Prognostic gene expression signature for high-grade serous ovarian cancer

BACKGROUND

Median overall survival (OS) for women with high-grade serous ovarian cancer (HGSOC) is ∼4 years, yet survival varies widely between patients. There are no well-established, gene expression signatures associated with prognosis. The aim of this study was to develop a robust prognostic signature for OS in patients with HGSOC.

PATIENTS AND METHODS

Expression of 513 genes, selected from a meta-analysis of 1455 tumours and other candidates, was measured using NanoString technology from formalin-fixed paraffin-embedded tumour tissue collected from 3769 women with HGSOC from multiple studies. Elastic net regularization for survival analysis was applied to develop a prognostic model for 5-year OS, trained on 2702 tumours from 15 studies and evaluated on an independent set of 1067 tumours from six studies.

RESULTS

Expression levels of 276 genes were associated with OS (false discovery rate < 0.05) in covariate-adjusted single-gene analyses. The top five genes were TAP1, ZFHX4, CXCL9, FBN1 and PTGER3 (P < 0.001). The best performing prognostic signature included 101 genes enriched in pathways with treatment implications. Each gain of one standard deviation in the gene expression score conferred a greater than twofold increase in risk of death [hazard ratio (HR) 2.35, 95% confidence interval (CI) 2.02-2.71; P < 0.001]. Median survival [HR (95% CI)] by gene expression score quintile was 9.5 (8.3 to -), 5.4 (4.6-7.0), 3.8 (3.3-4.6), 3.2 (2.9-3.7) and 2.3 (2.1-2.6) years.

CONCLUSION

The OTTA-SPOT (Ovarian Tumor Tissue Analysis consortium - Stratified Prognosis of Ovarian Tumours) gene expression signature may improve risk stratification in clinical trials by identifying patients who are least likely to achieve 5-year survival. The identified novel genes associated with the outcome may also yield opportunities for the development of targeted therapeutic approaches.

Dental occlusion: a critical reflection on past, present and future concepts

For nearly a century, the diversity of concepts about 'normal' and 'ideal' dental occlusal relationships has led to confusion in trying to describe the occlusion of any individual patient. In addition, a similar controversy arises when trying to formulate treatment plans for patients who need extensive dental restorations or orthodontic treatment. And finally, the application of occlusal concepts to patients with temporomandibular pain and dysfunction has created a third area of debate. Over the past few decades, however, an appreciable part of the tenacious dogmatic heritage of this topic has been challenged. As a result, the acceptance of morphological and functional variability of the stomatognathic system has gained increasing support, and this change has important consequences for modern dental practice. In this article, the past, present and future of the subject of occlusion will be considered.

The etiology of temporomandibular disorders: implications for treatment

This article begins by reviewing the history of etiologic thinking in the field of temporomandibular disorders (TMD). I conclude from this review that not only are the old mechanistic etiologic concepts incorrect, but also that 2 of the most popular current concepts (biopsychosocial and multifactorial) are seriously flawed. Therefore, what we really have at the individual TMD patient level is nearly always an idiopathic situation--we simply do not know enough, or cannot measure enough, or cannot precisely determine why each patient has a TMD. In addition, we do not understand the host resistance factors that ultimately determine why one person gets sick while another does not. The issue of "why" (etiology) must be differentiated from the issue of "how" (pathophysiology), both semantically and intellectually, to discuss all of this properly. However, our current inability to precisely identify etiologies in TMD patients does not prevent us from providing sensible (and often successful) treatment for most of these patients. Many health conditions currently are treated by physicians and dentists with either incomplete or flawed understanding of their etiology, but the availability of empirical data about treatment outcomes permits some level of appropriate care to be given. Fortunately, a large number of comparative studies have been done in the field of TMD therapy, providing us with a basis for selecting initial therapies as well as for dealing with treatment failures. Even in the absence of a perfect understanding of etiology, we still can provide good conservative care, and we should avoid aggressive and irreversible treatments, especially when they are based on flawed concepts of etiology. The article concludes by discussing current basic science research activities in the field of TMD and orofacial pain. I propose that these ongoing studies of the molecular and cellular mechanisms of joint disease, muscle pain, and chronic pain are the most likely avenues to future progress in this field, as specific countermeasures are developed to become the basis for more precisely targeted therapies.

Temporomandibular disorders and science: a response to the critics

This article was prepared by the above authors and submitted to members of the TMD academic community for their endorsement. A total of 120 people signed an endorsement; their names are available on request.

Pancraniosynostosis after surgery for single sutural craniosynostosis

Three children who developed pancraniosynostosis after surgery to correct nonsyndromic single suture synostosis (2 sagittal, 1 unilateral coronal) were noted on prolonged follow-up to have a decreased rate of head growth, and beaten copper findings on plain radiographs of the skull. All had elevated intracranial pressure as recorded by lumbar puncture. The children were reoperated, and then cranial growth resumed, and the radiographic abnormalities resolved. Because of the risk of pancraniosynostosis after surgery for single suture craniosynostosis, extended neurosurgical follow-up for patients with craniosynostosis is warranted.

Temporomandibular disorders and science: a response to the critics

This article was prepared and submitted to members of the TMD academic community for their endorsement. A total of 120 people signed an endorsement; their names are available on request.

Predictive value of letters of recommendation vs questionnaires for emergency medicine resident performance

OBJECTIVE

To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program.

METHODS

A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings.

RESULTS

Statistically, no differences were found between the LORs and PPQs in predicting resident performance.

CONCLUSIONS

PPQs may substitute for LORs in the evaluation of resident applicants.

Etiology of temporomandibular disorders

This article discusses the subject of causation (etiology) as it has been applied to the field of temporomandibular disorders (TMD). These disorders have been the focus of considerable disagreement about what constitutes proper diagnosis and treatment, and it is clear that the main basis for these controversies has been conflicting views about the etiology of the various disorders. Many earlier theories emphasized dental morphological factors of malocclusion, occlusal dysharmony, and bad mandibular alignment as being primarily responsible for the development of TMD symptoms. Certain versions of these dental/skeletal concepts have long been a part of the belief system of the orthodontic specialty, leading to some special orthodontic protocols for managing TM disorders. Today, it is generally agreed that the etiology of TM disorders includes a multifactorial combination of physical and psychosocial factors, with some of them being either poorly understood or difficult to assess. In most cases, there are no special occlusal or orthodontic factors to be considered, and therefore occlusion-changing procedures are not generally required for successful treatment. This means that contemporary orthodontists must face the same challenge as all their other dental colleagues: to learn about modern concepts of diagnosis and treatment for all types of orofacial pain patients, and then to use currently recommended protocols for pain management and musculoskeletal therapy for those patients who have temporomandibular disorders.

Temporomandibular disorders in the geriatric population

Contrary to popular assumptions that temporomandibular disorders may become more prevalent with increasing age, a review of the literature shows that this is clearly not the case. Instead, it seems that most objective "signs" of temporomandibular disorders, namely clicking, tender joints and muscles, crooked opening, limited movement, and so forth, are found either less often in the elderly or at approximately the same rate in all adult age groups. Subjective complaints, however, decrease as populations get older, and the demand for treatment declines accordingly.

A quantitative computer-assisted analysis of disc displacement in patients with internal derangement using sagittal view magnetic resonance imaging

Forty patients diagnosed clinically as having internal derangement of one or both temporomandibular joints underwent magnetic resonance imaging. Seventy-three films were obtained: 26 films from 13 patients with bilateral symptoms; 40 films from 20 patients with unilateral symptomatic joints; and seven films from only the symptomatic joint in the remaining seven patients. Disc positions were evaluated in all of these films, and also in 17 films obtained from 10 asymptomatic volunteers. A system for quantitative measurement of disc position relative to the condyle in the closed-mouth position was used in two ways: manually, with an operator locating reference points and measuring them; and computer-assisted, with a special program developed to locate and measure these points. There was no significant difference in the results produced by these two methods. Important findings of this study were as follows: 1) 35% of the joints in the asymptomatic volunteers were found to have moderately or severely displaced discs; 2) only 75% of the joints diagnosed clinically as having an internal derangement were found to have significant disc displacement, which suggests that the other 25% must have had a different pathologic basis for the symptoms; and 3) the contralateral disc in the unilateral patients was found to be displaced as often as the disc on the symptomatic side (75%).

The origins, benefits, harms, and implications of emergency medicine clinical policies

Emergency physicians desire to provide their patients with care that is of the highest quality and is cost effective. Any tool that promotes these aims is good and should be used. Clinical policies have been proposed as a new method of prompting physicians to provide better care. While there is no direct evidence that emergency medicine clinical policies improve care, there is indirect evidence that they may be useful. ACEP has initiated a process for the development and evaluation of selected clinical policies. We anxiously await information that sheds light on the value of policies in enhancing the clinical practice of emergency medicine.

Quality assurance in the teaching hospital

The approach emergency medical service (EMS) systems take to quality assurance and quality improvement is evolving rapidly. Methods of quality assurance that have been applied to the prehospital care environment are reviewed. Impediments to effective quality assurance strategies are discussed and an overview of the scope of the activities and resources necessary to perform this task is presented. The potential efficacy and limitations of quality improvement in EMS are also discussed.

Managing TMD patients: initial therapy is the key

It has been the intention of this brief paper to help dentists respond quickly and effectively to patients with TMD. (In lieu of a detailed bibliography, a brief list of articles and books that deal with diagnosis and therapy for TMD follows.) Several present actual guidelines for practice, while others discuss concepts in greater detail. Knowing how to help these troubled patients by using contemporary basic principles of pain management should make every practicing dentist feel a well-deserved sense of fulfillment.

Treating TM disorders: a survey on diagnosis, etiology and management

This survey of five dental groups revealed that the dental profession still is far from reaching a consensus about temporomandibular disorders. Despite a great deal of research that has clarified many issues in this field, clinicians often cling to outdated concepts and practices. However, many respondents did give answers that demonstrated their awareness of modern TMD diagnostic and treatment guidelines.

Technological methods in the diagnosis and treatment of temporomandibular disorders

Although there have been numerous technological devices introduced for the diagnosis and treatment of temporomandibular disorders, many are either ineffective or are research tools without direct clinical application. This article reviews the various modalities and makes recommendations regarding their effectiveness based on the available clinical and scientific evidence.

Conservative management of temporomandibular disorders: a posttreatment comparison between patients from a university clinic and from private practice

Long-term (1 to 7.5 years) follow-up evaluations of 110 adult patients who were seen for diagnosis and treatment of symptoms related to myofascial problems (MP), internal derangement (ID), or both were conducted by means of telephone interview. One half of the patients were seen at the Northwestern University Dental School TMJ Clinic, while the other half were seen in the private office of one author (H. T. P.). The purpose of this study was to evaluate patient response to conservative therapy combined with advice about self-management, as compared with the response to advice only. Further, we desired to compare treatment outcomes among (1) diagnostic categories ID, MP, and ID plus MP, (2) clinic patients and private patients, and (3) patients with acute disease and those with chronic disease. Chronic disease was identified as that in which pretreatment symptoms had persisted for more than 4 months. The ridit analysis was used to assess differences in outcomes for patients in the three diagnostic categories and for clinic patients compared with private patients. The results revealed no significant differences. There was a trend for patients with acute conditions to improve more than those with chronic problems; however, further research is needed to determine whether a correlation exists between symptom duration and treatment outcome. At the time of the follow-up evaluation, 88% of all patients reported substantial or total improvement in their symptoms of pain and dysfunction. Therefore, conservative therapy, including advice about self-management, was found to be both adequate and appropriate for most of these patients.

Cerebral blood flow during the acute therapy of severe hypertension with oral clonidine

A major risk associated with the acute treatment of severe hypertension is a reduction in cerebral blood flow (CBF) with ischemic injury to the central nervous system. The authors studied CBF before and after the acute treatment of severe hypertension (diastolic blood pressure greater than 115 mm Hg) with clonidine in 13 patients. One patient did not reach goal blood pressure (diastolic blood pressure 105 mm Hg or a decrease by 30 mm Hg) after clonidine alone. In the remaining 12 patients, oral clonidine reduced supine blood pressure from 201.7 +/- 5.0/126.3 +/- 2.1 mm Hg to 149.4 +/- 5.3/96.8 +/- 1.7 mm Hg over an average time period of 85 +/- 7 minutes. Although mean CBF for the group did not change (72.6 +/- 4.2 v 73.7 +/- 3.5 mL/100 mg/min), a significant (greater than 10%) change occurred in 9 of the 12 patients (5 increases and 4 reductions). The magnitude and direction of the change were dependent upon initial CBF (r = -0.65, P less than .05); patients with low pretreatment CBF experienced an increase, whereas those with high initial flow exhibited a decrease. No significant adverse effects were observed. These data confirm previous reports that clonidine is effective in the acute treatment of severe hypertension and demonstrate that its effects on CBF are determined by the pretreatment levels of flow.

The effect of furosemide on intracranial pressure and hemorrhage in preterm rabbits

The hypothesis that intracranial hypotension due to excessive postnatal fluid loss places the premature infant at risk for germinal matrix and intraventricular hemorrhage (GM-IVH) was tested in preterm rabbits delivered at 28 and 29 days of gestation (term 32 days). Furosemide administered to newborn pups induced a diuresis that resulted in a 11% to 22% loss in body weight and a concomitant decline in muscle water (13% to 16%) and sodium (18% to 21%). Paradoxically, no change occurred in the water or electrolyte content of the brain even though cerebrospinal fluid and brain tissue pressure, but not blood pressure, declined. These changes were absent in littermates treated with saline. Microscopic examination of brain sections revealed a greater incidence of intracranial hemorrhage, particularly in the germinal matrix and choroid plexus, in furosemide-treated than in saline-treated preterm rabbit pups. These results are consistent with the hypothesis that intracranial hypotension promotes the incidence of GH-IVH in preterm animals.

Long-term status of TMJ clicking in patients with myofascial pain and dysfunction

This study evaluated the long-term changes in TMJ clicking and general TM disorder symptoms in 190 subjects originally treated by conservative, nonsurgical modalities that were not specifically directed to the problems of TMJ noise or disk derangement. The findings are detailed and support the concept that if the symptoms of pain and dysfunction in patients with clicking can be treated successfully by conservative, nonsurgical modalities, it is generally not necessary to correct the internal derangement with surgery.

Treatment of scaphocephaly with sagittal craniectomy and biparietal morcellation

A series of 50 consecutive patients with scaphocephaly treated by a new operation are reported, and the results are reviewed in detail. The treatment consists of a broad sagittal craniectomy plus extensive morcellation of both parietal bones and, occasionally, the squamous portion of the occipital bone, without dislodging the bony fragments from their dural attachments. The procedure can be done relatively rapidly (median operative time = 55 min) and with minimal loss of blood (median transfusion = 85 ml). The results are analyzed by several criteria and are considered to be excellent.

Orthodontics and temporomandibular disorders

The presumed relationship between occlusal disharmonies and temporomandibular disorders has been the cornerstone of traditional orthodontic thinking about these disorders. Current research, however, indicates that temporomandibular problems are actually medical orthopedic diseases or dysfunctions that have little to do with occlusal morphology or maxillomandibular relationships. Therefore, orthodontists must discard some of their traditional beliefs and practices, replacing them with modern concepts of musculoskeletal pain and dysfunction, in order to provide appropriate care for patients suffering from temporomandibular disorders.

Hydrocephalus and intraspinal tumor

Hydrocephalus with spinal subarachnoid obstruction is rare, and its cause is obscure. Two such patients are presented. The pathophysiology is reviewed. Spinal absorptive pathways for cerebrospinal fluid are postulated to play a critical role in such cases.

Incidence of temporomandibular symptoms in patients with major skeletal malocclusions: a survey of oral and maxillofacial surgery training programs

A survey was done of 116 graduate training programs in oral and maxillofacial surgery to determine (1) the percentage of patients screened for orthognathic surgery who had symptoms of temporomandibular pain and dysfunction preoperatively and (2) how many who were asymptomatic preoperatively developed temporomandibular symptoms postoperatively. Of the fifty-one programs that responded, most reported that fewer than 20% of the patients were symptomatic before surgery and that few patients had symptoms postoperatively. The implications of these findings are discussed.

Indications for plain abdominal radiography in the emergency department

Despite the proliferation of new imaging methods, plain abdominal radiographs remain the first films ordered in a significant number of emergency department patients. Several small studies suggest that abdominal films are ordered unnecessarily. Over-ordering takes two forms: inappropriate indications and poor choice of the number and/or types of views ordered. Criteria for obtaining plain abdominal radiographs are suggested based on the likelihood of radiographic findings and the probability of a change in management resulting from the findings. Benefit versus risk in fertile women is considered. Recommendations are made for the selection of views based on clinical suspicion and initial film review. There is a need for studies using larger sample sizes to confirm these conclusions.

The lowering of cerebral spinal fluid and brain interstitial pressure of preterm and term rabbits by furosemide

CSF, brain interstitial, and arterial or venous pressures were measured in preterm and term rabbits. Ten to sixty minutes after the infusion of furosemide, in concentrations reported to inhibit CSF production, CSF and brain interstitial pressures fell an average of 1.4 and 1.8 cm H2O, respectively. No changes were observed in plasma osmolality, arterial or venous pressures. Histopathological examination of coronal brain sections showed the presence of germinal matrix and/or choroid plexus haemorrhages in four of eight brains examined. These results indicate that CSF and brain interstitial pressures of anaesthetised, restrained rabbits can be reduced to subatmospheric levels without altering serum osmolality. It remains to be established whether diminution of intracranial pressure by this method will increase the incidence of IVH in the awake, unrestrained preterm animal.

Long-term evaluation of treatment for myofascial pain-dysfunction syndrome: a comparative analysis

This paper reports the short-term and long-term results of conservative reversible treatment used in 175 patients with MPD syndrome. These results are compared with those from ten published papers in which investigators used either irreversible treatment methods, reversible methods, or a combination of both approaches. The treatment outcome results in this study were similar to those in all of the previously reported studies. These findings suggest that conservative reversible therapies are both sufficient and appropriate for management of MPD syndrome in most patients. Major alterations of mandibular position or dentoalveolar relationships do not appear to be necessary for obtaining either short-term or long-term success, and therefore they can be generally regarded as inappropriate treatment for this disorder.

Spinal epidural abscess in children

This is a report of three children with spinal epidural abscess. The literature is reviewed and the features of this condition in children are noted. Because of the nonspecificity of presenting symptoms in children, the diagnosis may be delayed, resulting in a worse outcome, especially in children under 1 year of age. The extensive laminectomy advised for the treatment of spinal epidural abscesses in adults is undesirable in children because of the risk of spinal deformity and in most cases is probably not necessary.

Holistic dentistry. Where does the holistic end and the quackery begin?

The question of where holistic dentistry ends and quackery begins is a serious issue for our profession to consider. Although we obviously want to permit great latitude in the practice of dentistry, there must be some definitions of the limits of that latitude. More importantly, as we want to improve and expand the treatment services that dentists can provide to patients, there must be some guidelines regulating both the development and the use of new therapies. The major guideline for doing this already exists: it is called the scientific method.