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Hill SK, Bempong-Ahun N, Okolo ID, Lalla AT, Worku D, Asres T, Philpotts L, Fallah PN, Varallo J, Corlew S, Kamfwa P, Parham GP, Hicks ML, Ibbotson G, Randall T. Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024; 165:552-561. [PMID: 37927080 DOI: 10.1002/ijgo.15156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/16/2023] [Accepted: 09/10/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs). OBJECTIVES This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers. SEARCH STRATEGY The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE. SELECTION CRITERIA Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included. DATA COLLECTION AND ANALYSIS Results were synthesized using narrative synthesis approach with emergence of key themes by frequency. MAIN RESULTS The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing. CONCLUSIONS A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.
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Affiliation(s)
- Sarah K Hill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Isioma Dianne Okolo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amber Trujillo Lalla
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dawit Worku
- Department of Obstetrics and Gynecology, University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
| | - Tadios Asres
- Department of Obstetrics and Gynecology, Rwanda Military Hospital (RMH), Kigali, Rwanda
| | - Lisa Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Parisa N Fallah
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John Varallo
- The Global Surgery Foundation, Geneva, Switzerland
| | - Scott Corlew
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Kamfwa
- Department of Gynecologic Oncology, Cancer Diseases Hospital, Lusaka, Zambia
| | - Groesbeck P Parham
- Women and Newborn Hospital-University Teaching Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Michael L Hicks
- Women and Newborn Hospital-University Teaching Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Department of Gynecologic Oncology, Michigan Cancer Institute, St. Joseph Mercy Oakland, Pontiac, USA
| | - Geoffrey Ibbotson
- The Global Surgery Foundation, Geneva, Switzerland
- United Nations Institute for Training and Research, Geneva, Switzerland
| | - Thomas Randall
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Millien C, Henderson R, Joel Saint Hubert J, Parra-Herran C, Randall T. A case of placental site trophoblastic tumor managed in a low resource setting. Gynecol Oncol Rep 2024; 51:101329. [PMID: 38322734 PMCID: PMC10843990 DOI: 10.1016/j.gore.2024.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/30/2023] [Accepted: 01/21/2024] [Indexed: 02/08/2024] Open
Abstract
Placental trophoblastic site tumor (PSTT) is a rare type of gestational trophoblastic neoplasia (GTN). PSTT has a higher mortality than other types of gestational trophoblastic disease (GTD), with a rate of 16.1%, due to its relatively unpredictable behavior and reduced response to chemotherapy. Its diagnostic and management are very challenging in Low resources settings particularity in Haiti where MRI, PET Scan and IHC are not available. Further, the follow-up is very difficult because of social, political, and economic issues limiting the capacity of our patients to be present at all scheduled visits. No case of PSTT has been publicly described yet the Haitian experience in the literature in the management of such case compared to the developed world. We present a case of PSTT successfully diagnosed and managed at Mirebalais University Hospital (MUH) in Haiti with the support of telepathology and intentional partners while highlighting the difference that we observed compare to the developed world.
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Affiliation(s)
| | | | | | | | - Thomas Randall
- Department of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, USA
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Pearce A, Ponnam S, Holt MR, Randall T, Beckingham R, Kho AL, Kampourakis T, Ehler E. Missense mutations in the central domains of cardiac myosin binding protein-C and their potential contribution to hypertrophic cardiomyopathy. J Biol Chem 2024; 300:105511. [PMID: 38042491 PMCID: PMC10772716 DOI: 10.1016/j.jbc.2023.105511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023] Open
Abstract
Myosin binding protein-C (MyBP-C) is a multidomain protein that regulates muscle contraction. Mutations in MYBPC3, the gene encoding for the cardiac variant (henceforth called cMyBP-C), are amongst the most frequent causes of hypertrophic cardiomyopathy. Most mutations lead to a truncated version of cMyBP-C, which is most likely unstable. However, missense mutations have also been reported, which tend to cluster in the central domains of the cMyBP-C molecule. This suggests that these central domains are more than just a passive spacer between the better characterized N- and C-terminal domains. Here, we investigated the potential impact of four different missense mutations, E542Q, G596R, N755K, and R820Q, which are spread over the domains C3 to C6, on the function of MyBP-C on both the isolated protein level and in cardiomyocytes in vitro. Effect on domain stability, interaction with thin filaments, binding to myosin, and subcellular localization behavior were assessed. Our studies show that these missense mutations result in slightly different phenotypes at the molecular level, which are mutation specific. The expected functional readout of each mutation provides a valid explanation for why cMyBP-C fails to work as a brake in the regulation of muscle contraction, which eventually results in a hypertrophic cardiomyopathy phenotype. We conclude that missense mutations in cMyBP-C must be evaluated in context of their domain localization, their effect on interaction with thin filaments and myosin, and their effect on protein stability to explain how they lead to disease.
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Affiliation(s)
- Amy Pearce
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Saraswathi Ponnam
- British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom; Randall Centre for Cell and Molecular Biophysics (School of Basic and Biosciences), King's College London, London, United Kingdom
| | - Mark R Holt
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Thomas Randall
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Rylan Beckingham
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Ay Lin Kho
- British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom; Randall Centre for Cell and Molecular Biophysics (School of Basic and Biosciences), King's College London, London, United Kingdom
| | - Thomas Kampourakis
- British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom; Randall Centre for Cell and Molecular Biophysics (School of Basic and Biosciences), King's College London, London, United Kingdom
| | - Elisabeth Ehler
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom; Randall Centre for Cell and Molecular Biophysics (School of Basic and Biosciences), King's College London, London, United Kingdom.
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Millien C, Henderson R, Saint Hubert JJ, McKenzie ND, Randall T. The tug of war: delivering safe gynecologic oncology treatment amid insecurity in Haiti. Int J Gynecol Cancer 2023:ijgc-2023-005007. [PMID: 37903563 DOI: 10.1136/ijgc-2023-005007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Affiliation(s)
- Christophe Millien
- Department of Obstetrics and Gynecology, University Hospital of Mirebalais, Mirebalais, Haiti
| | - Rebecca Henderson
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jean Joel Saint Hubert
- Department of Obstetrics and Gynecology, University Hospital of Mirebalais, Mirebalais, Haiti
| | | | - Thomas Randall
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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Silberman JN, Bercow AS, Gockley AA, Eisenhauer EL, Sisodia R, Randall T, Del Carmen MG, Goodman A, Castro CM, Melamed A, Bregar AJ. Trends in the use of neoadjuvant chemotherapy for low-grade serous ovarian cancer in the United States. Gynecol Oncol 2023; 175:60-65. [PMID: 37327540 DOI: 10.1016/j.ygyno.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To describe trends in neoadjuvant chemotherapy (NACT) use for low-grade serous ovarian carcinoma (LGSOC) and to quantify associations between NACT and extent of cytoreductive surgery. METHODS We identified women treated for stage III or IV serous ovarian cancer in a Commission on Cancer accredited program between January 2004-December 2020. Regression models were developed to evaluate trends in NACT use for LGSOC, to identify factors associated with receipt of NACT, and to quantify associations between NACT and bowel or urinary resection at the time of surgery. Demographic and clinical factors were used for confounder control. RESULTS We observed 3350 patients who received treatment for LGSOC during the study period. The proportion of patients who received NACT increased from 9.5% in 2004 to 25.9% in 2020, corresponding to an annual percent change of 7.2% (95% CI 5.6-8.9). Increasing age (rate ratio (RR) 1.15; 95% CI 1.07-1.24), and stage IV disease (RR 2.66; 95% CI 2.31-3.07) were associated with a higher likelihood of receiving NACT. For patients with high-grade disease, NACT was associated with a decrease in likelihood of bowel or urinary surgery (35.3% versus 23.9%; RR 0.68, 95% CI 0.65-0.71). For LGSOC, NACT was associated with a higher likelihood of these procedures (26.6% versus 32.2%; RR 1.24, 95% CI 1.08-1.42). CONCLUSION NACT use among patients with LGSOC has increased from 2004 to 2020. While NACT was associated with a lower rate of gastrointestinal and urinary surgery among patients with high-grade disease, patients with LGSOC receiving NACT were more likely to undergo these procedures.
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Affiliation(s)
- Jason N Silberman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Alexandra S Bercow
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Allison A Gockley
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Eric L Eisenhauer
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Sisodia
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Randall
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Marcela G Del Carmen
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Annekathryn Goodman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Cesar M Castro
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Alexander Melamed
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
| | - Amy J Bregar
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
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6
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Adler AJ, Randall T, Schwartz LN, Drown L, Matthews S, Pace LE, Mugabo C, Kateera F, Bukhman G, Baganizi E, Ng'ang'a LM. What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts. Int J Gynaecol Obstet 2023. [PMID: 36815725 DOI: 10.1002/ijgo.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/17/2022] [Accepted: 02/20/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda. METHODS We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers. RESULTS Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care. CONCLUSION These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.
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Affiliation(s)
- A J Adler
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - T Randall
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - L N Schwartz
- Harvard Medical School, Boston, Massachusetts, USA
| | - L Drown
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - S Matthews
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - L E Pace
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - C Mugabo
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - F Kateera
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - G Bukhman
- Center for Integration Science, Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Partners in Health, Boston, Massachusetts, USA
| | - E Baganizi
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
| | - L M Ng'ang'a
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
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Bercow AS, Rauh-Hain JA, Melamed A, Mazina V, Growdon WB, Del Carmen MG, Goodman A, Bouberhan S, Randall T, Sisodia R, Bregar A, Eisenhauer EL, Minami C, Molina G. Association of hospital-level factors with utilization of sentinel lymph node biopsy in patients with early-stage vulvar cancer. Gynecol Oncol 2023; 169:47-54. [PMID: 36508758 DOI: 10.1016/j.ygyno.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate utilization of sentinel lymph node biopsy (SLNB) for early-stage vulvar cancer at minority-serving hospitals and low-volume facilities. METHODS Between 2012-2018, individuals with T1b vulvar squamous cell carcinoma were identified using the National Cancer Database. Patient, facility, and disease characteristics were compared between patients undergoing SLNB or inguinofemoral lymph node dissection (IFLD). Multivariable logistic regression, adjusted for patient, facility, and disease characteristics, was used to evaluate factors associated with SLNB. Kaplan-Meier survival analysis using log rank test and Cox regression was performed. RESULTS Of the 3,532 patients, 2,406 (68.1%) underwent lymph node evaluation, with 1,704 (48.2%) undergoing IFLD and 702 (19.8%) SLNB. In a multivariable analysis, treatment at minority-serving hospitals (OR 0.39, 95% CI 0.19-0.78) and low-volume hospitals (OR 0.44, 95% CI 0.28-0.70) were associated with significantly lower odds of undergoing SLNB compared to receiving care at non-minority-serving and high-volume hospitals, respectively. While SLNB utilization increased over time for the entire cohort and stratified subgroups, use of the procedure did not increase at minority-serving hospitals. After controlling for patient and tumor characteristics, SLNB was not associated with worse OS compared to IFLD in patients with positive (HR 1.02, 95% CI 0.63-1.66) or negative (HR 0.92, 95% CI 0.70-1.21) nodal pathology. CONCLUSIONS For patients with early-stage vulvar cancer, treatment at minority-serving or low-volume hospitals was associated with significantly decreased odds of undergoing SLNB. Future efforts should be concentrated toward ensuring that all patients have access to advanced surgical techniques regardless of where they receive their care.
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Affiliation(s)
- Alexandra S Bercow
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Varvara Mazina
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Whitfield B Growdon
- Division of Gynecologic Oncology, New York University Langone Medical Center, New York, NY, United States of America
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sara Bouberhan
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas Randall
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel Sisodia
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Amy Bregar
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Eric L Eisenhauer
- Division of Gynecologic Oncology, Vincent Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Christina Minami
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Breast Surgery, Department of Surgery, Dana-Farber/Brigham and Women's Hospital, Boston, MA, United States of America
| | - George Molina
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
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Fokom Domgue J, Pande M, Yu R, Manjuh F, Welty E, Welty T, Elit L, Lopez-Varon M, Rodriguez J, Baker E, Dangou JM, Basu P, Plante M, Lecuru F, Randall T, Starr E, Kamgno J, Foxhall L, Waxman A, Hawk E, Schmeler K, Shete S. Development, Implementation, and Evaluation of a Distance Learning and Telementoring Program for Cervical Cancer Prevention in Cameroon. JAMA Netw Open 2022; 5:e2240801. [PMID: 36346631 PMCID: PMC9644259 DOI: 10.1001/jamanetworkopen.2022.40801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
IMPORTANCE Although Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region. OBJECTIVES To adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022. MAIN OUTCOMES AND MEASURES Main outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers. RESULTS Of the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol's iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P < .001). Approximately two-thirds of participants (68.8% [95% CI, 51.8%-85.8%]) reported that they had applied knowledge learned in our ECHO sessions to patient care in their practice or adopted best-practice care through their participation in this ECHO program. CONCLUSIONS AND RELEVANCE These findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.
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Affiliation(s)
- Joel Fokom Domgue
- University of Texas MD Anderson Cancer Center, Houston
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Mala Pande
- University of Texas MD Anderson Cancer Center, Houston
| | - Robert Yu
- University of Texas MD Anderson Cancer Center, Houston
| | - Florence Manjuh
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - Edith Welty
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - Thomas Welty
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - Laurie Elit
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | | | | | - Ellen Baker
- University of Texas MD Anderson Cancer Center, Houston
| | - Jean-Marie Dangou
- African Regional Office of the World Health Organization, Brazzaville, Congo
| | - Partha Basu
- International Agency for Research on Cancer of the World Health Organization, Lyon, France
| | - Marie Plante
- Division of Gynecologic Oncology, CHU de Quebec, Laval University, Quebec, Canada
| | | | - Thomas Randall
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Joseph Kamgno
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Lewis Foxhall
- University of Texas MD Anderson Cancer Center, Houston
| | - Alan Waxman
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque
| | - Ernest Hawk
- University of Texas MD Anderson Cancer Center, Houston
| | | | - Sanjay Shete
- University of Texas MD Anderson Cancer Center, Houston
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Philp L, Eisenhauer E, Bregar A, Carmen MD, Goodman A, Randall T, Mazina V, Hubbell H, Sisodia R. Patient-reported quality of life during PARP-inhibitor treatment for high-grade serous ovarian cancer (468). Gynecol Oncol 2022. [DOI: 10.1016/s0090-8258(22)01689-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chuang L, Rainville N, Byrne M, Randall T, Schmeler K. Cervical cancer screening and treatment capacity: A survey of members of the African Organisation for Research and Training in Cancer (AORTIC). Gynecol Oncol Rep 2021; 38:100874. [PMID: 34692968 PMCID: PMC8511835 DOI: 10.1016/j.gore.2021.100874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 11/21/2022] Open
Abstract
This is a survey report of AORTIC members on cervical cancer screening and treatment capacity. Radiation therapy capacity is the most limited treatment modality available in Africa. Gynecologic oncologists who can provide surgical care for women with cervical cancer is needed.
Background Cervical cancer is the second most common cancer among women in Africa, and in half of the sub-Saharan African countries, it is the most common cancer. Currently, there are scarce resources and limited infrastructure to support cervical cancer screening and treatment in many African countries. Objectives The aim of this study is to investigate the capacity of cervical cancer screening and treatment among members of the African Organization for Research and Training in Cancer (AORTIC). Methods Data were collected from 183 participants through online surveys over a 3-month study period in 2016. Results The respondents reported large variations among different African countries. This study highlights the differences between African countries in the availability of screening programs as a result of the resources allocated to healthcare development. Radiation therapy capacity remained the most limited treatment modality available, followed by the lack of gynecologists or gynecologic oncologists who can perform radical hysterectomy. Conclusions This information is critical for physicians, public health educators, and policymakers aiming to improve the outcomes among women with cervical cancer in Africa.
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Affiliation(s)
- Linus Chuang
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, New York, NY, United States
| | - Nicole Rainville
- Department of Obstetrics and Gynecology, Danbury Hospital, Danbury, CT, United States
- Corresponding author at: Department of Obstetrics & Gynecology, Danbury Hospital, 24 Hospital Ave, Danbury, CT 06810, United States.
| | - Maureen Byrne
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Thomas Randall
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States
| | - Kathleen Schmeler
- Department of Gynecologic Oncology, MD Anderson Cancer Center, Houston, TX, United States
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Randall T, Chuang L, Ng SYJ, Schmeler KM, Quinn MA. The IGCS global curriculum mentorship and training program: building human capacity for gynecologic cancer treatment and research where the need is greatest. Int J Gynecol Cancer 2021; 31:1380-1381. [PMID: 33727221 DOI: 10.1136/ijgc-2021-002480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Thomas Randall
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Linus Chuang
- Department of Obstetrics, Gynecology and Reproductive Biology, Danbury Hospital, Danbury, Connecticut, USA
| | | | - Kathleen M Schmeler
- Department of Gynecologic Oncology, M.D. Anderson Cancer Center, Houston, Texas, USA
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Wall JA, Meza-Perez S, Scalise CB, Katre A, Londoño AI, Turbitt WJ, Randall T, Norian LA, Arend RC. Manipulating the Wnt/β-catenin signaling pathway to promote anti-tumor immune infiltration into the TME to sensitize ovarian cancer to ICB therapy. Gynecol Oncol 2020; 160:285-294. [PMID: 33168307 DOI: 10.1016/j.ygyno.2020.10.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/25/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Immune checkpoint blockade (ICB) therapy shows limited efficacy in ovarian cancers due to the "cold" immune phenotype surrounding these tumors. Previous studies have shown that in ovarian cancer Wnt/β-catenin pathway activation contributes to this immune phenotype. Here, we evaluated the anti-tumor and immune-enhancing properties of the Wnt inhibitor, CGX-1321, used alone or in combination with either DKN-01 or anti-PD-1 therapy, in pre-clinical ovarian cancer models. METHODS The parental ID8 murine ovarian cancer model harboring a knock-out of p53 (ID8p53-/-) and MISIIR-Tag spontaneous ovarian cancer models were used to test the effects of CGX-1321 alone or in combination therapies on tumor burden and immune cell landscape in the tumor microenvironment (TME). Flow cytometry and NanoString analyses were used to characterize the changes in tumor-intrinsic signaling and immune-related profiles in the TME of ovarian cancer in response to treatments. RESULTS CGX-1321 significantly reduced tumor burden and constrained tumor progression in the ID8p53-/- and MISIIR-Tag models. Furthermore, CGX-1321 increased infiltrating CD8+ T cells in the TME. Combining CGX-1321 with either DKN-01 or anti-PD-1 therapy also decreased tumor burden and increased CD8+ T cell infiltration in the omentum TME but did not do so to a greater extent that CGX-1321 monotherapy. CONCLUSIONS CGX-1321 significantly reduced tumor burden and enhanced CD8+ T cell levels in ovarian cancer, nevertheless the addition of DKN-01 or anti-PD-1 therapies did not enhance these effects of CGX-1321. Further investigation is needed to determine if CGX-1321 + DKN-01 combination treatment sensitizes pre-clinical ovarian cancer to ICB therapy.
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Affiliation(s)
- J A Wall
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - S Meza-Perez
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - C B Scalise
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - A Katre
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - A I Londoño
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - W J Turbitt
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - T Randall
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - L A Norian
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35294, USA; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - R C Arend
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Goldsberry W, Wall J, Meza-Perez S, Katre A, Londono A, Norian L, Randall T, Arend R. Inhibition of PORCN in a p53-/- knockout syngeneic ovarian cancer model. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Torr O, Randall T, Knowles R, Giles D, Atkins S. Reliability and Validity of a Method for the Assessment of Sport Rock Climbers' Isometric Finger Strength. J Strength Cond Res 2020; 36:2277-2282. [PMID: 32149883 DOI: 10.1519/jsc.0000000000003548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Torr, O, Randall, T, Knowles, R, Giles, D, and Atkins, S. The reliability and validity of a method for the assessment of sport rock climbers' isometric finger strength. J Strength Cond Res XX(X): 000-000, 2020-Isometric strength of the finger flexors is considered to be one of the main physical determinants of sport rock climbing performance. We set out to determine the test-retest reliability and criterion validity of a low resource maximal isometric finger strength (MIFS) testing protocol that uses a pulley system to add or remove weight to/from a climber's body. To determine test-retest reliability, 15 subjects' MIFS was assessed on 2 occasions, separated by a minimum of 48 hours. Body mass and maximum load were recorded on both occasions. Intra-class correlation coefficients (ICCs) between visits for all variables were very good (ICC > 0.91), with small bias and effect sizes-particularly when expressed as a percentage of body mass (ICC = 0.98, 95% confidence interval 0.93-0.99). To determine the criterion validity of MIFS and climbing ability, data of 229 intermediate to higher elite climbers were compared. Pearson's product moment correlations demonstrated good agreement, again particularly between total load when expressed as a percentage of body mass and climbing performance (r = 0.421-0.503). The results illustrate the sensitivity of a simple test for the determination of MIFS in intermediate to height elite climbers from an ecologically valid, climbing specific test that only requires equipment found at most climbing walls. This low resource test protocol for the assessment of isometric finger strength has wide-reaching utility, for instance when assessing strength before and after a training intervention or when prescribing load intensities for exercises aimed at improving maximal finger strength.
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Affiliation(s)
- Oliver Torr
- School of Health Sciences, University of Salford, Manchester, United Kingdom.,Lattice Training Ltd., Chesterfield, United Kingdom
| | | | | | - David Giles
- Lattice Training Ltd., Chesterfield, United Kingdom.,Health and Social Care Research Center, College of Health and Social Care, University of Derby, Derby, United Kingdom
| | - Stephen Atkins
- School of Health Sciences, University of Salford, Manchester, United Kingdom
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Pathania D, Landeros C, Rohrer L, D'Agostino V, Hong S, Degani I, Avila-Wallace M, Pivovarov M, Randall T, Weissleder R, Lee H, Im H, Castro CM. Point-of-care cervical cancer screening using deep learning-based microholography. Am J Cancer Res 2019; 9:8438-8447. [PMID: 31879529 PMCID: PMC6924258 DOI: 10.7150/thno.37187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022] Open
Abstract
Most deaths (80%) from cervical cancer occur in regions lacking adequate screening infrastructures or ready access to them. In contrast, most developed countries now embrace human papillomavirus (HPV) analyses as standalone screening; this transition threatens to further widen the resource gap. Methods: We describe the development of a DNA-focused digital microholography platform for point-of-care HPV screening, with automated readouts driven by customized deep-learning algorithms. In the presence of high-risk HPV 16 or 18 DNA, microbeads were designed to bind the DNA targets and form microbead dimers. The resulting holographic signature of the microbeads was recorded and analyzed. Results: The HPV DNA assay showed excellent sensitivity (down to a single cell) and specificity (100% concordance) in detecting HPV 16 and 18 DNA from cell lines. Our deep learning approach was 120-folder faster than the traditional reconstruction method and completed the analysis in < 2 min using a single CPU. In a blinded clinical study using patient cervical brushings, we successfully benchmarked our platform's performance to an FDA-approved HPV assay. Conclusions: Reliable and decentralized HPV testing will facilitate cataloguing the high-risk HPV landscape in underserved populations, revealing HPV coverage gaps in existing vaccination strategies and informing future iterations.
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Cremer ML, Conzuelo-Rodriguez G, Cherniak W, Randall T. Ablative Therapies for Cervical Intraepithelial Neoplasia in Low-Resource Settings: Findings and Key Questions. J Glob Oncol 2019; 4:1-10. [PMID: 30372399 PMCID: PMC7010451 DOI: 10.1200/jgo.18.00093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Barriers to access for cervical precancer care in low-resource settings go beyond cost. Gas-based cryotherapy has emerged as the standard treatment in these areas, but there are barriers to this technology that have necessitated the development and implementation of affordable and portable alternatives. This review identifies knowledge gaps with regard to technologies primarily used in low-resource settings, including standard cryotherapy, nongas-based cryotherapy, and thermoablation. These gaps are addressed using evidence-based guidelines, patient and provider acceptability, long-term obstetric outcomes, and treatment of women with HIV infection. This review highlights the need for prospective studies that compare ablative methods, especially given the increasing use of thermoablation.
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Affiliation(s)
- Miriam L Cremer
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Gabriel Conzuelo-Rodriguez
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - William Cherniak
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
| | - Thomas Randall
- Miriam L. Cremer, Cleveland Clinic, Cleveland, OH; Gabriel Conzuelo-Rodriguez, Basic Health International, New York, NY; William Cherniak, Bridge to Health Medical and Dental, Toronto, Ontario, Canada; and Thomas Randall, Massachusetts General Hospital, Boston, MA
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Doo D, Meza-Perez S, Londono A, Boone J, Moore D, Hudson C, Betella I, Luke J, Yang E, Birrer M, Starenki D, Buchsbaum D, Norian L, Randall T, Arend R. Inhibition of the Wnt/β-catenin pathway enhances anti-tumor immunity in ovarian cancer. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Castro C, Im H, Lee H, Avila-Wallace M, Weissleder R, Randall T. Harnessing artificial intelligence and digital diffraction to advance point-of-care HPV 16 and 18 detection. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Goldsberry W, Phillips R, Montgomery A, Katre A, Doo D, Norian L, Randall T, Yemelyanova A, Cooper S, Arend R. Correlation between Wnt signaling and T-cell infiltration in high-grade serous ovarian cancer. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Park PH, Davey S, Fehr AE, Butonzi J, Shyirambere C, Hategekimana V, Bigirimana JB, Borg R, Uwizeye R, Tapela N, Shulman LN, Randall T, Mpanumusingo E, Mpunga T. Patient Characteristics, Early Outcomes, and Implementation Lessons of Cervical Cancer Treatment Services in Rural Rwanda. J Glob Oncol 2019; 4:1-11. [PMID: 30582433 PMCID: PMC7010450 DOI: 10.1200/jgo.18.00120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Low- and middle-income countries account for 86% of all cervical cancer cases and 88% of cervical cancer mortality globally. Successful management of cervical cancer requires resources that are scarce in sub-Saharan Africa, especially in rural settings. Here, we describe the early clinical outcomes and implementation lessons learned from the Rwanda Ministry of Health's first national cancer referral center, the Butaro Cancer Center of Excellence (BCCOE). We hypothesize that those patients presenting at earlier stage and receiving treatment will have higher rates of being alive. METHODS The implementation of cervical cancer services included developing partnerships, clinical protocols, pathology services, and tools for monitoring and evaluation. We conducted a retrospective study of patients with cervical cancer who presented at BCCOE between July 1, 2012, and June 30, 2015. Data were collected from the electronic medical record system and by manually reviewing medical records. Descriptive, bivariable and multivariable statistical analyses were conducted to describe patient demographics, disease profiles, treatment, and clinical outcomes. RESULTS In all, 373 patients met the study inclusion criteria. The median age was 53 years (interquartile rage, 45 to 60 years), and 98% were residents of Rwanda. Eighty-nine percent of patients had a documented disease stage: 3% were stage I, 48% were stage II, 29% were stage III, and 8% were stage IV at presentation. Fifty percent of patients were planned to be treated with a curative intent, and 54% were referred to chemoradiotherapy in Uganda. Forty percent of patients who received chemoradiotherapy were in remission. Overall, 25% were lost to follow-up. CONCLUSION BCCOE illustrates the feasibility and challenges of implementing effective cervical cancer treatment services in a rural setting in a low-income country.
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Affiliation(s)
- Paul H Park
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Sonya Davey
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Alexandra E Fehr
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - John Butonzi
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Cyprien Shyirambere
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Vedaste Hategekimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Jean Bosco Bigirimana
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Ryan Borg
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Regis Uwizeye
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Neo Tapela
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Lawrence N Shulman
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Thomas Randall
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Egide Mpanumusingo
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
| | - Tharcisse Mpunga
- Paul H. Park, Alexandra E. Fehr, Cyprien Shyirambere, Jean Bosco Bigirimana, Ryan Borg, Regis Uwizeye, and Egide Mpanumusingo, Partners In Health/Inshuti Mu Buzima, Rwinkwavu; John Butonzi, Vedaste Hategekimana, and Tharcisse Mpunga, Butaro District Hospital, Rwanda Ministry of Health, Butaro, Rwanda; Sonya Davey and Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA; Paul H. Park and Neo Tapela, Brigham and Women's Hospital; Paul H. Park, Harvard Medical School; Thomas Randall, Harvard Medical School, and Massachusetts General Hospital, Boston, MA; and Neo Tapela, Oxford University, Oxford, United Kingdom
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Randall T, Crabtree D, Antrim L. Relations between Personality Measures and Physiological Reactivity Using a Perceptual Motor Challenge. Percept Mot Skills 2019; 69:944-6. [PMID: 2608413 DOI: 10.1177/00315125890693-144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
60 undergraduates participated in research designed to investigate the relations between psychological and physiological measures of personality under stress. Psychological assessments were elicited from responses to the Jenkins Activity Survey. Physiological assessments were elicited during 5 1-min. trials on the pursuit rotor, a perceptual motor task. Pearson correlations and multiple regression analyses were consistent with the notion that psychological and physiological assessments yield contradictory information and that research is needed to develop valid methodologies with which to assess human stress.
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Affiliation(s)
- T Randall
- University of Cincinnati, OH 45221-0022
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Chuang L, Berek J, Randall T, McCormack M, Schmeler K, Manchanda R, Rebbeck T, Jeng C, Pyle D, Quinn M, Trimble E, Naik R, Lai C, Ochiai K, Denny L, Bhatla N. Collaborations in gynecologic oncology education and research in low- and middle- income countries: Current status, barriers and opportunities. Gynecol Oncol Rep 2018; 25:65-69. [PMID: 29928684 PMCID: PMC6008286 DOI: 10.1016/j.gore.2018.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/05/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022] Open
Abstract
Eighty-five percent of the incidents and deaths from cervical cancer occur in low and middle income countries. In many of these countries, this is the most common cancer in women. The survivals of the women with gynecologic cancers are hampered by the paucity of prevention, screening, treatment facilities and gynecologic oncology providers. Increasing efforts dedicated to improving education and research in these countries have been provided by international organizations. We describe here the existing educational and research programs that are offered by major international organizations, the barriers and opportunities provided by these collaborations and hope to improve the outcomes of cervical cancer through these efforts.
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Affiliation(s)
- L. Chuang
- Western Connecticut Health Network, Larner College of Medicine at the University of Vermont, Danbury, CT, USA
| | - J. Berek
- Stanford University School of Medicine, Stanford, CA, USA
| | - T. Randall
- The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - K. Schmeler
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R. Manchanda
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - T. Rebbeck
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - C.J. Jeng
- Kaohsiung Medical University Hospital, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - D. Pyle
- American Society of Clinical Oncology, Alexandria, VA, USA
| | - M. Quinn
- University of Melbourne, Melbourne, VIC, Australia
| | - E. Trimble
- Center for Global Health, National Cancer Institute, Bethesda, MS, USA
| | - R. Naik
- Northern Gynecological Oncology Centre, Gateshead, UK
| | - C.H. Lai
- Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - K. Ochiai
- Jikei University School of Medicine, Tokyo, Japan
| | - L. Denny
- University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa
| | - N. Bhatla
- All India Institute of Medical Sciences, New Delhi, India
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Turner T, Meza-Perez S, Peabody J, Smith H, Norian L, Buchsbaum D, Straughn J, Randall T, Arend R. Augmenting the MHC II antigen-presentation pathway with epigenetic therapy in epithelial ovarian cancer. Gynecol Oncol 2017. [DOI: 10.1016/j.ygyno.2017.03.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Thomas E, Meza-Perez S, Bevis K, Gillespie Y, Randall T, Langford C, Alvarez R. A novel virotherapy-based immunotherapy approach to ovarian cancer using an IL-12–expressing oncolytic herpes simplex virus. Gynecol Oncol 2016. [DOI: 10.1016/j.ygyno.2016.04.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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25
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Randall T, Luciani S, Salicrup L, Mendoza-Cervantes D. The role of HPV testing in reducing the burden of cervical cancer in low
and middle income countries. Ann Glob Health 2015. [DOI: 10.1016/j.aogh.2015.02.733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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26
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Evans T, Randall T, Wilkinson-Ryan I. Robotic surgery for the management of ovarian cancer. Gynecol Oncol 2013. [DOI: 10.1016/j.ygyno.2013.04.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cardenas Goicoechea J, Shephard A, Momeni M, Kolev V, Davis A, Rahaman J, Gretz H, Randall T, Chuang L. Survival and Operative Outcome Analysis of Robotic Assisted Versus Laparoscopic Surgical Staging for Endometrial Cancer. J Minim Invasive Gynecol 2012. [DOI: 10.1016/j.jmig.2012.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Shen XJ, Rawls JF, Randall T, Burcal L, Mpande CN, Jenkins N, Jovov B, Abdo Z, Sandler RS, Keku TO. Molecular characterization of mucosal adherent bacteria and associations with colorectal adenomas. Gut Microbes 2010; 1:138-47. [PMID: 20740058 PMCID: PMC2927011 DOI: 10.4161/gmic.1.3.12360] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 05/11/2010] [Accepted: 05/13/2010] [Indexed: 02/03/2023] Open
Abstract
The human large bowel is colonized by complex and diverse bacterial communities. However, the relationship between commensal bowel bacteria and adenomas (colorectal cancer precursors) is unclear. This study aimed to characterize adherent bacteria in normal colon and evaluate differences in community composition associated with colorectal adenomas. We evaluated adherent bacteria in normal colonic mucosa of 21 adenoma and 23 non-adenoma subjects enrolled in a cross sectional study. Terminal restriction fragment length polymorphism, clone sequencing and fluorescent in-situ hybridization analysis of the 16S rRNA genes were used to characterize adherent bacteria. A total of 335 clones were sequenced and processed for phylogenetic and taxonomic analysis. Differences in bacterial composition between cases and controls were evaluated by UniFrac and analysis of similarity matrix. Overall, Firmicutes (62%), Bacteroidetes (26%) and Proteobacteria (11%) were the most dominant phyla. The bacterial composition differed significantly between cases and controls (UniFrac p < 0.001). We observed significantly higher abundance of Proteobacteria (p < 0.05) and lower abundance of Bacteroidetes (p < 0.05) in cases compared to controls. At the genus level, case subjects showed increased abundance of Dorea spp. (p < 0.005), Faecalibacterium spp. (p < 0.05) and lower proportions of Bacteroides spp. (p < 0.03) and Coprococcus spp. (p < 0.05) than controls. Cases had higher bacterial diversity and richness than controls. These findings reveal that alterations in bacterial community composition associated with adenomas may contribute to the etiology of colorectal cancer. Extension of these findings could lead to strategies to manipulate the microbiota to prevent colorectal adenomas and cancer as well as to identify individuals at high risk.
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Affiliation(s)
- Xiang Jun Shen
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - John F Rawls
- Department of Cell and Molecular Physiology; University of North Carolina at Chapel Hill; Chapel Hill, NC USA,Department of Microbiology and Immunology; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Thomas Randall
- Center for Bioinformatics; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Lauren Burcal
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Caroline N Mpande
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Natascha Jenkins
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Biljana Jovov
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Zaid Abdo
- Department of Mathematics; University of Idaho; Moscow, ID USA
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
| | - Temitope O Keku
- Center for Gastrointestinal Biology and Disease; University of North Carolina at Chapel Hill; Chapel Hill, NC USA
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Saidin NA, Randall T, Takayama H, Holmes E, Gooderham NJ. Malaysian Kratom, a phyto-pharmaceutical of abuse: Studies on the mechanism of its cytotoxicity. Toxicology 2008. [DOI: 10.1016/j.tox.2008.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Silber JH, Rosenbaum PR, Polsky D, Millman AM, Ross RN, Even-Shoshan O, Schwartz JS, Armstrong K, Randall T. Beware of the isolated intermediate quality measure: A lesson in choosing an ovarian cancer surgeon. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.6546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6546 Background: Measuring surgical quality has recently focused on isolated processes (such as P4P measures) and intermediate outcomes (such as infection rates). Some have argued that such isolated measures are inherently flawed since they may have only minor influence on more important primary outcomes such as survival. Hence, referral decisions based on such isolated processes or intermediate outcomes may lead to less than optimal care. We asked whether surgeon type influenced isolated process measures (longer operative time, thought to be a function of increased node sampling), intermediate outcomes (deep wound infection, often found to be a function of operative time) and the primary outcome of survival. Methods: We obtained SEER-Medicare claims for the years 1991–2001 for ovarian cancer. We identified the first definitive cancer surgery and the surgical provider type for that procedure: General Surgeon (GS) N=545 and GYN Oncologist (GO) N=1,554. We determined operative time from the anesthesia claims, number of nodes sampled from the SEER record, deep wound infection from the ICD9CM secondary diagnoses and survival from Medicare vital status files. Models were adjusted for 30 patient characteristics and comorbidities. To account for potential reclassification bias due to variations in the pattern of node dissection across GO and GS surgical types, which can potentially influence stage identification, we report survival results both with and without stage adjustments. Results: Definitive surgery by GOs was associated with more extensive node dissection and longer operative time. GO patients also displayed a trend for increased deep wound infection as compared to cases operated on by GS. However, 5-year survival was significantly longer in the GO group, with or without stage adjustment. Conclusions: GO cases took longer, tended to have higher infection rates, yet had better overall 5-year survival. Isolated intermediate outcome measures, such as deep wound infection, may not be good quality indicators. No significant financial relationships to disclose. [Table: see text]
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Affiliation(s)
- J. H. Silber
- The University of Pennsylvania, Philadelphia, PA
| | | | - D. Polsky
- The University of Pennsylvania, Philadelphia, PA
| | | | - R. N. Ross
- The University of Pennsylvania, Philadelphia, PA
| | | | | | - K. Armstrong
- The University of Pennsylvania, Philadelphia, PA
| | - T. Randall
- The University of Pennsylvania, Philadelphia, PA
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Resseguie ME, Niculescu M, Costa KD, Randall T, Zeisel S. Estrogen induces the PEMT (phosphatidylethanolamine N‐methyltransferase) gene in human and murine hepatocytes. FASEB J 2007. [DOI: 10.1096/fasebj.21.5.a61-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mary E Resseguie
- NutritionUniversity of North Carolina at Chapel Hill, School of Public HealthChapel HillNC27599
| | - Mihai Niculescu
- NutritionUniversity of North Carolina at Chapel Hill, School of Public HealthChapel HillNC27599
| | - Kerry‐Ann da Costa
- NutritionUniversity of North Carolina at Chapel Hill, School of Public HealthChapel HillNC27599
| | - Thomas Randall
- Center for Bioinformatics, University of North Carolina at Chapel Hill, School of MedicineChapel HillNC27599
| | - Steven Zeisel
- NutritionUniversity of North Carolina at Chapel Hill, School of Public HealthChapel HillNC27599
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Linsell L, Dawson J, Zondervan K, Rose P, Randall T, Fitzpatrick R, Carr A. Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral. Rheumatology (Oxford) 2005; 45:215-21. [PMID: 16263781 DOI: 10.1093/rheumatology/kei139] [Citation(s) in RCA: 213] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation. METHODS Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer-Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation. RESULTS The annual prevalence and incidence of people consulting for a shoulder condition was 2.36% [95% confidence interval (CI) 2.32-2.40%] and 1.47% (95% CI 1.44-1.50%), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2%. Around half of the incident cases consulted once only, while 13.6% were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4% of patients were referred to secondary care, 30.8% were prescribed non-steroidal anti-inflammatory drugs and 10.6% were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6% of the diagnoses of new cases recorded by GPs. CONCLUSIONS The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.
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Affiliation(s)
- L Linsell
- Medical Statistician, Centre for Statistics in Medicine, Wolfson College Annexe, Linton Road, Oxford OX2 6UD, UK.
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Dawson J, Linsell L, Doll H, Zondervan K, Rose P, Carr A, Randall T, Fitzpatrick R. Assessment of the Lequesne index of severity for osteoarthritis of the hip in an elderly population. Osteoarthritis Cartilage 2005; 13:854-60. [PMID: 16126417 DOI: 10.1016/j.joca.2005.05.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 05/29/2005] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the measurement properties of the Lequesne index of severity for osteoarthritis of the hip (LISOH) together with its overall usefulness with reference to the original stated aims. METHOD Postal questionnaire was sent to a random sample of 5500 Oxfordshire residents, aged 65 and above. Respondents with hip symptoms at baseline (but without verification of a diagnosis) were sent an identical follow-up questionnaire 12 months later. The questionnaire included a general health section, including the Short Form-36 survey, and a hip section which began with a screening question about hip pain. Respondents who reported having a prolonged episode of hip pain were asked to complete the LISOH. RESULTS At baseline, response rate of 66.3% (3341/5039) was obtained from eligible participants; 19.2% (610/3175) of respondents reported having hip pain. Internal reliability (Cronbach's alpha) was 0.84 (95% CI: 0.81-0.86) for all 11 items of the LISOH; however, factor analysis identified two factors (sub-scales): "function and mobility" and "pain and discomfort". Rasch analysis revealed that the two factors were only unidimensional when applied to sub-groups of respondents. Convergent validity of the LISOH was questionable, as the "function and mobility" factor was more highly correlated with SF-36 bodily pain score than was the "pain and discomfort" factor. The assessment of sensitivity over time was problematic due to changing patterns of symptomatic weight-bearing joints over time. CONCLUSIONS The current study identifies major limitations with the LISOH--particularly if used as a single composite measure.
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Affiliation(s)
- J Dawson
- School of Health and Social Care, Oxford Brookes University, Marston Road Campus, Jack Straws Lane, Oxford OX3 0FL, UK.
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Armstrong K, Schwartz JS, Randall T, Rubin SC, Weber B. Hormone Replacement Therapy and Life Expectancy After Prophylactic Oophorectomy in Women With BRCA1/2 Mutations: A Decision Analysis. J Clin Oncol 2004; 22:1045-54. [PMID: 14981106 DOI: 10.1200/jco.2004.06.090] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Purpose The decision about prophylactic oophorectomy is difficult for many premenopausal women with BRCA1/2 mutations because of concerns and controversy about the use of hormone replacement therapy (HRT) after oophorectomy. Patients and Methods A Markov decision analytic model used the most current epidemiologic data to assess the expected outcomes of prophylactic oophorectomy with or without HRT (to age 50 years or for life) in cohorts of women with BRCA1/2 mutations. Sensitivity analyses were conducted to assess the impact of alternative assumptions about effects of HRT, effects of prophylactic oophorectomy, and risks of cancer associated with BRCA1/2 mutations. Results In our model, prophylactic oophorectomy lengthened life expectancy in women with BRCA1/2 mutations, irrespective of whether HRT was used after oophorectomy. This gain ranged from 3.34 to 4.65 years, depending on age at oophorectomy. Use of HRT after oophorectomy was associated with relatively small changes in life expectancy (+0.17 to −0.34 years) when HRT was stopped at age 50, but larger decrements in life expectancy if HRT was continued for life (−0.79 to −1.09 years). HRT was associated with a gain in life expectancy of between 0.39 and 0.79 years for mutation carriers undergoing both prophylactic mastectomy and oophorectomy. Conclusion On the basis of the results of this decision analysis, we recommend that women with BRCA1/2 mutations undergo prophylactic oophorectomy after completion of childbearing, decide about short-term HRT after oophorectomy based largely on quality-of-life issues rather than life expectancy, and, if using HRT, consider discontinuing treatment at the time of expected natural menopause, approximately age 50 years.
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Affiliation(s)
- Katrina Armstrong
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA.
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Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A, Fitzpatrick R. Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology (Oxford) 2004; 43:497-504. [PMID: 14762225 DOI: 10.1093/rheumatology/keh086] [Citation(s) in RCA: 210] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To obtain prevalence rates of hip and knee pain in elderly people and compare combinations of symptoms with overall health status. METHODS We performed a cross-sectional postal survey of a random sample of 5500 Oxfordshire residents aged 65 yr and older. Prevalence estimates were based on the screening question: 'During the past 12 months, have you had pain in or around either of your hip/knee joints on most days for one month or longer?' Overall health status was assessed with the SF-36 questionnaire. RESULTS The response rate was 66.3% (3341/5039 eligible people), and was highest (approximately reverse similar 72%) for the 65-74 yr age-group. The percentage reporting hip pain was 19.2% [95% confidence interval (CI) 17.9-20.6], and 32.6% (95% CI 31.0-34.3) reported knee pain. The percentage reporting hip and knee pain was 11.3%, and 40.7% reported hip or knee pain. Less than half (48%) of the symptomatic respondents had unilateral problems affecting one hip or knee joint only. SF-36 scores worsened as the number of symptomatic hip and knee joints increased (P<0.001 for physical function, physical role limitation and bodily pain). CONCLUSIONS Patterns of hip and knee symptoms are complex in older people. Amongst the symptomatic, most have more than one hip/knee affected. This has implications for treatment and health status measurement. In the absence of hip and knee symptoms, general health status scores of elderly people are similar to those of people aged under 65 yr.
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Affiliation(s)
- J Dawson
- Oxford Centre for Health Care Research and Development, School of Health and Social Care, Oxford Brookes University, UK.
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Wilson KJ, Illig CR, Subasinghe N, Hoffman JB, Rudolph MJ, Soll R, Molloy CJ, Bone R, Green D, Randall T, Zhang M, Lewandowski FA, Zhou Z, Sharp C, Maguire D, Grasberger B, DesJarlais RL, Spurlino J. Synthesis of thiophene-2-carboxamidines containing 2-aminothiazoles and their biological evaluation as urokinase inhibitors. Bioorg Med Chem Lett 2001; 11:915-8. [PMID: 11294390 DOI: 10.1016/s0960-894x(01)00102-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The serine protease urokinase (uPa) has been implicated in the progression of both breast and prostate cancer. Utilizing structure based design, the synthesis of a series of substituted 4-[2-amino-1,3-thiazolyl]-thiophene-2-carboxamidines is described. Further optimization of this series by substitution of the terminal amine yielded urokinase inhibitors with excellent activities.
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Affiliation(s)
- K J Wilson
- 3-Dimensional Pharmaceuticals, Inc., Exton, PA 19341, USA.
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Stringer MD, Randall T, Rutter DP, Picton SV, Puntis JW. Appropriate investigation of inflammatory bowel disease in children. J R Soc Med 1998; 91:589-91. [PMID: 10325877 PMCID: PMC1296954 DOI: 10.1177/014107689809101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- M D Stringer
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK
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Randall T, Baxter R. Anterior instability of the knee. Clin Orthop Relat Res 1997:285-6. [PMID: 9224271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Randall T, Butler N, Vance AM. Rehabilitation of ten soldiers with exertional rhabdomyolysis. Mil Med 1996; 161:564-6. [PMID: 8840800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This case study describes the rehabilitation of 10 active duty U.S. soldiers with exertional rhabdomyolysis. The pathophysiology of rhabdomyolysis is discussed. The initial management is concerned with accurate diagnosis and monitoring of laboratory values to prevent complications. Active and passive range of motion, strength, and induration were used as indicators of recovery. The goal of rehabilitation was to safely return patients to their basic training units without activity restrictions as quickly as possible. All 10 soldiers were able to pass the Army Physical Fitness Test at the end of their training cycle. For those patients with rhabdomyolysis who desire to return to a high level of function, close monitoring of exercise intensity appears to allow for a safe, expedient return to previous levels of function. This description of a rare disorder will increase awareness and stimulate discussion so that more specific guidelines for rehabilitation can be developed.
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Affiliation(s)
- T Randall
- Physical Therapy Department, Reynolds Army Community Hospital, Fort Sill, OK 73503, USA
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Belanich M, Randall T, Pastor MA, Kibitel JT, Alas LG, Dolan ME, Schold SC, Gander M, Lejeune FJ, Li BF, White AB, Wasserman P, Citron ML, Yarosh DB. Intracellular Localization and intercellular heterogeneity of the human DNA repair protein O(6)-methylguanine-DNA methyltransferase. Cancer Chemother Pharmacol 1996; 37:547-55. [PMID: 8612308 DOI: 10.1007/s002800050427] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
O(6)-Methylguanine-DNA methyltransferase (MGMT) is a DNA repair protein that removes alkyl adducts from DNA and may be important in tumor resistance to alkylation chemotherapy. MGMT was visualized in human cells and tumor tissues with monoclonal antibodies against MGMT and immunofluorescence microscopy, and fluorescent signals were quantified by digital image analysis. MGMT was found both in the cytoplasm and the nucleus, and in either locale the protein reacts with alkylated DNA bases and becomes inactivated and lost from the cell. Cell lines in culture and xenografts showed a broad normal distribution of nuclear MGMT levels, but human brain tumors often showed a skewed distribution, with a significant fraction of cells with high levels of MGMT. O(6)-Benzylguanine, a suicide substrate inactivator for MGMT activity, reduced MGMT in human cells and in a mouse xenograft to levels undetectable by antibody assay 1 h post-treatment. In melanoma specimens taken from a patient 3 h post-treatment with temozolomide, MGMT levels were reduced by 70%. This quantitative immunofluorescence assay can be used to monitor MGMT and it depletion in human tumors to improve the use of alkylating agents in cancer chemotherapy.
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Affiliation(s)
- M Belanich
- Applied Genetics Inc., Freeport, NY 11520 USA
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Belanich M, Pastor M, Randall T, Guerra D, Kibitel J, Alas L, Li B, Citron M, Wasserman P, White A, Eyre H, Jaeckle K, Schulman S, Rector D, Prados M, Coons S, Shapiro W, Yarosh D. Retrospective study of the correlation between the DNA repair protein alkyltransferase and survival of brain tumor patients treated with carmustine. Cancer Res 1996; 56:783-8. [PMID: 8631014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We tested the hypothesis that the level of the DNA repair protein O6-alkylguanine-DNA alkyltransferase in brain tumors was correlated with resistance to carmustine (BCNU) chemotherapy. Alkyltransferase levels in individual cells in sections from 167 primary brain tumors treated with BCNU were quantitated with an immunofluorescence assay using monoclonal antibodies against human alkyltransferase. Patients with high levels of alkyltransferase had shorter time to treatment failure (P = 0.05) and death (P = 0.004) and a death rate 1.7 times greater than patients with low alkyltransferase levels. Furthermore, the size of the subpopulation of cells with high levels of alkyltransferase was correlated directly with drug resistance. For all tumors the variables most closely correlated with survival, in order of importance, were age, tumor grade, and alkyltransferase levels. For glioblastoma multiforme, survival was more strongly correlated with alkyltransferase levels than with age. These results should encourage prospective studies to evaluate alkyltransferase levels as a method, for identifying brain tumor patients with the best likelihood of response to BCNU chemotherapy.
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Affiliation(s)
- M Belanich
- Applied Genetics Inc., Freeport, New York 11520, USA
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Randall T. Glenoid dysplasia. J Athl Train 1995; 30:259-60. [PMID: 16558346 PMCID: PMC1317872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Athletic trainers evaluate many athletes with acute and chronic shoulder problems such as rotator cuff pathology, impingement syndromes, and inflammatory conditions. They also need to be aware of more obscure reasons for shoulder pain and dysfunction. The purpose of this paper is to describe a rare congenital abnormality called glenoid dysplasia, which can be responsible for a variety of shoulder complaints in athletes. Characteristics of glenoid dysplasia are seen on radiographs and include a shallow glenoid fossa and a hypoplastic scapular neck. This case study depicts an athlete who functioned at a very high level for many years before developing symptoms. This athlete was able to continue an active lifestyle but some limitations were recommended.
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Affiliation(s)
- T Randall
- Terry Randall is Assistant Chief of Physical Therapy at Reynolds Army Community Hospital, Fort Sill, OK 73507
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Watson B, Gupta R, Randall T, Starr S. Persistence of cell-mediated and humoral immune responses in healthy children immunized with live attenuated varicella vaccine. J Infect Dis 1994; 169:197-9. [PMID: 8277182 DOI: 10.1093/infdis/169.1.197] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Two hundred fourteen healthy seronegative children immunized with various doses of Oka/Merck varicella vaccine were studied for persistence of varicella-zoster virus (VZV)-specific lymphocyte proliferation and antibodies to VZV as determined by a glycoprotein (gp) ELISA. Of the 140 vaccinees tested for VZV-specific lymphocyte proliferation, 94% had positive responses, with a mean stimulation index of 8.9 (range, 3.0-44.6). Of 214 tested by gpELISA, 95% were positive for up to 6 years after immunization; the geometric mean titer was 30.2 (range, 1.3-3510.0). Of 122 individuals tested both by ELISA and for VZV-specific lymphocyte proliferation, 91% had persistence of both responses. Persistence of cellular and humoral immune responses in a large percentage of vaccinees for up to 6 years after immunization with Oka/Merck varicella vaccine suggests that protection against severe varicella is likely to be similarly long-lasting.
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Affiliation(s)
- B Watson
- Division of Allergy, Immunology, Joseph Stokes, Jr. Research Institute, Children's Hospital of Philadelphia, PA 19104
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Randall T. Women need more and better information on menopause from their physicians, says survey. JAMA 1993; 270:1664. [PMID: 8411483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Randall T. New partnership pursues research on biosensors. JAMA 1993; 270:1285-6. [PMID: 8360955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Randall T. Rural health care faces reform too; providers sow seeds for better future. JAMA 1993; 270:419-21. [PMID: 8320769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Randall T. Producers of videodisc programs strive to expand patient's role in medical decision-making process. JAMA 1993; 270:160-2. [PMID: 8315717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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