Commentary on "DNA damage response and repair gene alterations are associated with improved survival in patients with platinum-treated advanced urothelial carcinoma."

PURPOSE

Platinum-based chemotherapy remains the standard treatment for advanced urothelial carcinoma by inducing DNA damage. We hypothesize that somatic alterations in DNA damage response and repair (DDR) genes are associated with improved sensitivity to platinum-based chemotherapy.

EXPERIMENTAL DESIGN

Patients with diagnosis of locally advanced and metastatic urothelial carcinoma treated with platinum-based chemotherapy who had exon sequencing with the Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets (MSK-IMPACT) assay were identified. Patients were dichotomized based on the presence/absence of alterations in a panel of 34 DDR genes. DDR alteration status was correlated with clinical outcomes and disease features.

RESULTS

One hundred patients were identified, of which 47 harbored alterations in DDR genes. Patients with DDR alterations had improved progression-free survival (9.3 vs. 6.0 months, log-rank P = 0.007) and overall survival (23.7 vs. 13.0 months, log-rank P = 0.006). DDR alterations were also associated with higher number mutations and copy-number alterations. A trend toward positive correlation between DDR status and nodal metastases and inverse correlation with visceral metastases were observed. Different DDR pathways also suggested variable effect on clinical outcomes.

CONCLUSIONS

Somatic DDR alteration is associated with improved clinical outcomes in platinum-treated patients with advanced urothelial carcinoma. Once validated, it can improve patient selection for clinical practice and future study enrollment.

An effective system to measure and report quality indicators in acute medical units

The Society for Acute Medicine has developed a number of clinical quality indicators by which all UK Acute Medicine Units can bench mark their activity. These will help to ensure high quality care for patients, inform the continuing development of acute medical services and demonstrate the positive impact of this new specialty. Prospective collection of these data may be a challenge for many busy units. This paper describes a local solution developed in house in a North East hospital. It demonstrates how the data collected can be analysed to assess the effect of changes in consultant presence on the unit and also time taken for patients to be seen by a doctor. The limitations of the system and potential for future development are considered.

Unusual presentation of adenoid cystic carcinoma of the maxillary antrum

Unusual presentation of adenoid cystic carcinoma of the maxillary antrum. Adenoid cystic carcinoma (ACC) is a rare tumour which affects mainly the major and accessory salivary glands. It is an aggressive neoplasm characterized by early neural invasion and a high incidence of local recurrence and distant metastases, which may develop years after the initial resection. Surgery followed by radiotherapy seems to be the best treatment. Based on a well-illustrated case of extensive maxillary ACC involving the palate, orbit floor, and pterygo-palatine fossa, we discuss the prognosis and the importance of an early diagnosis of ACC.

All-cause and cardiovascular mortality in diabetic subjects increases significantly with reduced estimated glomerular filtration rate (eGFR): 10 years' data from the South Tees Diabetes Mortality study

AIMS

To investigate the association between estimated glomerular filtration rate (eGFR) and total and cardiovascular mortality in a population-based cohort of diabetic subjects.

METHODS

A longitudinal study using a population-based district diabetes register comprising 3288 subjects in South Tees, UK. The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Patients were stratified by baseline eGFR into five stages as per the National Kidney Foundation guidelines: Stage 1, eGFR > 90; Stage 2, eGFR 60-89; Stage 3, eGFR 30-59; Stage 4, eGFR 15-29; and Stage 5, eGFR < 15 ml/min per 1.73 m(2). Main outcome was all-cause and cardiovascular mortality between 1 January 1994 and 31 July 2004.

RESULTS

At baseline, mean age (58.4 years) differed between groups. Persons with lower eGFR were older (P < 0.001). Thirty-six percent (n = 1193, males 56%) had died by 10 years (cardiovascular cause in 60%). Median follow-up was 10.5 years amounting to 28 342 person years. Stages 4 and 5 (eGFR <or= 29 ml/min per 1.73 m(2)) were amalgamated for mortality analysis. Total and cardiovascular mortality increased with reduced eGFR. Adjusted hazard ratios (HR) [95% confidence interval (CI)] for all-cause mortality comparing groups 2 and 3, and 4 and 5 combined with group 1 were 1.28 (1.02, 1.60), 2.58 (2.05, 3.25) and 6.42 (4.25, 9.71), respectively. Adjusted HRs (95% CI) for mortality due to circulatory disease comparing groups 2 and 3, and 4 and 5 combined with group 1 were 1.50 (1.10, 2.06), 3.32 (2.41, 4.58) and 7.99 (4.69, 13.62), respectively.

CONCLUSIONS

In diabetic subjects, mortality increases significantly with reduced GFR. Low eGFR identifies patients at high risk of cardiovascular mortality who should be targeted for aggressive risk factor modification.

Definition of nursing: 2

In the first article of this two-part series, Nancy Roper attempted to answer the question 'What is nursing?' by recollecting past experiences that have formed her view. In this article, she continues her quest by examining current developments in practice and education.

Definition of nursing: 1

A definitive description of nursing has always seemed to elude nurse theorists. Roper's nursing model based on the Activities of Living has played a key role in defining and developing nursing over the past two decades. In this article, the first in a two-part series, Nancy Roper recollects past experiences that have formed her view of nursing.