Developing an interpretable machine learning model for predicting COVID-19 patients deteriorating prior to intensive care unit admission using laboratory markers

Coronavirus disease (COVID-19) remains a significant global health challenge, prompting a transition from emergency response to comprehensive management strategies. Furthermore, the emergence of new variants of concern, such as BA.2.286, underscores the need for early detection and response to new variants, which continues to be a crucial strategy for mitigating the impact of COVID-19, especially among the vulnerable population. This study aims to anticipate patients requiring intensive care or facing elevated mortality risk throughout their COVID-19 infection while also identifying laboratory predictive markers for early diagnosis of patients. Therefore, haematological, biochemical, and demographic variables were retrospectively evaluated in 8,844 blood samples obtained from 2,935 patients before intensive care unit admission using an interpretable machine learning model. Feature selection techniques were applied using precision-recall measures to address data imbalance and evaluate the suitability of the different variables. The model was trained using stratified cross-validation with k=5 and internally validated, achieving an accuracy of 77.27%, sensitivity of 78.55%, and area under the receiver operating characteristic (AUC) of 0.85; successfully identifying patients at increased risk of severe progression. From a medical perspective, the most important features of the progression or severity of patients with COVID-19 were lactate dehydrogenase, age, red blood cell distribution standard deviation, neutrophils, and platelets, which align with findings from several prior investigations. In light of these insights, diagnostic processes can be significantly expedited through the use of laboratory tests, with a greater focus on key indicators. This strategic approach not only improves diagnostic efficiency but also extends its reach to a broader spectrum of patients. In addition, it allows healthcare professionals to take early preventive measures for those most at risk of adverse outcomes, thereby optimising patient care and prognosis.

[Evolución de marcadores de laboratorio en pacientes con detección persistente de SARS-CoV-2.]

OBJECTIVE

The study of the evolution of certain biomarkers in patients with persistent detection of SARS-CoV-2 could determine the profile of the pathology that these patients may suffer. The objective of this study was to describe the evolution of different laboratory markers in patients with persistent detection of SARS-CoV-2, and determining these parameters were into reference values.

METHODS

Patients were divided into two groups: the control group (G0) included patients with a positive direct test for SARS-CoV-2 followed by 2 negative, while the problem group (G1) included patients with at least 3 consecutive positive tests. The time between consecutive samples was five to twenty days, and only patients with negative serology were included. Demographic data, comorbidities, symptoms, radiology and hospitalization were collected, as well as data from analytic and blood gases. The comparison between the study groups was realized using the t-student and U Mann-Whitney test for quantitative variables, and the χ2 test for qualitative variables. Results with p<0.05 were taken as significant.

RESULTS

Ninety patients were included, thirty-eight in G0 and fifty-two in G1. D-dimer decreased 10.20 times more in G0 patients, and normal levels of this parameter at t1 were 1.46 times more frequent in these patients. The percentage of lymphocytes increased sixteen times more in G0, and the normal values in t1 were 10.40 times more common in these patients. C-reactive protein decreased significantly in both groups, and lactate increased more in G1 patients.

CONCLUSIONS

The results of the study suggest that some biomarkers evolve differently in patients with persistent detection of SARS-CoV-2, which may have significant clinical impact. This information could help to determine the main organs or systems affected, allowing to anticipate socio-sanitary measures to prevent or compensate these alterations.

Comparison of reference intervals for biochemical and hematology markers derived by direct and indirect procedures based on the Isfahan cohort study

INTRODUCTION

Indirect methods for reference interval (RI) establishment apply statistical techniques to generate RIs for test result interpretation using stored laboratory data. They present unique advantages relative to traditional direct approaches such as fewer resource requirements; however, there is debate regarding their performance. Herein, we aimed to compare indirect and direct approaches for RI establishment by harnessing data from the Isfahan Cohort Study (ICS). This cohort includes both healthy individuals and those with a history of disease, enabling a direct comparison.

METHODS

Participants were recruited as part of ICS, including 6504 adults aged 34 years and older. Sociodemographic characteristics, anthropometry, blood pressure, various biochemical indices, and hematology parameters were collected. The refineR method was used to establish indirect RIs (before applying exclusion criteria). Direct RIs were calculated using nonparametric methods per CLSI EP28-A3 guidelines (after applying exclusion criteria). Bias ratios were calculated for each parameter to assess significant differences in estimations.

RESULTS

Direct and indirect RI estimations for most hematological and biochemical parameters were comparable. Statistically significant bias ratios between methods were observed for the upper limits of total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), hemoglobin (female), and platelet count as well as the lower limits of mean corpuscular hemoglobin (female), mean corpuscular volume, hemoglobin, and hematocrit (female).

CONCLUSION

Data presented indicate RIs derived from direct and indirect approaches are similar, but not identical. Further work should focus on the clinical significance of such differences as well as the investigation of necessary data-cleaning criteria before indirect method application.

Machine learning prediction for COVID-19 disease severity at hospital admission

IMPORTANCE

Early prognostication of patients hospitalized with COVID-19 who may require mechanical ventilation and have worse outcomes within 30 days of admission is useful for delivering appropriate clinical care and optimizing resource allocation.

OBJECTIVE

To develop machine learning models to predict COVID-19 severity at the time of the hospital admission based on a single institution data.

DESIGN, SETTING, AND PARTICIPANTS

We established a retrospective cohort of patients with COVID-19 from University of Texas Southwestern Medical Center from May 2020 to March 2022. Easily accessible objective markers including basic laboratory variables and initial respiratory status were assessed using Random Forest's feature importance score to create a predictive risk score. Twenty-five significant variables were identified to be used in classification models. The best predictive models were selected with repeated tenfold cross-validation methods.

MAIN OUTCOMES AND MEASURES

Among patients with COVID-19 admitted to the hospital, severity was defined by 30-day mortality (30DM) rates and need for mechanical ventilation.

RESULTS

This was a large, single institution COVID-19 cohort including total of 1795 patients. The average age was 59.7 years old with diverse heterogeneity. 236 (13%) required mechanical ventilation and 156 patients (8.6%) died within 30 days of hospitalization. Predictive accuracy of each predictive model was validated with the 10-CV method. Random Forest classifier for 30DM model had 192 sub-trees, and obtained 0.72 sensitivity and 0.78 specificity, and 0.82 AUC. The model used to predict MV has 64 sub-trees and returned obtained 0.75 sensitivity and 0.75 specificity, and 0.81 AUC. Our scoring tool can be accessed at https://faculty.tamuc.edu/mmete/covid-risk.html .

CONCLUSIONS AND RELEVANCE

In this study, we developed a risk score based on objective variables of COVID-19 patients within six hours of admission to the hospital, therefore helping predict a patient's risk of developing critical illness secondary to COVID-19.

Interpretable generalized neural additive models for mortality prediction of COVID-19 hospitalized patients in Hamadan, Iran

BACKGROUND

The high number of COVID-19 deaths is a serious threat to the world. Demographic and clinical biomarkers are significantly associated with the mortality risk of this disease. This study aimed to implement Generalized Neural Additive Model (GNAM) as an interpretable machine learning method to predict the COVID-19 mortality of patients.

METHODS

This cohort study included 2181 COVID-19 patients admitted from February 2020 to July 2021 in Sina and Besat hospitals in Hamadan, west of Iran. A total of 22 baseline features including patients' demographic information and clinical biomarkers were collected. Four strategies including removing missing values, mean, K-Nearest Neighbor (KNN), and Multivariate Imputation by Chained Equations (MICE) imputation methods were used to deal with missing data. Firstly, the important features for predicting binary outcome (1: death, 0: recovery) were selected using the Random Forest (RF) method. Also, synthetic minority over-sampling technique (SMOTE) method was used for handling imbalanced data. Next, considering the selected features, the predictive performance of GNAM for predicting mortality outcome was compared with logistic regression, RF, generalized additive model (GAMs), gradient boosting decision tree (GBDT), and deep neural networks (DNNs) classification models. Each model trained on fifty different subsets of a train-test dataset to ensure a model performance. The average accuracy, F1-score and area under the curve (AUC) evaluation indices were used for comparison of the predictive performance of the models.

RESULTS

Out of the 2181 COVID-19 patients, 624 died during hospitalization and 1557 recovered. The missing rate was 3 percent for each patient. The mean age of dead patients (71.17 ± 14.44 years) was statistically significant higher than recovered patients (58.25 ± 16.52 years). Based on RF, 10 features with the highest relative importance were selected as the best influential features; including blood urea nitrogen (BUN), lymphocytes (Lym), age, blood sugar (BS), serum glutamic-oxaloacetic transaminase (SGOT), monocytes (Mono), blood creatinine (CR), neutrophils (NUT), alkaline phosphatase (ALP) and hematocrit (HCT). The results of predictive performance comparisons showed GNAM with the mean accuracy, F1-score, and mean AUC in the test dataset of 0.847, 0.691, and 0.774, respectively, had the best performance. The smooth function graphs learned from the GNAM were descending for the Lym and ascending for the other important features.

CONCLUSIONS

Interpretable GNAM can perform well in predicting the mortality of COVID-19 patients. Therefore, the use of such a reliable model can help physicians to prioritize some important demographic and clinical biomarkers by identifying the effective features and the type of predictive trend in disease progression.

Demographic, clinical, and laboratory factors associated with renal parenchymal injury in Iranian children with acute pyelonephritis

Background

The association between renal parenchyma changes on dimercaptosuccinic acid (DMSA) scans and demographic, clinical, and laboratory markers was assessed in pediatric patients with acute pyelonephritis.

Methods

A retrospective study of 67 Iranian babies and children aged 1-month to 12-year with APN was conducted between 2012 and 2018. The presence of renal parenchymal involvement (RPI) during APN was determined using technetium-99m DMSA during the first 2 weeks of hospitalization. The association of DMSA results with demographic data, clinical features (hospitalization stay, fever temperature and duration), and laboratory parameters such as pathogen type, and hematological factors (ESR, CRP, BUN, Cr, Hb, and WBC) was evaluated.

Results

92.5% of children with an average age of 43.76 ± 5.2 months were girls. Twenty-four children (35.8%) did not have renal parenchymal injury (RPI), while 26 (38.8%) and 17 (25.4%) patients showed RPI in one and both kidneys, respectively. There was no significant association between RPI and mean ESR, CRP, BUN, and WBC. However, there were significant associations between RPI and higher mean levels of Cr, Hb, and BMI.

Conclusions

Low BMI and Hb levels and increased Cr levels might be indicative of the presence of RPI in children with APN.

Expert consensus on the monitoring of transthyretin amyloid cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a life-threatening condition with a heterogeneous clinical presentation. The recent availability of treatment for ATTR-CM has stimulated increased awareness of the disease and patient identification. Stratification of patients with ATTR-CM is critical for optimal management and treatment; however, monitoring disease progression is challenging and currently lacks best-practice guidance. In this report, experts with experience in treating amyloidosis and ATTR-CM developed consensus recommendations for monitoring the course of patients with ATTR-CM and proposed meaningful thresholds and frequency for specific parameters. A set of 11 measurable features across three separate domains were evaluated: (i) clinical and functional endpoints, (ii) biomarkers and laboratory markers, and (iii) imaging and electrocardiographic parameters. Experts recommended that one marker from each of the three domains provides the minimum requirements for assessing disease progression. Assessment of cardiac disease status should be part of a multiparametric evaluation in which progression, stability or improvement of other involved systems in transthyretin amyloidosis should also be considered. Additional data from placebo arms of clinical trials and future studies assessing ATTR-CM will help to elucidate, refine and define these and other measurements.

Mild versus severe COVID-19: Laboratory markers. Int J Infect Dis. 2020;95:304-307. [PMID: 32344011 PMCID: PMC7194601 DOI: 10.1016/j.ijid.2020.04.061]

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Several laboratory parameters may facilitate the assessment of COVID-19 severity

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Discriminating mild from severe COVID-19 disease

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Cumulative data from clinical characteristics of COVID-19 patients

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Low lymphocyte count as well as the serum levels of CRP, D-dimers, ferritin and IL-6

The number of COVID-19 patients is dramatically increasing worldwide. Treatment in intensive care units (ICU) has become a major challenge; therefore, early recognition of severe forms is absolutely essential for timely triaging of patients. While the clinical status, in particular peripheral oxygen saturation (SpO2) levels, and concurrent comorbidities of COVID-19 patients largely determine the need for their admittance to ICUs, several laboratory parameters may facilitate the assessment of disease severity. Clinicians should consider low lymphocyte count as well as the serum levels of CRP, D-dimers, ferritin, cardiac troponin and IL-6, which may be used in risk stratification to predict severe and fatal COVID-19 in hospitalised patients. It is more likely that the course of the disease will be unfavourable if some or all of these parameters are altered.

Laboratory markers as useful prognostic measures for survival in patients with spinal metastases

BACKGROUND CONTEXT

Laboratory values have been found to be useful predictive measures of survival following surgery. The utility of laboratory values for prognosticating outcomes among patients with spinal metastases has not been studied.

PURPOSE

To determine the prognostic capacity of laboratory values at presentation including white blood cell count, serum albumin and platelet-lymphocyte ratio (PLR) in patients with spinal metastases.

STUDY DESIGN

Retrospective review of records from two tertiary care centers (2005-2017).

PATIENT SAMPLE

Patients, aged 40 to 80, who received operative or nonoperative management for spinal metastases.

OUTCOME MEASURES

Survival, complications, or hospital readmissions within 90 days of treatment and a composite measure for treatment failure accounting for changes in ambulatory function and mortality at 6 months following presentation.

METHODS

Multivariable Cox proportional hazard regression analysis was used to analyze the relationship between laboratory values and length of survival, adjusting for confounders. Multivariable logistic regression was used in analyses related to 6-month and 1-year mortality, complications, readmissions, and treatment failure. A scoring rubric was developed based on the performance of laboratory values in the multivariable tests. Internal validation was performed using a bootstrap simulation that consisted of sampling with replacement and 1,000 replications.

RESULTS

We included 1,216 patients. Thirty-seven percent of patients received a surgical intervention and 63% were treated nonoperatively. Median survival for the cohort as a whole was 255 days (interquartile range 93-642 days). The PLR (hazard ratio [HR] 1.53; 95% confidence interval [CI] 1.29, 1.80; p<.001) and albumin (HR 0.54; 95% CI 0.45, 0.64; p<.001) were significantly associated with survival, whereas WBC count (HR 1.08; 95% CI 0.86, 1.36; p=.50) was not associated with this outcome. Similar findings were encountered for 6-month and 1-year mortality as well as the composite measure for treatment failure. The PLR and albumin performed well in our scoring rubric and findings were preserved in the bootstrapping validation.

CONCLUSIONS

Individuals with low serum albumin and elevated PLR should be advised regarding the impact of these laboratory markers on outcomes including survival, irrespective of treatments received. An effort should also be made to optimize nutrition and PLR, if practicable, before treatment to minimize the potential for development of adverse events.

Dengue Outbreak in Peshawar: Clinical Features and Laboratory Markers of Dengue Virus Infection

BACKGROUND

Dengue is a tropical disease caused by dengue virus (DENV). It is one of the most significant arthropod-borne viral infection.

OBJECTIVES

The aim of the current study was to characterize epidemiological, clinical features and laboratory markers of dengue infection during the recent epidemic in Peshawar, KP.

METHODS

During the prospective hospital-based observational study, 2000 dengue suspected cases were serologically examined at Lady Reading Hospital (LRH) Peshawar. Dengue NS1 antigen and Dengue IgG and IgM antibody ELISA tests were conducted for the confirmation of dengue infection. Data regarding the clinical features, platelet count and liver function tests were also recorded for the dengue positive patients.

RESULTS

Out of total samples 415 (21%) cases including 309 (74%) male and 106 (25%) female were detected positive for the dengue infection. In the dengue positive patients, the highest prevalence was observed in the age group of 21-40years with 160 (38%) followed by the age group of 1-20years with 89 (21%) patients. Fever was recorded in 100% of the dengue patients followed by a headache and fatigue in 73% and liver abnormality observed in 70% of the cases. During laboratory examinations IgM antibody was detected in 180 cases, followed by IgG antibody in 87, NS1 antigen in 43, NS1 antigen along with IgG and IgM antibodies in 41 dengue positive cases. Another combine detection of NS1 antigen with IgM antibody, NS1 antigen with IgG antibody and both IgG and IgM antibodies was observed in 21, 21, 22 dengue cases respectively.

CONCLUSION

It was concluded that the dengue infection can be early diagnosed on the basis of described clinical features and with the detection of dengue-specific NS1 antigen along with antibodies such as IgG and IgM.

Biochemical Markers, Genotype, and Inflammation in Pediatric Inflammatory Bowel Disease: A Danish Population-Based Study

BACKGROUND

Our aim was to characterize the biochemical markers at diagnosis in patients with inflammatory bowel disease (IBD), to assess the utility of these to predict disease course and investigate if genotype influences biochemical markers of inflammation.

SUMMARY

Patients were included from a population-based pediatric IBD cohort from Eastern Denmark. Data on biochemical markers and medical as well as surgical treatment were registered at diagnosis, 30 days, 6 and 12 months after diagnosis. Fifty-two single nucleotide polymorphisms (SNPs) known to be associated with IBD were selected for genotyping based on previous genetic studies. Key messages: A total of 190 IBD patients (97 ulcerative colitis [UC], 87 Crohn's disease [CD], and 6 IBD unclassified) were included. UC patients with extensive disease had higher C-reactive protein, erythrocyte sedimentation rate, and platelet count at diagnosis compared to UC patients with less extensive disease. No similar differences between disease extent groups were found in CD. Low albumin at diagnosis was associated with an increased risk of surgery in both UC (OR 1.35; 95% CI: 1.05-1.75) and CD patients (OR 1.23; 95% CI: 1.01-1.48) and increased use of azathioprine and anti-tumor necrosis factor alpha use in the total IBD cohort (OR 1.15; 95% CI: 1.04-1.27 and OR 1.19 [1.08-1.34]). One SNP (rs4986791 in the TLR-4 locus) and 2 SNPs (rs6785049 in the Pregnane-x-receptor gene and rs10500264 in the SLCA10 gene) were associated with a change in albumin and hemoglobin over time respectively in our IBD cohort. Our study confirms albumin to be a marker of severe disease course. Furthermore, the patient's genotype possibly affects the inflammatory response. Future studies in larger pediatric cohorts are needed to confirm our findings.

To Compare the Efficacy of C-Reactive Protein and Total Leucocyte Count as Markers for Monitoring the Course of Odontogenic Space Infections

OBJECTIVE

To compare the efficacy of CRP and TLC as markers for monitoring the course of odontogenic space infections (OSI) in 50 patients.

METHODS

A Clinical severity scale (CSS) was developed to grade the severity of infections in patients. Blood samples were taken preoperatively and postoperatively at day 1, day 2, day 3 and day 7 for measuring the levels of CRP and TLC. The trends of CRP and TLC were analysed against the CSS. The data was subjected to paired "t" test, ANOVA, Spearman rank correlation, Pearson's bivariate correlation as appropriate.

RESULTS

The CRP values were elevated in all 50/50 (100 %) patients as compared to TLC which were elevated in 32/50 (64 %) patients only. The CSS displayed a high internal consistency and reliability (Cronbach α = 0.748). A significant strong positive correlation (ρ = 0.754) was found between CRP and CSS as compared to a moderate correlation (ρ = .607) between TLC and CSS.

CONCLUSION

CRP displayed a more consistent relation with clinical severity of the infection than TLC. Hence it could be more reliably employed to judge the progress in a patient with OSI.

Alcohol, microbiome, life style influence alcohol and non-alcoholic organ damage

This paper is based upon the "8th Charles Lieber's Satellite Symposium" organized by Manuela G. Neuman at the Research Society on Alcoholism Annual Meeting, on June 25, 2016 at New Orleans, Louisiana, USA. The integrative symposium investigated different aspects of alcohol-induced liver disease (ALD) as well as non-alcohol-induced liver disease (NAFLD) and possible repair. We revealed the basic aspects of alcohol metabolism that may be responsible for the development of liver disease as well as the factors that determine the amount, frequency and which type of alcohol misuse leads to liver and gastrointestinal diseases. We aimed to (1) describe the immuno-pathology of ALD, (2) examine the role of genetics in the development of alcoholic hepatitis (ASH) and NAFLD, (3) propose diagnostic markers of ASH and non-alcoholic steatohepatitis (NASH), (4) examine age and ethnic differences as well as analyze the validity of some models, (5) develop common research tools and biomarkers to study alcohol-induced effects, 6) examine the role of alcohol in oral health and colon and gastrointestinal cancer and (7) focus on factors that aggravate the severity of organ-damage. The present review includes pre-clinical, translational and clinical research that characterizes ALD and NAFLD. Strong clinical and experimental evidence lead to recognition of the key toxic role of alcohol in the pathogenesis of ALD with simple fatty infiltrations and chronic alcoholic hepatitis with hepatic fibrosis or cirrhosis. These latter stages may also be associated with a number of cellular and histological changes, including the presence of Mallory's hyaline, megamitochondria, or perivenular and perisinusoidal fibrosis. Genetic polymorphisms of ethanol metabolizing enzymes and cytochrome p450 (CYP) 2E1 activation may change the severity of ASH and NASH. Other risk factors such as its co-morbidities with chronic viral hepatitis in the presence or absence of human deficiency virus were discussed. Dysregulation of metabolism, as a result of ethanol exposure, in the intestine leads to colon carcinogenesis. The hepatotoxic effects of ethanol undermine the contribution of malnutrition to the liver injury. Dietary interventions such as micro and macronutrients, as well as changes to the microbiota have been suggested. The clinical aspects of NASH, as part of the metabolic syndrome in the aging population, have been presented. The symposium addressed mechanisms and biomarkers of alcohol induced damage to different organs, as well as the role of the microbiome in this dialog. The microbiota regulates and acts as a key element in harmonizing immune responses at intestinal mucosal surfaces. It is known that microbiota is an inducer of proinflammatory T helper 17 cells and regulatory T cells in the intestine. The signals at the sites of inflammation mediate recruitment and differentiation in order to remove inflammatory inducers and promote tissue homeostasis restoration. The change in the intestinal microbiota also influences the change in obesity and regresses the liver steatosis. Evidence on the positive role of moderate alcohol consumption on heart and metabolic diseases as well on reducing steatosis have been looked up. Moreover nutrition as a therapeutic intervention in alcoholic liver disease has been discussed. In addition to the original data, we searched the literature (2008-2016) for the latest publication on the described subjects. In order to obtain the updated data we used the usual engines (Pub Med and Google Scholar). The intention of the eighth symposia was to advance the international profile of the biological research on alcoholism. We also wish to further our mission of leading the forum to progress the science and practice of translational research in alcoholism.

Prevalence of potential underlying aetiology of macrocytic anaemia in Dutch general practice

BACKGROUND

Macrocytic anaemia (MCV ≥ 100 fL) is a relatively common finding in general practice. However, literature on the prevalence of the different causes in this population is limited. The prevalence of macrocytic anaemia and its underlying aetiology were analysed in a general practice population. The potential effect of the different aetiology on survival was also evaluated.

METHODS

Between the 1st of February 2007 and the 1st of February 2015, patients aged 50 years or older and presenting to their general practitioner with a newly diagnosed anaemia, were included in the study. Anaemia was defined as haemoglobin level below 13.7 g/dL in men and below 12.1 g/dL in women. A broad range of laboratory tests was performed for each patient. The causes of anaemia were consequently determined by two independent observers based on the laboratory results.

RESULTS

Of the 3324 included patients, 249 (7.5 %) displayed a macrocytic anaemia and were subsequently analysed. An underlying explanation could be established in 204 patients (81.9 %) with 27 patients (13.2 %) displaying multiple causes. Classic aetiology (i.e. alcohol abuse, vitamin B12/folic acid deficiency, haemolysis and possible bone marrow disease) was found in 115 patients. Alternative causes (i.e. anaemia of chronic disease, iron deficiency, renal anaemia and other causes) were encountered in 101 patients. In addition, a notable finding was the median gamma GT of 277 U/L in patients diagnosed with alcohol abuse (N = 24, IQR 118.0-925.5) and 23 U/L in the remaining cohort (N = 138, IQR 14.0-61.0). The distribution of gamma GT values was statistically different (P < 0.001). Five year survival rates were determined for six categories of causes, ranging from 39.9 % (95 % CI 12.9-66.9) for renal anaemia to 76.2 % (95 % CI 49.4-103.0) for the category multiple causes.

CONCLUSION

In addition to classic explanations for macrocytosis, alternative causes are frequently encountered in patients with macrocytic anaemia in general practice.

Persistent, Unexplained Leukocytosis Is a Paraneoplastic Syndrome Associated With a Poor Prognosis in Patients With Urothelial Carcinoma

BACKGROUND

We sought to define the disease characteristics and outcomes of those patients presenting with urothelial carcinoma and a persistently elevated white blood cell (WBC) count.

MATERIALS AND METHODS

We queried a prospectively maintained institutional database. Patients were included if they had had a histologic diagnosis of urothelial carcinoma and a WBC count of > 20,000 cells/μL on ≥ 2 occasions separated by 30 days. The patients' medical records were reviewed and were excluded from the analysis if an underlying cause for the leukocytosis could be identified. The clinical, histologic, and laboratory data were then collected from the remaining patient cohort.

RESULTS

We identified a total of 1410 patients with a histologic diagnosis of urothelial carcinoma, 9 (0.6%) of whom met our inclusion criteria. These 9 patients had a median age of 63 years. At their presentation with leukocytosis, all 9 had muscle-invasive disease and 5 had evidence of metastatic disease. Leukocytosis was frequently associated with hypercalcemia (n = 6), thrombocytosis (n = 5), and anemia (n = 9). Chemotherapy was able to achieve a WBC response in 3 of 5 patients, although only 1 patient demonstrated a substantial reduction in tumor volume radiographically. Extirpative surgery was able to provide a response in the laboratory parameters in 2 of 4 patients. However, all studied patients ultimately developed leukocytosis recurrence after systemic or local therapy and experienced rapid disease progression, with a median interval from leukocytosis until death of 71 days.

CONCLUSION

Paraneoplastic leukocytosis in the setting of urothelial carcinoma is a rare phenomenon but confers a poor prognosis, with a rapid progression to death.

Alcoholic and non-alcoholic steatohepatitis

This paper is based upon the "Charles Lieber Satellite Symposia" organized by Manuela G. Neuman at the Research Society on Alcoholism (RSA) Annual Meetings, 2013 and 2014. The present review includes pre-clinical, translational and clinical research that characterize alcoholic liver disease (ALD) and non-alcoholic steatohepatitis (NASH). In addition, a literature search in the discussed area was performed. Strong clinical and experimental evidence lead to recognition of the key toxic role of alcohol in the pathogenesis of ALD. The liver biopsy can confirm the etiology of NASH or alcoholic steatohepatitis (ASH) and assess structural alterations of cells, their organelles, as well as inflammatory activity. Three histological stages of ALD are simple steatosis, ASH, and chronic hepatitis with hepatic fibrosis or cirrhosis. These latter stages may also be associated with a number of cellular and histological changes, including the presence of Mallory's hyaline, megamitochondria, or perivenular and perisinusoidal fibrosis. Genetic polymorphisms of ethanol metabolizing enzymes such as cytochrome p450 (CYP) 2E1 activation may change the severity of ASH and NASH. Alcohol mediated hepatocarcinogenesis, immune response to alcohol in ASH, as well as the role of other risk factors such as its co-morbidities with chronic viral hepatitis in the presence or absence of human immunodeficiency virus are discussed. Dysregulation of hepatic methylation, as result of ethanol exposure, in hepatocytes transfected with hepatitis C virus (HCV), illustrates an impaired interferon signaling. The hepatotoxic effects of ethanol undermine the contribution of malnutrition to the liver injury. Dietary interventions such as micro and macronutrients, as well as changes to the microbiota are suggested. The clinical aspects of NASH, as part of metabolic syndrome in the aging population, are offered. The integrative symposia investigate different aspects of alcohol-induced liver damage and possible repair. We aim to (1) determine the immuno-pathology of alcohol-induced liver damage, (2) examine the role of genetics in the development of ASH, (3) propose diagnostic markers of ASH and NASH, (4) examine age differences, (5) develop common research tools to study alcohol-induced effects in clinical and pre-clinical studies, and (6) focus on factors that aggravate severity of organ-damage. The intention of these symposia is to advance the international profile of the biological research on alcoholism. We also wish to further our mission of leading the forum to progress the science and practice of translational research in alcoholism.