ESMO Expert Consensus Statements on Cancer Survivorship: promoting high-quality survivorship care and research in Europe

BACKGROUND

The increased number of cancer survivors and the recognition of physical and psychosocial challenges, present from cancer diagnosis through active treatment and beyond, led to the discipline of cancer survivorship.

DESIGN AND METHODS

Herein, we reflected on the different components of survivorship care, existing models and priorities, in order to facilitate the promotion of high-quality European survivorship care and research.

RESULTS

We identified five main components of survivorship care: (i) physical effects of cancer and chronic medical conditions; (ii) psychological effects of cancer; (iii) social, work and financial effects of cancer; (iv) surveillance for recurrences and second cancers; and (v) cancer prevention and overall health and well-being promotion. Survivorship care can be delivered by structured care models including but not limited to shared models integrating primary care and oncology services. The choice of the care model to be implemented has to be adapted to local realities. High-quality care should be expedited by the generation of: (i) focused and shared European recommendations, (ii) creation of tools to facilitate implementation of coordinated care and (iii) survivorship educational programs for health care teams and patients. The research agenda should be defined with the participation of health care providers, researchers, policy makers, patients and caregivers. The following patient-centered survivorship research areas were highlighted: (i) generation of a big data platform to collect long-term real-world data in survivors and healthy controls to (a) understand the resources, needs and preferences of patients with cancer, and (b) understand biological determinants of survivorship issues, and (ii) develop innovative effective interventions focused on the main components of survivorship care.

CONCLUSIONS

The European Society for Medical Oncology (ESMO) can actively contribute in the efforts of the oncology community toward (a) promoting the development of high-quality survivorship care programs, (b) providing educational material and (c) aiding groundbreaking research by reflecting on priorities and by supporting research networking.

Management of fulminant myocarditis: peripheral venoarterial extracorporeal membranous oxygenation and associated complications

Background

Fulminant Myocarditis (FM) leads to cardiogenic shock with multi-organic dysfunction, being peripheral venoarterial extracorporeal membranous oxygenation (VA-ECMO) a rescue technique. Despite growing experience, it is still related with several complications. We aim to appraise the management of patients with FM and the adverse events associated to VA-ECMO.

Methods

We conducted a retrospective study in a ECMO centre in Portugal, which included 15 patients diagnosed with FM and managed on VA-ECMO from 2008 to 2018. Hemorrhage or infection on cardiac device site, cardiac tamponade, limb ischemia, ischemic stroke, cerebral hemorrhage, severe hemolysis and accidental decannulation were considered major complications.

Results

For sample characteristics and resumed complications, see Table. Inotropic and mechanical ventilation support were transversal to all, with only one patient extubated before decannulation. Six patients received renal replacement therapy, whom half recovered renal function and the remaining died. VA-ECMO operated on average for 8,5 days (range, 1 to 20 days). 3 patients had concomitant Impella heart pump and one of them had a third assistance device with Intra-Aortic Ballon pump.

Major complications were observed in 9 patients (60%), being ischemic stroke the most common. Limb ischemia, observed in 5 patients, related with longer duration of VA-ECMO support (limb ischemia vs non-limb ischemia; 12,8±4,9 vs. 6,8±6,5 days). Two patients presented hemorrhage on cardiac assistance device site, and 1 patient had a cardiac tamponade, all with fatal outcome. Infection on cardiac site, cerebral hemorrhage, severe hemolysis and accidental decannulation were not observed.

Conclusion

The most common complications were ischemic stroke and limb ischemia, both not apparently related with mortality. Differently, hemorrhage on cardiac site and cardiac tamponade were less frequent but presented ominous outcome. Overall, adverse events can be serious and hinder recovery and discharge.

Funding Acknowledgement

Type of funding sources: None.

Safety of assisted reproductive techniques in young women harboring germline pathogenic variants in BRCA1/2 with a pregnancy after prior history of breast cancer

BACKGROUND

Knowledge is growing on the safety of assisted reproductive techniques (ART) in cancer survivors. No data exist, however, for the specific population of breast cancer patients harboring germline BRCA1/2 pathogenic variants.

PATIENTS AND METHODS

This is a multicenter retrospective cohort study across 30 centers worldwide including women diagnosed at ≤40 years with stage I-III breast cancer, between January 2000 and December 2012, harboring known germline BRCA1/2 pathogenic variants. Patients included in this analysis had a post-treatment pregnancy either achieved through use of ART (ART group) or naturally (non-ART group). ART procedures included ovulation induction, ovarian stimulation for in vitro fertilization or intracytoplasmic sperm injection, and embryo transfer under hormonal replacement therapy.

RESULTS

Among the 1424 patients registered in the study, 168 were eligible for inclusion in the present analysis, of whom 22 were in the ART group and 146 in the non-ART group. Survivors in the ART group conceived at an older age compared with those in the non-ART group (median age: 39.7 versus 35.4 years, respectively). Women in the ART group experienced more delivery complications compared with those in the non-ART group (22.1% versus 4.1%, respectively). No other apparent differences in obstetrical outcomes were observed between cohorts. The median follow-up from pregnancy was 3.4 years (range: 0.8-8.6 years) in the ART group and 5.0 years (range: 0.8-17.6 years) in the non-ART group. Two patients (9.1%) in the ART group experienced a disease-free survival event (specifically, a locoregional recurrence) compared with 40 patients (27.4%) in the non-ART group. In the ART group, no patients deceased compared with 10 patients (6.9%) in the non-ART group.

CONCLUSION

This study provides encouraging safety data on the use of ART in breast cancer survivors harboring germline pathogenic variants in BRCA1/2, when natural conception fails or when they opt for ART in order to carry out preimplantation genetic testing.

Artificial intelligence: an attempt to automate remote device follow-up

Funding Acknowledgements

Type of funding sources: None.

Introduction

Artificial intelligence (AI) through machine learning (ML) refers to the simulation of human intelligence with the capacity for achieving goals within computers. In electrophysiology, ML has many applications in electrocardiography, intracardiac mapping and cardiac implantable electronic devices (CIEDs).

Remote monitoring (RM) of patients equipped with CIEDs associates the analysis of event reports and calendar-based remote follow-ups (FU). ML applications have allowed for risk stratification, improved arrhythmia localisation and streamlined remote monitoring which may significantly reduce the workload faced by electrophysiologists.

Aim

To develop a system that automates cardiac implantable electronic devices remote follow-up.

Methods and Results

We created a Java software application, that uses the latest optical character recognition techniques combined with artificial intelligence and natural language processing to extract information from PDF reports of RM of CIEDs from different manufacturers. The current version is HIPAA (Health Insurance Portability and Accountability Act) complaint and runs on local computers only.

Using the current system, we were able to run and extract data from 30 remote follow-up PDF reports of Cardiac Implantable Defibrillators (ICDs) and Cardiac Resynchronization Therapy with Defibrillator (CRT-Ds).

Time taken from data extraction to conversion of all 30 device PDFs was under 5 minutes.

Process and data extracted are presented in the figure below. (Figure 1)

Conclusion

This machine learning algorithm proved that it is possible to facilitate and automate remote follow-up of cardiac implantable electronic devices.

In a near future this will allow to us to efficiently increase productivity, by speeding and facilitating interpretation of remote device follow-ups, leading to improvements in patientcare and precision cardiovascular medicine.

Furthermore, in the current and future pandemics it may help prevent unnecessary in-person medical visits, avoiding additional, unnecessary strain on an already overburdened and overwhelmed healthcare system, and saving costs. Abstract Figure 1

Differential impact of endocrine therapy and chemotherapy on quality of life of breast cancer survivors: a prospective patient-reported outcomes analysis

BACKGROUND

In early breast cancer (BC), there has been a trend to escalate endocrine therapy (ET) and to de-escalate chemotherapy (CT). However, the impact of ET versus CT on the quality of life (QoL) of early BC patients is unknown. Here, we characterize the independent contribution of ET and CT on patient-reported outcomes (PROs) at 2 years after diagnosis.

PATIENTS AND METHODS

We prospectively collected PROs in 4262 eligible patients using the European Organization for Research and Treatment of Cancer QLQ-C30/BR23 questionnaires inside CANTO trial (NCT01993498). The primary outcome was the C30 summary score (C30-SumSc) at 2 years after diagnosis.

RESULTS

From eligible patients, 37.2% were premenopausal and 62.8% postmenopausal; 81.9% received ET and 52.8% CT. In the overall cohort, QoL worsened by 2 years after diagnosis in multiple functions and symptoms; exceptions included emotional function and future perspective, which improved over time. ET (Pint = 0.004), but not CT (Pint = 0.924), had a persistent negative impact on the C30-SumSc. In addition, ET negatively impacted role and social function, pain, insomnia, systemic therapy side-effects, breast symptoms and further limited emotional function and future perspective recovery. Although CT had no impact on the C30-SumSc at 2-years it was associated with deteriorated physical and cognitive function, dyspnea, financial difficulties, body image and breast symptoms. We found a differential effect of treatment by menopausal status; in premenopausal patients, CT, despite only a non-significant trend for deteriorated C30-SumSc (Pint = 0.100), was more frequently associated with QoL domains deterioration than ET, whereas in postmenopausal patients, ET was more frequently associated with QoL deterioration, namely using the C30-SumSc (Pint = 0.004).

CONCLUSION(S)

QoL deterioration persisted at 2 years after diagnosis with different trajectories by treatment received. ET, but not CT, had a major detrimental impact on C30-SumSc, especially in postmenopausal women. These findings highlight the need to properly select patients for adjuvant ET escalation.

Serological evidence of Borrelia circulation among blood donors in the São Paulo state, Brazil

OBJECTIVE

The objective of this study was to examine the Borrelia seroprevalence among blood donors in Southeast Brazil.

BACKGROUND

There is evidence that Borrelia spirochetes are circulating in Brazil; however, there are no studies that characterise these bacteria and investigate their seroprevalence in the Brazilian population. Such a situation, combined with a recent outbreak of tick-borne Rocky Mountain spotted fever in the São Paulo state demonstrates the increasing role of ticks as arthropod vectors in Brazil.

METHODS

For the purpose of the study, 452 blood donors from Ribeirão Preto city, São Paulo state were tested using anti-Borrelia immunoglobulin G (IgG) assay. The positive results were also confirmed by Western blot for anti-borrelia IgM/IgG.

RESULTS

The anti-Borrelia IgG enzyme-linked immunosorbent assay (ELISA) showed nine positive and nine borderline reactive samples, giving a total seroprevalence of 2·0% of anti-Borrelia IgG among Brazilian blood donors. The confirmation of the seropositive and borderline samples by Borrelia Western blot was demonstrated by IgG-positive results in 16 samples (a seroprevalence of 3.5%). Anti-Borrelia IgM antibodies were also detected in one sample.

CONCLUSIONS

Our results demonstrate that Borrelia-like spirochetes may be circulating among blood donors from the São Paulo State and that the ticks have an important epidemiological role as vectors of bacterial infections in this Brazilian region. These results not only alert us to possible actions that might be undertaken in order to completely characterise the aetiological agents of Lyme-like syndromes in Brazil but also the possible impact that these bacterial agents might have on haemotherapy practices.

Autoimmune hepatitis in 828 Brazilian children and adolescents: clinical and laboratory findings, histological profile, treatments, and outcomes

OBJECTIVE

This large study with a long-term follow-up aimed to evaluate the clinical presentation, laboratory findings, histological profile, treatments, and outcomes of children and adolescents with autoimmune hepatitis.

METHODS

The medical records of 828 children and adolescents with autoimmune hepatitis were reviewed. A questionnaire was used to collect anonymous data on clinical presentation, biochemical and histological findings, and treatments.

RESULTS

Of all patients, 89.6% had autoimmune hepatitis-1 and 10.4% had autoimmune hepatitis-2. The female sex was predominant in both groups. The median age at symptom onset was 111.5 (6; 210) and 53.5 (8; 165) months in the patients with autoimmune hepatitis 1 and autoimmune hepatitis-2, respectively. Acute clinical onset was observed in 56.1% and 58.8% and insidious symptoms in 43.9% and 41.2% of the patients with autoimmune hepatitis-1 and autoimmune hepatitis-2, respectively. The risk of hepatic failure was 1.6-fold higher for autoimmune hepatitis-2. Fulminant hepatic failure occurred in 3.6% and 10.6% of the patients with autoimmune hepatitis-1 and autoimmune hepatitis-2, respectively; the risk was 3.1-fold higher for autoimmune hepatitis-2. The gamma globulin and immunoglobulin G levels were significantly higher in autoimmune hepatitis-1, while the immunoglobulin A and C3 levels were lower in autoimmune hepatitis-2. Cirrhosis was observed in 22.4% of the patients; biochemical remission was achieved in 76.2%. The actuarial survival rate was 93.0%. A total of 4.6% underwent liver transplantation, and 6.9% died (autoimmune hepatitis-1: 7.5%; autoimmune hepatitis-2: 2.4%).

CONCLUSIONS

In this large clinical series of Brazilian children and adolescents, autoimmune hepatitis-1 was more frequent, and patients with autoimmune hepatitis-2 exhibited higher disease remission rates with earlier response to treatment. Patients with autoimmune hepatitis-1 had a higher risk of death.

Reproductive potential and performance of fertility preservation strategies in BRCA-mutated breast cancer patients

Background

Preclinical evidence suggests a possible negative impact of deleterious BRCA mutations on female fertility. However, limited and rather conflicting clinical data are available. This study assessed the reproductive potential and performance of fertility preservation strategies in BRCA-mutated breast cancer patients.

Patients and methods

This was a retrospective analysis of two prospective studies investigating oocyte cryopreservation and ovarian tissue cryopreservation in newly diagnosed early breast cancer patients. In the current analysis, baseline anti-Mullerian hormone (AMH) and performance of cryopreservation strategies were compared between patients with or without germline deleterious BRCA mutations.

Results

Out of 156 patients included, 101 had known BRCA status of whom 29 (18.6%) were BRCA-mutated and 72 (46.1%) had no mutation. Median age in the entire cohort was 31 years [interquartile range (IQR) 28-33). Median AMH levels were 1.8 μg/l (IQR 1.0-2.7) and 2.6 µg/l (IQR 1.5-4.1) in the BRCA-positive and BRCA-negative cohorts, respectively (P = 0.109). Among patients who underwent oocyte cryopreservation (N = 29), women in the BRCA-positive cohort tended to retrieve (6.5 versus 9; P = 0.145) and to cryopreserve (3.5 versus 6; P = 0.121) less oocytes than those in the BRCA-negative cohort. Poor response rate (i.e. retrieval of ≤4 oocytes) was 40.0% and 11.1% in the BRCA-positive and BRCA-negative cohorts, respectively (P = 0.147). Among patients who underwent ovarian tissue cryopreservation (N = 72), women in the BRCA-positive cohort tended to have a numerically lower number of oocytes per fragment (0.08 versus 0.14; P = 0.193) and per square millimeter (0.33 versus 0.78; P = 0.153) than those in the BRCA-negative cohort. Two BRCA-mutated patients were transplanted after chemotherapy and one delivered at term a healthy baby. No difference between BRCA1- and BRCA2-mutated patients was observed in any of the above-mentioned outcomes.

Conclusion

A consistent trend for reduced reproductive potential and performance of cryopreservation strategies was observed in BRCA-mutated breast cancer patients. Independent validation of these results is needed.

Abstract P1-18-02: Impact of the metastatic compartment on bone biomarkers and bone outcomes in patients (pts) with breast cancer (BC) and bone metastases (BM) in trial NCT00321464 of denosumab vs. zoledronic acid

Background: Bone is the most common site of metastatic disease in pts with BC, and BM are frequently associated with skeletal related events (SRE), as, e.g., bone pain or fracture. Bone targeted agents (BTAs; denosumab or zoledronic acid) decrease the rate of SREs. Previous exploratory studies in pts with BM showed that the site of metastatic disease (bone-only disease [BO] vs. bone + extraskeletal disease [BES]) might impact both bone remodeling (reflected in the concentration of bone biomarkers) and the risk for SREs. In this large study of pts with BC and BM, we assessed bone biomarkers after the introduction of BTAs, time to first and subsequent on-study SRE/symptomatic SRE (SSE), and bone pain score variation according to metastatic compartment (BO vs. BES).

Methods: This is a retrospective analysis of the prospective, multicenter, randomized, registration clinical trial of denosumab vs. zoledronic acid in pts with BC and BM (NCT00321464). Study outcomes were variation of corrected urinary N-terminal telopeptide (uNTX) and bone alkaline phosphatase (bALP) at 3 months, time to first and subsequent SRE and SSE, and brief pain inventory (BPI) scores over time. Chi-squared test and t-test were used to compare biomarkers levels. We used the Kaplan-Meier method to describe time to event outcomes and differences were tested using the Cox proportional hazard model and Andersen–Gill model for multiple failure-time data. BPI scores were compared using mixed linear models.

Results: A cohort of 2046 pts was identified, 969 (47.4%) with BO and 1077 (52.6%) with BES, all treated with either denosumab or zoledronic acid. Median follow-up was 20.1 months (interquartile range 15.9-23.8; balanced between arms). Compared to pts with BO, those with BES were more frequently hormone receptor negative (20.9 vs. 15.1%) and HER2-positive (31.0 vs. 23.4%). The number of BM was similar in both groups, but those with BES had less previous SRE (31.7 vs. 42.2%). Pts with BES were more commonly treated with chemotherapy (84.0 vs. 77.5%), but less frequently with radiotherapy (59.7 vs. 65.9%) or surgery (85.0 vs. 88.1%). Absolute levels of uNTX and bALP at baseline and at 3 months, as well as normalization rates, did not differ between groups. However, when compared to those with BO and after controlling for unbalanced clinicopathological and treatment features, pts with BES presented a lower risk of first and subsequent SREs (adjusted-hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.58 – 0.94; p=0.013) and first SSE (adjusted-HR 0.75; 95% CI 0.60 – 0.94; p=0.014). Hazard rates for SRE were higher in the first 6 months of treatment. Despite the small magnitude, pts with BO consistently showed slightly higher BPI scores (+0.2 points; p=0.014). Pts with BES had a shorter OS (HR 1.97, 95% CI 1.66 – 2.33).

Conclusion: Despite the consistent reduction in uNTX and bALP in pts with BC and BO or BES disease, pts with BO disease had a higher risk for SREs and higher pain score. Hazard rates for SREs were greater in the first 6 months of treatment. Strategies of treatment de-escalation of BTAs should consider the metastatic compartment and time variation of the hazard for SRE.

Citation Format: Ferreira AR, Casimiro S, Ali S, Leitzel K, Lipton A, Costa L. Impact of the metastatic compartment on bone biomarkers and bone outcomes in patients (pts) with breast cancer (BC) and bone metastases (BM) in trial NCT00321464 of denosumab vs. zoledronic acid [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-18-02.

Factors Associated With Bleeding Secondary to Rupture of Esophageal Varices in Children and Adolescents With Cirrhosis

OBJECTIVE

Bleeding of esophageal varices is the main cause of morbidity and mortality in children with portal hypertension. It is important to understand the factors related with a bleeding episode to evaluate more effective primary prophylaxis. The present study aims to describe the endoscopic and laboratory findings associated with upper gastrointestinal bleeding (UGIB) secondary to esophageal varices.

METHOD

A cross-sectional study with 103 children and adolescents with cirrhosis, divided into a group that had experienced an episode of upper UGIB (35 patients) and a group without a history of UGIB (68 patients), was carried out. The esophageal and gastric varices were classified, and the portal hypertensive gastropathy, laboratory findings, and Child-Pugh classification were measured.

RESULTS

Factors observed in univariate analysis to be associated with UGIB were the presence of esophageal varices of medium caliber or larger, portal hypertensive gastropathy, presence of red spots on esophageal varices, Child-Pugh class B or C, and hypoalbuminemia (P < 0.05). After multivariate logistic regression analysis, the significant factors were the presence of red spots on esophageal varices and the presence of gastric varices. When separated the autoimmune hepatitis, nonbiliary atresia patients (all patients except the patients with biliary atresia), and biliary atresia groups the findings in the univariate analysis were the presence of esophageal varices of medium or larger caliber, presence of red spots on varices, and presence of gastric varices in the autoimmune hepatitis patients and nonbiliary atresia patients and presence of red spots on esophageal varices, presence of gastric varices, and Child-Pugh classification B or C in biliary atresia group (P < 0.05). After multivariate logistic regression analysis, no statistical significance was found for any factor analyzed in any groups.

CONCLUSIONS

The presence of gastric varices and red spots on esophageal varices were related to episodes of UGIB secondary to rupture of esophageal varices. When these findings are observed, indications for endoscopic primary prophylaxis should be evaluated. More studies are, however, necessary to better understand this problem.

Clinical Characteristics and Prognosis in Children and Adolescents With Autoimmune Hepatitis and Overlap Syndrome

OBJECTIVES

This is a cohort study of 134 children and adolescents with a known diagnosis of autoimmune hepatitis (AIH). During follow-up, some of them developed autoimmune sclerosing cholangitis (ASC). This study describes the characteristics of the patients upon diagnosis, and their response to treatment and any complications, and compares the patients who developed ASC during follow-up (ASC group) with those who did not (AIH group).

METHODS

A total of 73.1% of the patients were girls with a median age upon diagnosis of 10.41 (7.41-12.53) years.

RESULTS

Of 134 patients, 28 (20.9%) developed cholestatic manifestations, with features of ASC. A few differences were observed between the AIH and ASC groups when they were analyzed by χ test, such as the smaller predominance of girls in ASC group (P = 0.04), and more common asymptomatic presentation in the ASC group (P = 0.01). Cirrhosis was observed in 68% of biopsies, with no significant difference between groups (P = 0.43). Of 16 deaths, 15 were in the AIH group and 1 in the ASC group (P = 0.22). Of 11 transplants, 10 were in the AIH group and one in the ASC group (P = 0.53). The presence of cirrhosis at baseline was associated with a smaller survival probability (P = 0.015). The survival rate by Kaplan-Meier method was 94% at 5 years and 80% at 10 years, and was similar in both the groups (P = 0.08).

CONCLUSIONS

No statistically significant difference was observed between the groups in relation to prognosis and response to treatment.

Characterization of allele-specific expression of the X-linked gene MAO-A in trophectoderm cells of bovine embryos produced by somatic cell nuclear transfer

Somatic cell nuclear transfer (SCNT) may affect epigenetic mechanisms and alter the expression of genes related to embryo development and X chromosome inactivation (XCI). We characterized allele-specific expression of the X-linked gene monoamine oxidase type A (MAO-A) in the trophectoderm (TF) of embryos produced by SCNT. Total RNA was isolated from individual biopsies (N = 25), and the allele-specific expression assessed by reverse transcription-polymerase chain reaction-restriction fragment length polymorphism. Both paternal and maternal alleles were expressed in the trophectoderm. However, a higher frequency of the mono-allelic expression of a specific allele was observed (N = 17; 68%), with the remaining samples showing the presence of mRNA from both alleles (N = 8; 32%). Considering that MAO-A is subject to XCI in bovine, our results suggest that SCNT may influence XCI because neither an imprinted (mono-allelic expression in all samples) nor a random (presence of mRNA from both alleles in all samples) pattern of XCI was observed in TF. Due to the importance of XCI in mammalian embryo development and its sensitivity to in vitro conditions, X-linked genes subject to XCI are candidates for use in the development of embryo quality molecular markers for assisted reproduction.

[Application of the Pediatric Index of Mortality 2 in pediatric patients with complex chronic conditions]

OBJECTIVE

To evaluate the performance of the Pediatric Index of Mortality 2 (PIM2) in a pediatric intensive care unit (PICU) with a high prevalence of patients with complex chronic conditions (CCCs), and compare the performance between patients with and without CCCs.

METHODS

A prospective cohort study was conducted in a PICU in Brazil, with patients admitted between 2009 and 2011. The performance was evaluated through discrimination and calibration. Discrimination was assessed by calculating the area under the ROC curve, and calibration was determined using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 677 patients were included in the study, of which 83.9% had a CCC. Overall mortality was 9.7%, with a trend of higher mortality among patients with CCCs when compared to patients without CCCs (10.3% vs. 6.4%, p = 0.27), but with no difference in the mean probability of death estimated by PIM2 (5.9% vs. 5.6%, p = 0.5). Discrimination was considered adequate in the general population (0.840) and in patients with and without CCCs (0.826 and 0.944). Calibration was considered inadequate in the general population and in patients with CCCs (p < 0.0001 and p < 0.0001), but it was considered adequate in patients without CCCs (p = 0.527).

CONCLUSIONS

PIM2 showed poor performance in patients with CCCs and in the general population. This result may be secondary to differences in the characteristics between the study samples (high prevalence of patients with CCCs); the performance of the PIM2 should not be ruled out.

Interleukin-10 receptor signaling in innate immune cells regulates mucosal immune tolerance and anti-inflammatory macrophage function

Intact interleukin-10 receptor (IL-10R) signaling on effector and T regulatory (Treg) cells are each independently required to maintain immune tolerance. Here we show that IL-10 sensing by innate immune cells, independent of its effects on T cells, was critical for regulating mucosal homeostasis. Following wild-type (WT) CD4(+) T cell transfer, Rag2(-/-)Il10rb(-/-) mice developed severe colitis in association with profound defects in generation and function of Treg cells. Moreover, loss of IL-10R signaling impaired the generation and function of anti-inflammatory intestinal and bone-marrow-derived macrophages and their ability to secrete IL-10. Importantly, transfer of WT but not Il10rb(-/-) anti-inflammatory macrophages ameliorated colitis induction by WT CD4(+) T cells in Rag2(-/-)Il10rb(-/-) mice. Similar alterations in the generation and function of anti-inflammatory macrophages were observed in IL-10R-deficient patients with very early onset inflammatory bowel disease. Collectively, our studies define innate immune IL-10R signaling as a key factor regulating mucosal immune homeostasis in mice and humans.

Post-hatching development of in vitro bovine embryos from day 7 to 14 in vivo versus in vitro

This study evaluates the post-hatching development of in vitro-produced (IVP) embryos until Day 14. On Day 7, IVP embryos were either transferred to recipient uteruses or placed in a post-hatching development (PHD) system. As a control group, in vivo-produced (IVV), Day-7 embryos were also transferred to recipient uteruses. All groups were collected on Day 14 and were morphologically evaluated. Day-7 and Day-14 IVV and IVP embryos were used for quantification of eight genes (PLAC8, CD9, SLC2A1, SLC2A3, KRT8, SOD2, HSP1A1, and IFNT2) by reverse transcriptase qPCR. Day-14 embryos from the PHD system were smaller (2.92 ± 0.45 mm) and had a lower embryonic disk diameter (0.14 ± 0.00 mm) than those produced by IVV (24.18 ± 3.71; 0.29 ± 0.03 mm, respectively) or IVP (19.06 ± 2.43; 0.28 ± 0.01 mm) culture and transferred to the uterus (P > 0.05). Day-7 IVP embryos had a higher expression of the HSP1A1, SCL2A1, and SCL2A3 genes than IVV embryos. When these embryos were cultured in the uterus, no differences in gene expression were observed on Day 14. Conversely, Day-14 IVP embryos cultured in the PHD system showed a higher expression of PLAC8, SOD2, and SLC2A3 genes. It is concluded that Day-7 IVP embryos are different from IVV embryos in regards to gene expression, although exposure to the uterine environment during the elongation period allowed the IVP embryos to overcome this difference. In contrast, IVP embryos cultured in the PHD system were morphologically and molecularly different, being of poorer quality than those cultured in the uterus.

Accuracy of echogenic periportal enlargement image in ultrasonographic exams and histopathology in differential diagnosis of biliary atresia

OBJECTIVES

To define the sensitivity, specificity and accuracy of the ultrasound triangular cord sign and hepatic histopathology, in isolation or in combination, for diagnostic differentiation between biliary atresia and intrahepatic cholestasis.

METHODS

This was a retrospective study carried out between January 1990 and December 2004. Fifty-one cases of biliary atresia and 45 of intrahepatic cholestasis were analyzed. Histopathology was performed blind by a pathologist. The triangular cord sign was identified in ultrasound reports as the only diagnostic sign of biliary atresia. Sensitivity, specificity and accuracy were calculated for the triangular cord sign and histology both in isolation and in combination. The gold standard for diagnosis of biliary atresia was the appearance of the extrahepatic biliary tree via laparotomy.

RESULTS

The triangular cord sign alone had sensitivity of 49%, specificity of 100% and accuracy of 72.5%. Histopathology compatible with extrahepatic biliary obstruction alone had 90.2% sensitivity, 84.6% specificity and 87.8% accuracy. The triangular cord sign and histopathology in isolation or combination resulted in sensitivity of 93.2%, specificity of 85.7% and accuracy of 90.3%.

CONCLUSIONS

Finding the triangular cord sign on ultrasound is an indication for laparotomy. If the triangular cord sign is negative, liver biopsy is indicated; if histopathology reveals signs of biliary atresia, explorative laparotomy is indicated. In cases where the triangular cord sign is absent and histopathology indicates neonatal hepatitis or other intrahepatic cholestasis, clinical treatment or observation are recommended in accordance with the diagnosis.

Coagulation disorder in children and adolescents with moderate to severe traumatic brain injury

OBJECTIVES

To describe the epidemiological profile of children and adolescents with moderate to severe traumatic brain injury admitted to an intensive care unit; to describe the frequency of coagulation disorders in these patients; to determine the relationship between coagulopathy and trauma severity; to assess the factors associated with coagulopathy; and to assess the effect of coagulopathy on the mortality of these patients.

METHODS

Cross-sectional study with 301 patients aged up to 16 years admitted to an intensive care unit due to moderate to severe traumatic brain injury, carried out over a 5-year period. The coagulation profile was associated with clinical, epidemiological and CT findings. Univariate and multivariate analyses were used to check the association between coagulopathy and mortality.

RESULTS

Minimum age was 23 days, and maximum age was 16 years (mean of 7.9 years). About 77% of patients had coagulopathy, whose occurrence was directly associated with the severity of the trauma, but not with the rise in mortality. The factors associated with the presence of coagulopathy were the following: severity of the traumatic brain injury (OR=2.83; 95%CI 1.58-5.07), diagnosis of brain swelling on cranial computed tomography (OR=2.11; 95%CI 1.13-4.07) and occurrence of chest and/or abdominal injury (OR=2.07; 95%CI 1.11-4.00). Approximately 35% of patients died. The multivariate analysis showed that the factors associated with an increased risk of death were presence of sodium disorders (OR=5.56; 95%CI 2.90-10.65), hypotension in the intensive care unit (OR=12.58; 95%CI 4.40-35.00) and acute respiratory distress syndrome (OR=13.57; 95%CI 1.51-121.66).

CONCLUSION

The development of coagulopathy is a frequent complication in patients with moderate to severe traumatic brain injury. Even though it is not closely associated with death in this study, it may be regarded as a marker of injury severity.

Portal vein thrombosis in children and adolescents

OBJECTIVE

To review the literature on portal vein thrombosis in children and adolescents, focusing on its diagnosis, complications and treatment.

SOURCES OF DATA

The medical literature of the past 10 years was reviewed using the PubMed and MEDLINE search engines, with major focus on portal vein thrombosis and its clinical outcomes. The following keywords or expressions were used for the web search: portal vein thrombosis, extra-hepatic portal vein obstruction, prognosis, children, portal hypertension, esophagogastric varices. Additionally, we also reviewed the articles cited in the references of the initially selected papers, as well as relevant textbooks.

SUMMARY OF THE FINDINGS

Portal vein thrombosis is one of the most common causes of portal hypertension among children. The initial clinical manifestation is characterized either by episodes of upper gastrointestinal bleeding or by splenomegaly on routine clinical examination. The major complications include upper gastrointestinal bleeding, hypersplenism secondary to splenomegaly, growth retardation, and portal biliopathy. The diagnosis is made by abdominal Doppler ultrasonography. Treatment is targeted at the complications and includes primary and secondary prophylaxis against upper gastrointestinal bleeding (which results from the rupture of esophageal varices), and portosystemic shunting in selected cases.

CONCLUSIONS

Portal vein thrombosis is one of the major triggers of upper gastrointestinal bleeding in children. Bleeding episodes have a remarkable effect on the quality of life of affected patients. Thus, appropriate diagnosis and treatment are needed in order to reduce morbidity and mortality.

[Type 1 autoimmune hepatitis in children and adolescents: assessment of immunosuppressive treatment withdrawal]

OBJECTIVE

To assess treatment withdrawal in children and adolescents with autoimmune hepatitis, with clinical and laboratory remission for a minimum period of 24 months, determining the relapse rate after treatment withdrawal.

METHODS

This is a descriptive, retrospective and partially prospective study of 21 children and adolescents with type 1 autoimmune hepatitis treated at the Outpatient Division of Pediatric Hepatology, Teaching Hospital of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil, between January 1986 and December 2001.

RESULTS

We assessed 54 patients and selected 21, of whom 19 were female subjects (90.5%), aged between 5.7 and 17.6 years (median = 13.8 years), with a mean follow-up of 5.1+/-2.4 years (median = 4.4 years) and an average clinical and laboratory remission of 4.1+/-1.5 years (median = 4.1 years). Out of the 21 patients studied, 10 (47.6%) manifested some inflammatory activity that prevented the discontinuation of treatment, which was withdrawn in 11 patients (52.4%). Out of these, six patients (54.5%) presented reactivation of the disease and five maintained clinical and laboratory remission with a mean follow-up of 4+/-1 years (median = 3.9 years). The time interval between discontinuation of treatment and reactivation of the disease ranged from 29 days to 40.3 months (median = 2.2 months).

CONCLUSIONS

We observed a high relapse rate (54.5%) in this group of patients with autoimmune hepatitis, which was more frequent within the first 12 months after treatment withdrawal, in addition to a high number of patients that presented some degree of inflammatory activity despite the long period of clinical and laboratory remission.

[Type 1 autoimmune hepatitis in children and adolescents: assessment of immunosuppressive treatment withdrawal]

OBJECTIVE

To assess treatment withdrawal in children and adolescents with autoimmune hepatitis, with clinical and laboratory remission for a minimum period of 24 months, determining the relapse rate after treatment withdrawal.

METHODS

This is a descriptive, retrospective and partially prospective study of 21 children and adolescents with type 1 autoimmune hepatitis treated at the Outpatient Division of Pediatric Hepatology, Teaching Hospital of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil, between January 1986 and December 2001.

RESULTS

We assessed 54 patients and selected 21, of whom 19 were female subjects (90.5%), aged between 5.7 and 17.6 years (median = 13.8 years), with a mean follow-up of 5.1+/-2.4 years (median = 4.4 years) and an average clinical and laboratory remission of 4.1+/-1.5 years (median = 4.1 years). Out of the 21 patients studied, 10 (47.6%) manifested some inflammatory activity that prevented the discontinuation of treatment, which was withdrawn in 11 patients (52.4%). Out of these, six patients (54.5%) presented reactivation of the disease and five maintained clinical and laboratory remission with a mean follow-up of 4+/-1 years (median = 3.9 years). The time interval between discontinuation of treatment and reactivation of the disease ranged from 29 days to 40.3 months (median = 2.2 months).

CONCLUSIONS

We observed a high relapse rate (54.5%) in this group of patients with autoimmune hepatitis, which was more frequent within the first 12 months after treatment withdrawal, in addition to a high number of patients that presented some degree of inflammatory activity despite the long period of clinical and laboratory remission.

[Autoimmune hepatitis in children and adolescents: clinical study, diagnosis and therapeutic response]

OBJECTIVE

The aim of this study was to evaluate the clinical, laboratory and histopathological characteristics and the response to immunosuppression in children and adolescents with autoimmune hepatitis (AIH).

METHODS

The present research is a descriptive study consisting of 39 children and adolescents with AIH who receive care at the Department of Pediatric Gastroenterology of Hospital das Clínicas (UFMG) from 1986 to 1998.

RESULTS

Children's age ranged from 1.6 to 17 years (mean 8.7 +/- 3.49), most of them were females (87.2%). There were three types of clinical presentations: chronic (53.9%), acute (41%), and serious hepatic failure (5.1%). The most relevant laboratory parameters were the aminotransferases and gamma-globulin increase. Antinuclear antibodies were positive in 66.7% of the patients, while smooth muscle antibodies were positive in 52.8% and anti-LKM1 in 3% of the patients. In the histopathology the most important findings were the piecemeal necrosis (93.7%), moderate to severe portal inflammation (78.1%), definitive or incomplete cirrhosis (76.9%), absence of lesion of biliary ducts (93.7%) and presence of rosettes (90.6%). During the treatment, 77.8% obtained complete resolution, associated to side effects in 27.8% of them. Seven patients died (17.9%). During the treatment there was significant z score reduction (p<0.05) for height/age.

CONCLUSIONS

After carrying out this study, we observed that the typical characteristics of AIH were: female sex, several clinical presentations, increased aminotransferase, and hypergammaglobulinemia. Histopathology showed a predominance of incipient and/or definitive cirrhosis associated with moderate to severe portal inflammation and piecemeal necrosis. Treatment using corticosteroids and azathioprine, turned out to be effective. However, the reduction in the height/age z score probably represents an adverse effect of corticoid treatment.

Soybean genetic map of RAPD markers assigned to an existing scaffold RFLP map

A 356-marker linkage map of Glycine max (L.) Merr. (2n = 20) was established by anchoring 106 RAPD markers to an existing RFLP map built with a large recombinant inbred line population (330 RILs). This map comprises 24 major and 11 minor linkage groups for this genome which is estimated to be approximately 3,275 cM. The RAPD markers show similar distribution throughout the genome and identified similar levels of polymorphism as the RFLP markers used in the framework. By using a subset population to anchor the RAPD markers, it was possible to enhance the throughput of selecting and adding reliable marker loci to the existing map. The procedures to generate a dependable genetic linkage map are also described in this report.

N-terminal chimeric constructs improve the expression of sarcoplasmic reticulum Ca(2+)-ATPase in yeast

Wild-type and chimeric constructs comprising rabbit sarcoplasmic reticulum (SR) Ca(2+)-ATPase and the N-terminal cytoplasmic portion of yeast plasma membrane H(+)-ATPase were expressed in yeast under control of a heat-shock regulated promoter. The wild-type ATPase was found predominantly in endoplasmic reticulum (ER) membranes. Addition of the first 88 residues of H(+)-ATPase to the Ca(2+)-ATPase N-terminal end promoted a marked shift in the localization of chimeric H(+)/Ca(2+)-ATPase which accumulated in a light membrane fraction associated with yeast smooth ER. Furthermore, there was a three-fold increase in the overall level of expression of chimeric H(+)/Ca(2+)-ATPase. Similar results were obtained for a chimeric Ca(2+)-ATPase containing a hexahistidine sequence added to its N-terminal end. Both H(+)/Ca(2+)-ATPase and 6xHis-Ca(2+)-ATPase were functional as demonstrated by their ability to form a phosphorylated intermediate and undergo fast turnover. Conversely, a replacement chimera in which the N-terminal end of SR Ca(2+)-ATPase was replaced by the corresponding segment of H(+)-ATPase was not stably expressed in yeast membranes. These results indicate that the N-terminal segment of Ca(2+)-ATPase plays an important role in enzyme assembly and contains structural determinants necessary for ER retention of the ATPase.

RAPD marker estimation of genetic structure among isolated northern leopard frog populations in the south-western USA

Amphibians in the south-western United States are currently experiencing population declines. Causal explanations for these population changes as well as the implementation of sound management practices requires an understanding of the genetic structure of natural amphibian populations. To this end, we estimated genetic differences within and among seven isolated populations of northern leopard frogs, Rana pipiens, from Arizona and southern Utah using random amplified polymorphic DNA (RAPD) analyses. Fourteen arbitrarily designed primers detected 38 polymorphic loci in 85 individual frogs. Three types of population structure were observed in this study. (i) Two populations showed low genetic diversity (D = 0.10 and 0.04) and may have been established by relatively recent events. (ii) Two were not genetically distinct and exhibited a high degree of within-population diversity (D = 0.35). The possibility of gene flow between these populations is high due to their geographical proximity and their shared genetic structure. (iii) Three populations were genetically distinct from each other and the other populations, and exhibited intermediate within-population variation (D = 0.19, 0.17, 0.14). Genetic distances among the seven populations ranged from 0.00 to 0.20, suggesting that some of these leopard frog populations are genetically distinct. Although based on relatively small samples, these data suggest that leopard frog populations in the south-west are likely to represent unique genetic entities worthy of conservation. The management implications of these results are that isolated leopard frog populations should be evaluated on an individual basis to best preserve them.