Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Endocrine Patients' Views on Transoral Endoscopic Thyroidectomy via Vestibular Approach (TOETVA)

TOETVA's adoption has been slow in the Western hemisphere. Our study aimed to evaluate how endocrine patients in the United States perceive the risks and benefits of TOETVA. This was a cross-sectional study where a de novo survey was sent via email to patients seen from 2018 to 2020. The survey asked how each of TOETVA's risks and benefits affect their choice between traditional thyroidectomy (TT) and TOETVA on a scale from 1 (favors TT) to 10 (favors TOETVA). Statistical significance was determined at p < 0.05. Of 422 patients (3.2% response rate), 76.0% were female, 28.9% were non-Whites, 58.3% possessing graduate/professional degrees, and 34.1% were diagnosed with thyroid cancer. Significant differences were found between groups of age, race, educational attainment, thyroid cancer diagnosis, and history of thyroid or parathyroid surgery with respect to their preference for thyroidectomy between TT and TOETVA. In multivariate analysis, attitudes towards longer operative time (estimate 0.130, 95% CI 0.026-0.235, p = 0.002), limited outcome data (estimate 0.142, 95% CI 0.029-0.254, p = 0.024), having less pain (estimate 0.108, 95% CI 0.004-0.212, p = 0.042), travel to seek care (estimate 0.166, 95% CI 0.042-0.290, p = 0.009), as well as African American race (estimate 0.714, 95% CI 0.093-1.334, p = 0.024), and history of surgery (estimate - 0.843, 95% CI - 1.364- - 0.323, p = 0.002) were independently predictive of overall preferences. TOETVA's risks and benefits may carry varying degrees of significance in patients' decision-making process, which helps tailor the discussion to choose the right procedure for patients.

Improved sexual function after parathyroidectomy in women with primary hyperparathyroidism

BACKGROUND

The study aimed to evaluate whether women with primary hyperparathyroidism (PHPT) experience improvement in their sexual function after parathyroidectomy.

METHODS

Women with PHPT or benign thyroid nodules (controls) undergoing surgery were administered the validated Parathyroidectomy Assessment Score (PAS), Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) and Female Sexual Function Index (FSFI) pre-operatively, at 3 months and 6 months postoperatively.

RESULTS

Of the 26 PHPT and 18 control patients, PHPT patients were older (53.1 vs 45.3 years, p ​= ​0.008). Post-operatively, both PHPT (pre-op 2.4 vs 3-month 3.0 vs 6-month 2.4, p ​= ​0.022) and control patients (pre-operative 2.4 vs 3-month 3.3 vs 6-month 3.6, p ​= ​0.032) reported increased desire for sexual activities. In addition, PHPT patients experienced increased arousal (pre-operative 2.7 vs 3-month 3.9 vs 6-month 3.6, p ​= ​0.047) and satisfaction (pre-operative 3.0 vs 3-month 4.8 vs 6-month 4.0, p ​= ​0.006).

CONCLUSIONS

The current study indicates that women with PHPT may experience improved sexual function after parathyroidectomy.

Optimal water supply reservoir operation by leveraging the meta-heuristic Harris Hawks algorithms and opposite based learning technique

To ease water scarcity, dynamic programming, stochastic dynamic programming, and heuristic algorithms have been applied to solve problem matters related to water resources. Development, operation, and management are vital in a reservoir operating policy, especially when the reservoir serves a complex objective. In this study, an attempt via metaheuristic algorithms, namely the Harris Hawks Optimisation (HHO) Algorithm and the Opposite Based Learning of HHO (OBL-HHO) are made to minimise the water deficit as well as mitigate floods at downstream of the Klang Gate Dam (KGD). Due to trade-offs between water supply and flood management, the HHO and OBL-HHO models have configurable thresholds to optimise the KGD reservoir operation. To determine the efficacy of the HHO and OBL-HHO in reservoir optimisation, reliability, vulnerability, and resilience are risk measures evaluated. If inflow categories are omitted, the OBL-HHO meets 71.49% of demand compared to 54.83% for the standalone HHO. The HHO proved superior to OBL-HHO in satisfying demand during medium inflows, achieving 38.60% compared to 20.61%, even though the HHO may have experienced water loss at the end of the storage level. The HHO is still a promising method, as proven by its reliability and resilience indices compared to other published heuristic algorithms: at 62.50% and 1.56, respectively. The Artificial Bee Colony (ABC) outcomes satisfied demand at 61.36%, 59.47% with the Particle Swarm Optimisation (PSO), 55.68% with the real-coded Genetic Algorithm (GA), and 23.5 percent with the binary GA. For resilience, the ABC scored 0.16, PSO scored 0.15, and real coded GA scored 0.14 whilst the binary-GA has the worst failure recovery algorithm with 0.09.

Gender Disparity in Earliest Phase of Academic Surgical Training: An Area for Intervention

BACKGROUND

To overcome persistent gender disparities in academic surgery, it is critical to examine the earliest phase of surgical training. This national study sought to assess whether gender disparities also existed among surgical interns, as a proxy for medical school research experience in both quantity and quality.

STUDY DESIGN

Using the 2021 to 2022 public information of 1,493 US-graduated categorical general surgery interns, a bibliometric evaluation was conducted to assess medical school research experience. Multivariable linear regressions with response log-transformed were performed to evaluate the impact of intern gender on (1) total number of peer-reviewed publications, (2) total impact factor (TIF), and (3) adjusted TIF based on authorship placement (aTIF). Back-transformed estimates were presented.

RESULTS

Of these interns, 52.3% were female. Significant differences were observed in TIF (male 6.4 vs female 5.3, p = 0.029), aTIF (male 10.8 vs female 8.7, p = 0.035), gender concordance with senior authors (male 79.9% vs female 34.1%, p < 0.001), Hirsch index (male 21.0 vs female 18.0, p = 0.026), and the geographic region of their medical schools (p = 0.036). Multivariable linear regressions revealed that female interns were associated with lower TIF (0.858, p = 0.033) and aTIF (0.851, p = 0.044). Due to a significant gender-by-region interaction, adjusted pairwise comparisons showed that male interns in the Northeast had approximately 70% higher TIF (1.708, p = 0.003) and aTIF (1.697, p = 0.013) than female interns in the South.

CONCLUSIONS

Gender disparities existed in the quality of research experience in the earliest phase of surgical training. These timely results call for additional interventions by the stakeholders of graduate medical education.

Efficacy of machine learning to identify clinical factors influencing levothyroxine dosage after total thyroidectomy

BACKGROUND

We employed Machine Learning (ML) to evaluate potential additional clinical factors influencing replacement dosage requirements of levothyroxine.

METHOD

This was a retrospective study of patients who underwent total or completion thyroidectomy with benign pathology. Patients who achieved an euthyroid state were included in three different ML models.

RESULTS

Of the 487 patients included, mean age was 54.1 ± 14.1 years, 86.0% were females, 39.0% were White, 53.0% Black, 2.7% Hispanic, 1.4% Asian, and 3.9% Other. The Extreme Gradient Boosting (XGBoost) model achieved the highest accuracy at 61.0% in predicting adequate dosage compared to 47.0% based on 1.6 mcg/kg/day (p < 0.05). The Poisson regression indicated non-Caucasian race (p < 0.05), routine alcohol use (estimate = 0.03, p = 0.02), and osteoarthritis (estimate = -0.10, p < 0.001) in addition to known factors such as age (estimate = -0.003, p < 0.001), sex (female, estimate = -0.06, p < 0.001), and weight (estimate = 0.01, p < 0.001) were associated with the dosing of levothyroxine.

CONCLUSIONS

Along with weight, sex, age, and BMI, ML algorithms indicated that race, ethnicity, lifestyle and comorbidity factors also may impact levothyroxine dosing in post-thyroidectomy patients with benign conditions.

Social Determinants of Health and Quality of Life in Endocrine Surgery Patients

INTRODUCTION

Quality of life (QoL) of endocrine surgery patients is an important patient outcome but the role of social determinants of health (SDH) on preoperative QoL is understudied.

METHODS

This study used preoperative data of 233 endocrine surgery patients participating in a longitudinal QoL study to examine the influence of SDH (patient-level and environmental) on preoperative QoL. Patient-level SDH was assessed with structured survey questions and environmental SDH with the Social Vulnerability Index. Multiple domains of QoL were assessed with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29).

RESULTS

The average age of the sample was 52.9 y and 76.8% were female, 10% were Hispanic, 55.8% were White, 32.6% were Black, 6.9% were Other, and 4.7% were Asian. Patients with patient-level SDH were more likely to have worse preoperative QoL in multiple PROMIS domains. Patients who lived in the most socially vulnerable areas had the same or better QoL scores in the PROMIS-29 domains than those living in less vulnerable areas. Minority race patients were more likely to have patient-level SDH and to live in the most vulnerable areas.

CONCLUSIONS

This study is the first to our knowledge to examine the role of patient-level and environmental SDH on preoperative QoL among endocrine surgery patients. The results identified specific patient-level factors that could be used as the basis for interventions aimed to improve patients' QoL. Future studies that evaluate the role of preoperative SDH on long-term QoL and clinical outcomes would further enhance our understanding of the impact of SDH on patient wellbeing.

Drug delivery strategies in maximizing anti-angiogenesis and anti-tumor immunity

Metronomic chemotherapy has been shown to elicit anti-tumor immune response and block tumor angiogenesis distinct from that observed with maximal tolerated dose (MTD) therapy. This review delves into the mechanisms behind anti-tumor immunity and seeks to identify the differential effect of dosing regimens, including daily low-dose and medium-dose intermittent chemotherapy (MEDIC), on both innate and adaptive immune populations involved in observed anti-tumor immune response. Given reports of VEGF/VEGFR blockade antagonizing anti-tumor immunity, drug choice, dose, and selective delivery determined by advanced formulations/vehicles are highlighted as potential sources of innovation for identifying anti-angiogenic modalities that may be combined with metronomic regimens without interrupting key immune players in the anti-tumor response. Engineered drug delivery mechanisms that exhibit extended and local release of anti-angiogenic agents both alone and in combination with chemotherapeutic treatments have also been demonstrated to elicit a potent and potentially systemic anti-tumor immune response, favoring tumor regression and stasis over progression. This review examines this interplay between various cancer models, the host immune response, and select anti-cancer agents depending on drug dosing, scheduling/regimen, and delivery modality.

Comparing the rate and extent of malignancy in surgically excised thyroid nodules across race and ethnicity

BACKGROUND

Few studies have compared the features of thyroid cancer among races and ethnicities. We hypothesized that race and ethnicity may influence the frequency and features of thyroid malignancy in thyroid nodules.

METHOD

This was a retrospective chart review of patients between 2013 and 2020 who underwent thyroidectomy.

RESULTS

In the analysis of 2737 patients, thyroid cancer was less prevalent among Blacks (24.0% vs Whites 52.1%, Hispanics 58.7%, Asians 71.7%, and Others 57.9%, p < 0.001). Thyroid cancer in Blacks was less likely to have extrathyroidal extension (9.7% vs Whites 18.6%, Hispanics 25.8%, Asians 18.2%, and Others 17.8%, p = 0.01), overall nodal involvement (12.4% vs Whites 31.1%, Hispanics 37.5%, Asians 36.3%, and Others 30.1%, p < 0.01), and lateral neck metastasis (4.4% vs Whites 10.8%, Hispanics 6.3%, Asians 13.2%, and Others 9.6%, p = 0.02).

CONCLUSIONS

Race and ethnicity may play important roles in the risk of malignancy as well as in the extent of thyroid cancer.

Endocrine Surgery Patients' and Providers' Perceptions of Telemedicine in the COVID Era

Background

Telemedicine has become a key modality for health care delivery during the COVID-19 pandemic, including for endocrine surgery. Little data exists on patients’ and referring endocrinologists’ perspectives of its use. The study aimed to assess and compare endocrine surgery patients’ attitudes about telemedicine to that of referring endocrinologists.

Method

Patients from a regional endocrine surgery practice and referring endocrinologists were sent surveys about their perspectives on telemedicine use.

Results

Fifty two patients responded: average age was 58.3 years; 78% were female; 33% were Black. Sixteen referring endocrinologists responded: average age was 52.4 years; 62.5% were female. Nearly all patients (92%) and providers (100%) would try telemedicine or use it again. Providers were more likely than patients to use telemedicine because of COVID-19 (100% versus 70.6%, P = 0.03). Patients were more concerned about the lack of personal connection with telemedicine than providers (60.8% versus 25.0%, P = 0.02). Endocrinologists were more interested in using telemedicine to review abnormal results (81.3% versus 35.3%, P <0.01), and more patients were specifically disinterested in reviewing abnormal results via telemedicine (54.9% versus 6.3%, P = 0.04). Patients were more interested in its use for postoperative visits (47.1% versus 0%, P <0.01). More endocrinologists were specifically disinclined to conduct new consultations with telemedicine (87.5% versus 58.8%, P <0.01).

Conclusion

Telemedicine is a mutually acceptable method for patients and their referring providers for endocrine surgery delivery, although in-person visits continue to have their place. Telemedicine use may continue to expand after the pandemic as an important point of access for endocrine surgery.

Drop Spreading and Confinement in Swelling-Driven Folding of Thin Films

Surface instabilities are a versatile method for generating three-dimensional (3D) surface microstructure. When an elastomeric film weakly bonded to a substrate is swollen with solvent, buckle delamination and subsequent sliding of the film on the substrate lead to the formation of tall, self-contacting, and permanent folds. This paper explores the mechanics of fold development when such folding is induced by placing a drop on the surface of the film. We show that capillary effects can induce a strong coupling between folding and drop spreading: as folds develop, they wick the solvent toward the periphery of the drop, further propagating radially aligned folds. Accordingly, a solvent drop spreads far more on films that are weakly adhered to the substrate. As drop size reduces and folding becomes increasingly confined, debonding propagates along the perimeter of the wetted region, thus leading to corral-shaped fold patterns. On the other hand, as drop size increases and confinement effects weaken, isotropically oriented folds appear at a spacing that reduces as swelling increases. The spacing between the folds and the size of the corrals are both determined by the extent to which a single fold relieves compressive stress in its vicinity by sliding. We develop a model for folding which explicitly accounts for the fact that folds must initiate with near-zero volume under the buckle. The model shows that folds can appear even at very low swelling if there are large pre-existing debonded regions at the film-substrate interface.

Comparing surgical thoroughness and recurrence in thyroid cancer patients across race/ethnicity

BACKGROUND

For patients with differentiated thyroid cancer who will receive postoperative radioactive iodine, thyroid remnant uptake can be calculated and may point to the thoroughness of the surgical resection. In the United States, outcome disparities exist among ethnic/racial minorities with differentiated thyroid cancer. Data about surgical thoroughness and recurrence rates across races/ethnicities do not exist. This study compared the amount of thyroid remnant uptake and cancer recurrence rates across race/ethnicity.

METHODS

This was a retrospective analysis of adult patients with differentiated thyroid cancer who had postoperative radioactive iodine in 2017 and 2018 and were followed to 2020. We collected thyroid bed remnant uptake from postoperative radioactive iodine scans and analyzed it as a ratio of percent of uptake to dose of radioactive iodine received to control for varying radioactive iodine doses. Thyroid remnant, uptake to dose of radioactive iodine received, and recurrence were evaluated across race/ethnicity.

RESULTS

Of 218 patients: 61% were White, 21% Black, 11% Asian, and 7% Hispanic; 72% were female. Seventy-one percent of patients had their surgery done by a high-volume surgeon, although volume data were not available for all. In White, Black, Asian, and Hispanic patients, median uptake was 0.68%, 0.44%, 1.5%, and 0.8%, respectively (P = .13). We did not observe differences in median uptake to dose of radioactive iodine received across groups (P = .41). Recurrence rate was 17.0% among White patients, 16.7% among Black patients, 17.6% among Asian patients, and 16.7% among Hispanic patients (P = 1.00).

CONCLUSION

We did not observe differences across race/ethnicity in surgical thoroughness or rate of recurrence. These findings suggest that disparities may be mitigated when ethnic/racial minorities have similar access to quality surgical care.

Polytobacco product use among current cigarette smokers in Hong Kong, China: results from population surveys (2015-17)

BACKGROUND

Polytobacco product use is increasingly popular, but little is known about the prevalence, trend, and factors of such use particularly in non-western countries.

METHOD

A representative sample of 1139 current cigarette smokers aged 15+ (84.1% male) were telephone interviewed in Tobacco Control Policy-related Surveys in 2015-2017. Information collected included poly-tobacco use (PTU), smoking and socio-demographic characteristics. Associations of current PTU with related factors were analyzed using logistic regression with adjustment for confounders. Prevalence was weighted by age and sex of current cigarette users in the general population.

RESULTS

Eighty-four point one percent (95% CI 81.4-86.6%) were exclusive cigarette smokers. Fifteen point nine percent (13.4-18.6%) were current polytobacco product users, 12.3% (10.2-14.8%) used one tobacco product and 2.52% (1.59-3.97%) used two tobacco products in addition to cigarette. Cigarette use with cigar was more common (6.28%, 4.75-8.27%), and the least used product with cigarette was e-cigarette (1.05%, 0.44-2.50%). The changes in overall prevalence of PTU by number of products use varied in 3 years. Current PTU was associated with being male (AOR 2.01, 95% CI 1.12-3.61), younger age (AORs range from 1.34-4.65, P for trend < .001) and less ready to quit (2.08, 1.09-3.97).

CONCLUSIONS

Prevalence of PTU increased slowly by year, one tobacco product use with cigarette was more common. The most used tobacco product with cigarette was cigar. Being male, younger and less ready to quit were associated with current PTU.

Self-driving laboratory for accelerated discovery of thin-film materials

Discovering and optimizing commercially viable materials for clean energy applications typically takes more than a decade. Self-driving laboratories that iteratively design, execute, and learn from materials science experiments in a fully autonomous loop present an opportunity to accelerate this research process. We report here a modular robotic platform driven by a model-based optimization algorithm capable of autonomously optimizing the optical and electronic properties of thin-film materials by modifying the film composition and processing conditions. We demonstrate the power of this platform by using it to maximize the hole mobility of organic hole transport materials commonly used in perovskite solar cells and consumer electronics. This demonstration highlights the possibilities of using autonomous laboratories to discover organic and inorganic materials relevant to materials sciences and clean energy technologies.

The Influence of Phonomotor Treatment on Word Retrieval: Insights From Naming Errors

Purpose An increasing number of anomia treatment studies have coupled traditional word retrieval accuracy outcome measures with more fine-grained analysis of word retrieval errors to allow for more comprehensive measurement of treatment-induced changes in word retrieval. The aim of this study was to examine changes in picture naming errors after phonomotor treatment. Method Twenty-eight individuals with aphasia received 60 hr of phonomotor treatment, an intensive, phoneme-based therapy for anomia. Confrontation naming was assessed pretreatment, immediately posttreatment, and 3 months posttreatment for trained and untrained nouns. Responses were scored for accuracy and coded for error type, and error proportions of each error type (e.g., semantic, phonological, omission) were compared: pre- versus posttreatment and pretreatment versus 3 months posttreatment. Results The group of treatment participants improved in whole-word naming accuracy on trained items and maintained their improvement. Treatment effects also generalized to untrained nouns at the maintenance testing phase. Additionally, participants demonstrated a decrease in proportions of omission and description errors on trained items immediately posttreatment. Conclusions Along with generalized improved whole-word naming accuracy, results of the error analysis suggest that a global (i.e., both lexical-semantic and phonological) change in lexical knowledge underlies the observed changes in confrontation naming accuracy following phonomotor treatment.

Abstract P5-13-04: Needle-to-knife wait time and impact on pCR in patients undergoing neoadjuvant chemotherapy for breast cancer

Introduction: In the setting of pre-operative neoadjuvant chemotherapy (NAC) for the treatment of breast cancer, it is important to ensure coordination between medical and surgical oncology. A study by Sanford et al. show that patients receiving surgery &gt;8 weeks after NAC have worse overall survival. As NAC continues to expand its role in breast cancer treatment, a closer look at the maximal acceptable time between NAC and surgery becomes more important. We wished to assess the impact of time between last dose of chemotherapy and surgery on pathological complete response (pCR), disease free survival (DFS), overall survival (OS), and surgical complications.

Methods: A cohort study was conducted utilizing the BC Cancer Agency's prospective neoadjuvant database, located in Vancouver, BC. Patients were selected if they had undergone NAC with curative intent for treatment of breast cancer, followed by surgical resection. Patients who received neoadjuvant radiation and/or hormone therapy were excluded. Patients were divided into three groups: those who had surgery &lt;4 weeks from last dose of chemo, 4-8 weeks from last dose, and &gt;8 weeks from last dose. Charts were audited for demographic data, tumour characteristics, and complications from surgery. Data was analyzed using a Chi Squared test to determine any differences in pCR, OS, DFS, and surgical complications, between the three different time intervals.

Results: 347 patients were identified and included in this study. The median time to surgery after last dose of chemotherapy was 4.86 weeks (range 0.86-22.86 weeks). The percentage of patients that achieved pCR was 31.3%, 30.5%, and 28.6% in the &lt;4 weeks, 4-8 weeks, and &gt;8 weeks groups respectively (p= NS for all comparisons). There was no difference in pCR observed between the three groups based on receptor status. At the median follow up of 3 years, DFS was 85%, 85.8%, and 85.7% in all three groups. Likewise OS was 95%, 90%, and 89% respectively. The rate of surgical complications are 16%, 23.4%, and 21.4% for the three groups respectively (p=NS).

Conclusions: This study demonstrated no difference between receiving surgery &lt;4 weeks, 4-8 weeks, or &gt;8 weeks after last dose of NAC on pCR, survival, or surgical complications. This finding was preserved in all receptor subtypes. This has important implications for resource allocation. This data may also help in counselling and easing patient anxiety in terms of the urgency (or lack thereof) and wait times for surgery. Subsequent studies with larger sample sizes will help to ensure that clinical differences in outcomes are not affected by wait times.

Comparison of outcome measures based on needle to knife time &lt; 4 weeks (n=80)4-8 weeks (n=239)&gt;8weeks (n=28)p (&lt;4 weeks vs. &lt; 8 weeks)pCR31.3% (25)30.5% (73)28.6% (8)0.791HR+Her2-4.5% (1/22)6.5% (6/92)0% (0/5)--TNBC31.5% (6/19)42.1% (24/57)0% (0/6)--Her2+46.1% (18/39)48.8% (44/90)47.1% (8/17)--3 year DFS85%85.5%85.7%0.9273 year OS95%90%89%0.290Surgical Complication16.3%23.4%21.4%0.536

Citation Format: Lai V, Hajjaj O, Chia S, Simmons C. Needle-to-knife wait time and impact on pCR in patients undergoing neoadjuvant chemotherapy for breast cancer [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 P5-13-04.

Cognition in multiple sclerosis: Between cognitive reserve and brain volume

BACKGROUND

Several correlations between cognitive impairment (CI), radiologic markers and cognitive reserve (CR) have been documented in MS.

OBIECTIVE

To evaluate correlation between CI and brain volume (BV) considering CR as possibile mitigating factor.

METHODS

195 relapsing MS patients underwent a neuropsychological assessment using BICAMS. BV was estimated using SIENAX to obtain normalized volume of brain (NBV), white matter (NWV), gray matter (NGV) and cortical gray matter (CGV). CR was estimated using a previously validated tool.

RESULTS

Pearson test showed a correlation between the symbol digit modality test (SDMT) score and NBV (r=0.38; p<0.000) NGV(r=0.31; p<0.000), CGV (r=0.35; p<0.000) and CRI score(r=0.42; p<0.000). Linear regression (dependent variable:SDMT) showed a relationship with CR scores (p=0.000) and NGV(p<0.000). A difference was detected between cognitive impaired and preserved patients regarding mean of NBV(p=0.002), NGV(p=0.007), CGV(p=0.002) and CR Scores (p=0.007). Anova showed a association between the presence of CI (dependent variable) and the interaction term CRIQ × CGV (p=0.004) whit adjustment for age and disability evaluated by EDSS.

CONCLUSIONS

Our study shows a correlation between cognition and BV, in particular gray matter volume. Cognitive reserve is also confirmed as an important element playing a role in the complex interaction to determine the cognitive functions in MS.

Plasma uric acid effects on glomerular haemodynamic profile of patients with uncomplicated Type 1 diabetes mellitus

AIMS

Increased plasma uric acid (PUA) levels are associated with impaired renal function in patients with Type 1 diabetes, but the mechanisms are not well understood. Our aim was to evaluate whether higher PUA levels are associated with increased afferent arteriolar resistance in patients with Type 1 diabetes vs. healthy controls, thereby influencing renal function.

METHODS

PUA, GFR (inulin) and effective renal plasma flow (ERPF; para-aminohippurate) were measured in 70 otherwise healthy patients with Type 1 diabetes and 60 healthy controls. Gomez's equations were used to estimate afferent (RA ) and efferent (RE ) arteriolar resistances, glomerular hydrostatic pressure (PGLO ) and filtration pressure (ΔPF ). The relationships between PUA and glomerular haemodynamic parameters were evaluated by univariable linear regression correlation coefficients.

RESULTS

In patients with Type 1 diabetes, higher PUA correlated with lower PGLO (P = 0.002) and ΔPF (P = 0.0007), with higher RA (P = 0.001), but not with RE (P = 0.55). These associations were accompanied by correlations between higher PUA with lower GFR (P = 0.0007), ERPF (P = 0.008), RBF (P = 0.047) and higher RVR (P = 0.021). There were no significant correlations between PUA and renal haemodynamic parameters in the healthy controls.

CONCLUSIONS

The association between higher PUA with lower GFR and lower ERPF in patients with Type 1 diabetes is driven by alterations in the estimated RA . PUA-mediated RA may be caused by increased tone or thickening of the afferent renal arteriole, which might potentiate renal injury by causing ischaemia to the renal microcirculation.

Delayed Calcium Normalization After Presumed Curative Parathyroidectomy is Not Associated with the Development of Persistent or Recurrent Primary Hyperparathyroidism

BACKGROUND

Following parathyroidectomy for primary hyperparathyroidism (pHPT), serum calcium levels typically normalize relatively quickly. The purpose of this study was to identify potential factors associated with delayed normalization of calcium levels despite meeting intraoperative parathyroid hormone (IOPTH) criteria and to determine whether this phenomenon is associated with higher rates of persistent pHPT.

METHODS

This was a retrospective review of 554 patients who underwent parathyroidectomy for sporadic pHPT from January 2009 to July 2013. Patients who underwent presumed curative parathyroidectomy and had elevated POD0 calcium levels (>10.2 mg/dL) were matched 1:2 for age and gender to control patients with normal POD0 calcium levels.

RESULTS

Of the 554 patients, 52 (9 %) had an elevated POD0 Ca (median 10.7, range 10.3-12.2). Compared with the control group, these patients had higher preoperative calcium (12 vs. 11.1, p < 0.001) and PTH (144 vs. 110 pg/mL, p = 0.004) levels and lower 25OH vitamin D levels (26 vs. 31 pg/mL; p = 0.024). Calcium normalization occurred in 64, 90, and 96 % of patients by postoperative days (POD) 1, 14, and 30, respectively. There was no difference in rates of single-gland disease or cure rates between the groups.

CONCLUSIONS

After presumed curative parathyroidectomy, nearly 10 % of patients had transiently persistent hypercalcemia. Most of these patients had normal serum calcium levels within the first 2 weeks and did not have increased rates of persistent pHPT. Immediate postoperative calcium levels do not predict the presence of persistent pHPT, and these patients may not require more stringent follow-up.

Glomerular haemodynamic profile of patients with Type 1 diabetes compared with healthy control subjects

AIMS

To evaluate the glomerular haemodynamic profile of patients with Type 1 diabetes with either renal hyperfiltration (GFR ≥ 135 ml/min/1.73 m2 ) or renal normofiltration (GFR 90-134 ml/min/1.73 m2 ) during euglycaemic and hyperglycaemic conditions, and to compare this profile with that of a similar group of healthy control subjects.

METHODS

Gomez's equations were used to derive afferent and efferent arteriolar resistances, glomerular hydrostatic pressure and filtration pressure.

RESULTS

At baseline, during clamped euglycaemia, patients with Type 1 diabetes and hyperfiltration had lower mean ± sd afferent arteriolar resistance than both those with Type 1 diabetes and normofiltration (914 ± 494 vs. 2065 ± 597 dyne/s/cm5 ; P < 0.001) and healthy control subjects (1676 ± 707 dyne/s/cm(5) ; p < 0.001). By contrast, efferent arteriolar resistance was similar in the three groups. Patients with Type 1 diabetes and hyperfiltration also had higher mean ± sd glomerular hydrostatic pressure than both healthy control subjects and patients with Type 1 diabetes and normofiltration (66 ± 6 vs. 60 ± 3 vs. 55 ± 3 mmHg; P < 0.05). Similar findings for afferent arteriolar resistance, efferent arteriolar resistance, glomerular hydrostatic pressure and filtration pressure were observed during clamped hyperglycaemia.

CONCLUSION

Hyperfiltration in Type 1 diabetes is primarily driven by alterations in afferent arteriolar resistance rather than efferent arteriolar resistance. Renal protective therapies should focus on afferent renal arteriolar mechanisms through the use of pharmacological agents that target tubuloglomerular feedback, including sodium-glucose cotransporter 2 inhibitors and incretins.

The Effect of Thyroiditis on the Yield of Central Compartment Lymph Nodes in Patients with Papillary Thyroid Cancer

BACKGROUND

In patients who have undergone thyroidectomy and central compartment neck dissection (CCND) for papillary thyroid cancer (PTC), visualization of enlarged lymph nodes may lead to more extensive CCND. This study sought to determine the effect of patient age and the presence of thyroiditis on the number of malignant and total lymph nodes resected in patients who underwent CCND for PTC.

METHODS

This retrospective review examined a prospective database of patients who underwent total thyroidectomy and CCND for PTC between April 2009 and June 2013 and had thyroiditis on the final pathology. The patients were categorized into age groups by decade (18-29, 30-39, 40-49, 50-59, and ≥60 years) and compared with a control group of patients matched by age, gender, and tumor size.

RESULTS

Of 74 patients with thyroiditis, 64 (87 %) were women. The median age of the patients was 47.5 years (range 18.2-72.0 years). The patients with thyroiditis had more lymph nodes resected than those without thyroiditis (median 11 vs 7; p < 0.01). However, these patients had fewer malignant lymph nodes (median 0 vs 1.5; p = 0.06), resulting in a lower lymph node ratio (0 vs 0.18; p = 0.02) for the entire cohort, but particularly for the youngest (18-29 years) and oldest (≥60 years) age groups.

CONCLUSIONS

Patients with thyroiditis and PTC who underwent CCND had more lymph nodes resected but a had lower proportion of metastatic lymph nodes than those without thyroiditis. Given the relatively low yield of malignant cervical lymphadenopathy, a more judicious approach to CCND might be considered, particularly for the youngest and oldest patients with PTC and thyroiditis.

Central compartment lymph node dissection for differentiated thyroid cancer: review of the literature

Central lymph node dissection (CLND) remains an important component of the surgical treatment of differentiated thyroid cancer. The indication for CLND is the presence of image-positive metastases in level VI lymph nodes; the elective dissection of radiographically normal central compartment lymph nodes in patients with differentiated thyroid cancer remains controversial. The different types of CLND will be discussed herein, and some of the surrounding controversies will be highlighted.

The effect of renal hyperfiltration on urinary inflammatory cytokines/chemokines in patients with uncomplicated type 1 diabetes mellitus

AIMS/HYPOTHESIS

High intraglomerular pressure causes renal inflammation in experimental models of diabetes. Our objective was to determine whether renal hyperfiltration, a surrogate for intraglomerular hypertension, is associated with increased excretion of urinary cytokines/chemokines in patients with type 1 diabetes mellitus.

METHODS

Blood pressure, renal haemodynamic function (inulin and para-aminohippurate clearances for glomerular filtration rate (GFR) and effective renal plasma flow (ERPF), respectively) and urine samples were obtained during clamped euglycaemia in individuals with type 1 diabetes with either hyperfiltration (GFR determined using inulin [GFRINULIN] ≥ 135 ml min⁻¹ 1.73 m⁻², n = 28) or normofiltration (n = 21) and healthy control individuals (n = 18).

RESULTS

Baseline clinical characteristics, dietary sodium and protein intake and blood pressure levels were similar in the diabetic and healthy control groups. In addition, HbA1c levels were similar in the two diabetic groups. As expected baseline GFR was higher in hyperfilterers than either normofiltering diabetic patients or healthy control patients (165 ± 9 vs 113 ± 2 and 116 ± 4 ml min⁻¹ 1.73 m⁻², respectively, p < 0.01). ERPF and renal blood flow were also comparatively higher and renal vascular resistance was lower in hyperfiltering patients (p < 0.01). Hyperfiltering diabetic patients had higher excretion rates for eotaxin, IFNα2, macrophage-derived chemokine, platelet-derived growth factor (PDGF)-AA, PDGF-AB/BB and granulocyte-macrophage colony-stimulating factor (p ≤ 0.01). Urinary monocyte chemoattractant protein (MCP)-1 and RANTES (regulated on activation, normal T expressed and secreted) excretion was also higher in hyperfiltering vs normofiltering diabetic individuals (p < 0.01) and fibroblast growth factor-2, MCP-3 and CD40K excretion was elevated in hyperfiltering diabetic individuals vs healthy controls (p < 0.01).

CONCLUSIONS/INTERPRETATION

Renal hyperfiltration is associated with increased urinary excretion of inflammatory cytokines/chemokines in patients with uncomplicated type 1 diabetes.

Swelling-induced delamination causes folding of surface-tethered polymer gels

When a polymer film that is weakly attached to a rigid substrate is exposed to solvent, swelling-induced compressive stress nucleates buckle delamination of the film from the substrate. Surprisingly, the buckles do not have a sinusoidal profile, instead, the film near the delamination buckles slides toward the buckles causing growth of sharp folds of high aspect ratio. These folds do not result from a wrinkle-to-fold transition; instead, the film goes directly from a flat state to a folded state. The folds persist even after the solvent evaporates. We propose that patterned delamination and folding may be exploited to realize high-aspect ratio topological features on surfaces through control of a set of boundary constraints arising from the interrelation of film-surface adhesion, film thickness and degree of swellabilty.

Reversible posterior leukoencephalopathy syndrome in Chinese children induced by chemotherapy: a review of five cases

This is a retrospective review of the clinico-radiological features and neurological outcomes of reversible posterior leukoencephalopathy syndrome episodes in Chinese cancer children receiving chemotherapy in a regional hospital in Hong Kong from 1998 to 2008. Five children (3 males and 2 females) with a mean age of 7 years were identified, four of whom had acute lymphoblastic leukaemia and one had a central nervous system germ cell tumour. Presenting symptoms included seizures (100%), altered mental function (100%), headache (40%), and visual disturbance (60%). The mean systolic blood pressure at presentation was 158 mm Hg. Approximately 80% had typical radiological features of reversible posterior leukoencephalopathy syndrome. All showed complete recovery after the acute stage, but one subsequently developed epilepsy. Two patients ultimately died of refractory malignant disease. Two others were followed up for a mean of 6 years, and remained neurologically normal. This report was the first case review documenting reversible posterior leukoencephalopathy syndrome in Chinese cancer children. The clinico-radiological features and neurological outcomes were similar to those reported in western series. Early recognition of the syndrome is important to facilitate appropriate treatment. The central nervous system damage may not be reversible and thus long-term follow-up is warranted.

Abstract 4921: Selective promoter methylation of the cell differentiation marker, intestinal alkaline phosphatase (iALP), in microsatellite unstable colon cancer

Tumorigenesis is characterized by excessive cell growth, resistance to apoptosis and aberrant cellular differentiation. In particular, MSI colorectal cancer is frequently characterized by poorly differentiated histology. Histone Deacetylase inhibitors (HDACi) are a novel class of cancer therapeutics that induce growth arrest, apoptosis and differentiation of a variety of tumour types, including colon cancer cells. Differentiation inducing agents have been used effectively to treat hematopoietic malignancies, prompting us to examine the effects of HDACi treatment on differentiation of colon cancer cells, and to compare the effects induced in MSS and MSI colon cancers. Remarkably, while HDACi treatment robustly and consistently induced differentiation induction as measured by alkaline phosphatise activity and iALP gene expression in multiple MSS colon cancer cell lines, approximately 70% of MSI colon cancer cell lines were highly resistant to HDACi-induced ALP induction. Examination of the coding sequence of the iALP gene failed to identify any significant repeat elements suggesting mutation is unlikely to be responsible for lack of iALP induction. Furthermore, transient transfection of an iALP promoter reporter construct demonstrated robust induction in response to butyrate treatment in both MSS and MSI lines, suggesting loss of a key regulatory factor in MSI cell lines is not likely to be responsible. Conversely, examination of iALP promoter methylation by bisulphite conversion and direct sequencing demonstrated multiple CpG sites, including a Sp1/Sp3 binding site, to be methylated in 4 of 5 MSI lines examined, while no methylation was observed in MSS lines. These findings were confirmed using the sequenom assay. ALP promoter methylation was independent of CIMP status. The importance of Sp1/Sp3 in butyrate-induced iALP induction was demonstrated by the ability of the Sp1/Sp3 inhibitor, mithramycin, to attenuate butyrate-induced ALP activity. Finally, consistent with methylation being a key determinant of iALP expression in MSI lines, azacytidine treatment was able to re-induce iALP expression, and butyrate-induction of ALP expression was markedly enhanced in isogenic HCT116 cells lacking the DNA methyltransferases Dnmt1 and Dnmt3b (DKO), compared to parental cells. These findings demonstrate selective promoter methylation of iALP in MSI colon cancer cell lines.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4921.

Preventing the Development of Breast Cancer by Immunizing with Multi-Antigen Vaccines Targeting Proteins Associated with Oncogenesis

Vaccines have been extremely successful in the prevention of infectious diseases. Although cancer vaccines have long been studied for the treatment of cancer, they have not been exploited as chemoprevention agents except in virally mediated malignancies. Human breast cancer is immunogenic and a variety of proteins involved in the malignant transformation or maintenance of the malignant phenotype have been identified as tumor antigens. Transgenic animal models are uniquely suited for evaluating the potential efficacy of preventative cancer vaccines. TgMMTV-neu mice, for example, develop neu-mediated breast cancer at about 150-200 days of life. Tumors are histologically similar to human breast cancer and have a molecular profile consistent with the luminal subtype. We have developed two multi-antigen vaccines targeting immunogenic proteins associated with oncogenesis and evaluated whether we could prevent the development of breast cancer in TgMMTV-neu mice. Each vaccine was composed of 3 different antigens. Class II epitopes derived from antigenic proteins involved in growth factor pathways comprised one vaccine and the other vaccine was plasmid DNA based and encoded immunogenic proteins involved in cell proliferation. The ability of active immunization to prevent breast cancer was evaluated in both older (18 week) and younger (5 week) mice. Vaccines were administered intradermally every two weeks for 3 immunizations and then monthly until the development of disease or 1 year had passed. Both vaccines prevented breast cancer development in older animals. 40% of peptide immunized older mice were cancer free at 1 year compared to 5% of controls (p=0.02). The DNA vaccine appeared to be even more effective in older animals with 60% of vaccinated mice tumor free as compared to 20% of controls (p=0.01). Protection from the development of cancer was mediated by T cells as evidenced by adoptive transfer of CD3+ cells purified from vaccinated and protected mice, sham immunized mice, and naïve mice. T cells from protected mice resulted in significant inhibition of tumor growth after a syngeneic tumor challenge (p=0.01 protected vs. sham vaccine). The cancer protective effect of immunization was more pronounced when vaccines were administered to the younger mice. The Class II epitope vaccine prevented cancer development in 65% of mice as compared to 5% of controls. The plasmid based vaccine protected 70% of mice from breast cancer. Active immunization was associated with a survival benefit in all groups. These data suggest breast cancer vaccines targeting biologically relevant proteins may be an effective approach to the prevention of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1045.

Radiation-induced peripheral nerve neurofibromata in a patient receiving hypofractionated radiation therapy

Radiation-induced peripheral nerve tumor, in particular a benign entity such as a neurofibroma, is rare, with only a few cases being reported so far. We demonstrate a case of radiation-induced neurofibromata along the left cervical nerve roots in a man with a background of localized targeted hypofractionated radiation therapy as adjuvant treatment for left cervical nodal metastasis complicating nasopharyngeal carcinoma. The toxicity of high-dose radiation in a hypofractionated regime is also stressed.

Oral features in Kabuki make-up Syndrome

AIM

Kabuki make-up Syndrome is so named because of the characteristic facies of the affected patient. The face is similar to a Kabuki actor's mask. The main aim of this report was to describe the oral features in Kabuki Syndrome, focusing on the tooth anomalies.

PATIENTS AND METHODS

Five subjects with Kabuki Syndrome, identified by the Child Neuropsychiatric Clinic of the University of Sassari, Italy, were enrolled. Their medical records were reviewed and oral and dental examinations were completed. The diagnosis was based upon the typical pattern of malformations and dysmorphic features reviewed by Matsumoto and Niikawa.

RESULTS

All patients showed typical characteristics of the Syndrome such as a long palpebral fissure, lower palpebral eversion, arched eyebrows, short nasal septum, prominent and large ears, fingertip pads, mental retardation, and paramedian elevation of the lower lip.

CONCLUSION

Kabuki make-up Syndrome is of unknown origin but a genetic aetiopathogenesis has been proposed. It is extremely rare; in Japan, where it is most frequent, it affects 1:32000 newborns. The typical facies of the syndrome, combined with general medical and dental examinations, are very important for diagnosis confirmation.

The effect of oral contraceptives on the nitric oxide system and renal function

We have demonstrated that oral contraceptive (OC) users exhibit elevated angiotensin II levels and angiotensin II type 1 receptor expression, indicative of renin-angiotensin system (RAS) activation, yet the renal and systemic consequences are minimal, suggesting that there is increased vasodilatory activity, counteracting the effect of RAS activation. We hypothesized that the nitric oxide (NO) system would be upregulated in OC users and that this would be reflected by a blunted hemodynamic response to l-arginine infusion. All subjects were studied after a 7-day controlled sodium and protein diet. Inulin and para-aminohippurate clearance techniques were used to assess renal function. l-Arginine was infused at 100, 250, and 500 mg/kg, each over 30 min. Skin endothelial NO synthase mRNA expression was assessed by real-time PCR. While OC nonusers exhibited significant increases in effective renal plasma flow (670.8 +/- 35.6 to 816.2 +/- 59.7 ml.min(-1).1.73 m(-2)) and glomerular filtration rate (133.4 +/- 4.3 to 151.0 +/- 5.7 ml.min(-1).1.73 m(-2), P = 0.04) and declines in renal vascular resistance (81.1 +/- 6.1 to 63.5 +/- 6.2 mmHg.ml(-1).min, P = 0.001) at the lower l-arginine infusion rates, the responses in OC users were blunted. While l-arginine reduced mean arterial pressure at the 250 and 500 mg/kg doses in OC nonusers, OC users only exhibited a decrease in mean arterial pressure at the highest infusion rate. In contrast, tissue endothelial NO synthase mRNA levels were higher in the OC users (P = 0.04). In summary, these findings suggest that the NO system is upregulated by OC use in young, healthy women. Increased activity of the NO pathway may modulate the hemodynamic effects of RAS activation in OC users.

Inflammatory myofibroblastic tumor of the nasal cavity

Inflammatory myofibroblastic tumor (IMT) is a rare tumor with a variable natural history and biologic behavior, ranging from completely benign to malignant with fatal outcome. We report a case of benign IMT in the left nasal cavity with radiologic features mimicking angiofibroma. We also demonstrate the hypervascular nature of this disease on angiography and the contribution of preoperative embolization in assisting surgical excision and minimizing the potential uncontrolled intraoperative bleeding.

Pegylated interferon alpha-2b for patients with HCV recurrence and graft fibrosis following liver transplantation

Chronic hepatitis C is a principal indication for liver transplantation. Recurrent viral infection is inevitable and graft disease is common. We report tolerability, safety and efficacy of pegylated interferon alpha 2b (PEG-IFN) monotherapy for patients with hepatitis C virus (HCV) recurrence and fibrosis after liver transplantation. Repeated measurements of serum HCV titer permitted assessment of the kinetics of the antiviral response for all patients. We screened 63 patients transplanted for HCV at our center for antiviral treatment, 14 were eligible and treated, but only 6 completed the proposed 52 weeks of therapy. Eight were withdrawn because of severe/life-threatening side effects/events, including liver dysfunction (4 patients). None of those 8 achieved a sustained virological response (SVR). Five of 6 who completed treatment were HCV RNA negative at the end of treatment, and 2 achieved an SVR. Viral kinetics were similar to published observations for treatment of non-transplanted HCV patients. Patients with genotype non-1 infection displayed a more rapid decline of viral titer than was observed for genotype 1 infection. Post-transplant HCV patients are frequently unsuitable for, or intolerant of PEG-IFN. Liver dysfunction was a major concern.