Evaluation of optimum classification measures used to define textbook outcome among patients undergoing curative-intent resection of gastric cancer

BACKGROUND

Textbook outcome (TO) is a composite measure reflecting various aspects of services provided to patients with solid malignancies. We sought to evaluate the importance of various TO components previously proposed for gastric cancer.

METHODS

Prospectively maintained electronic databases of 1,743 patients treated in two academic surgical centres were reviewed. Six candidate definitions of TO were evaluated based on their ability to accurately predict patients' prognosis by Cox proportional hazards modelling.

RESULTS

TO definition combining 10 measures corresponding to complete tumour resection with an uneventful postoperative course showed the best goodness of fit by achieving the lowest values of Akaike (AIC) and Bayesian (BIC) information criteria and the best predictive performance based on the highest value of c-index. The overall median survival was significantly longer for patients with than without textbook outcome (69.0 vs 20.1 months, P < 0.001). TO maintained its prognostic value in a multivariate model controlling for age, sex, comorbidities, treatment, and tumour related variables and was associated with a 39% lower risk of death (HR 0.61, 95%CI 0.51 - 0.73, P < 0.001). Nine variables identified as predictors of TO were used to develop a nomogram showing very good correlation between the predicted and actual probability of achieving TO. The AUC of ROC obtained from the nomogram was 0.752 (95% CI 0.727 to 0.781).

CONCLUSIONS

A uniform definition of textbook outcome provides clinically relevant prognostic information and could be used in quality improvement programs for gastric cancer patients.

Nomogram-Based Prognostic Evaluation of Gastric Cancer Patients with Low Counts of Examined Lymph Nodes Outperforms the Predictive Ability of the 7th and 8th Editions of the American Joint Committee on Cancer Staging System

BACKGROUND

The American Joint Committee on Cancer (AJCC) staging system has limited accuracy in predicting survival of gastric cancer patients with inadequate counts of evaluated lymph nodes (LNs). We therefore aimed to develop a prognostic nomogram suitable for clinical applications in such cases.

METHODS

A total of 1511 noncardia gastric cancer patients treated between 1990 and 2010 in the academic surgical center were reviewed to compare the 7^th and 8^th editions of the AJCC staging system. A nomogram was developed for the prediction of 5-year survival in patients with less than 16 LNs evaluated (n = 546). External validation was performed using datasets derived from the Polish Gastric Cancer Study Group (n = 668) and the SEER database (n = 11,225).

RESULTS

The 8th edition of AJCC staging showed better overall discriminatory power compared to the previous version, but no improvement was found for patients with < 16 evaluated LNs. The developed nomogram had better concordance index (0.695) than the former (0.682) or latest (0.680) staging editions, including patients subject to neoadjuvant treatment, and calibration curves showed excellent agreement between the nomogram-predicted and actual survival. High discriminatory power was also demonstrated for both validation cohorts. Subsequently, the nomogram showed the best accuracy for the prediction of 5-year survival through the time-dependent ROC curve analysis in the training and validation cohorts.

CONCLUSIONS

A clinically relevant nomogram was built for the prediction of 5-year survival in patients with inadequate numbers of LNs evaluated in surgical specimens. The predictive accuracy of the nomogram was validated in two Western populations.

Clinical characteristics and outcome of patients over 60 years with Hodgkin lymphoma treated in Switzerland

Hodgkin lymphoma (HL) in older patients appears to be a different disease compared with younger patients with historically lower survival rates. This is related to a variety of factors, including increased treatment-related toxicity, the presence of comorbidities, and biologic differences. In order to better assess the clinical characteristics, treatment strategies, and outcome of this particular population, we conducted a population-based, retrospective analysis including 269 patients with HL older than 60 years (median age 71 years, range 60-94), treated between 2000 and 2017 in 15 referral centers across Switzerland. Primary endpoints were overall survival (OS), progression-free survival (PFS), and cause-specific survival (CSS). The vast majority of patients were treated with curative intent, either with a combined modality approach (chemotherapy followed by radiation therapy) or with systemic therapy. At a median follow-up of 6.6 years (95% confidence interval [CI], 6.0-7.6), 5-year PFS was 52.2% (95% CI, 46.0-59.2), 5-year OS was 62.5% (95% CI, 56.4-69.2), and 5-year CSS was 85.1.8% (95% CI, 80.3-90.1) for the entire cohort. A significant difference in terms of CSS was observed for patients older than 71 years in comparison to patients aged 60-70 years (hazard ratio 2.6, 1.3-5.0, p = 0.005). Bleomycin-induced lung toxicity (BLT) was documented in 26 patients (17.7%) out of the 147 patients exposed to this compound and was more frequent in patients older than 71 years (15/60, 25%). Outcome of HL pts older than 71 years appeared to decrease substantially in comparison to the younger counterpart. Treatment-related toxicities appeared to be relevant, in particular, BLT. New, potentially less toxic strategies need to be investigated in prospective clinical trials in this particular frail population.

Author Correction: Nearly all the sky is covered by Lyman-α emission around high-redshift galaxies

Change history: In this Letter, author M. Akhlaghi should be associated with affiliation (2) rather than (3). This error has been corrected online.

Purification of Urokinase by a Beta-Naphthamidine Affinity Column

Urokinase was purified by affinity chromatography using 6-amino-naphthamidine-(2), a new specific ligand based on the urokinase inhibitor β-naphthamidine. Urokinase was firmly bound at pH 7.0 and could be eluted at pH 3.0. The protein which passed the column at pH 7.0 without being bound did not contain any urokinase activity. This is an important property because it can be utilized for raising a monospecific urokinase antiserum by absorbing unspecific antibodies with only a minor loss of antiserum titre.

Considerations on the Improved Integration of Medical Guidelines into Routine Clinical Practice - a Review and Concept Proposal

Medical guidelines have become established as the standard for the comprehensive synopsis of all available information (scientific trials, expert opinion) on diagnosis and treatment recommendations. The transfer of guidelines to clinical practice and subsequent monitoring has however proven difficult. In particular the potential interaction between guideline developers and guideline users has not been fully utilised. This review article analyses the status quo and existing methodological and technical information solutions supporting the guideline life cycle. It is shown that there are numerous innovative developments that in isolation do not provide comprehensive support. The vision of the "Living Guidelines 2.0" is therefore presented. This outlines the merging of guideline development and implementation on the basis of clinical pathways and guideline-based quality control, and building on this, the generation of information for guideline development and research.

New insights into colloidal gold flakes: structural investigation, micro-ellipsometry and thinning procedure towards ultrathin monocrystalline layers

High-quality fabrication of plasmonic devices often relies on wet-chemically grown ultraflat, presumably single-crystalline gold flakes due to their superior materials properties. However, important details about their intrinsic structure and their optical properties are not well understood yet. In this study, we present a synthesis routine for large flakes with diameters of up to 70 μm and an in-depth investigation of their structural and optical properties. The flakes are precisely analyzed by transmission electron microscopy, electron backscatter diffraction and micro-ellipsometry. We found new evidence for the existence of twins extending parallel to the Au flake {111} surfaces which have been found to not interfere with the presented nanopatterning. Micro-Ellipsometry was carried out to determine the complex dielectric function and to compare it to previous measurements of bulk single crystalline gold. Finally, we used focused ion beam milling to prepare smooth crystalline layers and high-quality nanostructures with desired thickness down to 10 nm to demonstrate the outstanding properties of the flakes. Our findings support the plasmonics and nano optics community with a better understanding of this material which is ideally suited for superior plasmonic nanostructures.

Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer

AIMS

Local excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study.

METHODS

Functional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38).

RESULTS

In the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%-21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group.

CONCLUSIONS

Our study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.

Forensic paleoradiology: identification of a public figure murdered in 1837

Two unidentified graves were found during construction of a new crypt at the Metropolitan Cathedral in Santiago, Chile. One of the bodies was sent to the Teaching Hospital of the University of Chile for forensic identification. The fully mummified corpse was suspected to be that of Diego Portales, a prominent Chilean politician who was assassinated in 1837. The condition of the corpse determined that the best way to establish a positive identification was by means of a multislice CT scan, since the body had been autopsied and embalmed using unknown substances. This paper presents the results of the virtual autopsy of the remains and compares these results with the original autopsy report of 1837. The embalming method is also discussed, based on chemical analysis using inductively coupled mass spectroscopy (ICP-MS) and cold vapour atomic absorption spectrometry (HG-CVAAS).

B domain containing Tenascin-C: a new urine marker for surveillance of patients with urothelial carcinoma of the urinary bladder?

BACKGROUND

ECM remodelling during tumorigenesis entails the re-occurrence of different Tn-C(L) splicing variants. In patients with urothelial carcinoma of the urinary bladder (UBC), B and C domain containing Tenascin-C (B(+) and C(+) Tn-C) urine levels were shown to be increased in case of muscle invasiveness. Thus, the present study was aimed at examining the ability of B(+) and C(+) Tn-C as potential urinary surveillance markers of UBC patients.

METHODS

Urine levels of B(+) and C(+) Tn-C were determined by ELISA in 35 UBC patients during a 2 year follow-up period after therapy and related to clinical diagnosis and histological stage in 4 defined groups representing typical courses of disease.

RESULTS

B(+) Tn-C levels showed significant differences between cases of tumour progression or regression. The urine levels of B(+) Tn-C could be used to discriminate between cases without tumour recurrence and such with tumour existence (cut-off value: 0.8 ng/ml) or between non-muscle invasive and muscle invasive tumour growth (cut-off value: 3.5 ng/ml).

CONCLUSIONS

Progression of UBC with time is accompanied by significant changes in urinary levels of B(+) Tn-C. Urinary B(+) Tn-C can therefore be suggested as a valuable urine surveillance marker in UBC follow-up care.

Study of enrofloxacin and flumequine residues depletion in eggs of laying hens after oral administration

Two groups of laying hens (each n=12) were administered 10 mg/kg enrofloxacin (ENRO) (group A) or 26.6 mg/kg flumequine (FLU) (group B) by gastric catheter daily for five consecutive days. A third group (n=6) was untreated controls. Eggs were collected from day one of treatment and up to 30 days after withdrawal of the drug. Egg white and yolk from each egg were separated, and ENRO, its metabolite ciprofloxacin (CIP) and FLU residues were analysed by a high-performance liquid chromatography method with fluorescence detection. The sum of ENRO and CIP was detectable in egg white on the first day of treatment in high-level concentrations (2007.7 μg/kg) and remained steady during administration. In egg yolk, residues were detectable at day one in lower concentrations (324.4 μg/kg), increasing to the end of treatment. After treatment, these residues decreased and were detectable up to day 8 in egg white, and day 10 in yolk. FLU residues during drug administration in white were detectable in high concentrations from day one to five (6788.4-6525.9 μg/kg), and in yolk, concentrations were lower during administration (629.6-853.9 μg/kg). After drug withdrawal, FLU residues remained longer in egg white (30 days) than in yolk (26 days). For both drugs, differences of concentrations between matrices were significant.

Extra cellular matrix remodelling after heterotopic rat heart transplantation: gene expression profiling and involvement of ED-A+ fibronectin, alpha-smooth muscle actin and B+ tenascin-C in chronic cardiac allograft rejection

Chronic cardiac rejection is represented by cardiac allograft vasculopathy (CAV) and cardiac interstitial fibrosis (CIF) known to cause severe complications. These processes are accompanied by remarkable changes in the cardiac extra cellular matrix (cECM). The aim of our study was to analyse the cECM remodelling in chronic rejection and to elucidate a potential role of ED-A domain containing fibronectin (ED-A(+) Fn), alpha smooth muscle actin (ASMA) and B domain containing tenascin-C (B(+) Tn-C). A model of chronic rejection after heterotopic rat heart transplantation was used. Allografts, recipient and control hearts were subjected to histological assessment of rejection grade, to real-time PCR based analysis of 84 genes of ECM and adhesion molecules and to immunofluorescence labelling procedures, including ED-A(+) Fn, ASMA and B(+) Tn-C antibodies. Histological analysis revealed different grades of chronic rejection. By gene expression analysis, a relevant up-regulation of the majority of ECM genes in association with chronic rejection could be shown. For 8 genes, there was a relevant up-regulation in allografts as well as in the corresponding recipient hearts. Association of ASMA positive cells with the grade of chronic rejection could be proven. In CAV and also in CIF there were extensive co-depositions of ED-A(+) Fn, ASMA and B(+) Tn-C. In conclusion, chronic cardiac allograft rejection is associated with a cECM remodelling. ASMA protein deposition in CAV, and CIF is a valuable marker to detect chronic rejection. Interactions of VSMCs and Fibro-/Myofibroblasts with ED-A(+) Fn and B(+) Tn-C might functionally contribute to the development of chronic cardiac rejection.

The beating pattern of the flagellum of Euglena gracilis under altered gravity during parabolic flights

The unicellular freshwater flagellate Euglena gracilis shows negative gravitactic behavior. Previous experiments have revealed that the orientation is most likely an active physiological process in which the beating pattern of the flagellum is controlled by gravity and mediated by a change in the calcium concentration inside the cell. In a signal transduction chain, the calcium signal activates a calmodulin, which in turn raises the concentration of cAMP. This alters the beating pattern of the flagellum; reorientation is therefore not a passive process driven by buoyancy. In a recent parabolic flight experiment (ESA 45th parabolic flight campaign), we observed the beating of the flagellum with a high-resolution light microscope. Transition from hyper g to microg as well as from microg to hyper g caused a change of the beating pattern of the flagellum, which confirmed the physiological nature of the process. In microg cells stopped moving the flagellum or tried to reorient, while in hyper g, the cells realigned consecutively. The reaction times for the flagellar responses in previous experiments are confirmed.

[Gastroesophageal reflux disease. Standards of the Czech Society of Gastroenterology--actualization 2009]

Presently, gastroesophageal reflux disease is defined as a disorder where reflux of the stomach content is bothersome and/or brings about complications. The state when macroscopically detectable erosions of mucosa are present is known as erosive reflux disease and the term non-erosive reflux disease is used for the condition with no macroscopic erosions. Reflux oesophagitis is a frequent sign of the disease. A condition, where reflux symptoms persist or new occur and oesophagitis healing fails to take place despite maximum treatment, is classified as refractory gastroesophageal reflux disease. The main symptoms of gastroesophageal reflux disease include heartburn and regurgitation. Gastroesophageal reflux disease may, less frequently, manifest itself with isolated non-oesophageal symptoms, e.g. recurring upper respiratory tract infections or bronchial asthma. Etiopathogenesis involves refluxate, motility disorders, altered anatomic proportions, protective mechanisms disorder and external factors. Diagnosis takes place on the basis of typical symptomatology and endoscopic examination. Complications include bleeding, ulceration, strictures and Barrett's oesophagus. Lifestyle and dietary measures are an important treatment approach as are pharmacological (antisecretion and prokinetic agents) as well as surgical management.

Sleep disorderd breathing and recurrence of cerebrovascular events, case-fatality, and functional outcome in patients with ischemic stroke or transient ischemic attack

Ninety one patients with stroke or transient ischemic attack (TIA) were screened for sleep-disordered breathing (SDB). Case fatality, rate of recurrence of cerebrovascular events, and functional outcome were analyzed during a 2-year follow-up. The patients were stratified into groups: without (AH < or =5) and with SDB (AHI >5). SDB was present in 61 (67.7%) patients with stroke or TIA. The rate of recurrence of TIA or stroke in patients with SDB was significantly higher (12 patients, OR=1.52, P<0.05) as compared with patients without SDB (3 patients) within two years of observation. Case-fatality rates were not significantly different (4 patients with SDB and 2 patients without SDB). Our data show that SDB significantly increases the incidence of recurrent cerebrovascular events in patients with TIA or stroke in a two-year follow-up. SDB in patient with stroke or TIA did not influence functional outcome of stroke during the long-term observation.

Photodynamic control of human pathogenic parasites in aquatic ecosystems using chlorophyllin and pheophorbid as photodynamic substances

When used at low concentrations and added to the water body, water-soluble chlorophyllin (resulting from chlorophyll after removal of the phytol) and pheophorbid (produced from chlorophyllin by acidification) are able to kill mosquito larvae and other small animals within a few hours under exposure of solar radiation. Under laboratory conditions, the use of chlorophyllin/pheophorbid as photodynamic substances for pest control in water bodies promises to be not only effective and ecologically beneficial but also cheap. The LD50 (50% of mortality in the tested organisms) value in Culex sp. larvae was about 6.88 mg/l, in Chaoborus sp. larvae about 24.18 mg/l, and in Daphnia 0.55 mg/l. The LD50 values determined for pheophorbid were 8.44 mg/l in Culex, 1.05 mg/l in Chaoborus, and 0.45 mg/l in Daphnia, respectively. In some cases, chlorophyllin and pheophorbid were also found to be (less) active in darkness. The results presented in this paper show that chlorophyllin is about a factor of 100 more effective than methylene blue or hematoporphyrine, which were tested earlier for the same purpose. It is also much cheaper and, as a substance found in every green plant, it is 100% biodegradable.