Metagenomics for Pathogen Detection During a Mass Mortality Event in Songbirds

Mass mortality events in wildlife can be indications of an emerging infectious disease. During the spring and summer of 2021, hundreds of dead passerines were reported across the eastern US. Birds exhibited a range of clinical signs including swollen conjunctiva, ocular discharge, ataxia, and nystagmus. As part of the diagnostic investigation, high-throughput metagenomic next-generation sequencing was performed across three molecular laboratories on samples from affected birds. Many potentially pathogenic microbes were detected, with bacteria forming the largest proportion; however, no singular agent was consistently identified, with many of the detected microbes also found in unaffected (control) birds and thus considered to be subclinical infections. Congruent results across laboratories have helped drive further investigation into alternative causes, including environmental contaminants and nutritional deficiencies. This work highlights the utility of metagenomic approaches in investigations of emerging diseases and provides a framework for future wildlife mortality events.

Renal cell carcinoma in the Canadian Indigenous population

Background

Diagnosis and treatment of renal cell carcinoma (rcc) might be different in Indigenous Canadians than in non-Indigenous Canadians. In this cohort study, we compared rcc presentation and treatments in Indigenous and non-Indigenous Canadians.

Methods

Patients registered in the Canadian Kidney Cancer Information System treated at 16 institutions between 2011 and 2018 were included. Baseline patient, tumour, and treatment characteristics were compared between Indigenous and non-Indigenous Canadians. The primary objective was to determine if differences in rcc stage at diagnosis were evident between the groups. The secondary objective was to determine if treatments and outcomes were different between the groups.

Results

During the study period, 105 of the 4529 registered patients self-identified as Indigenous. Those patients were significantly younger at the time of clinical diagnosis (57.9 ± 11.3 years vs. 62.0 ± 12.1 years, p = 0.0006) and had a family history prevalence of rcc that was double the prevalence in the non-Indigenous patients (14% vs. 7%, p = 0.004). Clinical stage at diagnosis was similar in the two groups (p = 0.61). The disease was metastatic at presentation in 11 Indigenous Canadians (10%) and in 355 non-Indigenous Canadians (8%). Comorbid conditions that could affect the management of rcc-such as obesity, renal disease, diabetes mellitus, and smoking-were more common in Indigenous Canadians (p < 0.05). Indigenous Canadians experienced a lower rate of active surveillance (p = 0.01). Treatments and median time to treatments were similar in the two groups.

Conclusions

Compared with their non-Indigenous counterparts, Indigenous Canadian patients with rcc are diagnosed at an earlier age and at a similar clinical stage. Despite higher baseline comorbid conditions, clinical outcomes are not worse for Indigenous Canadians than for non-Indigenous Canadians.

Use of targeted therapy in patients with metastatic renal cell carcinoma: clinical and economic impact in a Canadian real-life setting

Introduction

Outside of randomized controlled clinical trials, the understanding of the effectiveness and costs associated with targeted therapies for metastatic renal cell carcinoma (mrcc) is limited in Canada. The purpose of the present study was to use real-world prospective data to assess the effectiveness and cost of targeted therapies for patients with mrcc.

Methods

The Canadian Kidney Cancer Information System, a pan-Canadian database, was used to identify prospectively collected data relating to patients with mrcc. First- and subsequent-line time to treatment termination (ttt) was determined from therapy initiation time (sunitinib or pazopanib) to discontinuation of therapy. Kaplan-Meier survival curves were used to estimate the unadjusted and adjusted overall survival (os) by treatment. Unit treatment cost was used to estimate the cost by line of treatment and the total cost of therapy for the management of patients with mrcc.

Results

The study included 475 patients receiving sunitinib or pazopanib in the first-line setting. Patients were treated mostly with sunitinib (81%); 19% of patients were treated with pazopanib. The median ttt in the first line was 7.7 months for patients receiving sunitinib and 4.6 months for those receiving pazopanib (p < 0.001). The adjusted os was 32 months with sunitinib and 21 months with pazopanib (hazard ratio: 1.61; p < 0.01). The total median cost of first- and second-line treatments was $56,476 (interquartile range: $23,738-$130,447) for patients in the sunitinib group and $46,251 (interquartile range: $28,167-$91,394) for those in the pazopanib group.

Conclusions

For the two therapies, os differed significantly, with a higher median os being observed in the sunitinib group. The cost of treatment was higher in the sunitinib group, which is to be expected with longer survival.

Relationship between initial PSA density with future PSA kinetics and repeat biopsies in men with prostate cancer on active surveillance

The objective of our study is to examine the correlation between PSA density (PSAd) at the time of diagnosis with PSA velocity (PSAV), PSA doubling time and tumour progression, on repeat biopsy, in men with prostate cancer on active surveillance. Data from 102 patients with clinically localized prostate cancer on active surveillance in the period between 1992 and 2007, who had the necessary parameters available, were collected. PSAd was calculated and correlated with PSAV, PSA doubling time (PSADT), Gleason score at diagnosis and local progression on repeated biopsies. PSAV was 0.64 and 1.31 ng ml^–1 per year (P=0.02), PSADT of 192 and 113 months (P=0.4) for PSAd below and above 0.15, respectively. The rate of detecting high Gleason score (⩾7) at diagnosis was 6 and 23% for PSAd below and above 0.15, respectively. A total of 101 patients underwent at least a second biopsy and the incidence of upgrading was 10 and 31% for PSAd below and above 0.15, respectively (P=0.001). Although low PSAd is an accepted measure for suggesting insignificant prostate cancer, our study expands its role to indicate that PSAd <0.15 may be an additional clinical parameter that may suggest indolent disease, as measured by future PSAV and repeat biopsy over time.

Natural history and management of small renal masses

The recent stage migration observed for renal tumours is contributing to a significant increase in the diagnosis of small renal masses. This evolution has led to a significant change in the approach to renal masses. New options such as observation or energy ablation are gaining popularity in a subset of this patient population. In addition, the observed changes directly contribute to the increased use of nephron-sparing surgery. A better understanding of the various characteristics of these masses will allow for a better understanding of the natural history of these masses and for selection of the optimal therapeutic approach.

The Wnt pathway regulator DKK1 is preferentially expressed in hormone-resistant breast tumours and in some common cancer types

In addition to new tumour antigens, new prognostic and diagnostic markers are needed for common cancers. In this study, we report the expression of Dickkopf-1 (DKK1) in multiple common cancers. This constitutes a comprehensive analysis of the DKK1 expression profile. Dickkopf-1 expression was evaluated by classical and quantitative reverse transcriptase–polymerase chain reaction (RT–PCR) and enzyme-linked immunosorbant assay for protein determination, in cancer lines and clinical specimens of several cancer origins. For breast cancer, expression was correlated with clinicopathological parameters. Dickkopf-1 expression was confirmed in several cancer cell lines derived from breast and other common cancers. Dickkopf-1 protein secretion was documented in breast, prostate and lung cancer lines, but was negligible in melanoma. Analysis of DKK1 expression in human cancer specimens revealed DKK1 expression in breast (21 out of 73), lung (11 out of 23) and kidney cancers (six out of 20). Interestingly, DKK1 was preferentially expressed in oestrogen and progesterone receptor-negative tumours (ER⁻/PR⁻; P=0.005) and in tumours from women with a family history of breast cancer (P=0.024). Importantly, DKK1 protein production was confirmed in multiple breast cancer specimens that were positive by RT–PCR. This work establishes DKK1 as a potential prognostic and diagnostic marker for cohorts of breast cancer patients with poor prognosis. Dickkopf-1 may also become a relevant candidate target for immunotherapy of different cancers.

Comparative evaluation of various prostate specific antigen ratios for the early detection of prostate cancer

OBJECTIVE

To compare the performance of various ratios using total prostate specific antigen (PSA), complexed PSA (cPSA) and free PSA (fPSA) in the early detection of prostate cancer.

PATIENTS AND METHODS

The study included 535 consecutive patients evaluated at a prostate cancer detection clinic between January 1998 and October 1999. Patients had blood samples drawn before transrectal ultrasonography and prostate biopsy to measure PSA, cPSA and fPSA. Receiver operating characteristic (ROC) curves (sensitivity vs 1 - specificity) were used to evaluate the performance of PSA, cPSA, f/tPSA, cPSA/tPSA, fPSA/cPSA, tPSA/prostate volume (PV), fPSA/PV, and cPSA/PV. The areas under the curve (AUC) were calculated for each ratio. The performance of each ratio over all patients or in those with a tPSA of 4-6 or 4-10 ng/mL were evaluated.

RESULTS

Of the 535 patients, 204 (38%) had biopsy-confirmed prostate cancer. The AUC obtained with tPSA alone was 0.64; when measured for all patients the cPSA/PV (0.78), PSA/PV (0.77), f/tPSA (0.76) and fPSA/cPSA (0.75) performed better than tPSA alone. Furthermore, in patients with a tPSA of 4-10 ng/mL, tPSA/PV (0.72), cPSA/PV (0.71), f/tPSA (0.69), fPSA/cPSA (0.69) and cPSA/tPSA (0.62) performed better than tPSA alone (0.52). Finally, in patients with a tPSA of 4-6 ng/mL, PSA/PV and cPSA/PV performed better than the other ratios.

CONCLUSIONS

The use of PSA ratios gives a higher sensitivity and specificity for detecting prostate cancer than the use of tPSA alone.

Natural history of renal masses followed expectantly

PURPOSE

An increasing number of incidental renal masses have been detected with increasing use of ultrasonography, computerized tomography and magnetic resonance imaging. We investigated the natural history of incidentally detected renal masses.

MATERIALS AND METHODS

A total of 24 patients were included in this retrospective analysis. Average patient age was 68.3 years (range 29 to 83). The 16 males and 8 females were followed with abdominal imaging for a mean and median followup of 31.6 and 24 months, respectively (range 8 to 86). Patients elected to be observed because of age, poor medical condition or the presence of a mass in a solitary kidney. The majority of patients (22 of 24) were asymptomatic at diagnosis. Two patients were followed with bilateral renal masses, and 2 with T3b tumors. Of the 20 patients with incidental solitary renal masses, 6 were at the upper pole, 9 were mid polar and 5 lower pole. Mean maximum diameter of lesions was 3.3 cm (median 2.7, range 0.9 to 10). Growth rate was calculated based on diameter and tumor volume.

RESULTS

Of the 24 patients only 5 demonstrated tumor growth during the surveillance period. No metastasis developed in any patients. Mean tumor growth rate observed in the 5 patients was 0.49 cm per year or 7.3 cc per year. Of the 24 patients 4 underwent surgery after surveillance because of apparent tumor growth or per patient request. Pathology revealed renal cell carcinoma in all 4.

CONCLUSIONS

Tumor growth of renal masses is often limited. Most of our patients did not demonstrate significant growth when followed expectantly. Without tumor growth the risk of metastasis seems limited.

Serum insulin-like growth factor (IGF)-1 and IGF-binding protein-3 do not correlate with Gleason score or quantity of prostate cancer in biopsy samples

OBJECTIVE

To examine the relationship of serum insulin-like growth factor (IGF)-1 and IGF binding protein-3 (IGFBP-3) with histological cancer characteristics in men undergoing transrectal ultrasonography (TRUS)-guided biopsy.

PATIENTS AND METHODS

Patients (652), with either an elevated serum prostate-specific antigen level or an abnormal digital rectal examination, were initially evaluated by TRUS and sextant prostatic needle biopsy. Blood was drawn before biopsy, serum extracted and stored frozen until IGF-1 and IGFBP-3 were measured. In all, 241 patients had prostate cancer (37%) and were included in this study. The number of positive biopsies, the volume of tumour in each positive biopsy and the Gleason score were recorded.

RESULTS

Of the 241 patients, 37 had five or six positive biopsies (from six), 128 had two to four and 76 had one. Serum IGF-1 did not correlate with the number of positive biopsies, with means of 176.7, 178.3 and 164.4 ng/mL, respectively (P = 0.3), while the mean IGFBP-3 was 2695, 2795 and 2572 ng/mL, respectively (P = 0.09). The additive percentiles of tumour volume in positive biopsies were assessed for each patient but serum IGF-1 and IGFBP-3 did not correlate (P = 0.7 and 0.9, respectively). In all, 92 patients had a Gleason score of < 7, 80 a score of 7 and 69 a score of > 7; the mean (sd) IGF-1 levels for the three groups were 181 (39), 174.6 (35) and 176 (26) ng/mL, and the mean IGFBP-3 2798 (240), 2735 (284) and 2647 (221) ng/mL, respectively, none of the differences being statistically significant.

CONCLUSIONS

Serum IGF-1 and IGFBP-3 do not correlate with quantity of cancer or Gleason score in biopsy samples from patients with prostate cancer.

Comparative evaluation of total PSA, free/total PSA, and complexed PSA in prostate cancer detection

OBJECTIVES

To compare the performance of prostate-specific antigen (PSA), the free/total PSA (F/T PSA) ratio, and complexed PSA (cPSA) in prostate cancer detection.

METHODS

Five hundred thirty-five patients evaluated at the UROMED prostate cancer detection clinic had total PSA, free PSA, and cPSA measured before undergoing transrectal ultrasonography and sextant prostate biopsies. A direct comparison was performed between the different PSA assays to evaluate their ability to detect prostate cancer.

RESULTS

Of the 535 patients evaluated, 38.1% had prostate cancer detected. The mean age of the entire population was 63.6 years (range 35 to 86). Abnormal digital rectal examination findings were present in 33.4% of the patients. The mean and median values of PSA and cPSA were significantly higher and the F/T PSA ratio was lower in patients with prostate cancer. The F/T PSA ratio performed better than either cPSA or total PSA. A higher specificity was observed with the F/T PSA ratio than with cPSA using either the entire patient population or subsets of patients with PSA levels between 4.0 and 10 ng/mL or 4.0 to 6.0 ng/mL.

CONCLUSIONS

The use of the F/T PSA ratio offers improved prostate cancer detection compared with either cPSA or total PSA.

Murine renal cell carcinoma: evaluation of a dendritic-cell tumour vaccine

OBJECTIVE

To use a murine model of renal cell carcinoma (RCC), Renca, to aid in developing a dendritic cell (DC)-mediated tumour vaccine for RCC; as conventional therapy has been unsuccessful for RCC and therapy using immune modulators has had limited success, novel therapies enhancing further the immune system must be developed.

MATERIALS AND METHODS

DCs were obtained from mouse bone marrow enriched for the haematopoietic progenitors, and cultured in the presence of interleukin-4 and granulocyte macrophage-colony stimulating factor. In vivo vaccines and in vitro proliferation assays were used to assess ability of the DCs to present tumour antigen.

RESULTS

The presence of DCs was confirmed in the cultures by fluorescent-activated cell sorting analysis. In vivo, tumour-bearing animals receiving tumour extract-pulsed DCs as a vaccine showed a two to threefold reduction in tumour growth at day 12 and day 16 but no significant difference at day 28. In vitro, tumour extract-pulsed DCs stimulated significant proliferation of splenocytes from naive animals but not tumour-bearing animals. In addition, splenocytes from tumour-bearing animals had an attenuated immune response in vitro.

CONCLUSION

These results show that it is possible to use the DC vaccine to modulate the immune response to achieve an antitumour effect, but further manipulation of the DC vaccine may be needed to overcome the tumour-induced immune suppression.

Daytime functional bladder capacity as a predictor of response to desmopressin in monosymptomatic nocturnal enuresis

OBJECTIVE

The objective of this study was to identify a cost-effective method of predicting a therapeutic response to desmopressin (DDAVP) by correlating daytime functional bladder capacity, age and urine osmolalities in patients with monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

Thirty-five children out of 51 who initially presented to our institutions were included in the study. The remainder was excluded for lack of complete data. Constipation was actively addressed and was managed by administration of evening enemas for 3 consecutive days and dietary adjustment prior to initiating the study. Each micturition as measured throughout the day and the maximal daytime functional bladder capacity was determined as the largest void over a 2-day period. Urine samples were collected at home at 08:00, 16:00 and 22:00 (times that would best reflect the fluctuations in plasma vasopressin levels). Intranasal DDAVP was then administered, titrating the dose over a 2-week period. The initial dose was 10 micrograms and the dose was increased 10 micrograms every 3 days.

RESULTS

The response to DDAVP was then evaluated and of the 35 children, 27 demonstrated a complete response to DDAVP (all at doses between 10 and 30 micrograms). These were then related to the possible predictive factors. There was a significant correlation between a high maximum daytime functional bladder capacity and response to DDAVP (p = 0.006). Similarly, age was also predictive of a good response to DDAVP treatment (p = 0.008). However, spot urine osmolalities were not predictive of a response to DDAVP (p > 0.1).

CONCLUSIONS

Functional bladder capacity is a reliable predictor of response to desmopressin; children with larger capacities are more likely to exhibit a successful response. Older children have a better response rate than younger ones. Spot urine osmolality measured on specimens collected in the home setting is not predictive of response to desmopressin.

Links between Fer tyrosine kinase expression levels and prostate cell proliferation

In our cloning strategy to identify tyrosine kinases implicated in the regulation of prostate growth, the dog fer cDNA was obtained and shown to be highly homologous to known fer cDNAs. Using a polyclonal Fer antibody directed against a C-terminal peptide, we studied its associations with cortactin, beta-catenin and p120Cas in human prostate carcinoma PC-3 cells. In contrast to previous reports, no interactions were observed. To assess its functional role, fer cDNA constructs were transfected in PC-3 cells. Antisense clones exhibiting a marked diminution of Fer expression had a reduced growth rate (doubling time of 29 vs. 42 h) and were unable to form colonies in soft agar. In agreement with these results, Fer protein expression was linked to human prostatic proliferative diseases, with enhanced levels in extracts from cancer tissues as compared to those from normal and hyperplastic ones, and was also expressed in the human prostate carcinoma cell lines DU145 and LNCaP. In the dog model, Fer expression was up-regulated in dividing versus resting prostate epithelial cells in vitro, and also in vivo when basal cell hyperplasia and metaplasia was induced by estrogen after castration. Minimal effects were observed when renewing the luminal epithelium with androgens. Taken together, these results show that Fer expression is associated with prostate cell proliferation and enhanced in prostate cancer.

Thirty-day mortality rates and cumulative survival after radical retropubic prostatectomy

OBJECTIVES

To assess the 30-day mortality rate and overall survival after radical retropubic prostatectomy (RRP).

METHODS

Identification of all RRPs performed in the Province of Quebec between January 5, 1988 and January 16, 1996 was accomplished through the Quebec Healthcare Plan Database.

RESULTS

Four thousand nine hundred ninety-seven RRPs were performed by 104 urologists. Overall, 451 deaths were recorded: 32 occurred during the first 30 days (0.6% 30-day mortality rate). A significant decrease in the 30-day mortality rate, from 2.45% to 0.5%, was recorded during the span of the study. The year of surgery, patient age, and hospital type were statistically significant short-term mortality variables (life table analysis). Patient age and year of surgery determined the cumulative survival probability (univariate and multivariate Cox analysis). Cumulative survival at 31 months of follow-up increased from 88.2% in 1988 to 98.1% in 1995. Men 75 years old and older were at a clear disadvantage with regard to survival probability compared with their younger counterparts.

CONCLUSIONS

In this population-based analysis of RRP outcomes, we demonstrated a significant improvement in short- and long-term outcomes, as evidenced by a decrease in the 30-day mortality rate and an improved cumulative survival, recorded over the span of the study. The recorded outcome trends may be explained by improved patient selection and optimal management. Although we are unable to determine cancer-specific outcomes, the results of this analysis should prove valuable to urologists and patients until there are results from randomized trials.

Predictors of HIV infection among newly sentenced male prisoners

The prevalence of individuals with or at risk for HIV infection in prisons and jails is severalfold higher than age-adjusted rates in surrounding communities. This HIV serosurvey of 975 newly sentenced male prisoners employed a new methodology that anonymously linked individual information to HIV serologic data. The HIV prevalence was 6.1%; multivariate regression analysis indicated injection drug use (OR = 18.9), black race (OR = 5.5), Hispanic ethnicity (OR = 3.4), psychiatric illness (OR = 3.1) and a history of having had a sexually transmitted disease (OR = 2.2) were independent predictors of HIV infection. Laboratory markers such as hypoalbuminemia, an elevated aspartate aminotransferase (AST) level, leukopenia, anemia, and thrombocytopenia suggest increased risk for HIV among prisoners, particularly in settings where HIV testing resources are scarce. This study, unlike those reported in other geographic regions, indicated that the majority (71%) of HIV-seropositive persons self-reported their HIV status. This finding may suggest that HIV-infected individuals will self-report their status if HIV care is comprehensive and consistent. The large number of HIV-infected individuals within prisons makes prisons important sites for the introduction of comprehensive HIV-related care. This is particularly relevant in that development of new guidelines issued for the management of HIV infection in which potent combination antiretroviral therapy has been demonstrated to decrease morbidity and mortality. The high prevalence of HIV-seronegative inmates with self-reported high-risk behaviors also suggests the importance of prisons as sites for the introduction of appropriate risk-reduction interventions.

Spot urine osmolality, age and bladder capacity as predictors of response to desmopressin in nocturnal enuresis

The objective of the current study was to find a cost-effective way of correlating spot urine osmolalities, bladder capacity and age in patients with monosymptomatic nocturnal enuresis with response to treatment with desmopressin (Minirin, DDAVP). A total of 35 children fulfilled the entry criteria and were included in the study. Constipation was eliminated in these children by appropriate enema treatment and diet adjustment prior to enrollment. Urine samples were collected at home at times that would best reflect fluctuations in plasma vasopressin levels (08:00, 16:00 and 22:00) over three consecutive 24-hour periods. Maximal functional bladder capacity was determined from the largest voided volume. A 2-week dose-titration treatment period with intranasal desmopressin was then conducted. With doses of desmopressin being increased by 10 micrograms every 3 days. Response to desmopressin treatment was then assessed and factors that were observed to be markers of a favourable response were noted. Of the 35 children, 27 demonstrated a complete response to desmopressin treatment, at doses of 10-30 micrograms. Spot urine osmolalities were not predictive of the response to desmopressin (P > 0.1). In contrast, there was a significant correlation between a high maximum functional bladder capacity and response to desmopressin (P = 0.006). Age was also predictive of a good response to desmopressin treatment (P = 0.008).

Renal cell carcinoma metastatic to the lung: potential benefit in the combination of biological therapy and surgery

PURPOSE

We evaluated outcomes in cases of renal cell carcinoma metastatic to the lung treated with surgery or biological therapy followed by surgery.

MATERIALS AND METHODS

We retrospectively evaluated 22 patients treated with surgical resection and 29 treated with biological therapy followed by surgery.

RESULTS

At the time of this study 31 patients (61%) were alive, including 15 with no residual disease and 16 with disease. Of the 22 patients treated with surgery without initial biological therapy 12 (55%) were alive at a median followup of 57 months (range 17 to 148) and 19 of the 29 (66%) treated with combination therapy were alive at a median followup of 48 months (range 19 to 78). A total of 19 patients (37%) died of progressive disease.

CONCLUSIONS

Our results suggest a role for an aggressive surgical approach in select patients with metastatic renal cell carcinoma, and demonstrate that patients who do not achieve a complete response to biological therapy may benefit from surgical resection of residual disease.

The risk of upper tract recurrence following cystectomy in patients with transitional cell carcinoma involving the distal ureter

PURPOSE

Risk factors for the development of an upper urinary tract transitional cell carcinoma following radical cystectomy are identified.

MATERIALS AND METHODS

The records of 430 patients who underwent cystectomy for transitional cell carcinoma of the bladder between 1981 and 1988 were retrospectively reviewed.

RESULTS

Upper tract tumors developed in 11 patients (2.6%) at a median of 40 months after radical cystectomy. Of the potential risk factors evaluated only the presence of transitional cell carcinoma within the distal ureter showed a statistically significant correlation with upper tract recurrence (p = 0.001). Six of the 11 recurrent neoplasms were asymptomatic. Among the patients with upper urinary tract recurrence 5 died of disease, 4 had no evidence of disease and 2 were alive with cancer.

CONCLUSIONS

Patients with distal ureteral involvement at cystectomy are at a high risk for upper tract recurrence. These patients should be monitored with routine upper tract cytology and imaging studies.

Therapy of locally recurrent renal cell carcinoma after nephrectomy

PURPOSE

We evaluated the outcome of patients with locally recurrent renal cell carcinoma treated at our university.

MATERIALS AND METHODS

We retrospectively analyzed 16 cases of locally recurrent renal cell carcinoma in the renal fossa treated with surgical resection alone or in combination with biological therapy.

RESULTS

Complete resection was possible in 15 patients of whom 3 had positive surgical margins. Of the 12 patients with negative margins 6 are free of disease while the 3 with positive margins had involvement of a remaining ipsilateral adrenal gland and distant metastasis. Of all 16 patients 12 are alive a median of 23.5 months after the diagnosis of locally recurrent renal cell carcinoma. Of those treated with the combination of biological therapy and surgery 50% have no evidence of disease compared to 25% of those treated with surgery alone.

CONCLUSIONS

Long-term survival can be achieved with an aggressive surgical approach. Incomplete resection or positive surgical margins are associated with a high risk of local or distant failure, and combined treatment with immunotherapy and surgery may offer a benefit compared to surgery alone.

Predictors of positive tuberculin skin test results in a jail population

The purpose of this analysis was to determine the prevalence and predictors of positive tuberculin skin tests (TSTs) in a jail population. TST results and demographic data were obtained for 996 male inmates of a Connecticut jail who were tested following identification of a case of multidrug-resistant Mycobacterium tuberculosis (MDR-TB). Inmates were predominantly young (median age, 26 years) and Black (51%) and were born in the United States (96%). Overall 109 (11%) inmates had positive TST results. TST positivity was strongly associated with being born outside the United States (adjusted odds ratio [aOR] = 11.3, 95% confidence interval [95% CI] 4.9-25.8), being Puerto Rican born (aOR = 3.7, 95% CI 1.9-7.4), and increasing age (15-24 years aOR = l [referent]; 25-34 years aOR = 2.1 95% CI 1.2-3.5; 35-44 years aOR = 4.3 95% CI 2.4-7.7; > or = 45 years aOR = 6.4 95% CI 2.8-14.6). The combination of being U.S.-born and Black was also associated with increased rates of positive TSTs. The prevalence of TST positivity was > 10% for all age groups of inmates born outside the United States or Puerto Rico and for Puerto Rican-born inmates aged > or = 25 years and U.S.-born inmates aged > or = 35 years. Analysis of routinely collected TST data allows predictors of TST positivity to be identified and may help determine population subgroups for whom anergy screening and preventive therapy should be considered.

Intravesical liposomal muramyl tripeptide phosphatidylethanolamine treatment of human bladder carcinoma growing in nude mice

The present study evaluated the in vivo activity of synthetic lipophilic muramyl tripeptide phosphatidylethanolamine (MTP-PE) when encapsulated into liposomes (phosphatidylcholine-phosphatidylserine, 7:3 molar ratio) and administered intravesically to athymic nude mice with human transitional cell carcinoma 253J-V cells growing in their bladder. Intravesical liposome-MTP-PE was effective in eradicating the human tumors implanted orthotopically in nude mice. Following therapy, activated macrophages were found in the bladders of liposome-MTP-PE-treated mice but not in control mice. In vitro activation of murine macrophages with liposome-MTP-PE increased their cytotoxicity against the 253J-V cell line used in these experiments. This effect was enhanced by cotreatment with interferon-gamma (IFN-gamma). Furthermore, cotreatment of macrophages with both liposome-MTP-PE and IFN-gamma resulted in the secretion of both tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6). Liposome-encapsulated MTP-PE shows promise as an effective therapeutic agent for bladder carcinoma.

In vivo modulation of macrophage tumoricidal activity by oral administration of the liposome-encapsulated macrophage activator CGP 19835A

The present study evaluated the in vivo biological activity of synthetic muramyl tripeptide, CGP 19835A, when encapsulated into phosphatidylcholine liposomes (POPC-19835A) and administered as an p.o. immunomodulator to BALB/c mice. Liposomes were rapidly absorbed in the intestine and reached the systemic circulation within 4 h. Alveolar macrophages harvested from the lungs of mice 24 h after a single p.o. feeding of POPC-19835A were tumoricidal toward syngeneic murine renal cell carcinoma target cells. Repeated daily feedings with POPC-19835A generated sustained activation of the alveolar macrophages. Activation of peritoneal macrophages to the tumoricidal state required at least three daily feedings of POPC-19835A. In vitro studies demonstrated the release of tumor necrosis factor alpha and interleukin 6 by macrophages activated by POPC-19835A in the presence of gamma-interferon. Interleukin 1 and nitric oxide were not induced in macrophages by this liposomal preparation. Daily administration of POPC-19835A after i.v. injection of renal cell carcinoma tumor in BALB/c mice inhibited the development of experimental lung metastasis and confirmed the potential role of long-term therapy with this new p.o. immunomodulator.

Direct comparison of ELISPOT and ELISA-based assays for detection of individual cytokine-secreting cells

A direct comparison was made between the insoluble ELISPOT, solubilized ELISPOT, and ELISA assays, to detect cytokine secretion by cells, using sterile ELISA plates and commercially available monoclonal antibodies. We evaluated the IL-6 secretion by resident peritoneal macrophages of BALB/c mice and the secretion of IL-2, IL-4, IL-5, and IL-6 by the murine T helper clone, D10.G4.1 cells. Our results demonstrated that ELISPOT can detect cytokine secretion at the single cell level in either adherent or nonadherent cells. The level of detection by ELISPOT was 10 to 200 times more sensitive than ELISA performed on culture supernatants. We also demonstrated that the solubilized ELISPOT can detect cytokine secretion by cells with greater sensitivity than conventional ELISA. These ELISPOT assays can be used to characterize the cytokine secretion pattern of different cell populations in a simple, reproducible, and reliable manner.

Development and evaluation of immunoassay for detection of antibodies to the feline T-lymphotropic lentivirus (feline immunodeficiency virus)

The feline T-cell lymphotropic lentivirus (feline immunodeficiency virus) is a recently described feline-specific retrovirus that can produce chronic immunodeficiency-like disorders in cats. A microdilution plate format enzyme-linked immunosorbent assay has been developed to detect the presence of antibody to the virus in feline serum or plasma. Temporal studies performed with experimentally infected animals show that seroconversion can be demonstrated 3 to 4 weeks after exposure to the virus. Results of a serosurvey (n = 1,556 samples) indicate that infection is fairly common in both clinic (5.2%) and sick cat (15.2%) populations. Western blot (immunoblot) and sodium dodecyl sulfate radioimmunoprecipitation assays were developed to confirm microdilution plate test results and to identify peptides specific for the feline immunodeficiency virus. All microdilution plate test positive results and selected negative results were confirmed by one or both of these procedures. These data demonstrate that this microassay plate enzyme-linked immunosorbent assay is a very sensitive and specific test for detection of antibody to the feline immunodeficiency virus.

Prognostic value of indocyanine green and lidocaine kinetics for survival and chronic hepatic encephalopathy in cirrhotic patients following elective end-to-side portacaval shunt

The objective of this study was to assess the prognostic value of spontaneous portosystemic shunting and liver function for survival and spontaneous hepatic encephalopathy after end-to-side portacaval shunt in cirrhotic patients. One hundred ninety-eight patients with variceal hemorrhage as shown by endoscopy were evaluated. Forty-five were excluded because of uncontrollable hemorrhage; 84 were rejected because they were poor operative risk, had portal vein thrombosis or had been previously treated with beta-blockers, sclerotherapy or surgery. The remaining 69 patients were enrolled in this prospective study. There were 43 patients with alcoholic cirrhosis, 23 with cryptogenic cirrhosis and three with primary biliary cirrhosis. The severity of liver disease was assessed according to the Pugh classification: 37 patients (54%) had Pugh's score 5 to 7, 26 (38%) had 8 to 10 and six (8%) had 11 to 12. Indocyanine green intrinsic clearance was used as a probe of preoperative liver function and lidocaine systemic availability as an index of spontaneous preoperative shunting. All the patients underwent an elective end-to-side portacaval shunt. The length of minimal follow-up was 40 months. One-year survival was 76% and 5-year survival was 46%. During follow-up, 25 patients died from their liver disease and 11 patients died from various causes unrelated to their liver disease. Spontaneous chronic encephalopathy occurred in 16 patients (23%). Age, Pugh's score, active alcoholism, indocyanine green intrinsic clearance and lidocaine systemic availability were tested as prognostic factors in a multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency portacaval shunt for variceal hemorrhage. A prospective study

Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.

Symposium on portal hypertension and its complications: current management. Preoperative assessment and predictors of encephalopathy

None of the preoperative predictors of encephalopathy proposed so far to evaluate the risk of portacaval shunting in cirrhotic patients has been of value. The authors have found, in preliminary studies, that measurement of the hepatic extraction of indocyanine green (ICG), which correlates highly with the "functional" portal blood supply, could be of prognostic value: cirrhotic patients with a near-normal value for ICG extraction often have encephalopathy after portacaval shunting whereas those with a low ICG extraction value seldom have encephalopathy. These preliminary data suggest that cirrhotic patients with markedly decreased ICG extraction have a lesser risk of encephalopathy since their portal blood supply is already shunted away from hepatocytes before the operation because of anatomic changes in the liver microcirculation.