appropriate operation and a concerted pathologic effort to identify lymph nodes in the colon specimen. The total number of lymph nodes analyzed for stage III colon cancer is not a prognostic indicator of cancer-specific and disease-free survival.

Immediate intraocular pressure changes following intravitreal injections of triamcinolone, pegaptanib, and bevacizumab

PURPOSE

To assess the intraocular pressure (IOP) changes, within the first 30 min after intravitreal injection of 0.1 ml (4 mg) triamcinolone, 0.09 ml (0.3 mg) pegaptanib, and 0.05 ml (1.25 mg) bevacizumab.

METHODS

Records of patients who received intravitreal triamcinolone, pegaptanib, and bevacizumab and who had their IOP measured post-injection were reviewed.

RESULTS

A total of 212 injections were performed (76 bevacizumab in 63 patients, 42 triamcinolone in 41 patients, 94 pegaptanib in 74 patients). At 10 min, over 87% of eyes receiving each drug had an IOP of less than 35 mmHg. Three of the 42 eyes receiving intravitreal triamcinolone were treated with IOP-lowering drops for pressures of 44, 46, and 60 mmHg. No patients treated with intravitreal bevacizumab or pegaptanib received IOP-lowering drops. The number of eyes in each injection group that had an IOP rise >10 mmHg within 30 min after injection was 27.6% of eyes receiving bevacizumab, 33.3% of eyes receiving triamcinolone, and 36.2% of eyes receiving pegaptanib. At 10 min, eyes with glaucoma were less likely to have an IOP<35 mmHg, but this difference became less marked with time.

CONCLUSION

In our series, most patients receiving intravitreal injections did not require IOP-lowering drops after injection, and none required a paracentesis.

Relative Risk of Mortality after Traumatic Brain Injury: A Population-Based Study of The Role of Age And Injury Severity

To test if observed vs. expected mortality differs by age among traumatic brain injury (TBI) cases, a population-based, historical cohort study was conducted in Olmsted County, Minnesota. From all residents with any diagnosis suggestive of TBI 1985-1999, we randomly sampled 7,800 and reviewed their medical records to confirm the event. Confirmed incident cases were categorized by age in years (<16 = pediatric, 16-65 = adult, > 65 elderly) and severity (moderate/severe vs. mild) and followed for vital status through 6/30/2004. We compared observed 6-month and 10-year mortality with expected and tested if the differences varied by age. Of 1,433 confirmed incident cases, 35% were pediatric; 55% were adult; only 9% were elderly; 11.2% of all cases were moderate/severe; the proportions by increasing age group were 11.4%, 8.5%, 26.7%. The proportions who died within 6 months increased with increasing age group, both for moderate/severe (10.3%, 40.3%, 50.0%) and mild cases (0%, 0%, 9.1%); mortality for moderate/severe cases was nearly 40 times that for mild cases, independent of age. Among 6-month survivors, 10-year mortality differed from expected only for adult cases. For all cases, after adjusting for sex, year of TBI, and severity, the difference between observed and expected 10-year mortality was greater for adult cases than for pediatric cases and similar for adult and elderly cases. Elderly individuals account for <10% of TBI cases and >50% of 10-year mortality, yet much of this discrepancy reflects age-associated mortality in general. Findings have implications for (1) reducing the number of excess deaths following TBI and (2) caring for survivors.

A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures

BACKGROUND AND AIMS

The aim of the study was to examine whether endoscopic intralesional corticosteroid injection into recalcitrant peptic esophageal strictures reduces the need for repeat stricture dilation.

METHODS

Patients with a peptic esophageal stricture and recurrent dysphagia having had at least one dilation in the preceding 18 months were enrolled in a prospective randomized, double-blind study comparing steroid and sham injection. After endoscopic confirmation of recurrent stricture, patients were randomized to receive either 0.5 cc/quadrant triamcinolone (40 mg/cc) or sham injection into the stricture followed by balloon dilation of the stricture. Patients were stratified by the number of dilations required in the preceding 18 months, severity of dysphagia, the presence of esophagitis, stricture severity, and prior therapy with a proton-pump inhibitor. Patients and their physicians were blinded to the type of intervention received. Baseline dysphagia questionnaires were completed. Post-procedurally all patients were placed on a standardized proton-pump inhibitor regimen and standardized telephone follow-up questionnaires were completed at 1 wk and at 1, 3, 6, 9, and 12 months. The original sample-size calculation of 60 patients could not be met in a timely fashion because of a low incidence of recalcitrant peptic stricture patients.

RESULTS

A total of 30 patients were enrolled, 15 in the steroid group (10 men, mean age 66 yr) and 15 in the sham group (11 M, mean age 67 yr). Patients were followed for 1 yr, unless they underwent an antireflux operation or died. Two patients, one per group, died of non-esophageal causes at 1 and 12 months. Four patients had fundoplication, two in each group, unrelated to stricture or dysphagia. Two patients in the steroid group (13%) and nine in the sham group (60%) required repeat dilation (p= 0.011).

CONCLUSIONS

In patients with recalcitrant peptic esophageal stricture, steroid injection into the stricture combined with acid suppression significantly diminishes both the need for repeat dilation and the average time to repeat dilation compared to sham injection and acid suppression alone.

Impairment in motor learning of somatostatin null mutant mice

Somatostatin was first identified as a hypothalamic factor which inhibits the release of growth hormone from the anterior pituitary (somatotropin release inhibitory factor, SRIF). Both SRIF and its receptors were subsequently found widely distributed within and outside the nervous system, in the adult as well as in the developing organism. Reflecting this wide distribution, somatostatin has been implicated regulating a diverse array of biological processes. These include body growth, homeostasis, sensory perception, autonomous functions, rate of intestinal absorption, behavior, including cognition and memory, and developmental processes. We produced null mutant mice lacking somatostatin through targeted mutagenesis. The mutant mice are healthy, fertile, and superficially indistinguishable from their heterozygous and wildtype littermates. A 'first round' phenotype screen revealed that mice lacking somatostatin have elevated plasma growth hormone levels, despite normal body size, and have elevated basal plasma corticosterone levels. In order to uncover subtle and unexpected differences, we carried out a systematic behavioral phenotype screen which identified a significant impairment in motor learning revealed when increased demands were made on motor coordination. Motor coordination and motor learning require an intact cerebellum. While somatostatin is virtually absent from the adult cerebellum, the ligand and its receptor(s) are transiently expressed at high levels in the developing cerebellum. This result suggests the functional significance of transient expression of SRIF and its receptors in the development of the cerebellum.

Generation of dynorphin knockout mice

The opioid system has important roles in controlling pain, reward and addiction, and is implicated in numerous other processes within and outside the nervous system, such as mood states, immune responses, and prenatal developmental processes. The effects of the opioid system are mediated by at least three ligands, enkephalin, endorphin, and dynorphin, which act through the opioid receptors mu, delta, and kappa. In order to dissect the roles of individual components of the opioid system, mutant mice lacking single ligands or receptors are instrumental. We report here on the generation and initial characterization of a mutant mouse strain lacking pre-prodynorphin. Dynorphin 'knockout' mice are viable, healthy, and fertile and show no overt behavioral differences to wildtype littermates. Dynorphin knockout mice constitute a valuable tool for many research areas, among them research into pain, substance abuse, and epilepsy.

Activation of p38 mitogen-activated protein kinase in vivo selectively induces apoptosis of CD8(+) but not CD4(+) T cells

CD4(+) and CD8(+) T cells play specific roles during an immune response. Different molecular mechanisms could regulate the proliferation, death, and effector functions of these two subsets of T cells. The p38 mitogen-activated protein (MAP) kinase pathway is induced by cytokines and environmental stress and has been associated with cell death and cytokine expression. Here we report that activation of the p38 MAP kinase pathway in vivo causes a selective loss of CD8(+) T cells due to the induction of apoptosis. In contrast, activation of p38 MAP kinase does not induce CD4(+) T-cell death. The apoptosis of CD8(+) T cells is associated with decreased expression of the antiapoptotic protein Bcl-2. Regulation of the p38 MAP kinase pathway in T cells is therefore essential for the maintenance of CD4/CD8 homeostasis in the peripheral immune system. Unlike cell death, gamma interferon production is regulated by the p38 MAP kinase pathway in both CD4(+) and CD8(+) T cells. Thus, specific aspects of CD4(+) and CD8(+) T-cell function are differentially controlled by the p38 MAP kinase signaling pathway.

Obesity in the mouse model of pro-opiomelanocortin deficiency responds to peripheral melanocortin

Pro-opiomelanocortin (POMC)-derived peptides (the melanocortins adrenocorticotropin, alpha-, beta- and gamma-melanocyte stimulating hormone; and the endogenous opioid beta-endorphin) have a diverse array of biological activities, including roles in pigmentation, adrenocortical function and regulation of energy stores, and in the immune system and the central and peripheral nervous systems. We show here that mice lacking the POMC-derived peptides have obesity, defective adrenal development and altered pigmentation. This phenotype is similar to that of the recently identified human POMC-deficient patients. When treated with a stable alpha-melanocyte-stimulating hormone agonist, mutant mice lost more than 40% of their excess weight after 2 weeks. Our results identify the POMC-null mutant mouse as a model for studying the human POMC-null syndrome, and indicate the therapeutic use of peripheral melanocortin in the treatment of obesity.