Primary Care Versus Oncology-Based Surveillance Following Adjuvant Chemotherapy in Resected Pancreatic Cancer

Introduction

High level evidence to guide surveillance following curative intent treatment for pancreatic cancer is lacking and this has likely resulted in wide variations in practice. We aim to describe patterns of surveillance and evaluate their impact on outcomes.

Methods

A total of 147 adult patients who received at least one cycle of adjuvant gemcitabine or 5-fluorouracil-based chemotherapy at any one of five British Columbia Cancer Agency centers between 2001 and 2015 were included. Surveillance strategies were classified into two categories: discharged to primary care physicians (PCPs) or follow-up at cancer centers (CC) that included regular clinical assessments, laboratory testing, and/or diagnostic imaging.

Results

Median age at diagnosis was 64 (range 38–85) years and 48% were men. More patients were followed by CC than by PCPs (66 vs. 44%). Among the measured prognostic factors, only patients with advanced tumor stage (T3/4) were more likely to be followed by cancer specialists (78 vs. 62%, P = 0.03), while other patient and disease characteristics were balanced between the two groups. In the entire cohort, 100 (68%) patients had a documented recurrence. Patients followed by CC were more likely to receive palliative chemotherapy at recurrence than those followed by PCPs (58 vs. 34%, respectively, P = 0.03). The median overall survival (OS) was 2.82 (95% CI 2.17–3.32) years in the CC group and 3.35 (95% CI 2.85–5.06) years in the PCP group while the median relapse-free survival (RFS) was 1.4 (95% CI 1.37–1.77) and 2.4 (95% CI 2.07–4.59) years, respectively. On multivariate analysis, there was no significant difference in OS between CC and PCP-based surveillance (HR 1.23; 95% CI 0.74–2.04, P = 0.40); however, RFS favored the PCP group (HR 1.62; 95% CI 1.01–2.56, P = 0.04, for the CC group).

Conclusion

In this population-based analysis, surveillance tests and imaging performed by CC detected recurrences earlier when compared to follow-up by PCPs, but this did not result in OS differences. Patients with more advanced tumors were more likely to be seen at CC. PCPs may play a larger role in the follow-up care of selected low risk patients with resected pancreatic cancer.

     

Molecular detection of Leishmania species in human and animals from cutaneous leishmaniasis endemic areas of Waziristan,Khyber Pakhtunkhwa,Pakistan

Objectives: To detect Leishmania species in human patients, animal reservoirs and Phlebotomus sandflies in Waziristan, Pakistan. Methods: Tissue smears and aspirates from 448 cutaneous leishmaniasis(CL) suspected patients were analyzed. To sort out role of the reservoir hosts, skin scrapings, spleen and liver samples from 104 rodents were collected. Furthermore, buffy coat samples were obtained from 60 domestic animals. Sandflies were also trapped. All human, animals and sandfly samples were tested by microscopy, kinetoplastic PCR and internal transcribed spacer 1(ITS1) PCR followed by restriction fragment length polymorphism for detection of Leishmania species. Results: An overall prevalence of 3.83% and 5.21% through microscopy and ITS1 PCR respectively was found. However, the statistically non-significant correlation was found between area, gender, and number of lesions. The presence of rodents, sandflies, domestic animals and internally displaced people increased the risk of CL. Using ITS1-PCR-RFLP, Leishmania tropica(L. tropica) was confirmed in 106 samples while 25 of the isolates were diagnosed as Leishmania major(L. major). Similarly, 3/104 rodents were positive for L. major and 14 pools of DNA samples containing Phlebotomus sergenti sandflies were positive for L. tropica. None of samples from domestic animals were positive for leishmaniasis. Conclusions: In the present study, L. tropica and L. major are found to be the main causative agents of CL in study area. Movement of internally displaced people from CL endemic areas presents a risk for nearby CL free areas. To the best of our knowledge, we report for the first time L. major infection in rodents(Rattus rattus) and L. tropica in Phlebotomus sergenti sandflies trapped in Waziristan, Pakistan.     

Prediction of mortality in pediatric trauma patients: new injury severity score outperforms injury severity score in the severely injured

BACKGROUND: The Injury Severity Score (ISS) is a widely accepted method of measuring severity of traumatic injury. A modification has been proposed--the New Injury Severity Score (NISS). This has been shown to predict mortality better in adult trauma patients, but it had no predictive benefit in pediatric patients. The aim of this study was to determine whether the NISS outperforms the ISS in a large pediatric trauma population. METHODS: Admissions in the National Pediatric Trauma Registry between April 1996 and September 1999 were included. The ISS and NISS were calculated for each patient. The study endpoints were mortality at hospital discharge, functional outcome in three domains (expression, locomotion, and feeding), and discharge disposition for the survivors. Predictive ability of each score was assessed by area under the receiver operating characteristic curve. RESULTS: The NISS and ISS performed equally well at predicting mortality in patients with lower injury severity (ISS < 25), but the NISS was significantly better at predicting mortality in the more severely injured patients. Both scores performed equally well at predicting expression and feeding ability. The NISS was superior to the ISS in predicting locomotion ability at discharge. Thirty-seven percent of patients had an NISS that was higher than their ISS. These patients had a significantly higher mortality and suffered worse functional outcomes. CONCLUSION: The NISS performs as well as the ISS in pediatric patients with lower injury severity and outperforms the ISS in those with higher injury severity.     

The association of seropositivity to Helicobacter pylori,Chlamydia pneumoniae,and cytomegalovirus with risk of cardiovascular disease: a prospective study

OBJECTIVES: We sought to determine whether seropositivity to Helicobacter pylori, Chlamydia pneumoniae, and cytomegalovirus (CMV) is an independent predictor of incident cardiovascular disease. BACKGROUND: Recent reports have suggested that infections may contribute to risk of cardiovascular disease. However, prospective studies of these associations in a free-living population are lacking. METHODS: We measured serum H. pylori IgG, C. pneumoniae IgG and IgA, and CMV IgG levels in Framingham Heart Study cohort participants. Blood samples were drawn during the 16th biennial examination cycle (1979 to 1982) from 1,187 participants free of cardiovascular disease (mean age 69 years) and stored at -20 degrees C. A pooled primary end point of myocardial infarction, atherothrombotic stroke, and coronary heart disease deaths was studied in relation to serology. Using a Cox model, hazard ratios (HR) and 95% confidence intervals (CI) were calculated, adjusting for age, gender, and established risk factors. RESULTS: Seropositivity to H. pylori IgG, C. pneumoniae IgG, C. pneumoniae IgA, and CMV IgG was 60%, 45%, 11%, and 69%, respectively. During 10 years of follow-up, incident cardiovascular disease occurred in 199 participants (16.8%). In age- and gender-adjusted models, H. pylori IgG (HR 1.09, 95% CI 0.81 to 1.46), C. pneumoniae IgG (HR 0.91, 95% CI 0.68 to 1.20), C. pneumoniae IgA (HR 0.65, 95% CI 0.39 to 1.07), and CMV IgG (HR 0.84, 95% CI 0.62 to 1.12) were not associated with incident cardiovascular disease. These associations were further attenuated after adjustment for risk factors including body mass index, total and high-density lipoprotein cholesterol, diabetes mellitus, smoking, and hypertension. These estimates did not change for the individual components of cardiovascular disease, and seropositivity to more than one organism did not alter these risk estimates substantially. CONCLUSIONS: In this elderly cohort, chronic H. pylori, C. pneumoniae, and CMV infections, as evidenced by seropositivity, were not associated with increased risk for cardiovascular disease. Additional studies are needed to determine the relations of chronic infections to cardiovascular disease risk in younger persons.     

The role of theta and alpha oscillations for language comprehension in the human electroencephalogram

The hypothesis is tested, whether increasing language processing demands draw on the capacity of working memory thereby leading to an increase in theta band power. Previous research has shown that theta reflects working memory whereas upper alpha semantic memory demands. Sentences were presented in four chunks in a reading and a semantic task. In the latter, subjects had to find a superordinate concept to a noun presented in the third chunk. The data show an increase in theta during sentence processing which was significantly smaller in the semantic task. In contrast, the upper alpha band exhibited a significantly larger change in band power during the semantic task and that time window in which subjects searched for the superordinate concept. Thus, we conclude that semantic processing does not draw selectively on the capacity of working memory and that different linguistic processes have no direct influence on theta oscillations.     

Improved cardiac performance and reduced pulmonary vascular constriction by epinephrine administration via a left atrial catheter in cardiac surgical patients

Diminished left ventricular contractility and increased right ventricular afterload are issues in cardiac surgery. The usual administration of catecholamines (epinephrine) via the central venous (CV) catheter increases cardiac output, but also may increase pulmonary vascular constriction. Epinephrine was, therefore, administered via the left atrial (LA) catheter or the CV catheter in 8 cardiac surgery patients, each serving as his or her own control. The LA administration of epinephrine has an advantage with its immediate effect on the coronary circulation, while avoiding associated pulmonary vasoconstriction by passing through the systemic capillary bed before reaching the lung. It was found in this study that administration of epinephrine via an LA catheter increased the average cardiac output by 1.05 L/ min, which was significantly (P < 0.05) greater than with administration via the CV catheter. With LA administration of epinephrine, systemic arterial pressures (systolic arterial pressure and diastolic arterial pressure) (SAP, DAP) were also elevated to a greater extent than by CV administration. On the other hand, pulmonary arterial pressures (systolic pulmonary arterial pressure and diastolic pulmonary arterial pressure) (SPAP, DPAP) were less elevated than by administration via the CV catheter. This produced increased coronary perfusion and a smaller increase in pulmonary vascular tone by LA administration in contrast to CV administration of epinephrine. It is concluded that epinephrine administration via an LA catheter improved myocardial performance and pulmonary perfusion due to direct entry of the agent into the coronary circulation and partial metabolism while passing through the systemic capillary bed before reaching the lung.     

Prevalence of human leukocyte antigen (HLA) DRB1 alleles in Kuwaiti children with juvenile rheumatoid arthritis.

The prevalence of human leukocyte antigen (HLA) DR alleles has been determined in 69 Kuwaiti Arab children with juvenile rheumatoid arthritis (JRA) and compared to that in 212 ethnically matched normal healthy controls using a PCR-sequence specific primers (PCR-SSP) method. A very high incidence of DR3 was detected in JRA patients compared to the controls (P < 0.0001, RR = 2.235). The high incidence of HLA-DR3 in JRA patients was accounted for mainly by an excess of DRB1*0307 (P < 0.05, RR = 3.072) and DRB1*0308 (P < 0.009, RR = 2.663) compared to the controls. Moreover, DR3 was more prevalent when patients with ANA-positive JRA were analysed separately; 73% compared to 58% for the whole JRA patient group. The frequency of DR1 was also higher in the JRA group compared to controls (P = 0.019, RR = 3.585). Although the incidence of some alleles was higher in the control group (DR13 and DR7), none reached a statistically significant level. All the patients with iridocyclitis had either a DR1 or DR3 allele, except for one child. The frequency of DRB1*03 was found to be much higher in the polyarticular subtype of Kuwaiti JRA cases compared to the oligoarticular subgroup and the controls. Also, a non-significant increase in the frequency of the DRB1*04, *11 and *15 alleles was detected in the polyarticular subtype of the Kuwaiti JRA cases compared to the controls.     

Hesperidin inhibits collagen-induced arthritis possibly through suppression of free radical load and reduction in neutrophil activation and infiltration

Rheumatoid arthritis is a chronic inflammatory disease characterized by the destruction of articular cartilage and bone in a chronic phase. Pathology of rheumatoid arthritis suggests autoimmunity linked to inflammation. In our study, rheumatoid arthritis was induced in Wistar rats by intradermal injections of 100 μl of emulsion containing bovine type II collagen in complete Freund’s adjuvant at the base of the tail. Disease developed about 13 ± 1 days after immunization and treatment with hesperidin (HES) at a dose of 160 mg kg^?1 body weight was given after onset of disease daily until 20th day. The effect of treatment in the rats was monitored by clinical scoring, biochemical parameters and histological evaluations in joints. A steady increase in the articular elastase, nitric oxide and lipid peroxidation was observed in joints of arthritic rats as compared to control, whereas a significant decrease in reduced glutathione, superoxide dismutase activity and catalase was observed in collagen-induced arthritis rats as compared to control group. The results from the present work indicate that the treatment with hesperidin was effective in bringing about significant changes on all the parameters studied in collagen-induced arthritis rats. These data confirm that erosive destruction of the joint cartilage in collagen-induced arthritis is due free radicals released by activated neutrophils and produced by other biochemical pathways. In the present study, an attempt has been made to amelioration of the disease process by a natural product. These results suggest that oral administration of HES could be effective for treating human RA patients.