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Patel PA, Teherani MF, Xiang Y, Bernardo V, Chandrakasan S, Goggin KP, Haight A, Horwitz E, Liang WH, Parikh SH, Schoettler ML, Spencer K, Stenger E, Watkins B, Williams KM, Leung K, Jaggi P, Qayed M. Short-Course Empiric Antibiotics in Children Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:778.e1-778.e6. [PMID: 37739225 DOI: 10.1016/j.jtct.2023.09.011] [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: 08/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
Fever is common in children undergoing hematopoietic cell transplantation (HCT). Empiric antibiotic (EA) therapy is initiated and often continued until neutrophil engraftment. Prolonged antibiotic exposure reduces microbiome diversity and causes overgrowth of pathogenic organisms, leading to such complications as infections from antibiotic-resistant organisms and Clostridium difficile colitis. Shorter courses of EA therapy have been studied in adults undergoing HCT without significant safety concerns, but data in children are lacking. We instituted a single-center preintervention/ postintervention quality improvement (QI) project to assess the feasibility of short-course EA therapy for first fever in patients undergoing HCT. We aimed to reduce the median duration of broad-spectrum antibiotic use in eligible patients from 20 days in 2020 to 10 days in 2021. Patients were eligible for the intervention, limiting EAs to 7 days for first fever, if they were admitted for their first allogeneic HCT, were afebrile for >24 hours, had no infection requiring systemic treatment, and were hemodynamically stable. Outcome measures included days of EA therapy for first fever and total broad-spectrum antibiotic use during the period of hospitalization, defined as the time from the start of conditioning to 30 days after HCT or hospital discharge, whichever occurred first. Balancing measures included bloodstream infection (BSI), fever, and intensive care (ICU) admission within 3 days of stopping EA therapy. Project criteria were applied retrospectively to patients who underwent HCT in 2020 to construct a preintervention short-course-eligible cohort. During the intervention period, 41 patients underwent allogeneic HCT, of whom 17 (41%) were eligible for short-course EA therapy. Among eligible patients, the median age was 5.3 years, 47% had an underlying malignancy, and 88% received myeloablative conditioning. There were no differences in demographic or HCT characteristics between patients eligible for short-course EA during the intervention and preintervention period (n = 24). The short-course EA schedule was adhered to by 14 of the 17 eligible patients (82%). The duration of EA for first fever and total broad-spectrum antibiotic use was significantly decreased in the short-course EA-eligible patients compared to the preintervention cohort, from a median of 17 days to 8 days and from 20 days to 10 days, respectively (P < .01). Of the 14 patients adhering to short-course EA, 2 experienced a balancing measure of recurrent fever requiring resumption of EA, but no infection was identified. There were no BSIs, ICU admissions, or deaths during the hospitalization period in patients who received short-course EA. In this single-center QI project, short-course EA for initial fever was successfully applied to children undergoing allogeneic HCT using strict criteria and led to a significant decrease in broad-spectrum antibiotic use during hospitalization. These results should be validated in a prospective clinical trial to include the impact of short-course EA on antibiotic-resistant organisms, the intestinal microbiome, and HCT outcomes.
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Affiliation(s)
- Pratik A Patel
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia; Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia.
| | - Mehgan F Teherani
- Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yijin Xiang
- Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Shanmuganathan Chandrakasan
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn P Goggin
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Ann Haight
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Edwin Horwitz
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Wayne H Liang
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Suhag H Parikh
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Michelle L Schoettler
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | | | - Elizabeth Stenger
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Benjamin Watkins
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kirsten M Williams
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Kathryn Leung
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
| | - Preeti Jaggi
- Pediatric Infectious Disease at Children's Healthcare of Atlanta, Emory University Department of Pediatrics, Atlanta, Georgia
| | - Muna Qayed
- Aflac Cancer & Blood Disorders Center of Children's Healthcare of Atlanta and Emory University Department of Pediatrics, Atlanta, Georgia
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Ho VT, Klumpp TR, Liang WH, Prestegaard M, Horwitz M, Hamilton BK, Page K, Jaglowski S, Huber J, Martinez C, Shenoy V, Chen A, Rizzo D. Cell Therapy Informatics: Updates on the Integration of HCT/IEC Functionalities into an Electronic Medical Record System in the US to Promote Efficiency, Patient Safety, Research, and Data Interoperability. Transplant Cell Ther 2023; 29:539-547. [PMID: 37379969 DOI: 10.1016/j.jtct.2023.06.014] [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: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 06/30/2023]
Abstract
The use of electronic health/medical record (EMR) systems has streamlined medical practice and improved efficiency of clinical care in recent years. However, EMR systems are not generally well designed to support research and tracking of longitudinal outcomes across populations, which are particularly important in hematopoietic stem cell transplantation (HCT) and immune effector cell therapy (IEC), where data reporting to registries and regulatory agencies are often required. Since its formation in 2014, the HCT EMR user group has worked with a large EMR vendor (Epic) to develop many functionalities within the EMR to improve the care of HCT/IEC patients and facilitate the capture of HCT/IEC data in an easily interoperable format. Awareness and the widespread adoption of these new tools among transplant centers remains a challenge, however. In this report, we aim to increase awareness and adoption of these new features in the Epic EMR across the transplantation community, advocate for the use of data standards, and promote future collaboration with other commercial EMRs to develop standardized HCT/IEC content to improve patient care and facilitate interoperable data exchange.
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Affiliation(s)
- Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
| | - Thomas R Klumpp
- Department of Medical Oncology, Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania
| | - Wayne H Liang
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | | | - Mitchell Horwitz
- Adult Blood and Marrow Transplant Program, Duke University Medical Center, Durham, North Carolina
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Kristin Page
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Madison, Wisconsin
| | | | - John Huber
- Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Charles Martinez
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Vinaya Shenoy
- Software Development, Epic Systems Corporation, Verona, Wisconsin
| | - Allen Chen
- Pediatric Hematology and Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Douglas Rizzo
- Division of Hematology and Oncology, Froedtert & the Medical College of Wisconsin Cancer Center Cancer, Medical College of Wisconsin, Madison, Wisconsin
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3
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Colicchio TK, Liang WH, Dissanayake PI, Do Rosario CV, Cimino JJ. Physicians' perceptions about a semantically integrated display for chart review: A Multi-Specialty survey. Int J Med Inform 2022; 163:104788. [DOI: 10.1016/j.ijmedinf.2022.104788] [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] [Received: 02/16/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022]
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4
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Lek SM, Liang WH, Ooi SHA, Tay CAG. Surgical management of benign idiopathic tracheo-oesophageal fistula: a case report. Singapore Med J 2022; 63:288-290. [DOI: 10.11622/smedj.2022077] [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: 11/18/2022]
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5
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Yuan X, Liu K, Li Y, Zhang AZ, Wang XL, Jiang CH, Liang WH, Zhang HJ, Pang LJ, Li M, Yang L, Qi Y, Zheng Q, Li F, Hu JM. HPV16 infection promotes an M2 macrophage phenotype to promote the invasion and metastasis of esophageal squamous cell carcinoma. Clin Transl Oncol 2021; 23:2382-2393. [PMID: 34075547 DOI: 10.1007/s12094-021-02642-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/06/2020] [Accepted: 05/07/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES High-risk human papillomavirus (HR-HPV) is an important risk factor for esophageal cancer. Macrophages constitute a crucial immune medium for regulating HPV-related tumors; however, the specific regulatory mechanisms remain unknown. Therefore, the purpose of our current study was to investigate the mechanism by which HPV16E6 regulates macrophages to promote the invasion and metastasis of esophageal cancer. METHODS HPV16E6 infection was detected by polymerase chain reaction. Immunohistochemistry was used to verify the distribution of tumor-associated macrophages (TAMs) and MMP-9 expression in esophageal squamous cell carcinoma tissues (ESCCs), and cancer adjacent normal tissues (CANs) from Kazakh patients. ESCC cells were transfected with a plasmid over-expressing HPV16E6 and non-contact cocultured with macrophages. RESULTS The infection rate of HPV16E6 in Kazakh ESCCs was clearly higher than that in CANs (P < 0.05). The density of CD163-positive TAMs was significantly positively correlated with HPV16E6 infection in ESCCs (P < 0.05). After coculturing macrophages and EC9706 cells transfected with the HPV16E6 plasmid, the phenotype of macrophages transformed into M2 macrophages. The migration and invasion ability of ESCC cells were higher in the HPV16E6-transfected and coculture group than in the HPV16E6 empty vector-transfected and non-cocultured HPV16E6-transfected groups (all P < 0.05). The density of M2-like TAMs in ESCCs was positively correlated with the level of MMP-9 expression. MMP-9 expression in the HPV16E6-ESCC coculture macrophages group was substantially higher than that in controls (all P < 0.05). CONCLUSIONS HPV16 infection mediates tumor-associated macrophages to promote ESCC invasion and migration.
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Affiliation(s)
- X Yuan
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - K Liu
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - Y Li
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - A Z Zhang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - X L Wang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - C H Jiang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - W H Liang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - H J Zhang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - L J Pang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - M Li
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - L Yang
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - Y Qi
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China
| | - Q Zheng
- 69245 Military Hospital, Urumqi, Xinjiang, 831500, China
| | - F Li
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China.,Department of Pathology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 10020, China
| | - J M Hu
- Department of Pathology and Key Laboratory for Xinjiang Endemic and Ethnic Diseases (Ministry of Education), The First Affiliated Hospital, Shihezi University School of Medicine, Shihezi , Xinjiang , 832000, China.
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6
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Liang WH, Federico SM, London WB, Naranjo A, Irwin MS, Volchenboum SL, Cohn SL. Tailoring Therapy for Children With Neuroblastoma on the Basis of Risk Group Classification: Past, Present, and Future. JCO Clin Cancer Inform 2020; 4:895-905. [PMID: 33058692 PMCID: PMC7608590 DOI: 10.1200/cci.20.00074] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [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] [Accepted: 09/01/2020] [Indexed: 12/12/2022] Open
Abstract
For children with neuroblastoma, the likelihood of cure varies widely according to age at diagnosis, disease stage, and tumor biology. Treatments are tailored for children with this clinically heterogeneous malignancy on the basis of a combination of markers that are predictive of risk of relapse and death. Sequential risk-based, cooperative-group clinical trials conducted during the past 4 decades have led to improved outcome for children with neuroblastoma. Increasingly accurate risk classification and refinements in treatment stratification strategies have been achieved with the more recent discovery of robust genomic and molecular biomarkers. In this review, we discuss the history of neuroblastoma risk classification in North America and Europe and highlight efforts by the International Neuroblastoma Risk Group (INRG) Task Force to develop a consensus approach for pretreatment stratification using seven risk criteria including an image-based staging system-the INRG Staging System. We also update readers on the current Children's Oncology Group risk classifier and outline plans for the development of a revised 2021 Children's Oncology Group classifier that will incorporate INRG Staging System criteria to facilitate harmonization of risk-based frontline treatment strategies conducted around the globe. In addition, we discuss new approaches to establish increasingly robust, future risk classification algorithms that will further refine treatment stratification using machine learning tools and expanded data from electronic health records and the INRG Data Commons.
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Affiliation(s)
- Wayne H. Liang
- Department of Pediatrics and Informatics Institute, University of Alabama at Birmingham, Birmingham, AL
| | - Sara M. Federico
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Wendy B. London
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | - Arlene Naranjo
- Department of Biostatistics, Children’s Oncology Group Statistics and Data Center, University of Florida, Gainesville, FL
| | - Meredith S. Irwin
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Samuel L. Volchenboum
- Department of Pediatrics and Comer Children’s Hospital, University of Chicago, Chicago, IL
| | - Susan L. Cohn
- Department of Pediatrics and Comer Children’s Hospital, University of Chicago, Chicago, IL
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7
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Lin G, Li C, Li PS, Fang WZ, Xu HP, Gong YH, Zhu ZF, Hu Y, Liang WH, Chu Q, Zhong WZ, Wu L, Wang HJ, Wang ZJ, Li ZM, Lin J, Guan YF, Xia XF, Yi X, Miao Q, Wu B, Jiang K, Zheng XB, Zhu WF, Zheng XL, Huang PS, Xiao WJ, Hu D, Zhang LF, Fan XR, Mok TSK, Huang C. Genomic origin and EGFR-TKI treatments of pulmonary adenosquamous carcinoma. Ann Oncol 2020; 31:517-524. [PMID: 32151507 DOI: 10.1016/j.annonc.2020.01.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 10/21/2019] [Revised: 01/05/2020] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Adenosquamous carcinoma (ASC) of the lung is a heterogeneous disease that is composed of both adenocarcinoma components (ACC) and squamous cell carcinoma components (SCCC). Their genomic profile, genetic origin, and clinical management remain controversial. PATIENTS AND METHODS Resected ASC and metastatic tumor in regional lymph nodes (LNs) were collected. The ACC and SCCC were separated by microdissection of primary tumor. The 1021 cancer-related genes were evaluated by next-generation sequencing independently in ACC and SCCC and LNs. Shared and private alterations in the two components were investigated. In addition, genomic profiles of independent cohorts of adenocarcinomas and squamous cell carcinomas were examined for comparison. We have also carried out a retrospective study of ASCs with known EGFR mutation status from 11 hospitals in China for their clinical outcomes. RESULTS The most frequent alterations in 28 surgically resected ASCs include EGFR (79%), TP53 (68%), MAP3K1 (14%) mutations, EGFR amplifications (32%), and MDM2 amplifications (18%). Twenty-seven patients (96%) had shared variations between ACC and SCCC, and pure SCCC metastases were not found in metastatic LNs among these patients. Only one patient with geographically separated ACC and SCCC had no shared mutations. Inter-component heterogeneity was a common genetic event of ACC and SCCC. The genomic profile of ASC was similar to that of 170 adenocarcinomas, but different from that of 62 squamous cell carcinomas. The incidence of EGFR mutations in the retrospective analysis of 517 ASCs was 51.8%. Among the 129 EGFR-positive patients who received EGFR-TKIs, the objective response rate was 56.6% and the median progression-free survival was 10.1 months (95% confidence interval: 9.0-11.2). CONCLUSIONS The ACC and SCCC share a monoclonal origin, a majority with genetically inter-component heterogeneity. ASC may represent a subtype of adenocarcinoma with EGFR mutation being the most common genomic anomaly and sharing similar efficacy to EGFR TKI.
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Affiliation(s)
- G Lin
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - C Li
- Department of Pathology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China; Department of Pathology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China; Fujian Provincial Key Laboratory of Translational Cancer Medicine, Fuzhou, China
| | - P S Li
- Geneplus-Beijing, Beijing, China
| | - W Z Fang
- Department of Oncology, 900 Hospital of the Joint Logistics Team, Clinical Medical College of Fujian Medical University in 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - H P Xu
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Y H Gong
- Geneplus-Beijing, Beijing, China
| | - Z F Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Fudan University Shanghai Medical School, Shanghai, China
| | - Y Hu
- Department of Medical Oncology, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - W H Liang
- Department of Thoracic Oncology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Q Chu
- Department of Oncology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - W Z Zhong
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China
| | - L Wu
- Department of Thoracic Medical Oncology, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital, Changsha, China
| | - H J Wang
- Henan Cancer Hospital/Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Z J Wang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Z M Li
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - J Lin
- Department of Medical Oncology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Y F Guan
- Geneplus-Beijing, Beijing, China
| | - X F Xia
- Geneplus-Beijing, Beijing, China
| | - X Yi
- Geneplus-Beijing, Beijing, China
| | - Q Miao
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - B Wu
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - K Jiang
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - X B Zheng
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - W F Zhu
- Department of Pathology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - X L Zheng
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - P S Huang
- Department of Pathology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - W J Xiao
- Department of Pathology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - D Hu
- Department of Pathology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - L F Zhang
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - X R Fan
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - T S K Mok
- State Key Laboratory of Translational Oncology, Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, China.
| | - C Huang
- Department of Thoracic Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou, China
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8
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Aronson S, Babb L, Ames D, Gibbs RA, Venner E, Connelly JJ, Marsolo K, Weng C, Williams MS, Hartzler AL, Liang WH, Ralston JD, Devine EB, Murphy S, Chute CG, Caraballo PJ, Kullo IJ, Freimuth RR, Rasmussen LV, Wehbe FH, Peterson JF, Robinson JR, Wiley K, Overby Taylor C. Empowering genomic medicine by establishing critical sequencing result data flows: the eMERGE example. J Am Med Inform Assoc 2019; 25:1375-1381. [PMID: 29860405 DOI: 10.1093/jamia/ocy051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 04/18/2018] [Indexed: 11/14/2022] Open
Abstract
The eMERGE Network is establishing methods for electronic transmittal of patient genetic test results from laboratories to healthcare providers across organizational boundaries. We surveyed the capabilities and needs of different network participants, established a common transfer format, and implemented transfer mechanisms based on this format. The interfaces we created are examples of the connectivity that must be instantiated before electronic genetic and genomic clinical decision support can be effectively built at the point of care. This work serves as a case example for both standards bodies and other organizations working to build the infrastructure required to provide better electronic clinical decision support for clinicians.
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Affiliation(s)
- Samuel Aronson
- Research Information Science and Computing, Partners HealthCare, Boston, Massachusetts, USA.,Partners Personalized Medicine, Partners HealthCare, Boston Massachusetts, USA
| | - Lawrence Babb
- Mitogen-GeneInsight, Sunquest Information Systems, Boston, Massachusetts, USA
| | - Darren Ames
- DNAnexus, Inc., Mountain View, California, USA
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas, USA
| | - Eric Venner
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas, USA
| | - John J Connelly
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Keith Marsolo
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Marc S Williams
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania, USA
| | - Andrea L Hartzler
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.,Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Wayne H Liang
- Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.,Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Emily Beth Devine
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Shawn Murphy
- Research Information Science and Computing, Partners HealthCare, Boston, Massachusetts, USA
| | | | | | - Iftikhar J Kullo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert R Freimuth
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke V Rasmussen
- Department of Preventive Medicine, Division of Health and Biomedical Informatics, Northwestern University, Chicago, Illinois, USA
| | - Firas H Wehbe
- Department of Preventive Medicine, Division of Health and Biomedical Informatics, Northwestern University, Chicago, Illinois, USA
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jamie R Robinson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ken Wiley
- National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Casey Overby Taylor
- Genomic Medicine Institute, Geisinger, Danville, Pennsylvania, USA.,Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Zouk H, Venner E, Lennon NJ, Muzny DM, Abrams D, Adunyah S, Albertson-Junkans L, Ames DC, Appelbaum P, Aronson S, Aufox S, Babb LJ, Balasubramanian A, Bangash H, Basford M, Bastarache L, Baxter S, Behr M, Benoit B, Bhoj E, Bielinski SJ, Bland HT, Blout C, Borthwick K, Bottinger EP, Bowser M, Brand H, Brilliant M, Brodeur W, Caraballo P, Carrell D, Carroll A, Almoguera B, Castillo L, Castro V, Chandanavelli G, Chiang T, Chisholm RL, Christensen KD, Chung W, Chute CG, City B, Cobb BL, Connolly JJ, Crane P, Crew K, Crosslin D, De Andrade M, De la Cruz J, Denson S, Denny J, DeSmet T, Dikilitas O, Friedrich C, Fullerton SM, Funke B, Gabriel S, Gainer V, Gharavi A, Glazer AM, Glessner JT, Goehringer J, Gordon AS, Graham C, Green RC, Gundelach JH, Dayal J, Hain HS, Hakonarson H, Harden MV, Harley J, Harr M, Hartzler A, Hayes MG, Hebbring S, Henrikson N, Hershey A, Hoell C, Holm I, Howell KM, Hripcsak G, Hu J, Jarvik GP, Jayaseelan JC, Jiang Y, Joo YY, Jose S, Josyula NS, Justice AE, Kalla SE, Kalra D, Karlson E, Kelly MA, Keating BJ, Kenny EE, Key D, Kiryluk K, Kitchner T, Klanderman B, Klee E, Kochan DC, Korchina V, Kottyan L, Kovar C, Kudalkar E, Kullo IJ, Lammers P, Larson EB, Lebo MS, Leduc M, Lee MT(M, Leppig KA, Leslie ND, Li R, Liang WH, Lin CF, Linder J, Lindor NM, Lingren T, Linneman JG, Liu C, Liu W, Liu X, Lynch J, Lyon H, Macbeth A, Mahadeshwar H, Mahanta L, Malin B, Manolio T, Marasa M, Marsolo K, Dinsmore MJ, Dodge S, Hynes ED, Dunlea P, Edwards TL, Eng CM, Fasel D, Fedotov A, Feng Q, Fleharty M, Foster A, Freimuth R, McGowan ML, McNally E, Meldrim J, Mentch F, Mosley J, Mukherjee S, Mullen TE, Muniz J, Murdock DR, Murphy S, Murugan M, Myers MF, Namjou B, Ni Y, Obeng AO, Onofrio RC, Taylor CO, Person TN, Peterson JF, Petukhova L, Pisieczko CJ, Pratap S, Prows CA, Puckelwartz MJ, Rahm AK, Raj R, Ralston JD, Ramaprasan A, Ramirez A, Rasmussen L, Rasmussen-Torvik L, Rasouly HM, Raychaudhuri S, Ritchie MD, Rives C, Riza B, Roden D, Rosenthal EA, Santani A, Schaid D, Scherer S, Scott S, Scrol A, Sengupta S, Shang N, Sharma H, Sharp RR, Singh R, Sleiman PM, Slowik K, Smith JC, Smith ME, Smoller JW, Sohn S, Stanaway IB, Starren J, Stroud M, Su J, Tolwinski K, Van Driest SL, Vargas SM, Varugheese M, Veenstra D, Verbitsky M, Vicente G, Wagner M, Walker K, Walunas T, Wang L, Wang Q, Wei WQ, Weiss ST, Wiesner GL, Wells Q, Weng C, White PS, Wiley KL, Williams JL, Williams MS, Wilson MW, Witkowski L, Woods LA, Woolf B, Wu TJ, Wynn J, Yang Y, Yi V, Zhang G, Zhang L, Rehm HL, Gibbs RA. Harmonizing Clinical Sequencing and Interpretation for the eMERGE III Network. Am J Hum Genet 2019; 105:588-605. [PMID: 31447099 PMCID: PMC6731372 DOI: 10.1016/j.ajhg.2019.07.018] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/26/2019] [Indexed: 12/25/2022] Open
Abstract
The advancement of precision medicine requires new methods to coordinate and deliver genetic data from heterogeneous sources to physicians and patients. The eMERGE III Network enrolled >25,000 participants from biobank and prospective cohorts of predominantly healthy individuals for clinical genetic testing to determine clinically actionable findings. The network developed protocols linking together the 11 participant collection sites and 2 clinical genetic testing laboratories. DNA capture panels targeting 109 genes were used for testing of DNA and sample collection, data generation, interpretation, reporting, delivery, and storage were each harmonized. A compliant and secure network enabled ongoing review and reconciliation of clinical interpretations, while maintaining communication and data sharing between clinicians and investigators. A total of 202 individuals had positive diagnostic findings relevant to the indication for testing and 1,294 had additional/secondary findings of medical significance deemed to be returnable, establishing data return rates for other testing endeavors. This study accomplished integration of structured genomic results into multiple electronic health record (EHR) systems, setting the stage for clinical decision support to enable genomic medicine. Further, the established processes enable different sequencing sites to harmonize technical and interpretive aspects of sequencing tests, a critical achievement toward global standardization of genomic testing. The eMERGE protocols and tools are available for widespread dissemination.
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Osborne JD, Khare A, Dempsey DM, Wells JM, Wyatt M, Gordon G, Liang WH, Cimino J. Phenotype Detection Registry System (PheDRS) - Implementation of a Generalizable Single Institution Clinical Registry Architecture. AMIA Annu Symp Proc 2018; 2018:847-856. [PMID: 30815127 PMCID: PMC6371346] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Precision medicine requires that groups of patients matching clinical or genetic characteristics be identified in a clinical care setting and treated with the appropriate intervention. In the clinical setting, this process is often facilitated by a patient registry. While the software architecture of federated patient registries for research has been well characterized, local registries focused on clinical quality and care have received less attention. Many clinical registries appear to be one-off projects that lack generalizability and the ability to scale to multiple diseases. We evaluate the applicability of existing registry guidelines for registries designed for clinical intervention, propose a software architecture more practical for single-institution clinical registries and report the implementation of a generalizable clinical patient registry architecture at the University of Alabama at Birmingham (UAB).
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Affiliation(s)
- John D Osborne
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adarsh Khare
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - J Michael Wells
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matt Wyatt
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Geoff Gordon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Wayne H Liang
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James Cimino
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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Liang WH, Madan-Swain A, Cronin RM, Jackson GP. Development of a Technology-Supported, Lay Peer-to-Peer Family Engagement Consultation Service in a Pediatric Hospital. AMIA Annu Symp Proc 2018; 2018:730-739. [PMID: 30815115 PMCID: PMC6371240] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Patient and caregiver engagement in making decisions and taking actions to promote health are critically important for improving outcomes, enhancing healthcare experience satisfaction, and reducing costs. Patients and caregivers have a wealth of expertise in illness self-management and can aid others in attaining high levels of activation through peer-to-peer social support. We describe the development of a technology-supported, family engagement consultation service at Children's of Alabama that integrates parent volunteers as front-line, peer-to-peer support consultants with a multidisciplinary team of informatics professionals in the pediatric hospital setting. This service was adapted from an existing engagement consultation service with a traditional medical consultation model at Vanderbilt Children's Hospital. The unique features of the new model are articulated, along with plans for a shared knowledge database of consumer health resources to meet needs. The layperson peer-to-peer design is highly innovative and relevant as healthcare transitions towards increasingly participatory and personalized medicine.
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Affiliation(s)
- Wayne H Liang
- University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
Cytosine methylation is an epigenetic mark found in the genome of fungi, plants, and animals. DNA methylation is catalyzed by DNA methyltransferases. The function of DNA methyltransferases was shown to be highly conversed, but biological role of these enzymes has not been clearly defined. We generated transgenic plants expressing METHYLTRANSFERASES::GUS reporter genes for three major DNA methyltransferases (MET1, DRM2 and CMT3) to gain insight into the potential physiological relevance of the distinct members of the DNA methyltransferase family in Arabidopsis thaliana, and to investigate the expression patterns in detail. We found that METHYLTRANSFERASE::GUS genes display unique tissue, cell-type, and temporal patterns of expression throughout normal development, particularly in the flower. Our findings are supported by semi-quantitative reverse-transcription PCR, as well as by analyses of microarray databases. These data suggest that DNA methyltransferase may contribute to morphogenesis at every developmental stage and in every plant organ.
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Cohen DN, Johnson MS, Liang WH, McDaniel HL, Young PP. Clinically significant hemolytic disease of the newborn secondary to passive transfer of anti-D from maternal RhIG. Transfusion 2014; 54:2863-6. [DOI: 10.1111/trf.12698] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 03/10/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel N. Cohen
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Mary S. Johnson
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Wayne H. Liang
- Department of Pediatrics; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Heather L. McDaniel
- Department of Pediatrics; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
- Division of Hematology and Oncology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
| | - Pampee P. Young
- Department of Pathology, Microbiology and Immunology; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
- Department of Medicine; Vanderbilt University Medical Center and Monroe Carell Jr. Children's Hospital at Vanderbilt; Nashville Tennessee
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Wu X, Huang PY, Peng PJ, Lu LX, Han F, Wu SX, Hou X, Zhao HY, Huang Y, Fang WF, Zhao YY, Xue C, Hu ZH, Zhang J, Zhang JW, Ma YX, Liang WH, Zhao C, Zhang L. Long-term follow-up of a phase III study comparing radiotherapy with or without weekly oxaliplatin for locoregionally advanced nasopharyngeal carcinoma. Ann Oncol 2013; 24:2131-6. [PMID: 23661293 DOI: 10.1093/annonc/mdt163] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Previous results from our trial showed that adding oxaliplatin to radiotherapy (RT) increased survival in patients with locoregionally advanced nasopharyngeal carcinoma (NPC) at 2 years. Here, we present the data of long-term efficacy and late toxic effects. PATIENTS AND METHODS Between January 2001 and January 2003, 115 Patients with nonkeratinizing/undifferentiated locoregionally advanced NPC were randomly to receive either RT alone (n = 56) or plus concurrent oxaliplatin 70 mg/m(2) weekly for six cycles (n = 59). RESULTS After a median follow-up of 114 months (range 18-139 months), the 5-year overall survival (OS) and metastasis-free survival (MFS) rates in the concurrent chemoradiotherapy (CCRT) group were significantly higher than those observed in the RT-alone group (OS, 73.2% versus 60.2%, P = 0.028; MFS, 74.7% versus 63.0%, P = 0.027). However, CCRT did not improve locoregional failure-free survival significantly. Subgroup analyses showed that the superiorities of CCRT mainly existed in the T3-4N0-1 stage subgroup (OS: HR = 0.394, P = 0.034). The grade 3/4 late toxic effects were similar in the two groups. CONCLUSION(S) The long-term follow-up data confirms the role of CCRT as a treatment of locoregionally advanced NPC. Oxaliplatin can be considered as an alternative optional therapeutic regimen for these patients due to its high efficiency and low toxic effect.
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Affiliation(s)
- X Wu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China
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Hu JM, Li L, Chen YZ, Pang LJ, Yang L, Liu CX, Zhao J, Chang B, Zou H, Qi Y, Liang WH, Li F. Human papillomavirus type 16 infection may be involved in esophageal squamous cell carcinoma carcinogenesis in Chinese Kazakh patients. Dis Esophagus 2013; 26:703-7. [PMID: 23607265 DOI: 10.1111/dote.12009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this study was to investigate human papillomavirus type 16 (HPV16) prevalence in esophageal squamous cell carcinoma (ESCC) in Xinjiang Kazakh patients and its role in ESCC carcinogenesis. One hundred and fifty cases of ESCC and 150 cases of corresponding normal esophageal mucosa (CNGM) samples were collected from north Xinjiang where the Kazakh ethnic group has lived since ancient times. HPV16 infection in ESCC and CNGM was detected by genotype-specific polymerase chain reaction. HPV16 DNA was detected in 55 of 150 ESCC samples (36.7%) and 24 of 150 corresponding normal esophageal mucosa samples (16%) with significant differences (P < 0.001, odds ratio = 3.039, 95% confidence interval: 1.756-5.260). No statistically significant correlations were found between HPV16 infection and the age or gender of patients, tumor site, tumor cell differentiation, or lymph node metastasis (P > 0.05). HPV16 infection is common in cases of ESCC in the Kazakh ethnic group in Xinjiang and may be involved in ESCC carcinogenesis.
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Liang WH, Lin JT, Hsiao LC, Lin ST. Congenital muscular dystrophy: report of one case. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1995; 36:442-4. [PMID: 8592933] [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] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A case is reported of a newborn who presented with generalized hypotonia shortly after delivery. Creatine kinase (CK) was highly elevated. Muscle biopsy of the rectus femoris muscle revealed varying sized muscle fibers, displacement by fat and connective tissues, necrosis and regeneration of the muscle fibers. Magnetic resonance imaging (M.R.I.) of the brain showed normal development, compatible with the patient's age. Congenital muscular dystrophy was diagnosed from clinical manifestations, laboratory findings, and the results of muscle biopsy.
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Affiliation(s)
- W H Liang
- Department of Pediatrics, Taipei Medical College Hospital, Taiwan, R.O.C
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Chang JT, Lou MA, Liang WH. An extra-adrenal pheochromocytoma with spontaneous remission and recurrence: report of a case. Taiwan Yi Xue Hui Za Zhi 1988; 87:1224-8. [PMID: 3252009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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18
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Chu PC, Sun SC, Liang WH, Fresh JW. Liver disease on Taiwan. Trop Geogr Med 1965; 17:282-8. [PMID: 5884323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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