Prognostic Significance of NLR and PLR in COVID-19: A Multi-Cohort Validation Study

INTRODUCTION

Recent studies have highlighted the prognostic value of easily accessible inflammatory markers, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) for predicting severe outcomes in patients affected by Coronavirus disease 2019 (COVID-19). Our study validates NLR and PLR cut-off values from a prior cohort at IRCCS Policlinico San Matteo (OSM) of Pavia, Italy, across two new cohorts from different hospitals. This aims to enhance the generalizability of these prognostic indicators.

METHODS

In this retrospective cohort study, conducted at Milan's Ospedale Luigi Sacco (OLS) and IRCCS Ospedale Maggiore Policlinico (OMP) hospitals, we assess the predictive capacity of NLR and PLR for three main outcomes-non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) usage, invasive ventilation (IV), and death-in patients with COVID-19 at admission. For each outcome, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed separately for male and female cohorts. Distinct NLR and PLR cut-off values were used for men (7.00, 7.29, 7.00 for NLR; 239.22, 248.00, 250.39 for PLR) and women (6.36, 7.00, 6.28 for NLR; 233.00, 246.45, 241.54 for PLR), retrieved from the first cohort at OSM.

RESULTS

A total of 3599 patients were included in our study, 1842 from OLS and 1757 from OMP. OLS and OMP sensitivity values for both NLR and PLR (NLR: 24-67%, PLR: 40-64%) were inferior to specificity values (NLR: 64-76%, PLR: 55-72%). Additionally, PPVs generally remained lower (< 63%), while NPVs consistently surpassed 68% for PLR and 72% for NLR. Finally, both PLR and NLR exhibited consistently higher NPVs for more severe outcomes (> 82%) compared to NPVs for CPAP/NIV.

CONCLUSIONS

Consistent findings across diverse patient populations validate the reliability and applicability of NLR and PLR cut-off values. High NPVs emphasize their role in identifying individuals less likely to experience severe outcomes. These markers not only aid in risk stratification but also guide resource allocation in emergencies or limited-resource situations.

Investigating the level of vitamin D receptor gene expression in two tumoral and healthy breast tissues in breast cancer patients and its association with prognostic factors

BACKGROUND

Breast cancer is one of the most common cancers known among women. This study aimed to investigate the level of vitamin D receptor gene expression in two tumoral and healthy breast tissues in breast cancer patients and its association with prognostic factors.

METHODS

This descriptive cross-sectional study was conducted in 2022 on 50 patients with high suspicion of breast cancer who were candidates for mastectomy and lumpectomy in a learning hospital. From the patients, two tissue samples were prepared, and there was a total of 100 samples. The samples were subjected to H/E staining and evaluated by a pathologist. The presence or absence of malignancy in each sample was confirmed by two pathologists, and HER2/ER/PR indices were determined. Descriptive and analytical statistical methods and SPSS version 22 software were used.

RESULTS

The average age of the patients was 51.60 ± 11.22 years old, and the average tumor size was 3.17 ± 1.28. Most tumors were grade 2 (48%). The expression of HER2, ER, and PR was positive in 24, 64, and 54%, respectively. The largest number of cases were in stage 2A. The expression level of vitamin D receptor (VDR) gene in healthy tissue (2.08 ± 1.01) was higher than tumoral tissue (0.25 ± 1.38) (P = 0.001). In tumoral and healthy tissue, VDR expression was not significant according to tumor grade, HER2, ER, PR, LVI, LN, disease stage, age, and tumor size.

CONCLUSIONS

The expression level of VDR in healthy tissue was significantly higher than tumoral tissue. However, there was no significant relationship between VDR and tumor grade, HER2, ER, PR, LVI, LN, disease stage, age, and tumor size.

A systematic review and meta-analysis of prognostic indicators in patients with head and neck malignancy treated with immune checkpoint inhibitors

INTRODUCTION

Tumor immunotherapy has recently emerged as a crucial focal point in oncology treatment research. Among tumor immunotherapy approaches, tumor immune checkpoint inhibitors (ICIs) have attracted substantial attention in clinical research. However, this treatment modality has benefitted only a limited number of patients. We conducted a meta-analysis of various biomarkers to decipher their prognostic implications in patients with head and neck squamous cell carcinoma (HNSCC) who are treated with ICIs, and thus identify predictive markers with practical clinical relevance.

METHODS

A systematic search of electronic databases was conducted to identify clinical studies that examined the correlation between biomarkers and treatment outcomes in the HNSCC patients. The included articles were screened and analyzed to extract data regarding overall survival (OS) and progression-free survival (PFS).

RESULTS

The relationship between the biomarkers included in the summary and prognosis was as follows: HPV positivity was associated with improved OS (HR = 0.76, 95% CI = 0.58-1.99), PFS (HR = 1.16, 95% CI = 0.81-1.67), and response (OR = 1.67, 95% CI = 1.37-2.99). PD-L1 positivity was associated with OS (HR = 0.71, 95% CI = 0.59-0.85), PFS (HR = 0.56 95% CI = 0.43-0.73), and response (OR = 2.16, 95% CI = 1.51-3.10). Neither HPV positivity nor PD-L1 positivity was associated with DCR. The following markers were collected for OS and PFS data and were associated with longer OS: lower Glasgow prognostic score (GPS/mGPS) grading, lower PS grading, high body mass index (BMI), low neutrophil-to-lymphocyte ratio (NLR), low platelet-to-lymphocyte ratio (PLR), high albumin (Alb), low lactate dehydrogenase (LDH). Factors associated with better PFS were lower GPS/mGPS grading, lower PS grading, high BMI, low NLR, high absolute lymphocyte count, and low LDH. Hyperprogressive disease was associated with worse OS and PFS. Fewer clinical studies have been completed on the tumor microenvironment and hypoxia, microsatellite instability/DNA mismatch repair, and microbiome and systematic analysis is difficult.

CONCLUSION

In our meta-analysis, different immune checkpoint factors were associated with different prognoses in HNSCC patients receiving immunotherapy. HPV, PD-L1, BMI, Alb, HPD, PS, GPS/mGPS, LDH, NLR, and PLR predicted the ICI outcome in HNSCC patients.

Clinical implications of heat shock protein 70 in oral carcinogenesis and prediction of progression and recurrence in oral squamous cell carcinoma patients: a retrospective clinicopathological study

BACKGROUND

Oral cancer is a common cause of death worldwide. The search for novel biomarkers for oral cancer is an ongoing struggle. Prognostic biomarkers are of great importance in diagnosis, and prediction of the cancer outcome. There are several disagreements in oral cancer studies over the role of heat shock proteins as prognostic markers. The current study investigated HSP70 expression in diverse tissues ranging from normal oral mucosa to dysplastic oral epithelium and oral squamous cell carcinoma to determine its role in oral carcinogenesis. Moreover, HSP70 was evaluated concerning different prognostic parameters to determine its capability in predicting cancer progression. Recurrence of tumor was recorded, and patients` disease-free survival was calculated and analyzed considering HSP70 expression to determine the potential utility of HSP70 immuno-expression in predicting recurrence.

METHODS

A retrospective study was accomplished on 50 cases of OSCC. Biopsies from the cancerous tissue, the free surgical margin, and the normal oral mucosa were used. The grading of dysplastic epithelium and OSCCs followed the criteria of WHO classification (2017). The clinicopathological and follow-up records for each patient were retrieved. Pearson's Chi-square test, one-way ANOVA, and post hoc tests were used to analyze the variance of HSP70 immuno-expression concerning different parameters. The Kaplan-Meier method was used to compute and visualize disease-free survival, and the log-rank test was used to analyze the data. With Cox regression, univariate and multivariate survival analyses were run. A P-value of 0.05 or less was regarded as statistically significant.

RESULTS

A significant increased expression of HSP70 was observed as the tissue progressed from normal to dysplastic epithelium, and carcinoma (P = 0.000). HSP70 revealed a significant increased expression by progression from mild to severe dysplasia (P = 0.023), and also from well to moderately and poorly differentiated carcinoma (P = 0.000). High HSP70 immuno-expression was significantly associated with progression of OSCC; large-sized tumors (P = 0.002), advanced TNM clinical stages (P = 0.001), positive nodal involvement (P = 0.001), presence of recurrence (P = .008), and reduced DFS (P = 0.014).

CONCLUSION

HSP70 has a crucial contribution to oral carcinogenesis, and its immune-expression could potentially be used as predictor of progression and recurrence of OSCC patients.

TRIAL REGISTRATION

Retrospectively registered.

Predictors of Developmental and Adaptive Behaviour Outcomes in Response to Early Intensive Behavioural Intervention and the Early Start Denver Model

Many autistic children require support to meet their learning needs. Given the heterogeneity within the autism spectrum it is plausible that different types of support might be better suited to different children. However, knowledge on what interventions work best for which children is limited. We examined the outcomes of autistic preschool-aged children receiving one of two community early intervention approaches. Our main objective was to understand which baseline child characteristics might be associated with the degree of individual response to intervention-whether prognostically (i.e., irrespective of intervention received) or predictively (i.e., specifically in the context of one or other EI approach). Participants comprised two matched groups of preschool-aged autistic children receiving either Group-based Early Start Denver Model (G-ESDM; n = 42) delivered in a 1:3-4 staff:child ratio or an Early Intensive Behavioural Intervention (EIBI; n = 40) delivered in combination of 1:1 and 1:2 staff:child ratio. Over an approximate one-year follow-up period, children in both groups made significant gains in Developmental Quotient (DQ) scores, and trend-level gains in adaptive behaviour composite scores. Higher attention to a playful adult measured via an eye-tracking task was prognostically indicative of better verbal DQ and adaptive behaviour outcomes for the cohort overall. Moderation analyses indicated a single predictive effect-of pre-program sustained attention for subsequent NVDQ outcomes specific to those children receiving G-ESDM. These findings suggest that fine-grained measures of learning skills offer promise towards the selection and tailoring of intervention approaches to meet individual children's learning needs.

Baseline Total Metabolic Tumor Volume is Prognostic for Refractoriness to Immunochemotherapy in DLBCL: Results From GOYA

INTRODUCTION

A good response to initial therapy is key to maximizing survival in patients with diffuse large B-cell lymphoma (DLBCL), but patients with chemorefractory disease and early progression have poor outcomes.

PATIENTS AND METHODS

Data from the GOYA study in patients with DLBCL who received first-line rituximab or obinutuzumab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) were analyzed. Positron emission tomography/computed tomography (PET/CT)-derived characteristics associated with total metabolic tumor volume (TMTV) and clinical risk factors for primary chemorefractory disease and disease progression within 12 months (POD12) were explored.

RESULTS

Of those patients fulfilling the criteria for analysis, 108/1126 (10%) were primary chemorefractory and 147/1106 (13%) had POD12. Primary chemorefractory and POD12 status were strongly associated with reduced overall survival. After multivariable analysis of clinical and imaging-based risk factors by backward elimination, only very high TMTV (quartile [Q] 1 vs. Q4 odds ratio [OR]: 0.45; P = .006) and serum albumin levels (low vs. normal OR of 1.86; P = .004) were associated with primary chemorefractoriness. After additionally accounting for BCL2/MYC translocation in a subset of patients, TMTV and BCL2/MYC double-hit status remained as significant predictors of primary chemorefractoriness (Q1 vs. Q4 OR: 0.32, P = .01 and double-hit vs. no-hit OR of 4.47, P = .02, respectively). Risk factors including very high TMTV, high sum of the product of the longest diameters (SPD), geographic region (Asia), short time since diagnosis, extranodal involvement and low serum albumin were retained for POD12.

CONCLUSION

PET-derived TMTV has prognostic value in identifying patients at risk of early treatment failure.

Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years

BACKGROUND

Endoscopic resection, especially endoscopic submucosal dissection (ESD), is increasingly performed in elderly patients with early gastric cancer, and lesions beyond the expanded indications are also resected endoscopically in some patients. It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.

AIM

To assess the efficacy and feasibility of gastric ESD for elderly patients, and define high-risk lesions and prognostic indicators.

METHODS

Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014, 179 sessions (15.3%) were performed in patients aged ≥ 80 years, and 172 of these sessions were done in patients with a final diagnosis of gastric cancer. These patients were studied retrospectively to evaluate short-term outcomes and survival. The short-term outcomes included the rates of en bloc resection and curative resection, complications, and procedure-related mortality. Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010. Fisher’s exact test was used to statistically analyze risk factors. Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test. Survival rates at each time point were based on Kaplan-Meier estimation. Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test. To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting, we used the least absolute shrinkage and selection operator (LASSO) Cox regression model including factors curative/ noncurative, age, gender, body mass index, prognostic nutritional index, Charlson comorbidity index (CCI), Glasgow prognostic score, neutrophil-to-lymphocyte ratio, and antithrombotic agent use. We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation. P < 0.05 was considered statistically significant.

RESULTS

The en bloc dissection rate was 97.1%, indicating that a high quality of treatment was achieved even in elderly patients. As for complications, the rates of bleeding, perforation and aspiration pneumonitis were 3.4%, 1.1% and 0.6%, respectively. These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients. A dissection incision > 40 mm, lesions associated with depressions, and lesions with ulcers were risk factors for post-ESD bleeding, and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients (P < 0.05). Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding. The overall survival (OS) did not differ significantly between curative and noncurative ESD (P = 0.69). In patients without additional surgery, OS rate was significantly lower in patients with a high CCI (≥ 2) than in those with a low CCI (≤ 1) (P < 0.001).

CONCLUSION

Gastric ESD is feasible even in patients aged ≥ 80 years. Observation without additional surgery after noncurative ESD is reasonable, especially in elderly patients with CCI ≥ 2.

Analysis of differentially expressed proteins between HER2 positive and triple negative breast cancer and their prognostic significance

Both triple negative breast cancer (TNBA) and HER2-positive breast cancer lack expression of estrogen receptor alpha (ER) and progesterone receptor (PR), while human epidermal growth factor receptor 2 (HER2) in TNBC is also negative. This study aimed to identify the differentially expressed proteins (DEPs) between TNBC and HER2-positive breast cancer and to improve understanding of their role in the prognosis of breast cancer. By analyzing the breast cancer data set in The Cancer Proteome Atlas (TCPA) database, 15 DEPs between TNBC and HER2-positive breast cancer were identified. GO and pathway enrichment analysis were performed on DEPs, and the protein-protein interaction (PPI) network was constructed. The overall survival (OS) analysis of the breast cancer protein dataset in the Kaplan-Meier plotter showed that low expression of ACC1 suggested a higher OS of HER2-positive breast cancer (HR = 5.34, P < 0.05) and TNBC (HR = 2.88, P < 0.05). And TNBC patients with high TBA1B (HR = 0.16, P < 0.01) or low INPP4B (HR = 3.47, P < 0.05) expression have a better prognosis. Our research provides new insights into the prognostic indicators of TNBC and HER2-positive breast cancer, which could be further studied.

Prognostic indicators and outcomes following surgical management of metastatic cutaneous squamous cell carcinoma of the head and neck

Metastatic cutaneous SCC carries a poor prognosis with five-year survival of 25%-57%. The aim of this study is to examine the outcomes following surgery with adjuvant therapy for management of metastatic cSCC in a UK-based population. This is a retrospective review of patients with metastatic cSCC of the head and neck who underwent primary surgery at a regional center during a six-year period. Overall and disease specific survival were calculated using Kaplan-Meier and log-rank tests. Results were reported as hazard ratios (HR) with 95% confidence intervals. Forty-five patients met the inclusion criteria. The mean time to discovery of metastases was 9.3 months (range, 0-40 months). Only two patients (4%) had discovery of metastases after two years, with none after 3.3 years. The overall five5-year survival was 31% (95% CI 15%to 48%) with two-year survival at 48% (95% CI 31%to 63%). The median OS survival was 722 days (95% CI 607to 1359). Patients aged >80 years had a decreased OS. This is the largest UK based study documenting the overall and disease specific survival associated with metastatic cutaneous SCC of the head and neck. Our overall survival is comparable to similar studies, but remains poor. Total number of involved nodes, and lymph node ratio were not statistically significant.

[Histomorphological and molecular-pathological prognostic factors in colorectal cancer]

Colorectal carcinomas are the second most common cancer and cause of cancer death in Germany for both men and women. Different aspects of morphological, immunohistochemical, and molecular pathological prognostic factors of colorectal carcinomas and their precursors were investigated. We demonstrated the prognostic relevance and importance of a precise classification of pericolonic tumor deposits (PTDs) in the pT category of the TNM classification. Furthermore, we demonstrated that patients with regional lymph node metastases after neoadjuvant chemoradiotherapy (nCRT) in rectal carcinomas with ypN0 status do not have a worse prognosis than patients without signs of preoperative lymph node metastases.Molecular pathological examinations of so-called serrated colorectal fibroblastic polyps as possible precursor lesions of colorectal carcinomas showed that their epithelial area represents a true neoplastic component and thus allows for their consideration in the context of a risk assessment for colorectal carcinomas.

PROGNOSTIC INDICATORS FOR SURVIVAL OF ORPHANED EASTERN GRAY SQUIRRELS (SCIURUS CAROLINENSIS)

The eastern grey squirrel (EGS), Sciurus carolinensis, is a tree squirrel native to the eastern United States. This species commonly presents to wildlife medical clinics for a variety of human-related injuries including confrontations with road traffic and pet predation. The purpose of this study was to assess initial examination findings as prognostic indicators for survival in EGS. The medical record database of the University of Illinois Wildlife Medical Clinic was searched from January 2012 through December 2018 for records of EGS weighing <300 g. The squirrels were identified as survivors (individuals surviving, released, or transferred to a rehabilitator within 72 hr of intake) or nonsurvivors (individuals euthanized or dying within 72 hr of intake after receiving medical care). Presenting weight, health status, method of feeding, and singleton versus group presentation were categorically recorded for each case. The data were modeled using a series of candidate logistic regression models fitted using the generalized linear model. An information theoretical approach determined the best fit model. A total of 955 EGS were included in this study. Factors that predicted a nonsurvivor status included EGSs that presented with any health system abnormality (odds ratio [OR], 4.81; 95% confidence interval [CI], 3.34-6.72), EGSs that presented between December and May (OR, 1.60; 95% CI, 1.12-2.27) rather than between June and November, and individuals with neurologic signs (OR, 2.61; 95% CI, 1.51-4.51) compared with EGSs without neurologic signs. Despite not being included in the final model, the presence of respiratory signs (OR, 3.43; 95% CI, 2.41-4.89) and diarrhea (OR, 4.01; 95% CI, 1.59-10.09) were significantly associated with a higher likelihood of nonsurvival status. Wildlife medical clinics and rehabilitation centers may use this information by initiating more aggressive therapies or instituting distinct euthanasia protocols for EGS that present with body system abnormalities, particularly neurologic clinical signs, and those that present in the winter months.

The StarT back screening tool and a pain mannequin improve triage in individuals with low back pain at risk of a worse prognosis - a population based cohort study

Background

The STarT Back Screening Tool (SBT) identifies patients with low back pain (LBP) at risk of a worse prognosis of persistent disabling back pain, and thereby facilitates triage to appropriate treatment level. However, the SBT does not consider the pain distribution, which is a known predictor of chronic widespread pain (CWP). The aim of this study was to determine if screening by the SBT and screening of multisite chronic widespread pain (MS-CWP) could identity individuals with a worse prognosis. A secondary aim was to analyze self-reported health in individuals with and without LBP, in relation to the combination of these two screening tools.

Methods

One hundred and nineteen individuals (aged 40–71 years, mean (SD) 59 (8) years), 52 with LBP and 67 references, answered two screening tools; the SBT and a pain mannequin – as well as a questionnaire addressing self-reported health. The SBT stratifies into low, medium or high risk of a worse prognosis. The pain mannequin stratifies into either presence or absence of CWP in combination with ≥7 painful areas of pain (0–18), here defined as MS-CWP (high risk of worse prognosis). The two screening tools were studied one-by-one, and as a combined screening. For statistical analyses, independent t-tests and Chi-square tests were used.

Results

Both the SBT and the pain mannequin identified risk of a worse prognosis in individuals with (p = 0.007) or without (p = 0.001) LBP. We found that the screening tools identified partly different individuals at risk. The SBT identified one individual, while the pain mannequin identified 21 (19%). When combining the two screening methods, 21 individuals (17%) were at high risk of a worse prognosis. When analyzing differences between individuals at high risk (combined SBT and MS-CWP) with those at low risk, individuals at high risk reported worse health (p = 0.013 - < 0.001).

Conclusions

Both screening tools identified individuals at risk, but they captured different aspects, and also different number of individuals at high risk of a worse prognosis. Thus, using a combination may improve early detection and facilitate triage to appropriate treatment level with multimodal approach also in those otherwise missed by the SBT.

Randomized Clinical Trial Representativeness and Outcomes in Real-World Patients: Comparison of 6 Hallmark Randomized Clinical Trials of Relapsed/Refractory Multiple Myeloma

BACKGROUND

Concern has been increasing in oncology regarding randomized clinical trial (RCT) eligibility limiting the generalizability of the findings to real-world populations. Using a large US electronic health record database, we investigated the real-world generalizability of the findings from recent RCTs for relapsed and/or refractory multiple myeloma (RRMM).

PATIENTS AND METHODS

Patients with RRMM initiating second-to fourth-line therapy with the control arm of the following RCTs were retrospectively identified and categorized as "RCT eligible" or "RCT ineligible" according to the eligibility criteria: (1) Rd (lenalidomide, dexamethasone)-ASPIRE, TOURMALINE-MM1, POLLUX, and ELOQUENT-2; and (2) Vd (bortezomib, dexamethasone)-CASTOR and ENDEAVOR. Predictors of RCT ineligibility and overall survival were analyzed using logistic regression and Cox regression analysis.

RESULTS

Variations in the individual trial ineligibility rates were noted, with up to 72.3% (range, 47.9%-72.3%) of patients not meeting the eligibility criteria for 1 of the 6 hallmark RCTs (n = 788 for Rd; n = 477 for Vd). Other malignancies, cardiovascular disease, acute infection, and renal dysfunction were the common reasons for ineligibility. Advanced age, Charlson comorbidity score of ≥ 2, later therapy lines (3-4), and refractory status to the previous line were independently predictive of RCT ineligibility. RCT-ineligible versus RCT-eligible patients had a significantly greater mortality risk (hazard ratio, Rd, 1.46; Vd, 1.51).

CONCLUSION

Most real-world patients with RRMM were ineligible for the hallmark RCTs. The eligibility rates varied across the RCTs, underlining the flawed nature of cross-study comparisons without RCT validation. Overall survival was significantly affected by the inability to meet the criteria, highlighting the limited generalizability of the RCT results. Greater efforts are required to broaden the eligibility criteria to reflect real-world clinical characteristics and narrow the gap between RCT efficacy and the observed effectiveness in real-world patients with RRMM.

[Analysis of 20-year survival rate and prognostic indicators of systemic lupus erythematosus]

Objective: To analyze the 20-year survival rate, causes of death and predictors of systemic lupus erythematosus (SLE). Methods: A retrospective analysis was performed on 217 newly SLE patients who were diagnosed and treated by Peking University People's Hospital before June 2008. The clinical features and serologic data were studied. Survival rate of SLE patients over time, living conditions, causes of death and prognostic indicators of mortality were studied. Results: The 10-, 15-and 20-year cumulative survival rate was 90.3%,88.1%and 79.6%, respectively. Infection and lupus encephalopathy were the main causes of death. Cox regression analysis revealed that lupus nephritis, neuropsychiatric systemic lupus erythematosus and age at the diagnosis were independent risk determinants for mortality. Conclusion: Prognosis of SLE remains to be improved. Early diagnosis, control of SLE organ damage and infection prevention are critical to improve survival of SLE patients.

Diagnosis and survival values of neutrophil-lymphocyte ratio (NLR) and red blood cell distribution width (RDW) in esophageal cancer

BACKGROUND

Recent studies have borne out claims that inflammation has a vital role in the development and progression of many diseases, including cancers. It has been reported that neutrophil-lymphocyte ratio (NLR) and red blood cell distribution width (RDW) could act as independent prognostic factors for several malignant tumors. We evaluated the diagnosis and prognosis values of preoperative inflammatory indicators, including NLR and RDW in esophageal cancer (EC).

METHODS

We retrospectively analyzed the clinical data of 354 EC patients and 220 early esophageal cancer (EEC) undergoing potentially curative esophagectomy in Shandong Provincial Hospital Affiliated to Shandong University and chose 201 age and sex-matched healthy volunteers as the control group. We compared the clinicopathological features, survival curves and prognosis of the EC patients between the high and low groups according to the cutoff values of NLR and RDW.

RESULTS

Significant higher preoperative NLR and RDW values were detected in patients with EEC and EC compared to the healthy controls (P < .001). A high RDW was significantly associated with an older age (P < .05). NLR and RDW values after surgery in EC group were significantly higher than those before surgery (P < .001 and P < .001, respectively). For EEC group, a higher RDW value showed a significantly worse overall survival (OS) and disease-free survival (DFS) (P = .040 and P = .013, respectively). For EC group, an increased NLR indicated a significantly association with poor overall survival (OS) (P = .004) and DFS (P = .001). Preoperative NLR can act as an independent prognostic indicator for EC.

CONCLUSION

The preoperative NLR and RDW are convenient, practical easily measured biomarkers of clinical diagnosis and prognostic assessment of patients with EC. Furthermore, NLR was more effective than RDW acting as an independent prognostic biomarker for EC.

Clinicopathological predictors of recurrence in nodular and superficial spreading cutaneous melanoma: a multivariate analysis of 214 cases

BACKGROUND

Nodular melanoma (NM) accounts for most thick melanomas and because of their frequent association with ulceration, fast growth rate and high mitotic rate, contribute substantially to melanoma-related mortality. In a multicentric series of 214 primary melanomas including 96 NM and 118 superficial spreading melanoma (SSM), histopathological features were examined with the aim to identify clinicopathological predictors of recurrence.

METHODS

All consecutive cases of histopathologically diagnosed primary invasive SSM and NM during the period 2005-2010, were retrieved from the 12 participating Italian Melanoma Intergroup (IMI) centers. Each center provided clinico-pathological data such as gender, age at diagnosis, anatomical site, histopathological conventional parameters, date of excision and first melanoma recurrence.

RESULTS

Results showed that NM subtype was significantly associated with Breslow thickness (BT) at multivariate analysis: [BT 1.01-2 mm (OR 7.22; 95% CI 2.73-19.05), BT 2.01-4 mm (OR 7.04; 95% CI 2.54-19.56), and BT > 4 mm (OR 51.78; 95% CI 5.65-474.86) (p < 0.0001)]. Furthermore, mitotic rate (MR) was significantly correlated with NM histotype: [(MR 3-5 mitoses/mm2 (OR 2.62; 95% CI 1.01-6.83) and MR > 5 mitoses/mm2 (OR 4.87; 95% CI 1.77-13.40) (p = 0.002)]. The risk of recurrence was not significantly associated with NM histotype while BT [BT 1.01-2.00 mm (HR 1.55; 95% CI 0.51-4.71), BT 2.01-4.00 mm (HR 2.42; 95% CI 0.89-6.54), BT > 4.00 mm. (HR 3.13; 95% CI 0.95-10.28) (p = 0.05)], mitotic rate [MR > 2 mitoses/mm2 (HR 2.34; 95% CI, 1.11-4.97) (p = 0.03)] and the positivity of lymph node sentinel biopsy (SNLB) (HR 2.60; 95% CI 1.19-5.68) (p = 0.007) were significantly associated with an increased risk of recurrence at multivariate analysis.

CONCLUSIONS

We found that NM subtype was significantly associated with higher BT and MR but it was not a prognostic factor since it did not significantly correlate with melanoma recurrence rate. Conversely, increased BT and MR as well as SNLB positivity were significantly associated with a higher risk of melanoma recurrence.

Prognostic indicators for decrease in tinnitus severity after cervical physical therapy in patients with cervicogenic somatic tinnitus

BACKGROUND

Tinnitus can be related to many different aetiologies such as hearing loss or a noise trauma, but it can also be related to the somatosensory system of the cervical spine, called cervicogenic somatic tinnitus(CST). Recently, a positive effect of multi-modal cervical physical therapy on tinnitus severity in patients with CST was demonstrated. To date however, the outcome of the intervention cannot be predicted.

OBJECTIVE

To identify prognostic indicators for decrease in tinnitus severity after cervical physical therapy in patients with CST.

PATIENTS

Patients with moderate to severe subjective tinnitus (Tinnitus Functional Index(TFI):25-90points) and neck complaints (Neck Bournemouth Questionnaire(NBQ) > 14points).

INTERVENTION

All patients received multimodal cervical physical therapy for 6 weeks (12 sessions). This physical therapy contained a combination of manual mobilizations and exercises of the cervical spine.

MEASUREMENTS

TFI and NBQ-scores were documented at baseline, after treatment and after a 6-weeks follow-up period. Impairments in cervical spine mobility and muscle function were identified at baseline and after 6-weeks follow-up.

RESULTS

Patients with co-varying (increasing or decreasing simultaneously) tinnitus and neck complaints had significantly lower TFI-scores after treatment (p = 0.001) and follow-up (p = 0.03). The presence of this co-variation and a combination of low pitched tinnitus and increasing tinnitus during inadequate cervical spine postures are prognostic indicators for a decrease in TFI-scores after cervical physical therapy (adjusted R² = 0.357).

CONCLUSION

Patients who experience a decrease in tinnitus annoyance from cervical physical therapy are those with co-varying tinnitus and neck complaints and those with a combination of low-pitched tinnitus and increasing tinnitus during inadequate cervical spine postures.

Reliability and screening ability of the StarT Back screening tool in patients with low back pain in physiotherapy practice, a cohort study

Background

Low back pain (LBP) is the most common reported musculoskeletal disorder, with large prevalence numbers and high costs. Focus on early identification of patients at risk of developing chronic LBP has increased. The Keele Start Back Tool (SBT) is a questionnaire aiming at screening prognostic indicators in LBP patients, categorizing patients into risk-groups and guide treatment. The aim of this study was to explore the Norwegian version of the SBT with regard to reliability of the SBT-scoring and the screening ability in LBP patients in primary care physiotherapy.

Methods

LBP patients answered a package of questionnaires twice, with 1-3 days in between, containing SBT, Hannover functional ability questionnaire, pain intensity questions and demographics. The relative and absolute reliability of SBT was calculated using intraclass correlation coefficient (ICC) and the smallest detectable change respectively. Independent sample t-tests were used for group comparisons.

Results

Fifty-two patients with LBP. Mean age (SD) was 45 (12) years and 62% were female. The ICC (95% CI) for SBT total score and psychosocial subscore was 0.89 (0.82, 0.94) and 0.82 (0.70, 0.90) respectively. None of the participants were allocated to the high risk group. The medium risk group reported significantly more pain last week and more activity limitations than the low risk group at both test and retest (0.001 ≤ p ≤ 0.003), whereas no significant difference between the groups was found on pain now (0.05 ≤ p ≤ 0.16).

Conclusions

The Norwegian version of the SBT was reliable and the screening ability was good as the subgrouping of patients into risk-groups reflected the severity of their back problems. The SBT may be an applicable and useful tool in physiotherapy practice.

Significance of blood neutrophil-to-lymphocyte ratio for prognostic stratification of patients with gastroesophageal junction adenocarcinoma in the era of the 8th edition of the American Joint Committee on Cancer (AJCC8) staging

The prognosis of patients with gastroesophageal junction (GOJ) adenocarcinoma depends mainly on the clinical staging, as described by the new AJCC8 (American Joint Committee on Cancer 8th edition). Evidence suggests that peripheral blood neutrophil-to-lymphocyte ratio (NLR) may be of prognostic significance in patients with upper gastrointestinal cancers. We examined the prognostic significance of NLR in the era of the new AJCC8 staging system. In this single-centre cohort study, retrospective data on patients with operable GOJ adenocarcinoma treated with perioperative chemotherapy were analysed. The prognostic significance of baseline NLR in combination with AJCC8 clinical staging and other patient characteristics was examined for both time-to-progression (TTP) and overall survival (OS). Of 316 patients, 245 (77.5%) underwent radical surgery. Fifty-one patients (16.2%) developed unresectable disease due to early disease progression. NLR was the only baseline factor independently associated with the development of early disease progression. AJCC8 clinical staging was significantly associated with TTP and OS. In addition, NLR ≥ 3 was predictive of poorer TTP (p = 0.001) and OS (p = 0.002), confirmed in multivariate Cox-regression analysis. NLR ≥ 3 was prognostic, especially in patients with clinical stage III for TTP (p = 0.006) and OS (p = 0.025) and in patients with clinical stage IVA for OS (p = 0.017). NLR significantly improved the prognostic classification of patients by different AJCC8 clinical stages, with a c-index improved from 0.554 to 0.592 (p < 0.001). NLR was confirmed to be an independent prognostic factor in this cohort and could be used in combination with AJCC8 clinical staging to improve the baseline prognostic stratification of patients with newly diagnosed resectable GOJ adenocarcinoma.

p53, cathepsin D, Bcl-2 are joint prognostic indicators of breast cancer metastatic spreading

Background

Traditional prognostic indicators of breast cancer, i.e. lymph node diffusion, tumor size, grading and estrogen receptor expression, are inadequate predictors of metastatic relapse. Thus, additional prognostic parameters appear urgently needed. Individual oncogenic determinants have largely failed in this endeavour. Only a few individual tumor growth drivers, e.g. mutated p53, Her-2, E-cadherin, Trops, did reach some prognostic/predictive power in clinical settings. As multiple factors are required to drive solid tumor progression, clusters of such determinants were expected to become stronger indicators of tumor aggressiveness and malignant progression than individual parameters. To identify such prognostic clusters, we went on to coordinately analyse molecular and histopathological determinants of tumor progression of post-menopausal breast cancers in the framework of a multi-institutional case series/case-control study.

Methods

A multi-institutional series of 217 breast cancer cases was analyzed. Twenty six cases (12 %) showed disease relapse during follow-up. Relapsed cases were matched with a set of control patients by tumor diameter, pathological stage, tumor histotype, age, hormone receptors and grading. Histopathological and molecular determinants of tumor development and aggressiveness were then analyzed in relapsed versus non-relapsed cases. Stepwise analyses and model structure fitness assessments were carried out to identify clusters of molecular alterations with differential impact on metastatic relapse.

Results

p53, Bcl-2 and cathepsin D were shown to be coordinately associated with unique levels of relative risk for disease relapse. As many Ras downstream targets, among them matrix metalloproteases, are synergistically upregulated by mutated p53, whole-exon sequence analyses were performed for TP53, Ki-RAS and Ha-RAS, and findings were correlated with clinical phenotypes. Notably, TP53 insertion/deletion mutations were only detected in relapsed cases. Correspondingly, Ha-RAS missense oncogenic mutations were only found in a subgroup of relapsing tumors.

Conclusions

We have identified clusters of specific molecular alterations that greatly improve prognostic assessment with respect to singularly-analysed indicators. The combined analysis of these multiple tumor-relapse risk factors promises to become a powerful approach to identify patients subgroups with unfavourable disease outcome.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2713-3) contains supplementary material, which is available to authorized users.

Osseous Metastases in Gynaecological Epithelial Malignancies: A Retrospective Institutional Study and Review of Literature

INTRODUCTION

Osseous metastasis in gynaecological epithelial tumours is an extremely rare phenomenon occurring in less than 1% of these cancers.

AIM

To analyse the clinical characteristics and prognosis in patients with gynaecological epithelial cancers with bone metastases.

MATERIALS AND METHODS

This was a single institutional retrospective study done with the data available from January 2008 to January 2015. Out of 1686 patients with epithelial gynaecological malignancies there were a total 18 (1.07%) patients with osseous metastasis. Clinico-pathologic characteristics were tabulated in Microsoft Excel 2013 and data were analysed using SPSS software Version 21. A p-value< 0.05 was taken to be statistically significant. Survival analysis was done by using Kaplan-Meier method and log-rank test was used to find out the difference in survivals.

RESULTS

Out of the 18 gynaecological epithelial cancer patients with bone metastases, 12 had cervical cancer, three had ovarian cancer, two had endometrial carcinoma and one patient had vulvar malignancy. Twelve patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 31.9 months (range, 1 - 60 months). Solitary bone lesion was present in seven patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 12 patients. The mean follow-up period was 8.3 months. During the follow-up period 12 out of the 18 patients died. There was significant difference in survival (p = 0.005) between patients with solitary bone metastasis and patients with multiple osseous metastases. Near significant survival difference (p = 0.056) was also noted in patients with extra-osseous metastases when compared to the patients without. Improved survival was also found in patients with controlled local disease (p = 0.003) when compared to patients with local failure.

CONCLUSION

Bone metastasis in gynaecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Multiple sites of bone involvement, recurrence at the primary tumour site and presence of other non-osseous metastases are poor prognostic indicators. Treatment in these patients should be tailored according to the patient's need.

Glomerular filtration rate, urine production, and fractional clearance of electrolytes in acute kidney injury in dogs and their association with survival

Background

Acute kidney injury (AKI) is common in dogs. Few studies have assessed sequential changes in indices of kidney function in dogs with naturally occurring AKI.

Objective

To document sequential changes of conventional indices of renal function, to better define the course of AKI, and to identify a candidate marker for recovery.

Animals

Ten dogs with AKI.

Methods

Dogs were prospectively enrolled and divided into surviving and nonsurviving dogs. Urine production was measured with a closed system for 7 days. One and 24‐hour urinary clearances were performed daily to estimate solute excretion and glomerular filtration rate (GFR). Solute excretion was calculated as an excretion ratio (ER) and fractional clearance (FC) based on both the 1‐ and 24‐hour urine collections.

Results

Four dogs survived and 6 died. At presentation, GFR was not significantly different between the outcome groups, but significantly (P = .03) increased over time in the surviving, but not in the nonsurviving dogs. Fractional clearance of Na decreased significantly over time (20.2–9.4%, P < .0001) in the surviving, but not in the nonsurviving dogs. The ER and FC of solutes were highly correlated (r, 0.70–0.95).

Conclusion and Clinical Impact

Excretion ratio might be used in the clinical setting as a surrogate marker to follow trends in solute excretion. Increased GFR, urine production, and decreased FC of Na were markers of renal recovery. The FC of Na is a simple, noninvasive, and cost‐effective method that can be used to evaluate recovery of renal function.

Fibronectin predicts the outcome of acute-on-chronic hepatitis B liver failure

BACKGROUND

Acute-on-chronic hepatitis B liver failure (ACHBLF) is a serious condition with varied etiologies and manifestations, and is associated with a high mortality rate. Fibronectin is involved in a number of biological processes, including cellular adhesion, motility, differentiation, apoptosis, hemostasis, wound healing and ischemic injury. Serum fibronectin concentrations may provide prognostic information in ACHBLF; however, as a prognostic marker of mortality in patients with ACHBLF, it needs further validation.

METHODS

The aim of this study was to examine whether admission levels of fibronectin in ACHBLF patients are correlated with outcomes. In this prospective study, 78 ACHBLF patients were compared to 70 matched healthy controls. Fibronectin levels were determined using a commercial enzyme-linked immunosorbent assay kit to determine the prognostic value of fibronectin levels on admission.

RESULTS

The median (range) fibronectin level at admission for ACHBLF patients was significantly reduced compared with that of healthy controls (142 [62-275] mg/l vs 265 [190-346] mg/l, respectively; p<0.001). Fibronectin levels were significantly higher in surviving patients than in those who died (155 [70-275] mg/l vs 119 [62-235] mg/l; p=0.020). Receiver operating characteristic curve analysis showed that a cut-off level of 135 mg/l was the best prognostic indicator, yielding positive and negative predictive values of 60% (18/30) and 71% (30/42), respectively.

CONCLUSIONS

Our results suggested that decreased serum fibronectin levels in patients with ACHBLF were correlated to hepatic injury and inflammation. However, because of the lack of specificity, the use of fibronectin as an independent prognostic indicator is limited.

Human papilloma virus in head and neck cancers-role and relevance in clinical management

The biology and clinical behavior of Head and Neck Squamous Cell Carcinomas (HNSCCs) is very distinct within different subgroups due to the distinct molecular profiles for the HPV positive versus HPV negative tumors. HPV status is the most important independent prognostic variable in multivariate analysis taking into account all other prognostic factors like tumour stage, smoking status, age and performance status. The debate today is whether the intense therapy is too aggressive in this group of patients since they show a superior survival regardless of treatment strategies. A highly divergent prognosis and distinct biology of HPV positive and HPV negative HNSCCs underlines the fact that treating them as distinct diseases is the need of the hour. Infection with HPV is associated with less aggressive disease, better loco regional control and lower rates of second primary cancers. An important caveat that remains is the emergence of intermediate prognosis of HPV positive smokers and HPV negative non smokers. Though molecular biology has provided important data on the interaction of the HPV onco proteins with genes important in cell cycle control, also speculated to be involved in pathogenesis of HNSCC, more basic research is needed to describe the differential mechanisms of tumorigenesis among the HNSCCs that show presence and absence of HPV. This is clinically relevant to reduce morbidity without compromising tumour control in HPV positive patients and improving tumour control and co-morbid illness that could be pre-existing or treatment related in HPV negative patients. There may be a need for treatment intensification and incorporation of newer agents into induction chemotherapy protocols for the HPV negative patients and so HPV detection is important to aid in this selection. HPV tumour status is therefore more important than just providing the prognostic information in these classes of tumours. This article discusses the role and clinical relevance of HPV in HNSCCs.

Upper Gastrointestinal Hemorrhage: Development of the Severity Score

Background

Emergency endoscopy for every patient with upper gastrointestinal hemorrhage is not possible in many medical centers. Simple guidelines to select patients for emergency endoscopy are lacking. The aim of the present report is to develop a simple scoring system to classify upper gastrointestinal hemorrhage (UGIH) severity based on patient clinical profiles at the emergency departments.

Methods

Retrospective data of patients with UGIH in a university affiliated hospital were analyzed. Patients were criterion-classified into 3 severity levels: mild, moderate and severe. Clinical and laboratory information were compared among the 3 groups. Significant parameters were selected as indicators of severity. Coefficients of significant multivariable parameters were transformed into item scores, which added up as individual severity scores. The scores were used to classify patients into 3 urgency levels: non-urgent, urgent and emergent groups. Score-classification and criterion-classification were compared.

Results

Significant parameters in the model were age ≥ 60 years, pulse rate ≥ 100/min, systolic blood pressure < 100 mmHg, hemoglobin < 10 g/dL, blood urea nitrogen ≥ 35 mg/dL, presence of cirrhosis and hepatic failure. The score ranged from 0 to 27, and classifying patients into 3 urgency groups: non-urgent (score < 4, n = 215, 21.2%), urgent (score 4 - 16, n = 677, 66.9%) and emergent (score > 16, n = 121, 11.9%). The score correctly classified 81.4% of the patients into their original (criterion-classified) severity groups. Under-estimation (7.5%) and over-estimation (11.1%) were clinically acceptable.

Conclusions

Our UGIH severity scoring system classified patients into 3 urgency groups: non-urgent, urgent and emergent, with clinically acceptable small number of under- and over-estimations. Its discriminative ability and precision should be validated before adopting into clinical practice.

Clinical Risk Characteristics of Upper Gastrointestinal Hemorrhage Severity: A Multivariable Risk Analysis

Background

Upper gastrointestinal hemorrhage (UGIH) is one of the common clinical manifestations encountered in most emergency departments. Patient characteristics indicating UGIH severity in developing countries may be different from those in developed countries. The present study was designed to explore clinical prognostic indicators for UGIH severity.

Methods

A retrospective cohort study was conducted in a university affiliated tertiary hospital in Kamphaeng Phet, Thailand. Medical folders of patients with UGIH were reviewed. Patients were grouped into 3 severity levels, based on criteria proposed by The American College of Surgeon. Pre-defined prognostic indicators were compared. The prognostic indicators for UGIH severity were analyzed by a multivariable continuation ratio ordinal logistic regression and presented with odds ratios.

Results

From 1,043 eligible medical folders, 984 (94.3%) complete folders were used in analysis. There were 241, 631 and 112 patients in the mild, moderate and severe UGIH groups. Six independent indicators of severe UGIH were, hemoglobin < 100 g/dL (OR = 13.82, 95% CI = 9.40 to 20.33, P < 0.001), systolic blood pressure < 100 mmHg (OR = 11.01, 95% CI = 7.41 to 16.36, P < 0.001), presence of hepatic failure (OR = 5.50, 95% CI = 1.14 to26.64, P = 0.037), presence of cirrhosis (OR = 2.03, 95% CI = 1.32 to 3.11, P = 0.001), blood urea nitrogen ≥ 35 mmol/L (OR = 1.73, 95% CI = 1.25 to 2.40, P = 0.001), and pulse rate ≥ 100 per minute (OR = 1.72, 95% CI = 1.21 to 2.45, P = 0.003).

Conclusions

Pulse rate ≥ 100 per minute, systolic blood pressure < 100 mmHg, hemoglobin < 10 g/dL, blood urea nitrogen ≥ 35 mmol/L, presence of cirrhosis and presence of hepatic failure are prognostic indicators for an increase in UGIH severity levels. They are potentially useful in UGIH risk stratification.