The National Association of Medical Examiners Position Paper on the Investigation and Certification of Pediatric Deaths From Environmental Neglect

ABSTRACT

Pediatric deaths that occur because of environmental neglect often involve 4 common scenarios: (1) hyperthermia due to environmental exposure, (2) ingestion of an accessible drug or poison, (3) unwitnessed/unsupervised drownings, and (4) unsafe sleep practices. Given the same fact pattern, the manner of death will vary from accident to homicide to undetermined based on local custom and/or the certifier's training and experience. Medical examiner/coroner death certifications are administrative public health determinations made for vital statistical purposes. Because the manner of death is an opinion, it is understandable that manner determinations may vary among practitioners. No prosecutor, judge, or jury is bound by the opinions expressed on the death certificate. This position paper does not dictate how these deaths should be certified. Rather, it describes the challenges of the investigations and manner determinations in these deaths. It provides specific criteria that may improve consistency of certification. Because pediatric deaths often are of public interest, this paper provides the medical examiner/coroner with a professional overview of such manner determination issues to assist various stakeholders in understanding these challenges and variations.

Intelligent digital tools for screening of brain connectivity and dementia risk estimation in people affected by mild cognitive impairment: the AI-Mind clinical study protocol

More than 10 million Europeans show signs of mild cognitive impairment (MCI), a transitional stage between normal brain aging and dementia stage memory disorder. The path MCI takes can be divergent; while some maintain stability or even revert to cognitive norms, alarmingly, up to half of the cases progress to dementia within 5 years. Current diagnostic practice lacks the necessary screening tools to identify those at risk of progression. The European patient experience often involves a long journey from the initial signs of MCI to the eventual diagnosis of dementia. The trajectory is far from ideal. Here, we introduce the AI-Mind project, a pioneering initiative with an innovative approach to early risk assessment through the implementation of advanced artificial intelligence (AI) on multimodal data. The cutting-edge AI-based tools developed in the project aim not only to accelerate the diagnostic process but also to deliver highly accurate predictions regarding an individual's risk of developing dementia when prevention and intervention may still be possible. AI-Mind is a European Research and Innovation Action (RIA H2020-SC1-BHC-06-2020, No. 964220) financed between 2021 and 2026. First, the AI-Mind Connector identifies dysfunctional brain networks based on high-density magneto- and electroencephalography (M/EEG) recordings. Second, the AI-Mind Predictor predicts dementia risk using data from the Connector, enriched with computerized cognitive tests, genetic and protein biomarkers, as well as sociodemographic and clinical variables. AI-Mind is integrated within a network of major European initiatives, including The Virtual Brain, The Virtual Epileptic Patient, and EBRAINS AISBL service for sensitive data, HealthDataCloud, where big patient data are generated for advancing digital and virtual twin technology development. AI-Mind's innovation lies not only in its early prediction of dementia risk, but it also enables a virtual laboratory scenario for hypothesis-driven personalized intervention research. This article introduces the background of the AI-Mind project and its clinical study protocol, setting the stage for future scientific contributions.

The EBV Gastric Cancer Resource (EBV-GCR): A Suite of Tools for Investigating EBV-Associated Human Gastric Carcinogenesis

Epstein-Barr virus (EBV) causes lifelong infection in over 90% of the world’s population. EBV infection leads to several types of B cell and epithelial cancers due to the viral reprogramming of host-cell growth and gene expression. EBV is associated with 10% of stomach/gastric adenocarcinomas (EBVaGCs), which have distinct molecular, pathological, and immunological characteristics compared to EBV-negative gastric adenocarcinomas (EBVnGCs). Publicly available datasets, such as The Cancer Genome Atlas (TCGA), contain comprehensive transcriptomic, genomic, and epigenomic data for thousands of primary human cancer samples, including EBVaGCs. Additionally, single-cell RNA-sequencing data are becoming available for EBVaGCs. These resources provide a unique opportunity to explore the role of EBV in human carcinogenesis, as well as differences between EBVaGCs and their EBVnGC counterparts. We have constructed a suite of web-based tools called the EBV Gastric Cancer Resource (EBV-GCR), which utilizes TCGA and single-cell RNA-seq data and can be used for research related to EBVaGCs. These web-based tools allow investigators to gain in-depth biological and clinical insights by exploring the effects of EBV on cellular gene expression, associations with patient outcomes, immune landscape features, and differential gene methylation, featuring both whole-tissue and single-cell analyses.

Evaluation of single-cell RNAseq labelling algorithms using cancer datasets

Single-cell RNA sequencing (scRNA-seq) clustering and labelling methods are used to determine precise cellular composition of tissue samples. Automated labelling methods rely on either unsupervised, cluster-based approaches or supervised, cell-based approaches to identify cell types. The high complexity of cancer poses a unique challenge, as tumor microenvironments are often composed of diverse cell subpopulations with unique functional effects that may lead to disease progression, metastasis and treatment resistance. Here, we assess 17 cell-based and 9 cluster-based scRNA-seq labelling algorithms using 8 cancer datasets, providing a comprehensive large-scale assessment of such methods in a cancer-specific context. Using several performance metrics, we show that cell-based methods generally achieved higher performance and were faster compared to cluster-based methods. Cluster-based methods more successfully labelled non-malignant cell types, likely because of a lack of gene signatures for relevant malignant cell subpopulations. Larger cell numbers present in some cell types in training data positively impacted prediction scores for cell-based methods. Finally, we examined which methods performed favorably when trained and tested on separate patient cohorts in scenarios similar to clinical applications, and which were able to accurately label particularly small or under-represented cell populations in the given datasets. We conclude that scPred and SVM show the best overall performances with cancer-specific data and provide further suggestions for algorithm selection. Our analysis pipeline for assessing the performance of cell type labelling algorithms is available in https://github.com/shooshtarilab/scRNAseq-Automated-Cell-Type-Labelling.

TMExplorer: A tumour microenvironment single-cell RNAseq database and search tool

Motivation

The tumour microenvironment (TME) contains various cells including stromal fibroblasts, immune and malignant cells, and its composition can be elucidated using single-cell RNA sequencing (scRNA-seq). scRNA-seq datasets from several cancer types are available, yet we lack a comprehensive database to collect and present related TME data in an easily accessible format.

Results

We therefore built a TME scRNA-seq database, and created the R package TMExplorer to facilitate investigation of the TME. TMExplorer provides an interface to easily access all available datasets and their metadata. The users can search for datasets using a thorough range of characteristics. The TMExplorer allows for examination of the TME using scRNA-seq in a way that is streamlined and allows for easy integration into already existing scRNA-seq analysis pipelines.

Rare protein-coding variants implicate genes involved in risk of suicide death

Identification of genetic factors leading to increased risk of suicide death is critical to combat rising suicide rates, however, only a fraction of the genetic variation influencing risk has been accounted for. To address this limitation, we conducted the first comprehensive analysis of rare genetic variation in suicide death leveraging the largest suicide death biobank, the Utah Suicide Genetic Risk Study (USGRS). We conducted a single-variant association analysis of rare (minor allele frequency <1%) putatively functional single-nucleotide polymorphisms (SNPs) present on the Illumina PsychArray genotyping array in 2,672 USGRS suicide deaths of non-Finnish European (NFE) ancestry and 51,583 NFE controls from the Genome Aggregation Database. Secondary analyses used an independent control sample of 21,324 NFE controls from the Psychiatric Genomics Consortium. Five novel, high-impact, rare SNPs were identified with significant associations with suicide death (SNAPC1, rs75418419; TNKS1BP1, rs143883793; ADGRF5, rs149197213; PER1, rs145053802; and ESS2, rs62223875). 119 suicide decedents carried these high-impact SNPs. Both PER1 and SNAPC1 have other supporting gene-level evidence of suicide risk, and psychiatric associations exist for PER1 (bipolar disorder, schizophrenia), and for TNKS1BP1 and ESS2 (schizophrenia). Three of the genes (PER1, TNKS1BP1, and ADGRF5), together with additional genes implicated by genome-wide association studies on suicidal behavior, showed significant enrichment in immune system, homeostatic and signal transduction processes. No specific diagnostic phenotypes were associated with the subset of suicide deaths with the identified rare variants. These findings suggest an important role for rare variants in suicide risk and implicate genes and gene pathways for targeted replication.

«If you give them your little finger, they'll tear off your entire arm»: losing trust in biobank research

Why do some people withdraw from biobank studies? To our knowledge, very few studies have been done on the reflections of biobank ex-participants. In this article, we report from such a study. 16 years ago, we did focus group interviews with biobank participants and ex-participants. We found that the two groups interestingly shared worries concerning the risks involved in possible novel uses of their biobank material, even though they drew opposite conclusions from their worries. Revisiting these interviews today reveals a remarkable relevance to present concerns, since the possible developments that worried ex-participants and participants 16 years ago now are becoming realities. Drawing on conceptual distinctions by sociologist and philosopher Niklas Luhmann, we argue that while ex-participants express a loss of trust in the biobank institution to manage the use of their biobank material in a legitimate way, remaining participants expressed confidence in the management of the biobank institution to secure their interests. This analysis brings out important aspects of emerging trends in biobank research participation.

CReSCENT: CanceR Single Cell ExpressioN Toolkit

CReSCENT: CanceR Single Cell ExpressioN Toolkit (https://crescent.cloud), is an intuitive and scalable web portal incorporating a containerized pipeline execution engine for standardized analysis of single-cell RNA sequencing (scRNA-seq) data. While scRNA-seq data for tumour specimens are readily generated, subsequent analysis requires high-performance computing infrastructure and user expertise to build analysis pipelines and tailor interpretation for cancer biology. CReSCENT uses public data sets and preconfigured pipelines that are accessible to computational biology non-experts and are user-editable to allow optimization, comparison, and reanalysis for specific experiments. Users can also upload their own scRNA-seq data for analysis and results can be kept private or shared with other users.

Diagnosis of peroxisomal disorders by analysis of phytanic and pristanic acids in stored blood spots collected at neonatal screening

Concentrations of phytanic acid and pristanic acid were measured in stored dried blood spots collected at neonatal screening from patients with peroxisomal disorders, and compared with concentrations in control blood spots. In blood spots from two patients with Zellweger syndrome both phytanic acid and pristanic acid concentrations were increased but their concentration ratio was normal. In the blood spot from a patient with rhizomelic chondrodysplasia punctata, the concentration of phytanic acid was increased, whereas pristanic acid was within the control range, resulting in a low pristanic acid/phytanic acid ratio. In the blood spot from a patient with X-linked adrenoleukodystrophy, the concentrations of the acids and their ratio were normal. These findings are consistent with results for these acids in plasma from such patients. Measurement of phytanic acid and pristanic acid and their ratios in stored dried blood collected at neonatal screening can therefore be used in the diagnosis of peroxisomal disorders, especially for those cases in which, owing to early death of the patient, no other material is available for biochemical investigations.

Sepsis-related Organ Failure Assessment Score is a strong predictor of survival in acute-on-chronic liver failure

INTRODUCTION

The mortality of patients with an exacer-bation of decompensated liver cirrhosis is high even if treated in the intensive care unit (ICU), and the criteria for referral to ICU are not well defined. The objective of this study was to identify variables associated with mortality.

METHODS

A single-centre retrospective cohort analysis was conducted in a university-affiliated ICU. A total of 53 adult patients with decompensated alcoholic liver cirrhosis were admitted from January 2012 to June 2015. Variables associated with survival were identified using Cox regression analysis.

RESULTS

The ten-day, 30-day, 90-day, and one-year mortality were 36%, 57%, 66%, and 80%, respectively. Univariate Cox regression analysis showed that mortality was significantly associated with a low oxygen saturation, low diastolic blood pressure, terlipressin treatment, high Acute Physiology And Chronic Health Evaluation II score, high Simplified Acute Physiology Score II score, high Sepsis-related Organ Failure Assessment (SOFA) score and high Model For End-Stage Liver Disease score, but only a high SOFA score and old age were independently associated with increased mortality. These two variables were combined to the Age-SOFA index to predict the probability of surviving a given period.

CONCLUSIONS

The mortality was high in these severely ill patients, even when they received optimum supportive therapy in the ICU. The finding that the SOFA score and age best predicted mortality shows that the increased mortality was caused mainly by insufficiency of organs other than the liver.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

[The gut microbiome is important in chronic liver disease]

There is increasing evidence of gut dysbiosis being a significant factor in the development and progression of important chronic liver diseases including non-alcoholic steatohepatitis (NASH), alcoholic liver disease, primary sclerosing cholangitis and cirrhosis. Dysbiotic microbiota and their toxic metabolites translocate across the gut epithelium via the portal vein and cause damage to the liver. In NASH, alcohol-producing gut bacteria may be critical for its development. Therapeutic measures to normalise the gut microbiota with diet, probiotics or transplantation of normal microbiota seem to have a beneficial effect.

Hepatocellular carcinoma in Danish patients: a single Copenhagen center experience

OBJECTIVE

Hepatocellular carcinoma (HCC) is a common cause of cancer, and most HCC patients have underlying cirrhosis. Retrospectively, we aimed to characterize patients with newly diagnosed HCC at a Danish hospital and to investigate survival and identify predictive factors for survival.

METHODS

All patients diagnosed with HCC from January 2008 to December 2014 were retrospectively enrolled in this study. Overall survival was estimated by using the Kaplan-Meier method. A multivariate Cox regression analysis was performed to identify predictive factors for survival.

RESULTS

Sixty-seven patients were diagnosed with HCC (incidence rate 3.55/100,000 people/year). Ninety-three percent had underlying cirrhosis. Alcohol-related liver disease and chronic viral hepatitis B or C were responsible for 55 and 31% of cases, respectively. Median survival was 81 days and 1-month, 3-months and 1-year cumulative survival rates were 74, 40 and 17%, respectively. We identified the presence of portal vein thrombosis, high Child-Pugh score, high MELD score and high AST as independent negative prognostic factors for survival. Survival was poorer in patients seen for the first time when the diagnosis of HCC was made than in patients followed in the outpatient clinic (p = .06) indicating a substantial delay in diagnosis.

CONCLUSIONS

Survival was poor in this cohort of patients, almost exclusively caused by delay in diagnosis and admittance to hospital. An increased general information about HCC and the possibilities of therapy seems warranted.

The importance of family to health, development and welfare of children

OBJECTIVES

Recent investigations have shown that a number of families in Greenland have problems related to parents' use of alcohol. One of the consequences is that children get more difficult conditions during childhood. Children suffer when their parents have alcohol-related problems. An alcoholic parent is generally not able to meet the needs of his or her child. Many children are very lonely and do not discuss their thoughts, their situation or their problems with anyone. Some children get serious psychosocial problems as grown-ups.

RESULTS AND CONCLUSIONS

Professionals who work with children in health services, social services or within the school system are generally not adequately aware of the importance of family to the children's reactions. This means that the children are at risk of being treated only for symptoms when the unity of child and family is not adequately taken into account. Prevention has to focus on the first steps. Children must be allowed to talk about their problems. The whole family should be included in the treatment.

Epidemiologic and therapeutic aspects of refractory coeliac disease - a systematic review

INTRODUCTION

Refractory coeliac disease (RCD) is a rare and severe malabsorptive disease. The condition has two subtypes: RCDI and RCDII. Different treatments have been tested: and because RCD has a poor prognosis due to progress to enteropathy-associated T-cell lymphoma, the aim was to review the epidemiologic aspects and the therapeutic options for RCD.

METHODS

A systematic literature search was performed in 18 databases, and 122 records were identified. Incidence, prevalence, treatment methods and their efficacy were evaluated.

RESULTS

Among coeliac disease patients, the cumulative incidence of RCD is 1-4% per ten-year period and the prevalence is 0.31-0.38%. In the general population, the prevalence of RCD is 0.002%. Treatment of RCDI is azathioprine (effect 100%), mesalamine (effect 60%) or tioguanine (effect 83%). Treatment for RCDII is the antimetabolite cladribine (effect 81%) and autologous haematopoetic stem cell transplantation (effect 85%).

CONCLUSION

RCD is a very rare disease. The current evidence for RCDI treatment includes prednisolone in combination with the immunosuppressants azathioprine, mesalamine or tioguanine. The current evidence for RCDII treatment documents use of the antimetabolite cladribine, and if there is no effect, autologous haematopoetic stem cell transplantation may be attempted. In the future, there is a need for more effective treatments which will also prevent further progression to enteropathy-associated T-cell lymphoma.

[The hepatopulmonary syndrome]

The hepatopulmonary syndrome (HPS) - a complication of liver disease - seems to be underdiagnosed, probably because of decreased awareness. HPS consists of the triade liver disease, intrapulmonary vascular dilatation and as a consequence arterial hypoxaemia. No medical therapy has proven effective perhaps with the exception of garlic, which has been effective in one controlled clinical trial. However, liver transplantation seems to improve HPS in most cases. Liver patients with unexplained hypoxaemia should be investigated for HPS.

[Vegetarians are at high risk of vitamin B12 deficiency]

Since vegetarians have a lower intake of vitamin B12 (B12) than non-vegetarians, they are at increased risk of developing B12 deficiency. The less animal products the food contains the worse the B12 status. However, even lacto-ovo-vegetarians run the risk of becoming deficient in B12. Vegetarians are recommended regularly to take supplements of B12, and they should be informed of the lacking content of B12 of plant products and the hazards of B12 deficiency. Furthermore, vegetarians should routinely be checked for possible B12 deficiency.

[Cirrhosis and liver fibrosis are potentially reversible]

Cirrhosis is the end result of most chronic liver diseases. Contrary to the general view of liver fibrosis and cirrhosis being irreversible, recent findings have revealed that liver fibrosis can decrease if the cause(s) for the fibrosis formation can be weakened or eliminated. Thus, liver fibrosis and cirrhosis are potentially reversible. This paper reviews current evidence of reversibility in cirrhosis of varying aetiology and the consequence for therapeutic strategies.

Cardiac and proinflammatory markers predict prognosis in cirrhosis

BACKGROUND & AIMS

Inflammation and cardiac dysfunction plays an important role in the development of complications leading to increased mortality in patients with cirrhosis. Novel cardiac markers such as prohormone of ANP (proANP), copeptin and high-sensitivity troponin T (hs-TnT) and proinflammatory markers including soluble urokinase-type plasminogen activator receptor (suPAR) and high-sensitive C-reactive protein (hs-CRP) are related to these complications. We aimed to investigate if cardiac and proinflammatory markers are related to severity of liver disease, cardiac and haemodynamic changes, and long-term survival.

METHODS

One hundred and ninety-three stable cirrhotic patients (Child class: A = 46; B = 97; C = 50) had a full haemodynamic investigation performed with measurement of splanchnic and systemic haemodynamics and measurement of circulating levels of proBNP, proANP, copeptin, hs-TnT, LBP, IL 6, IL 8, IP 10, VEGF, hs-CRP and suPAR.

RESULTS

Soluble urokinase-type plasminogen activator receptor soluble urokinase-type plasminogen activator receptor, hs-CRP, and hs-TnT were significantly different throughout the Child classes (P < 0.01; P < 0.01; P < 0.02). All markers except copeptin correlated with indicators of disease severity in cirrhosis; ProANP and suPAR correlated with hepatic venous pressure gradient (r = 0.24 and r = 0.34; P < 0.001) and systemic vascular resistance (r = -0.24 and r = -0.33; P < 0.001). Cardiac (proANP, hs-TnT; P < 0.01) and proinflammatory (hs-CRP, suPAR; P < 0.05) markers were associated with mortality in a univariate Cox analysis, however, the strongest predictors of mortality in a multivariate Cox analysis were hs-TnT, ascites and hepatic venous pressure gradient (reg.coeff.: 0.34, P < 0.001; 0.16, P < 0.001; 0.06, P = 0.04).

CONCLUSION

Markers of cardiac dysfunction and inflammation are significantly associated with disease severity, degree of portal hypertension and survival in cirrhosis. In particular, hs-TnT and suPAR seem to contain prognostic information.

Modification of extracorporeal photopheresis technology with porphyrin precursors. Comparison between 8-methoxypsoralen and hexaminolevulinate in killing human T-cell lymphoma cell lines in vitro

BACKGROUND

Extracorporeal photopheresis that exposes isolated white blood cells to 8-methoxypsoralen (8-MOP) and ultraviolet-A (UV-A) light is used for the management of cutaneous T-cell lymphoma and graft-versus-host disease. 8-MOP binds to DNA of both tumor and normal cells, thus increasing the risk of carcinogenesis of normal cells; and also kills both tumor and normal cells with no selectivity after UV-A irradiation. Hexaminolevulinate (HAL)-induced protoporphyrin-IX is a potent photosensitizer that localizes at membranous structures outside of the nucleus of a cell. HAL-mediated photodynamic therapy selectively destroys activated/transformed lymphocytes and induces systemic anti-tumor immunity. The aim of the present study was to explore the possibility of using HAL instead of 8-MOP to kill cells after UV-A exposure.

METHODS

Human T-cell lymphoma Jurkat and Karpas 299 cell lines were used to evaluate cell photoinactivation after 8-MOP and/or HAL plus UV-A light with cell proliferation and long term survival assays. The mode of cell death was also analyzed by fluorescence microscopy.

RESULTS

Cell proliferation was decreased by HAL/UV-A, 8-MOP/UV-A or HAL/8-MOP/UV-A. At sufficient doses, the cells were killed by all the regimens; however, the mode of cell death was dependent on the treatment conditions. 8-MOP/UV-A produced apoptotic death exclusively; whereas both apoptosis and necrosis were induced by HAL/UV-A.

CONCLUSION

8-MOP can be replaced by HAL to inactivate the Jurkat and Karpas 299 T-cell lymphoma cells after UV-A irradiation via apoptosis and necrosis. This finding may have an impact on improved efficacy of photopheresis.

Physics performance of a low-luminosity low energy neutrino factory

We investigate the minimal performance, in terms of beam luminosity and detector size, of a neutrino factory to achieve a competitive physics reach for the determination of the mass hierarchy and the discovery of leptonic CP violation. We find that a low luminosity of 2×10(20) useful muon decays per year and 5 GeV muon energy aimed at a 10 kton magnetized liquid argon detector placed at 1300 km from the source provides a good starting point. This result relies on θ13 being large and assumes that the so-called platinum channel can be used effectively. We find that such a minimal facility would perform significantly better than phase I of the LBNE project and thus could constitute a reasonable step towards a full neutrino factory.

Rehabilitation for cirrhotic patients discharged after hepatic encephalopathy improves survival

INTRODUCTION

The 1-year mortality of cirrhotic patients with hepatic encephalopathy (HE) is approximately 60-80% in recent studies. We aimed to establish a rehabilitation out-patient clinic (RC) for alcoholic cirrhotic patients sur-viving HE.

MATERIAL AND METHODS

Prospectively, patients surviving HE were offered participation in the RC and were seen by a nurse for a one-hour interview with 1-3 weeks' interval after discharge and by a physician, if needed. Clinical, psychological and social problems were identified and addressed. Alcohol consumption was recorded and alcohol cessation was encouraged at each visit. Minimal or overt HE prompted referral to the Liver Unit. The patients were compared with HE patients discharged in 2008 (the control group).

RESULTS

A total of 19 patients were included in the RC group and compared with the 14 patients of the control group. The Child-Pugh score was higher in the RC group (median 13; range 8-14) than in the control group (median 11; range 7-13) (p = 0.033), whereas other clinical, demographic and biochemical parameters did not differ between the two groups. One-year survival was higher in the RC group (16/19; 84%) than in the control group versus (5/14; 36%) (p = 0.012). The log-rank test confirmed an improved survival for the RC group (p = 0.008). The economic costs of subsequent hospital admissions did not differ between the two groups. In the RC group, alcohol consumption was reduced in all but two patients.

CONCLUSION

Survival was significantly improved for patients in the rehabilitation clinic. The improved survival did not subsequently cause higher hospital admission costs.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Analysis of nontypeable haemophilus influenzae phase-variable genes during experimental human nasopharyngeal colonization

BACKGROUND

Studies of nontypeable Haemophilus influenzae (NTHi) have demonstrated that a number of genes associated with infectivity have long repeat regions associated with phase variation in expression of the respective gene. The purpose of this study was to determine the genes that underwent phase variation during a 6-day period of experimental human nasopharyngeal colonization.

METHODS

Strain NTHi 2019Str(R)1 was used to colonize the nasopharynx of human subjects in a study of experimental colonization. Thirteen phase-variable genes were analyzed in NTHi 2019Str(R)1. Samples of NTHi 2019Str(R)1 were cultured from subjects during the 6-day colonization period. We used capillary electrophoresis and Roche 454 pyrosequencing to determine the number of repeats in each gene from each sample.

RESULTS

A significant number of samples switched licA and igaB from phase off in the inoculated strain to phase on during the 4-day period of observation. lex2A also showed variability as compared to baseline, but the differences were not significant. The remaining genes showed no evidence of phase variation.

CONCLUSIONS

Our studies suggest that the phase-on genotypes of licA and igaB are important for early human nasopharynx colonization. lex2A showed a trend from phase off to phase on, suggesting a potentially important role in the colonization process.

Terlipressin for hepatorenal syndrome

BACKGROUND

Clinical trials suggest that terlipressin improves renal function in hepatorenal syndrome, but the evidence concerning mortality is equivocal.

OBJECTIVES

To assess the beneficial and harmful effects of terlipressin alone or with albumin versus placebo, no intervention or albumin for hepatorenal syndrome.

SEARCH METHODS

Eligible trials were identified through electronic (The Cochrane Library, MEDLINE, EMBASE and Science Citation Index databases) and manual searches until January 2012.

SELECTION CRITERIA

Randomised clinical trials involving patients with type 1 or type 2 hepatorenal syndrome were included irrespective of publication status or language.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from trial reports and undertook correspondence with the authors. Primary outcome measures included mortality, reversal of hepatorenal syndrome and adverse events. Intention-to-treat, random-effects model meta-analyses were performed and results were expressed as risk ratios (RR) with 95% confidence intervals (CI), and the I(2) statistic provided a measure of intertrial heterogeneity. Subgroup, sensitivity, regression and sequential analyses were performed.

MAIN RESULTS

We identified six randomised clinical trials. All had high risk of bias. Five trials assessed terlipressin (with albumin in three trials) versus no intervention (with albumin in three trials) and one trial assessed terlipressin versus albumin. Data from five randomised trials on terlipressin alone (one trial) or terlipressin and albumin (four trials) were included in the review. In total, 74 of 155 (47.7%) patients randomised to terlipressin alone or terlipressin with albumin versus 98 of 154 (63.6%) patients randomised to no intervention, placebo or albumin died. Random-effects model meta-analysis found that terlipressin reduced mortality (RR 0.76, 95% CI 0.61 to 0.95). The results were stable when repeated with trials on terlipressin plus albumin, trials on patients with type 2 hepatorenal syndrome, and trials with a low risk of selection bias. No evidence of bias or small study effects were identified in regression analyses. In a trial sequential analysis on mortality, the cumulative Z curve approached but did not cross the monitoring boundary suggesting that the results were not stable to adjustment for sparse data and multiple comparisons. Analyses of the remaining outcome measures found that terlipressin and albumin increased the number of patients with reversal of hepatorenal syndrome as well as adverse events, including cardiovascular and gastrointestinal symptoms.

AUTHORS' CONCLUSIONS

Terlipressin may reduce mortality and improve renal function in patients with type 1 hepatorenal syndrome. Whether the evidence is strong enough to support the intervention for clinical practice could be debated due to the results of the trial sequential analyses. However, the outcome measures assessed are objective, which reduces the risk of bias.

High and sustained efficacy after two sessions of topical 5-aminolaevulinic acid photodynamic therapy for basal cell carcinoma: a prospective, clinical and histological 10-year follow-up study

BACKGROUND

Prolonged follow-up data on topical photodynamic therapy (PDT) in basal cell carcinoma (BCC) are necessary for a full evaluation of its effect and for comparison with conventional treatment methods.

OBJECTIVES

To assess 10-year long-term PDT efficacy in primary and recurrent BCC and to evaluate clinical and histopathological factors which may be associated with treatment failure.

METHODS

We performed a longitudinal study on 60 histologically verified BCCs in 44 patients treated with curettage and one or two sessions of dimethylsulphoxide (DMSO)-supported topical 5-aminolaevulinic acid (ALA)-based PDT. Treated lesions were investigated by clinical and histopathological examination at regular intervals. The main outcomes were 10-year lesion complete response rate using a time-to-event analysis, histological treatment failure and cosmesis.

RESULTS

Overall complete response rate for all lesions was 75% (95% confidence interval 64-87%); 60% after one and 87% after two treatment sessions. The response rate was 78% for primary lesions; 63% after one and 90% after two sessions. The cosmetic outcome was rated as good or excellent in 91-100% of evaluated cases. Treatment failure was documented in 15 (25%) of 60 lesions; clinical investigation identified 14 of them. All failures were noted within 3 years of treatment. Male gender, recurrent tumour and one treatment session were factors significantly associated with treatment failure. The only lesion larger than 2·0 cm relapsed.

CONCLUSIONS

Two sessions of DMSO-supported topical ALA-PDT and curettage can provide long-term effective treatment results with favourable cosmetic outcome in primary, small BCC.

Plasma osteopontin as a biomarker of prostate cancer aggression: relationship to risk category and treatment response

BACKGROUND

High plasma osteopontin (OPN) has been linked to tumour hypoxia, metastasis, and poor prognosis. This study aims to assess whether plasma osteopontin was a biomarker of increasing progression within prostate cancer (PCa) prognostic groups and whether it reflected treatment response to local and systemic therapies.

METHODS

Baseline OPN was determined in men with localised (n=199), locally recurrent (n=9) and castrate-resistant, metastatic PCa (CRPC-MET; n=37). Receiver-operating curves (ROC) were generated to describe the accuracy of OPN for distinguishing between localised risk groups or localised vs metastatic disease. We also measured OPN pre- and posttreatment, following radical prostatectomy, external beam radiotherapy (EBRT), androgen deprivation (AD) or taxane-based chemotherapy.

RESULTS

The CRPC-MET patients had increased baseline values (mean 219; 56-513 ng ml(-1); P<0.0001) compared with the localised, non-metastatic group (mean 72; 12-438 ng ml(-1)). The area under the ROC to differentiate localised vs metastatic disease was improved when OPN was added to prostate-specific antigen (PSA) (0.943-0.969). Osteopontin neither distinguished high-risk PCa from other localised PCa nor correlated with serum PSA at baseline. Osteopontin levels reduced in low-risk patients after radical prostatectomy (P=0.005) and in CRPC-MET patients after chemotherapy (P=0.027), but not after EBRT or AD.

CONCLUSION

Plasma OPN is as good as PSA at predicting treatment response in CRPC-MET patients after chemotherapy. Our data do not support the use of plasma OPN as a biomarker of increasing tumour burden within localised PCa.