Association of the minimal cyclophosphamide equivalent dose and outcome of microdissection testicular sperm extraction in patients with persistent azoospermia after chemotherapy

Objective

To investigate whether the minimal cyclophosphamide equivalent dose (mCED), a novel approach for estimating alkylating agent exposure, is associated with the sperm retrieval rates by microdissection testicular sperm extraction (mTESE) in azoospermic postchemotherapy cancer survivors.

Design

A retrospective cohort study conducted between 2002 and 2017.

Setting

An academic medical center.

Patients

A total of 28 azoospermic postchemotherapy cancer survivors who underwent mTESE.

Interventions

Chemotherapy exposure and mCED calculation.

Main Outcome Measures

The primary outcome was the association between the mCED and sperm retrieval rate using mTESE. The mCED value for each patient's regimen received was estimated using the lowest recommended dosing regimen from the range of recommended doses at the time of administration.

Results

Spermatozoa were successfully retrieved in 11 (39.3%) of the patients. Age at the time of receiving chemotherapy and mCED were significant factors associated with sperm retrieval. An mCED of <4,000 mg/m2 had a higher sperm retrieval rate (10/14, 71.4%) than an mCED of >4,000 mg/m2 (0/8, 0). The hormone levels were not significantly different when comparing patients with and without successful sperm retrieval. Seminoma, nonseminomatous germ cell tumor, and acute lymphoblastic leukemia had favorable sperm retrieval rates-100% (2/2), 66.7% (2/3), and 66.7% (2/3), respectively-although the numbers of patients in each group were small.

Conclusion

Among this cohort of patients with cancer who required chemotherapy regimens, successful sperm retrieval by mTESE was only noted among cancer survivors receiving an mCED of <4,000 mg/m2.

Characteristics of men who use direct-to-consumer men's health telemedicine services

The characteristics of men who use direct-to-consumer (DTC) men's health services are not well understood. We conducted an online survey of adult men via ResearchMatch, assessing sociodemographic data, health behaviors, and concern for low testosterone and infertility. Logistic regression estimated the association between participant characteristics and familiarity with and reported use of DTC services such as Hims® and Roman®. Among 1276 men surveyed, 62.2% were concerned about low testosterone. While almost half (48.5%) were familiar with men's DTC health services, only 37 (2.9%) reported using these services. On multivariable analysis, men who used DTC men's health services were more likely to be younger (age 18-39: odds ratio [OR] 2.94, 95% confidence interval [CI] 1.03-8.38, p = 0.04; age 40-59: OR 3.26, CI 1.17-9.10, p = 0.02; referent age ≥60), have annual income between $75k and $100k (OR 5.25, CI 1.39-19.87.45, p = 0.02), and be concerned about low testosterone (OR 3.81, CI 1.46-9.96, p = 0.01). In conclusion, younger men and those with mid-range incomes were more likely to use online DTC men's health services compared to older or wealthier men. Likewise, men with concerns about low testosterone were more likely to use DTC services, but other health-conscious behaviors and frequency of doctor visits did not predict use.

Donor-derived duodenal adenocarcinoma of a bladder-drained pancreas allograft

The subset of the population that received bladder-drained allograft pancreata during peak utilization of the technique in the 1990s is approaching 20-30 postoperative years. This time frame is salient, as it parallels the time in which patients in the urologic literature develop adenocarcinomas after bladder reconstruction using gastrointestinal segments. We present the case of a 57-year-old simultaneous pancreas/kidney recipient who presented with microhematuria twenty-four years after transplantation and was found to have an adenocarcinoma of the duodenum of his failed, bladder-drained pancreas. After allograft pancreatectomy/duodenectomy, he remains disease-free eleven months postoperatively. As this patient population ages, practitioners should consider pathology of the donor duodenum and pancreas in recipients who present with gross or microscopic hematuria.

POS0098 LINC01871, IMPLICATED IN SJÖGREN’S DISEASE PATHOGENESIS, IS REGULATED BY INTERFERON-G AND CALCINEURIN SIGNALING

Background

Sjögren’s disease (SjD) is an autoimmune disease characterized by exocrine gland dysfunction. Long non-coding RNAs (lncRNAs) are a functionally diverse class of non-protein coding RNAs that are longer than 200 nucleotides. Our previous study using whole blood RNA-seq found that lncRNA, LINC01871, is overexpressed in SjD relative to controls [1]. CRISPR-Cas9 targeting in HSB2 T cells yielded a LINC01871-/- clone with altered expression of many genes implicated in immune regulation [1].

Objectives

The goal of this study was to analyze the gene expression perturbations resulting from the loss of LINC01871 and to characterize the regulation of LINC01871 in both the LINC01871-/- clone and primary human T cells in response to immune stimuli.

Methods

Flow cytometry and LegendPlex bead assays were used to compare surface and secreted protein expression changes, respectively, in LINC01871-/- cells and the parental HSB2 cells. Parental HSB2 T cells, LINC01871-/- cells, Kasumi-3 myeloid cells, and primary human T cells were stimulated in vitro and changes in gene expression were measured over time using qRT-PCR. Responses to interferons (IFN) were assessed using universal type I IFN (IFNα) or IFNγ. TCR signaling responses were assessed using PMA/Ionomycin (PMA/I) or anti-CD3/CD28 stimulations in the presence or absence of the calcineurin inhibitor, FK506.

Results

Previous RNA-seq analysis found 1166 differentially expressed (DE) transcripts (log2FC ≥1 or ≤-1; padj ≤0.05) in LINC01871-/- cells compared to parental HSB2 cells, including many prominent immune regulatory genes. Changes in the basal expression of 7 proteins in LINC01871-/- cells were confirmed using flow cytometry (significantly decreased: CD8a (p=0.0004), CD30 (p=0.0008), CXCR3 (p=0.037), T-Bet (p=0.0002), and Aiolos (p=0.02); significantly increased: CD226 (p=0.0059) and CD44 (p=0.024)). Analysis of LINC01871-/- cells revealed a growth inhibition in LINC01871-/- cells (p=0.0014 at 72h), in which multiple secreted growth and adhesion factors were significantly reduced: GM-CSF (p=2.0e-06), M-CSF (p=2.7e-09), IGBPF4 (p=1.2e-07), s-ICAM1 (p=0.015), MMP9 (p=3.0e-14), and MMP2 (p=6e-08). In contrast, the IL-6 cytokine family member, LIF, was significantly increased in LINC01871-/- cells (p=1.2e-07). Because HSB2 cells were not responsive to all IFNs, IFN-mediated regulation of LINC01871 expression was examined in the Kasumi-3 myeloid cell line. While LINC01871 expression was not modulated by type I IFN stimulation, it was robustly responsive to IFNγ treatment. Since LINC01871 was expressed in T cells and implicated in T cell pathways, responses to TCR signaling pathways were characterized in HSB2 cells or purified primary human T cells treated with PMA/I. In both cell types, LINC01871 exhibited a prolonged decrease in expression that was abrogated by concurrent treatment with FK506, indicating that LINC01871 is regulated by calcineurin signaling. Treatment of primary human T cells with anti-CD3/CD28 to mimic true TCR engagement resulted in a modest decrease of LINC01871 expression at early time points, followed by an increase in expression with longer stimulation (2d).

Conclusion

Our findings suggest that LINC01871 is a potential mediator of the dysregulated T cell inflammatory response pathways implicated in SjD pathogenesis. LINC01871 influences the expression of many important immune cell genes and growth factors, is inducible by IFNγ, and is regulated directly by calcineurin signaling and TCR ligand engagement. Although LINC01871 functions are still unknown, observed LINC01871 overexpression in whole blood of SjD cases and after prolonged TCR stimulation in primary human T cells suggests that it could be a biomarker of SjD.

References

[1]Joachims, et al. Annals of the Rheumatic Diseases 2020;79:90.

Disclosure of Interests

Michelle L Joachims: None declared, Bhuwan Khatri: None declared, Chuang Li: None declared, Kandice L Tessneer: None declared, John Ice: None declared, Anna M Stolarczyk: None declared, Nicolas Means: None declared, Kiely Grundahl: None declared, Stuart Glenn: None declared, Jennifer Kelly: None declared, David Lewis: None declared, Lida Radfar: None declared, Donald Stone: None declared, Joel Guthridge: None declared, Judith A. James: None declared, R Hal Scofield: None declared, Graham B Wiley: None declared, Jonathan Wren: None declared, Patrick M Gaffney: None declared, Courtney Montgomery: None declared, Kathy Sivils Employee of: Current employee of Janssen., Astrid Rasmussen: None declared, A Darise Farris: None declared, Indra Adrianto: None declared, Christopher Lessard: None declared

Perceptions of Infertility and Semen Analysis Testing Among American Men Without Children

OBJECTIVE

To determine whether health-conscious men are more likely to be concerned about infertility and self-initiate semen analysis at a laboratory/clinic or through a direct-to-consumer at-home product without a health care provider recommendation.

METHODS

Cross-sectional survey conducted online via ResearchMatch.org between November 2019 and January 2020. Men age 18 and older without children (n = 634) were included for analysis. Outcomes were likelihood of self-initiating a semen analysis, prevalence of infertility concern.

RESULTS

Of the 634 participants, 186 expressed concern about infertility but only 29% were likely to discuss these concerns with a health care provider. More men would self-initiate a semen analysis using an at-home product than through a traditional laboratory/clinic (14.2% vs 10.4%, P = .04). Odds of self-initiating a traditional semen analysis were higher for men concerned about low testosterone (odds ratio [OR] 2.30, 95% confidence interval [CI] 1.12-4.74, P = .023) and infertility (OR 3.91, 95% CI 2.14-7.15, P <.001). Self-initiating an at-home semen analysis was associated with concern for low testosterone and infertility as well as middle age (age 40-59: OR 3.02, 95% CI 1.16-7.88, P = .024) and fitness tracker use (OR: 1.95, 95% CI 1.12-3.39, P = .018).

CONCLUSION

Many men were unlikely to discuss infertility concerns with a health care provider. Middle aged men and those who used fitness trackers were more likely to self-initiate fertility evaluation through at-home semen analysis. Concern about low serum testosterone was pervasive and strongly associated with concern for being infertile and self-initiating a semen analysis of any kind.

Prevalence of Hyperprolactinemia and Clinically Apparent Prolactinomas in Men Undergoing Fertility Evaluation

OBJECTIVE

To determine prevalence of hyperprolactinemia and prolactinoma among men presenting for initial fertility evaluation.

METHODS

We performed a retrospective review of men presenting for initial fertility evaluation at a tertiary care, academic health system between 1999 and 2018. Men with measured prolactin levels were analyzed to determine prevalence of hyperprolactinemia and prolactinoma. We compared clinical characteristics of men with and without hyperprolactinemia. Univariable and multivariable analysis were used to determine factors associated with hyperprolactinemia. We assessed effects of hyperprolactinemia and prolactinoma on testosterone levels, semen parameters and pregnancy outcomes after treatment.

RESULTS

3,101 men had serum prolactin level measured. 65 (2.1%) had hyperprolactinemia. Patients with hyperprolactinemia had lower testosterone (median 280 ng/dL vs. 313 ng/dL, p=0.038) and lower total motile sperm count (TMSC) (median 7.0 million vs. 34.7 million, p=0.001) compared to men without hyperprolactinemia. 43.1% of men with hyperprolactinemia had oligospermia versus 21.5% of men without hyperprolactinemia (p<0.001). Univariable analysis demonstrated that men with elevated luteinizing hormone (LH) (OR 1.077, p=0.001) and follicle-stimulating hormone (FSH) (OR 1.032, p=0.002) were more likely to have hyperprolactinemia. Men with oligospermia were more likely to have hyperprolactinemia (OR 2.334, p=0.004). On multivariable analysis, neither hormone parameters nor oligospermia were associated with elevated prolactin (p>0.05). Of the 65 men with hyperprolactinemia, 11 (17%) were diagnosed with a prolactinoma, resulting in an overall prevalence of 11 in 3,101 (0.35%).

CONCLUSION

The overall prevalence of prolactinoma in our cohort of men undergoing fertility evaluation was 35-fold higher than the prevalence in the general male population.

Anti-TNF agents and potential effects on male fertility: are men being counseled?

BACKGROUND

Adult men with autoimmune conditions are commonly prescribed anti-tumor necrosis factor (anti-TNF) agents; however, there is a paucity of quality evidence as to their effect on male fertility (e.g. semen parameters and sperm quality). Our objective was to determine if men with autoimmune conditions are being counseled regarding the unknown reproductive effects of anti-TNF agents prior to initiation of therapy.

METHODS

A retrospective analysis of 1010 male patients age 18-45 who were prescribed an anti-TNF agent were assessed for (1) receipt of counseling regarding potential reproductive effects; (2) screening for anatomic or laboratory abnormalities associated with infertility; (3) election for sperm cryopreservation.

RESULTS

Only 10.3% of men received counseling, and this was not associated with age (p = 0.77). Those who received counseling were significantly more likely to have a genitourinary exam performed, be assessed for presence of a varicocele, be asked about or endorse low libido or erectile dysfunction, have a testosterone, LH, FSH, or prolactin level checked, and have a semen analysis performed (all, p < 0.0001). Rates of sperm cryopreservation were low, but statistically higher in men who received counseling (5.77% (+) counseling, 1.10% (-) counseling) (p = 0.002).

CONCLUSIONS

The limited current literature lacks a consensus regarding the short- and long-term male reproductive effects of anti-TNF therapy. Despite this lack of clarity, rates of pre-initiation counseling were low. Rates of sperm cryopreservation, while improved in the counseled group remained low, suggesting prescribing physicians may be unaware of this option for patients.

Underutilization of primary medical care among men presenting for fertility evaluation

Objective

To determine the proportion of men presenting for fertility evaluation who reported having an established primary care physician (PCP).

Design

Retrospective, observational study.

Setting

Academic health center.

Patient(s)

All men presenting for initial male factor infertility consultation with a single reproductive urologist between 2002 and 2018.

Intervention(s)

Men were asked to provide the name of their PCP at the time of initial visit.

Main Outcome Measure(s)

Descriptive statistics characterized the proportion of men with a PCP at the time of evaluation and associations between PCP status and clinical characteristics.

Result(s)

Among 4,127 men presenting for initial fertility consultation, 844 (20.5%) reported having an established PCP, 480 (11.6%) reported no PCP, and 2,803 (67.9%) did not have data available. Among 1,302 men who had a prior primary care visit within our healthcare system, 414 (31.8%) had been seen within 1 year before their fertility evaluation. Men with an established PCP were slightly older than those without a PCP, with higher body mass index, and lower systolic blood pressure. Hormonal profiles were similar across groups, but men with an established PCP had a significantly higher total motile sperm count than those without a PCP, median 53 (interquartile range, 11–109) versus 35 (interquartile range, 8–98).

Conclusion(s)

More than one third of men presenting for fertility evaluation did not have an established PCP. Reproductive urologists are uniquely positioned to facilitate the critical relationship between young men and PCPs, which should be a key component of the male fertility treatment paradigm.

Do partial AZFc deletions affect the sperm retrieval rate in non-mosaic Klinefelter patients undergoing microdissection testicular sperm extraction?

BACKGROUND

The purpose of this study is to evaluate the prognostic factors for sperm retrieval and determine if Y chromosome deletion is associated with deleterious effects on spermatogenesis in non-mosaic Klinefelter patients. Whether Y chromosome deletion determines the sperm retrieval rate in non-mosaic Klinefelter patients has not yet been addressed.

METHODS

We retrospectively collected medical records of azoospermic patients from Sep 2009 to Dec 2018, and enrolled 66 non-mosaic 47, XXY patients who were receiving mTESE. The predictive values of patients age, serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, prolactin, estradiol and Y chromosome deletion were assessed for successful sperm recovery.

RESULTS

Testicular sperm recovery was successful in 24 (36.4%) of 66 men. The mean age (36.0 vs. 36.6 years), and levels of FSH (30.0 vs 36.9 IU/L), LH (17.7 vs 21.9 IU/L), testosterone (2.4 vs. 2.1 ng/ml), prolactin (9.1 vs. 8.8 ng/ml), and estradiol (19.4 vs. 22.3 pg/ml) did not show any significant difference when comparing patients with and without successful sperm retrieval. Partial deletion of azoospermic factor c (AZFc) was noted in 5 (20.8%) of 24 patients with successful sperm retrieval, including three b2/b3 and two gr/gr deletion cases, whereas 4 (9.5%) of 42 patients with unsuccessful sperm retrieval were noted to have AZFc partial deletion (one b2/b3, one sY1206 and two gr/gr deletion), though the difference was not statistically significant (p = 0.27).

CONCLUSION

According to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE.

Sperm retrieval success and testicular histopathology in idiopathic nonobstructive azoospermia

Prior studies have investigated sperm retrieval rates in men with nonobstructive azoospermia (NOA) secondary to specific etiologies, yet most cases of NOA are idiopathic. We compared sperm retrieval rates and testicular histopathology in idiopathic NOA (iNOA) and nonidiopathic NOA (niNOA). We performed a retrospective review of men with NOA who underwent microdissection testicular sperm extraction (microTESE) between 2000 and 2016. Men with no history of malignancy or cryptorchidism and negative genetic evaluation were considered idiopathic. Multivariable regression determined the association between idiopathic etiology and primary outcomes of sperm retrieval and active spermatogenesis on histopathology. Among 224 men, 86 (38.4%) were idiopathic, 75 (33.5%) were nonidiopathic, and 63 (28.1%) did not undergo genetic testing. Median age and serum testosterone were higher among iNOA or no testing versus niNOA. Median follicle-stimulating hormone (FSH) was lower among iNOA or no testing versus niNOA. A higher proportion of iNOA or no testing versus niNOA had a clinical varicocele. Sperm retrieval rates were similar between iNOA, niNOA, and no testing (41.8% vs 48.0% vs 55.6%, respectively; P = 0.255). Active spermatogenesis was seen in a higher proportion of iNOA or no testing versus niNOA (31.4% and 27.0% vs 16.0%, P = 0.073). On multivariable analysis, iNOA was not associated with sperm retrieval or spermatogenesis (P = 0.430 and P = 0.078, respectively). Rates of sperm retrieval and spermatogenesis on testis pathology were similar in men with iNOA and niNOA. These data will be useful to clinicians in preoperative counseling for men with NOA and negative genetic evaluation.

Outcomes of Acellular Dermal Matrix for Immediate Tissue Expander Reconstruction with Radiotherapy: A Retrospective Cohort Study

BACKGROUND

Despite increasing literature support for the use of acellular dermal matrix (ADM) in expander-based breast reconstruction, the effect of ADM on clinical outcomes in the presence of post-mastectomy radiation therapy (PMRT) has not been well described.

OBJECTIVES

To analyze the impact ADM plays on clinical outcomes on immediate tissue expander (ITE) reconstruction undergoing PMRT.

METHODS

We retrospectively reviewed patients who underwent ITE breast reconstruction from 2004 to 2014 at MD Anderson Cancer Center. Patients were categorized into four cohorts: ADM, ADM with PMRT, non-ADM, and non-ADM with PMRT. Outcomes and complications were compared among cohorts.

RESULTS

Over 10 years, 957 patients underwent ITE reconstruction (683 non-ADM, 113 non-ADM with PMRT, 486 ADM, and 88 ADM with PMRT) with 1370 reconstructions. Overall complication rates for the ADM and non-ADM cohorts were 39.0% and 16.7%, respectively (P < 0.001). Within both cohorts, mastectomy skin flap necrosis (MSFN) was the most common complication, followed by infection. ADM use was associated with a significantly higher rate of infections and seromas in both radiated and non-radiated groups; however, when comparing radiated cohorts, the incidence of explantation was significantly lower with the use of ADM.

CONCLUSIONS

The decision to use ADM for expander-based breast reconstruction should be performed with caution, given higher overall rates of complications, including infections and seromas. There may, however, be a role for ADM in cases requiring PMRT, as the overall incidence of implant failure is lower than non-ADM cases.

LEVEL OF EVIDENCE: 3

Clinical Consultation Guide on Imaging in Male Infertility and Sexual dysfunction

Imaging can benefit clinicians in evaluating men with infertility or sexual dysfunction by giving an overview of a patient's overall clinical condition before undertaking an invasive procedure. An understanding of the limitations and advantages of image modalities used in clinical practice will ensure that clinicians can optimize patient care with imaging when necessary. PATIENT SUMMARY: The objective of this article was to review the current literature on imaging modalities used for the diagnosis and management of male infertility and sexual dysfunction. An understanding of the advantages and limitations of these imaging modalities will ensure that clinicians can optimize patient care with imaging when necessary.

Intravenous Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function: A Double-blind, Clinically-integrated, Randomized Trial

BACKGROUND

Mannitol is currently used as a renal protective agent to mitigate the effects of renal ischemia during nephron-sparing surgery (NSS). This routine practice lacks rigorous methodological study.

OBJECTIVE

To assess the effect on renal function outcomes after surgery of mannitol infusion prior to renal ischemia during NSS.

DESIGN, SETTING, PARTICIPANTS

This prospective, randomized, placebo-controlled, double-blind trial included 199 patients with a preoperative estimated glomerular filtration rate (eGFR) >45ml/min/1.73m² scheduled for NSS; the trial was conducted between July 2012 and July 2015.

INTERVENTION

Patients undergoing NSS were randomized to receive mannitol (12.5g) or placebo intravenously within 30min prior to renal vascular clamping.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the difference in eGFR (renal function) between the two groups at 6 mo following surgery assessed with an analysis of covariance model using preoperative eGFR, treatment group, and surgical approach as covariates.

RESULTS AND LIMITATIONS

At baseline, the median age of the patients was 58 yr, and the median eGFR was 88ml/min/1.73m². Comparing placebo with mannitol infusion, the adjusted difference of 0.2 eGFR units at 6 mo was not significant (p=0.9), with the upper bound of the 95% confidence interval (-3.1 to 3.5) excluding a clinically relevant effect of mannitol. Limitations include evaluation of a single mannitol dose and patients all had excellent preoperative renal function.

CONCLUSIONS

Intraoperative 12.5g mannitol infusion during NSS has no demonstrable clinical benefit when compared with standardized fluid hydration in patients with normal preoperative renal function, and its use in this setting is not warranted.

PATIENT SUMMARY

In this randomized trial, patients with normal kidney function who received mannitol during surgery to remove part of their kidney had no better kidney function 6 mo after surgery than those who did not receive mannitol. We conclude that this routine practice should be discontinued.

Urine neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury after kidney surgery

PURPOSE

We evaluated urine NGAL as a marker of acute kidney injury in patients undergoing partial nephrectomy. We sought to identify the preoperative clinical features and surgical factors during partial nephrectomy that are associated with renal injury, as measured by increased urine NGAL vs controls.

MATERIALS AND METHODS

Using patients treated with radical nephrectomy or thoracic surgery as controls, we prospectively collected and analyzed urine and serum samples from patients treated with partial or radical nephrectomy, or thoracic surgery between April 2010 and April 2012. Urine was collected preoperatively and at multiple time points postoperatively. Differences in urine NGAL levels were analyzed among the 3 surgical groups using a generalized estimating equation model. The partial nephrectomy group was subdivided based on a preoperative estimated glomerular filtration rate of less than 60, or 60 ml/minute/1.73 m(2) or greater.

RESULTS

Of 162 patients included in final analysis more than 65% had cardiovascular disease. The median estimated glomerular filtration rate was greater than 60 ml/minute/1.73 m(2) in the radical and partial nephrectomy, and thoracic surgery groups (61, 78 and 84.5 ml/minute/1.73 m(2), respectively). Preoperatively, a 10 unit increase in the estimated glomerular filtration rate was associated with a 4 unit decrease in urine NGAL in the partial nephrectomy group. Postoperatively, urine NGAL in the partial nephrectomy group was not higher than in controls and did not correlate with ischemia time. Patients with partial nephrectomy with a preoperative estimated glomerular filtration rate of less than 60 ml/minute/1.73 m(2) had higher urine NGAL postoperatively than those with a higher preoperative estimated rate.

CONCLUSIONS

Urine NGAL does not appear to be a useful marker for detecting renal injury in healthy patients treated with partial nephrectomy. However, patients with poorer preoperative renal function have higher baseline urine levels and appear more susceptible to acute kidney injury, as detected by urine levels and Acute Kidney Injury Network criteria, than those with a normal estimated glomerular filtration rate.

Clinical and pathologic impact of select chromatin-modulating tumor suppressors in clear cell renal cell carcinoma

BACKGROUND

Historically, VHL was the only frequently mutated gene in clear cell renal cell carcinoma (ccRCC), with conflicting clinical relevance. Recent sequencing efforts have identified several novel frequent mutations of histone modifying and chromatin remodeling genes in ccRCC including PBRM1, SETD2, BAP1, and KDM5C. PBRM1, SETD2, and BAP1 are located in close proximity to VHL within a commonly lost (approximately 90%) 3p locus. To date, the clinical and pathologic significance of mutations in these novel candidate tumor suppressors is unknown.

OBJECTIVE

To determine the frequency of and render the first clinical and pathologic outcome associated with mutations of these novel candidate tumor suppressors in ccRCC.

DESIGN, SETTING, AND PARTICIPANTS

Targeted sequencing was performed in 185 ccRCCs and matched normal tissues from a single institution. Pathologic features, baseline patient characteristics, and follow-up data were recorded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The linkage between mutations and clinical and pathologic outcomes was interrogated with the Fisher exact test (for stage and Fuhrman nuclear grade) and the permutation log-rank test (for cancer-specific survival [CSS]).

RESULTS AND LIMITATIONS

PBRM1, BAP1, SETD2, and KDM5C are mutated at 29%, 6%, 8%, and 8%, respectively. Tumors with mutations in PBRM1 or any of BAP1, SETD2, or KDM5C (19%) are more likely to present with stage III disease or higher (p = 0.01 and p = 0.001, respectively). Small tumors (<4 cm) with PBRM1 mutations are more likely to exhibit stage III pathologic features (odds ratio: 6.4; p = 0.001). BAP1 mutations tend to occur in Fuhrman grade III-IV tumors (p = 0.052) and are associated with worse CSS (p = 0.01). Clinical outcome data are limited by the number of events.

CONCLUSIONS

Most mutations of chromatin modulators discovered in ccRCC are loss of function, associated with advanced stage, grade, and possibly worse CSS. Further studies validating the clinical impact of these novel mutations and future development of therapeutics remedying these tumor suppressors are warranted.

CO2 induced seawater acidification impacts sea urchin larval development I: elevated metabolic rates decrease scope for growth and induce developmental delay

Anthropogenic CO(2) emissions are acidifying the world's oceans. A growing body of evidence is showing that ocean acidification impacts growth and developmental rates of marine invertebrates. Here we test the impact of elevated seawater pCO(2) (129 Pa, 1271 μatm) on early development, larval metabolic and feeding rates in a marine model organism, the sea urchin Strongylocentrotus purpuratus. Growth and development was assessed by measuring total body length, body rod length, postoral rod length and posterolateral rod length. Comparing these parameters between treatments suggests that larvae suffer from a developmental delay (by ca. 8%) rather than from the previously postulated reductions in size at comparable developmental stages. Further, we found maximum increases in respiration rates of +100% under elevated pCO(2), while body length corrected feeding rates did not differ between larvae from both treatments. Calculating scope for growth illustrates that larvae raised under high pCO(2) spent an average of 39 to 45% of the available energy for somatic growth, while control larvae could allocate between 78 and 80% of the available energy into growth processes. Our results highlight the importance of defining a standard frame of reference when comparing a given parameter between treatments, as observed differences can be easily due to comparison of different larval ages with their specific set of biological characters.

Evaluation of three temperature measurement methods used during microwave thermotherapy of prostatic enlargement

Three temperature measurement methods used during microwave thermotherapy of prostatic enlargement are analysed and evaluated using a phantom model. A commercial transurethral microwave thermotherapy (TUMT) system that uses a radiometric thermometer for temperature control was used to heat the phantom. The transient temperature distribution was obtained by using both fibreoptic (which is considered as gold standard) and thermocouple measurements. Both methods are subject to potential measurement errors caused by electromagnetic and/or thermal interference. The error sources are analysed and the measurement methods evaluated. The radiometric temperature and especially its relation to the transient temperature distribution was evaluated based on the fibreoptic and thermocouple measurements. These measurements in principle gave equivalent temperature distributions, and thermal interference was concluded to be the largest source of measurement error. The radiometric measurement method gave qualitative rather than quantitative readings of the temperature, and an underestimation of more than 10 degrees C was obtained for some parts of the heated area. The area that gives most of the radiometric signal was relatively close to the catheter in contrast to previously published results.

Comparative transcriptomic responses to chronic cadmium, fluoranthene, and atrazine exposure in Lumbricus rubellus

Transcriptional responses of a soil-dwelling organism (the earthworm Lumbricus rubellus) to three chemicals, cadmium (Cd), fluoranthene (FA), and atrazine (AZ), were measured following chronic exposure, with the aim of identifying the nature of any shared transcriptional response. Principal component analysis indicated full or partial separation of control and exposed samples for each compound but not for the composite set of all control and exposed samples. Partial least-squares discriminant analysis allowed separation of the control and exposed samples for each chemical and also for the composite data set, suggesting a common transcriptional response to exposure. Genes identified as changing in expression level (by the least stringent test for significance) following exposure to two chemicals indicated a substantial number of common genes (> 127). The three compound overlapping gene set, however, comprised only 25 genes. We suggest that the low commonality in transcriptional response may be linked to the chronic concentrations (approximately 10% EC50) and chronic duration (28 days) used. Annotations of the three compound overlapping gene set indicated that genes from pathways most often associated with responses to environmental stress, such as heat shock, phase I and II metabolism, antioxidant defense, and cation balance, were not represented. The strongest annotation signature was for genes important in mitochondrial function and energy metabolism.

Genetic associations between cathepsin D exon 2 C-->T polymorphism and Alzheimer's disease, and pathological correlations with genotype

Genetic variations represent major risk factors for Alzheimer's disease (AD). While familial early onset AD is associated with mutations in the amyloid precursor protein and presenilin genes, only the e4 allele of the apolipoprotein E (APOE) gene has so far been established as a genetic risk factor for late onset familial and sporadic AD. It has been suggested that the C-->T (224Ala-->Val) transition within exon 2 of the cathepsin D gene (CTSD) might represent a risk factor for late onset AD. The objective of this study was to investigate whether possession of the CTSD exon 2 T allele increases the risk of developing AD, and to determine whether this modulates the amyloid pathology of the disease in conjunction with, or independent of, the APOE e4 allele. Blood samples were obtained from 412 patients with possible or probable AD and brain tissues from a further 148 patients with AD confirmed by postmortem examination. CTSD and APOE genotyping were performed by PCR on DNA extracted from blood, or from frontal cortex or cerebellum in the postmortem cases. Pathological measures of amyloid beta protein (Abeta), as plaque Abeta40 and Abeta42(3) load and degree of cerebral amyloid angiopathy were made by image analysis or semiquantitative rating, respectively. CTSD genotype frequencies in AD were not significantly different from those in control subjects, nor did these differ between cases of early or late onset AD or between younger and older controls. There was no gene interaction between the CTSD T and APOE e4 alleles. The amount of plaque Abeta40 was greater in patients carrying the CTSD T allele than in non-carriers, and in patients bearing APOE e4 allele compared with non-carriers. Possession of both these alleles acted synergistically to increase levels of plaque Abeta40, especially in those individuals who were homozygous for the APOE e4 allele. Possession of the CTSD T allele had no effect on plaque Abeta42(3) load or degree of CAA. Possession of the CTSD T allele does not increase the risk of developing AD per se, but has a modulating effect on the pathogenesis of the disorder by increasing, in concert with the APOE e4 allele, the amount of Abeta deposited as senile plaques in the brain in the form of Abeta40.

Examining child restraint use and barriers to their use: lessons from a pilot study

OBJECTIVE

To determine the suitability of four research methods to measure the rate of child restraint device (CRD) use and incorrect use in New Zealand and obtain data on barriers to CRD use.

DESIGN AND SETTING

To assess the rates of CRD use among vehicles carrying children 8 years of age and under, two methods were piloted-namely, an unobtrusive observational survey and a short interview and close inspection. A self administered questionnaire and focus group interviews were also piloted to assess CRD use, reasons for use and non-use, and to obtain information on barriers to their use. Respondents to all methods except the focus groups were approached in supermarket car park sites at randomly selected times. Focus groups were established with parents identified through early childhood organisations. All methods were assessed on criteria related to efficiency, representativeness, and ability to obtain the necessary data.

RESULTS

The observational survey provided a simple method for identifying rates of CRD use, while the self administered questionnaire obtained data on demographic characteristics and reported the installation and use/non-use of CRDs. The interview/inspection addressed all the questions of both the above methods and enabled incorrect CRD use to be examined. The focus groups provided the most meaningful information of all methods on barriers to CRD use.

DISCUSSION

and conclusion: Advantages and limitations of these methods are discussed and some refinements of the original instruments are proposed. The interview/inspection and focus group methods were identified as being more appropriate for efficiently obtaining reliable data on CRD use and identification of barriers to CRD use.

A hybrid equation for simulation of perfused tissue during thermal treatment

Bio-heat equations (BHEs) are necessary for predicting tissue temperature during thermal treatment. For some applications, however, existing BHEs describe the convective heat transfer by the blood perfusion in an unsatisfactory way. The two most frequently used equations, the BHE of Pennes and the k(eff) equation, use for instance either a heat sink or an increased thermal conductivity in order to account for the blood perfusion. Both these methods introduce modelling inaccuracies when applied to an ordinary tissue continuum with a variety of vessel sizes. In this study, a hybrid equation that includes both an increased thermal conductivity and a heat sink is proposed. The equation relies on the different thermal characteristics associated with small, intermediate and large sized vessels together with the possibilities of modelling these vessels using an effective thermal conductivity in combination with a heat sink. The relative importance of these two terms is accounted for by a coefficient beta. For beta = 0 and beta = 1, the hybrid equation coincides with the BHE of Pennes and the k(eff) equation, respectively. The hybrid equation is used here in order to simulate temperature fields for two tissue models. The temperature field is greatly affected by beta, and the effect is dependent on, e.g. the boundary conditions and the power supply. Since the BHE of Pennes and the k(eff) equation are included in the hybrid equation, this equation can also be useful for evaluation of the included equations. Both these heat transfer modes are included in the proposed equation, which enables implementation in standard thermal simulation programmes.

Analysis of temperature measurement for monitoring radio-frequency brain lesioning

During ablative neurosurgery of movement disorders, for instance therapy of Parkinson's disease, temperature monitoring is crucial. This study aims at a quantitative comparison of measurement deviations between the maximum temperature located outside the lesioning electrode and two possible thermocouple locations inside the electrode. In order to obtain the detailed temperature field necessary for the analysis, four finite element models associated with different surroundings and with different power supplies are studied. The results from the simulations show that both the power level and the power density as well as the surrounding medium affect the temperature measurement and the temperature field in general. Since the maximum temperature is located outside the electrode there will always be a deviation in time and level between the measured and the maximum temperature. The deviation is usually 2-7 s and 3-12 degrees C, depending on, for example, the thermocouple location and surrounding medium. Therefore, not only the measured temperature but also the relation between measured and maximum temperature must be accounted for during therapy and device design.

Prompt Optical Observations of Gamma-Ray Bursts

The Robotic Optical Transient Search Experiment (ROTSE) seeks to measure simultaneous and early afterglow optical emission from gamma-ray bursts (GRBs). A search for optical counterparts to six GRBs with localization errors of 1 deg2 or better produced no detections. The earliest limiting sensitivity is mROTSE>13.1 at 10.85 s (5 s exposure) after the gamma-ray rise, and the best limit is mROTSE>16.0 at 62 minutes (897 s exposure). These are the most stringent limits obtained for the GRB optical counterpart brightness in the first hour after the burst. Consideration of the gamma-ray fluence and peak flux for these bursts and for GRB 990123 indicates that there is not a strong positive correlation between optical flux and gamma-ray emission.

A comparison between in vitro studies of protein lesions generated by brain electrodes and finite element model simulations

The aim of this study was to develop a finite element model for simulation of the thermal characteristics of brain electrodes and to compare its performances with an in vitro experimental albumin model. Ten lesions were created in albumin using a monopolar electrode connected to a Leksell Neuro Generator and a computer-assisted video system was used to determine the size of the generated lesions. A finite element model was set up of the in vitro experiments using the same thermal properties. With a very simple heat source applied to the finite element model in the proximity of the upper part of the tip, a good agreement (no deviations in width and distance from tip but a deviation in length of -1.6 mm) with the in vitro experiments (width 4.6 +/- 0.1 mm and length 7.4 +/- 0.1 mm) was achieved when comparing the outline of the lesion. In addition, a gelatinous albumin-model was set up and compared to computer simulations resulting in deviations in width of -0.4 mm, length of -2.2 mm and distance from the tip of -0.1 mm. Hence, the utilisation of finite element model simulations may be a useful complement to in-vitro experiments.

A cost-effectiveness study of changing medical practice in early pregnancy

Until recent years women with symptoms consistent with miscarriage either referred themselves or were referred by their doctors to the local Accident and Emergency (A&E) department. This generally resulted in admission to a gynaecological ward and delayed treatment. This paper examines the costs and benefits of an early pregnancy assessment clinic (EPAC), at a teaching hospital in North East England, to deal with the complications in the first trimester. The data show clear benefits together with cost savings. There is an unambiguous policy recommendation to implement the proposed clinic. The paper examines the delivery of service provision and the impact on referral patterns to the A&E department and raises the issue of care provision at the margin. Finally, the authors show the results of an evaluative survey of the clinic from returns of a questionnaire sent to and completed by local general practitioners.

Computerized polymorphic marker identification: experimental validation and a predicted human polymorphism catalog

A computational system for the prediction of polymorphic loci directly and efficiently from human genomic sequence was developed and verified. A suite of programs, collectively called POMPOUS (polymorphic marker prediction of ubiquitous simple sequences) detects tandem repeats ranging from dinucleotides up to 250 mers, scores them according to predicted level of polymorphism, and designs appropriate flanking primers for PCR amplification. This approach was validated on an approximately 750-kilobase region of human chromosome 3p21.3, involved in lung and breast carcinoma homozygous deletions. Target DNA from 36 paired B lymphoblastoid and lung cancer lines was amplified and allelotyped for 33 loci predicted by POMPOUS to be variable in repeat size. We found that among those 36 predominately Caucasian individuals 22 of the 33 (67%) predicted loci were polymorphic with an average heterozygosity of 0.42. Allele loss in this region was found in 27/36 (75%) of the tumor lines using these markers. POMPOUS provides the genetic researcher with an additional tool for the rapid and efficient identification of polymorphic markers, and through a World Wide Web site, investigators can use POMPOUS to identify polymorphic markers for their research. A catalog of 13,261 potential polymorphic markers and associated primer sets has been created from the analysis of 141,779,504 base pairs of human genomic sequence in GenBank. This data is available on our Web site (pompous.swmed.edu) and will be updated periodically as GenBank is expanded and algorithm accuracy is improved.

A cost-effectiveness study of changing medical practice in early pregnancy

Until recent years women with symptoms consistent with miscarriage either referred themselves or were referred by their doctors to the local Accident and Emergency (A&E) department. This generally resulted in admission to a gynaecological ward and delayed treatment. Examines the costs and benefits of an Early Pregnancy Assessment Clinic (EPAC), at a teaching hospital in North East England, to deal with the complications in the first trimester. The data show clear benefits together with cost savings. There is an unambiguous policy recommendation to implement the proposed clinic. Examines the delivery of service provision and the impact on referral patterns to the A&E department. Raises the issue of care provision at the margin. Finally, shows the results of an evaluative survey of the clinic from returns of a questionnaire sent to and completed by local general practitioners.

Pediatric bacterial meningitis: is prior antibiotic therapy associated with an altered clinical presentation?

STUDY HYPOTHESIS

The clinical features of children treated with oral antibiotics before the diagnosis of bacterial meningitis differ from those who receive no antibiotics.

DESIGN

Retrospective case series.

SETTING

University medical center.

PARTICIPANTS

Two hundred fifty-eight children 24 months old or younger with bacterial meningitis hospitalized during a 12-year period. Eighty-three children were treated with oral antibiotics before the diagnosis of meningitis, and 175 children were not.

INTERVENTIONS

None.

METHODS

The emergency department chart and hospital records were reviewed for presenting demographic, historical, physical examination, and laboratory features. Clinical features of pretreated and untreated patients were compared.

RESULTS

Pretreated children demonstrated less frequent temperature of 38.3 C or higher, altered mental status and a longer duration of symptoms before diagnosis, with more frequent vomiting; ear, nose, and throat infections; and physician visits in the week before detection of meningitis (P less than .05 for all comparisons). There was no difference in incidence of upper respiratory symptoms, seizures, nuchal rigidity, Kernig's and Brudzinski's signs, focal neurologic signs, mortality, and length of hospitalization between groups.

CONCLUSION

Clinical features of children who have taken antibiotics before the detection of meningitis differ significantly from those who have not undergone antibiotic therapy. Physicians should be aware of these differences when evaluating young children on antibiotics for the possibility of meningitis.