Libman-Sacks endocarditis and associated cerebrovascular disease: The role of medical therapy.

BACKGROUND: Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is commonly complicated with embolic cerebrovascular disease (CVD) or valve dysfunction for which high-risk valve surgery is frequently performed. However, the role of medical therapy alone for Libman-Sacks endocarditis and associated acute CVD remains undefined. OBJECTIVE: To determine in this cross-sectional and longitudinal study if conventional anti-inflammatory and anti-thrombotic therapy may be an effective therapy in SLE patients with Libman-Sacks endocarditis and associated acute CVD. METHODS AND MATERIALS: 17 SLE patients with Libman-Sacks endocarditis detected by two-and-three-dimensional transesophageal echocardiography (TEE) and complicated with acute CVD [stroke/TIA, focal brain injury on MRI, or cognitive dysfunction] were treated with conventional anti-inflammatory and anti-thrombotic therapy for a median of 6 months and then underwent repeat TEE, transcranial Doppler, brain MRI, and neurocognitive testing for re-assessment of Libman-Sacks endocarditis and CVD. RESULTS: Valve vegetations decreased in number, diameter, and area (all p ≤0.01); associated valve regurgitation significantly improved (p = 0.04), and valve thickening did not progress (p = 0.56). In 13 (76%) patients, valve vegetations or valve regurgitation resolved or improved in number and size or by ≥1 degree, respectively, as compared to 4 (24%) patients in whom vegetations or valve regurgitation persisted unchanged or increased in size or by ≥1 degree (p = 0.03). Also, cerebromicroembolism, lobar and global gray and white matter cerebral perfusion, ischemic brain lesion load, and neurocognitive dysfunction resolved or significantly improved (all p ≤0.04). CONCLUSION: These preliminary data suggest that combined conventional anti-inflammatory and antithrombotic therapy may be an effective treatment for Libman-Sacks endocarditis and its associated CVD and may obviate the need for high-risk valve surgery.

Prevalence and Treatment of Postpartum Stress Urinary Incontinence: A Systematic Review.

OBJECTIVES: Many women present for treatment of stress urinary incontinence (SUI) after childbirth. This systematic review describes the efficacy of treatment options for SUI initiated during the 12 months after delivery. METHODS: We conducted a systematic review to identify studies comparing treatment options for SUI initiated in the 12 months after parturition. We searched MEDLINE from inception to February 2019, using Medical Subject Heading terms related to pregnancy and urinary incontinence. Preintervention and postintervention populations were compared using analysis of variance with Fisher least significant difference method used to determine efficacy between groups. Grades for Recommendation, Assessment, Development and Evaluation system was used to categorize quality of evidence as high, moderate, low, or very low. RESULTS: We double screened 4548 abstracts, identifying 98 articles for full-text review. Seven studies met the eligibility criteria and were included. Compared with a control group, the 4 interventions identified outperformed the control group (P < 0.001) using Fisher (with effect sizes noted): (1) supervised pelvic floor physical therapy (0.76), (2) electrical stimulation (0.77), (3) home physical therapy (PT) (0.44), and (4) surgery (not applicable). Based on Grades for Recommendation, Assessment, Development and Evaluation assessment, there was moderate evidence to support PT and electrical stimulation, with insufficient evidence for surgery. There were no significant differences in parity, age, or body mass index via analysis of variance. The overall strength of evidence is poor for the treatment of postpartum SUI; more data are needed to fully evaluate other treatment options. CONCLUSIONS: All identified interventions demonstrated greater improvement for postpartum SUI over no treatment. Supervised PT ± electrostimulation was the most effective nonsurgical intervention.

A model for conditional male trimorphisms.

Conditional dimorphisms are widespread in color, morphology, behavior, and life history. Such traits have been successfully modeled in game theory as conditional strategies, and in quantitative genetics as threshold traits. Conditional trimorphisms have recently been unveiled, and here we combine the rock-paper-scissors (RPS) model of game theory and the environmental threshold (ET) model of quantitative genetics to model trimorphisms that are environmentally induced and result from the expression of two thresholds. We investigated the tactic fitness structure for maintenance of alternative reproductive tactics in scarab dung beetles that constitute the first known examples of conditional male trimorphism. We parameterized a novel ternary fitness landscape that explains how conditional male trimorphism in these beetles can be maintained. We tracked changes in tactic frequencies in a wild population of Phanaeus triangularis and detected fitness intransitivity consistent with RPS dynamics. Quantitative predictions of our model compare favorably with corresponding observed parameters. The ternary landscape further reveals how geographic populations of these beetles can evolve between conditional trimorphism and dimorphism. The ternary model also suggests that polyphenic systems could potentially evolve between conditional and purely genetic mediation.

Distal tibia allograft for glenohumeral instability: does radius of curvature match?

BACKGROUND: A distal tibia osteochondral allograft is a potential graft option for glenoid reconstruction because the distal tibia may have a similar radius of curvature (ROC) as the glenoid. This study evaluated ROC mismatch as measured on computed tomography (CT) scans between the glenoid, distal tibia, and humeral head. METHODS: Bilateral CT images were formatted for 10 decedents from the Office of the Medical Investigator database, giving 20 specimens per anatomic location. The ROCs of the glenoid, distal tibia, and humeral head were measured. A statistical model was generated to assess ROC mismatch of randomly paired distal tibias and glenoids. RESULTS: The mean ± standard deviation ROC was 2.9 ± 0.25 cm for the glenoid, 2.3 ± 0.21 cm for the distal tibia, and 2.5 ± 0.12 cm for the humeral head. No differences were found in laterality, intraobserver, or interobserver measurements. The least-squares difference in the ROC between the glenoid and tibia was 0.57 cm, glenoid and humerus was 0.40 cm, and humerus and tibia was 0.17 cm. Only 22% of randomly paired distal tibias and glenoids had a difference in ROC of 0.3 cm or less. CONCLUSION: CT measurement of the ROC of the glenoid, distal tibia, and humeral head is reliable and reproducible. The probability of obtaining a random distal tibia allograft with a similar ROC to the glenoid is low. Obtaining ROC measurements of the injured glenoid and the distal tibia allograft specimen before use for glenoid reconstruction may be useful.

Lambl's Excrescences: Association with Cerebrovascular Disease and Pathogenesis.

BACKGROUND: Lambl's excrescences (LEx) are detected by transesophageal echocardiography (TEE) and are characterized as thin, elongated, and hypermobile structures located at the leaflets' coaptation point of the heart valves. The association of LEx with cerebrovascular disease (CVD) is still undefined and yet patients with LEx and suspected CVD receive unproven effective antiplatelet or anticoagulant therapy or even undergo valve surgery. Also, the association of LEx with aging and atherogenic, inflammatory, or thrombogenic parameters has not been reported. METHODS: Seventy-seven patients with systemic lupus erythematosus (SLE) (71 women, age 37 ± 12 years) and 26 age- and sex-matched healthy controls (22 women, age 34 ± 11 years) prospectively underwent routine history and physical exam, transcranial Doppler, brain MRI, TEE, carotid duplex, and clinical and laboratory evaluations of atherogenesis, inflammation, platelet activity, coagulation, and fibrinolysis. Subjects without stroke/TIA on enrollment (with and without LEx) had a median follow-up of 57 months. RESULTS: On enrollment, 33 (43%) of 77 patients had CVD manifested as acute stroke/TIA (23 patients), cerebromicroembolism by transcranial Doppler (17 patients), or cerebral infarcts by MRI (14 patients). Mitral or aortic valve LEx were equally frequent in healthy controls (46%) as in patients with and without any CVD (39 and 43%), stroke/TIA (35 and 43%), cerebromicroembolism (41 and 42%), or cerebral infarcts (36 and 43%) (all p ≥ 0.72). Also, other mechanisms for CVD other than LEx such as Libman-Sacks vegetations, patent foramen ovale or interatrial septal aneurysm, aortic or carotid atherosclerosis, or thrombogenesis were found in ≥94% of patients with CVD. In addition, 36 subjects with and 44 without LEx had similar low incidence of stroke/TIA (1 (1.3%) and 2 (2.5%), respectively, p = 1.0) during follow-up. Finally, LEx were not associated with aging, atherogenic risk factors, atherosclerosis, inflammation, or thrombogenesis. CONCLUSIONS: In this study, LEx are similarly prevalent in healthy controls and SLE patients, are not associated with CVD, and are not associated with pathogenic risk factors. Therefore, the study findings suggest that LEx may not be cardioembolic substrates, may not represent pathologic valve structures, and may not require therapy.

Risk factors for lower urinary tract injury at the time of hysterectomy for benign reasons.

OBJECTIVES: To identify risk factors associated with lower urinary tract injury at the time of performing hysterectomy for benign indications. METHODS: We conducted a multi-center case-control study of women undergoing hysterectomy for benign disease. Cases were identified via ICD-9 codes for lower urinary tract injury at the time of hysterectomy from 2007 to 2011: controls were two subsequent hysterectomies following the index case in the same institution that did not have lower urinary tract injury. Logistic regression was used to perform univariate and multivariate comparisons between groups. RESULTS: At 7 centers, 135 cases and 270 controls were identified. Cases comprised 118 bladder injuries and 25 ureteral injuries; 8 women had both bladder and ureteral injury. Bladder injury was associated with a history of prior cesarean section OR 2.9 (95% CI 1.7-5), surgery by a general obstetrician and gynecologist OR 2.4 (95% CI 1.2-5.2), and total abdominal hysterectomy OR1.9 (95%CI 1.06-3.4). Ureteral injury was more likely among women who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) OR 10.4 (95%CI 2.3-46.6) and total abdominal hysterectomy (TAH) OR 4.7 (95% CI 1.4-15.6). CONCLUSION: Bladder injury at the time of benign hysterectomy is associated with a prior history of Cesarean section and TAH as well as surgery by generalist OB-GYN; ureteral injury is associated with LAVH and TAH.

Goal attainment after treatment in patients with symptomatic pelvic organ prolapse.

OBJECTIVE: The objectives of this study were to: (1) assess differences in goal attainment of self-described goals after treatment of symptomatic pelvic organ prolapse (POP) for women who chose surgery compared to women who chose pessary; and (2) compare patient global improvement between groups. STUDY DESIGN: Women who had symptomatic stage ≥II prolapse presenting for care of POP to the urogynecology clinic at the University of New Mexico were recruited. Patients listed up to 3 goals they had for their treatment. In addition, they completed the short forms of the Pelvic Floor Distress Inventory (PFDI-20), the POP/Urinary Incontinence Sexual Questionnaire, and the Body Image Scale. Goals listed by patients were then categorized into 10 categories. Each of the listed goals was categorized based on a consensus of 5 providers. At 3 months' follow-up patients listed if they had met their self-described goals on a scale of 0-10 and also answered the Patient Global Improvement Index (PGI-I). RESULTS: There were no significant differences between the 2 groups' baseline characteristics. Surgery patients ranked their goal attainment higher than pessary patients for all the 3 goals listed. Similarly, PGI-I scores were also higher in the surgical (2.4 ± 1.1) than the pessary (1.93 ± 0.8) treatment groups (P < .04). Patients in the surgery group also had better symptom improvement as measured by the PFDI-20 (P < .02). CONCLUSION: Patients who chose surgery had better global improvement and met their goals better compared to patients who chose pessary.

The clinical significance of inflammatory cytokines in primary cell culture in endometrial carcinoma.

Endometrial cancer is the most common malignancy of the female genital tract, and the incidence and mortality rates from this disease are increasing. Although endometrial carcinoma has been regarded as a tissue-specific disease mediated by female sex steroid pathways, considerable evidence implicates a role for an inflammatory response in the development and propagation of endometrial cancer. We hypothesized that if specific patterns of cytokine expression were found to be predictive of adverse outcome, then selective receptor targeting may be a therapeutic option. This study was therefore undertaken to determine the relationship between cytokine production in primary cell culture and clinical outcome in endometrial adenocarcinoma. Fresh endometrial tissues were fractionated into epithelial and stromal fractions and cultured. After 6-7 days, supernatants were collected and cells enumerated. Batched aliquots were assayed using ELISA kits specific for CSF-1, GMCSF, G-CSF, TNF-α, IL-6, IL-8, and VEGF. Data were compared using ANOVA, Fisher's exact, and log rank tests. Increased epithelial VEGF production was observed more often in tumors with Type 2 variants (p = 0.039) and when GPR30 receptor expression was high (p = 0.038). Although increased stromal VEGF production was detected more often in grade 3 endometrioid tumors (p = 0.050), when EGFR expression was high (p = 0.003), and/or when ER/PR expression was low (p = 0.048), VEGF production did not correlated with overall survival (OS). Increased epithelial CSF-1 and TNF-α production, respectively, were observed more often in tumors with deep myometrial invasion (p = 0.014) and advanced stage (p = 0.018). Increased CSF-1 (89.5% vs. 42.9%, p = 0.032), TNF-α (88.9% vs. 42.9%, p = 0.032, and IL-6 (92.3% vs. 61.5%, p = 0.052) also correlated with low OS. In Cox multivariate models, CSF-1 was an independent predictor of low survival when stratified by grade (p = 0.046) and histology (p = 0.050), and TNF-α, when stratified by histology (p = 0.037). In this study, high CSF-1, TNF-α, and IL-6 production rates identified patients at greatest risk for death, and may signify patients likely to benefit from receptor-specific therapy.

Risk factors for poor prognosis in microinvasive adenocarcinoma of the uterine cervix (IA1 and IA2): a pooled analysis.

OBJECTIVE: To identify adverse risk factors for FIGO IA1 and IA2 cervical adenocarcinoma. METHODS: PubMed was used to identify all microinvasive adenocarcinoma cases. Case specific data pooled for 35 "high risk" microinvasive adenocarcinoma (MIAC), defined as cases with lymph node or lymphovascular space involvement, positive surgical margins, or recurrence was compared with 478 "low risk" cases abstracted from the SEER database (1988-1997). Statistical methods included non-paired t and Fisher's Exact tests. RESULTS: Survival for 1A1 and 1A2 MIAC is 99% and 98%, respectively. Significantly more 1A2 patients underwent aggressive radical surgery and received postoperative treatment. Parametrial involvement was rare (1/373 cases). Significantly more "high-risk" cases were of endometrioid histology (6/34 vs. 14/478, p=0.001), whereas adenocarcinoma (p=0.046) and mucinous (p=0.021) tumors were observed in the "low-risk" group. Among the "high-risk" cases with at least 5 years follow-up, 1.4% has recurred or died. CONCLUSIONS: Endometrioid histology may be associated with late recurrence and worse survival in stage 1A1 and 1A2 MIAC.

Insulin-like growth factor 2 expression modulates Taxol resistance and is a candidate biomarker for reduced disease-free survival in ovarian cancer.

PURPOSE: This study was undertaken to examine the role of the insulin-like growth factor (IGF) signaling pathway in the response of ovarian cancer cells to Taxol and to evaluate the significance of this pathway in human epithelial ovarian tumors. EXPERIMENTAL DESIGN: The effect of Taxol treatment on AKT activation in A2780 ovarian carcinoma cells was evaluated using antibodies specific for phospho-AKT. To study the drug-resistant phenotype, we developed a Taxol-resistant cell line, HEY-T30, derived from HEY ovarian carcinoma cells. IGF2 expression was measured by real-time PCR. A type 1 IGF receptor (IGF1R) inhibitor, NVP-AEW541, and IGF2 small interfering RNA were used to evaluate the effect of IGF pathway inhibition on proliferation and Taxol sensitivity. IGF2 protein expression was evaluated by immunohistochemistry in 115 epithelial ovarian tumors and analyzed in relation to clinical/pathologic factors using the chi(2) or Fisher's exact tests. The influence of IGF2 expression on survival was studied with Cox regression. RESULTS: Taxol-induced AKT phosphorylation required IGF1R tyrosine kinase activity and was associated with upregulation of IGF2. Resistant cells had higher IGF2 expression compared with sensitive cells, and IGF pathway inhibition restored sensitivity to Taxol. High IGF2 tumor expression correlated with advanced stage (P < 0.001) and tumor grade (P < 0.01) and reduced disease-free survival (P < 0.05). CONCLUSIONS: IGF2 modulates Taxol resistance, and tumor IGF2 expression is a candidate prognostic biomarker in epithelial ovarian tumors. IGF pathway inhibition sensitizes drug-resistant ovarian carcinoma cells to Taxol. Such novel findings suggest that IGF2 represents a therapeutic target in ovarian cancer, particularly in the setting of Taxol resistance.

GPR30 predicts poor survival for ovarian cancer.

OBJECTIVES: GPR30 is a 7-transmembrane G protein-coupled estrogen receptor that functions alongside traditional estrogen receptors to regulate cellular responses to estrogen. Recent studies suggest that GPR30 expression is linked to lower survival rates in endometrial and breast cancer. This study was conducted to evaluate GPR30 expression in ovarian tumors. METHODS: GPR30 expression was analyzed using immunohistochemistry and archival specimens from 45 patients with ovarian tumors of low malignant potential (LMP) and 89 patients with epithelial ovarian cancer (EOC). Expression, defined as above or below the median (intensity times the percentage of positive epithelial cells) was correlated with predictors of adverse outcome and survival. RESULTS: GPR30 expression above the median was observed more frequently in EOC than in LMP tumors (48.3% vs. 20%, p=0.002), and in EOC was associated with lower 5-year survival rates (44.2% vs. 82.6%, Log-rank p<0.001). Tumor grade and FIGO stage, the other significant predictors of survival, were used to stratify cases into "high risk" and "low risk" groups. The 5-year survival rate for "low risk" EOC (all grade 1 and Stage I/II, grade 2) was 100%. In "high risk" EOC (all grade 3 and Stage III/IV, grade 2), the difference in 5-year survival by GPR 30 expression was significant (33.3% vs. 72.4%, p=0.001). CONCLUSIONS: The novel estrogen-responsive receptor GPR30 is preferentially expressed in "high risk" EOC and is associated with lower survival rates. Further investigation of GPR30 as a potential target for therapeutic intervention in high risk EOC is warranted.

Estrogen and progesterone receptor status and outcome in epithelial ovarian cancers and low malignant potential tumors.

OBJECTIVE: Receptors for estrogen (ER) and progesterone (PR) are prognostic indicators for a variety of endocrine tumors including breast and endometrial. This study was conducted to determine if ER and PR expression patterns are predictive of outcome in patients with epithelial ovarian cancer (EOC) or ovarian low malignant potential (LMP) tumors. METHODS: ER and PR protein levels were assessed by immunohistochemistry in 45 LMP and 89 EOC samples. Patterns of ER/PR expression (individually and combinations of ER-/PR-, ER+/PR-, ER-/PR+, and ER+/PR+) were correlated with standard prognostic factors of overall survival (OS) in this patient population. RESULTS: For patients with EOC, the 5-year OS per ER-/PR+, ER+/PR-, ER+/PR+, and ER-/PR- expression was 83%, 79%, 61%, and 48%, respectively, and these differences were statistically significant. In multivariate analyses, ER/PR expression patterns were found to be independent predictors of OS, as were the classical prognostic factors of grade, stage, debulking, and chemotherapy response to treatment. In patients with mucinous LMP tumors, ER and PR were absent. Because no LMP patients died of disease during the studied period, no correlation analysis with OS could be performed. CONCLUSIONS: Patterns of ER/PR expression provide prognostic information in EOC. Additional studies evaluating hormonal inhibition may help personalize the therapy of patients with ovarian cancer.

Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study.

OBJECTIVE: Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is complicated with thromboembolism, severe valve regurgitation, need for high-risk valve surgery, or death. Transesophageal echocardiography (TEE) is highly accurate for detection of valvular heart disease, but there are no prospective randomized controlled series comparing transthoracic echocardiography (TTE) to TEE for detection of Libman-Sacks endocarditis. METHODS: Eighty-one patients with SLE (73 women, 8 men) with a mean age of 39 +/- 11 years and 75 healthy volunteers (40 women, 35 men) with a mean age of 35 +/- 9 years underwent paired TTE and TEE to detect valve vegetations, thickening, or >or= moderate mitral, tricuspid, or pulmonic >or= mild aortic regurgitation. Paired TTE and TEE studies of patients and controls were randomized and interpreted by an experienced observer unaware of subjects' data. RESULTS: Libman-Sacks endocarditis: (1) was more common in patients than in controls by both TTE and TEE (p < 0.001); and (2) was more commonly detected by TEE than by TTE (p

GPR30: a novel indicator of poor survival for endometrial carcinoma.

OBJECTIVE: This study was undertaken to evaluate the relationship between GPR30, classical steroidal receptor expression, and clinical outcome in patients with endometrial carcinoma. STUDY DESIGN: Immunohistochemistry was used to investigate the expression of GPR30, estrogen, progesterone, epidermal growth factor receptors and Ki-67 in 47 consecutive consenting patients with endometrial carcinoma diagnosed between 1997 and 2001. Results were correlated with clinical and pathologic predictors of adverse outcome and survival. RESULTS: GPR30 correlated positively with epidermal growth factor receptor (P = .005), but negatively with progesterone (P = .05) receptor expression. GPR30 overexpression occurred more frequently in tumors with deep myometrial invasion, high-grade, biologically aggressive histologic subtypes, and advanced stage. In patients with GPR30 overexpression, survival was significantly poorer (65.2% vs 100%, P = .005). CONCLUSION: GPR30 represents an alternative estrogen-responsive receptor that is overexpressed in tumors where estrogen and progesterone receptors are downregulated, and in high-risk endometrial cancer patients with lower survival rates.

Changing trends in gestational trophoblastic disease.

OBJECTIVE: The New Mexico Tumor Registry (NMTR) and Surveillance, Epidemiology and End Results (SEER) registries were utilized to determine (30+)-year trends in gestational trophoblastic disease and choriocarcinoma. STUDY DESIGN: Age-adjusted incidence rates of gestational trophoblastic disease per 100,000 woman-years (1973-2003) and ratios per live births and pregnancies were calculated using data abstracted from the NMTR and state vital records. SEER data (1973-2002) were used to calculate age-adjusted incidence rates, estimated annual percentage change (EAPC) and relative survival rates for choriocarcinoma. RESULTS: In New Mexico there were 1,153 cases affecting 377 non-Hispanic whites, 504 Hispanics and 241 American Indians, with respective incidence rates of 3.494, 5.150 and 9.991 (p < 0.0001). American Indian incidence rates decreased 53.3%, from 13.34 (1988-1992) to 6.23 (1998-2002). Within SEER (1973-2002), there were 504 gestational choriocarcinomas. The 30-year incidence rate was 0.132 and decreased by 37.7% (EAPC, -2.1% per year; p=0.0001)-by 40.1% for whites, 55.9% for blacks and 62.1% for others. However, over the previous 10 years, rates among blacks (0.097 vs. 0.259, p = 0.01) and for distant disease (0.044 vs. 0.071, p = 0.046) increased. CONCLUSION: Disparities in incidence rates by race/ethnicity in New Mexico are decreasing. An increase in rates among blacks and distant disease diagnosis may be the consequence of fewer regional trophoblastic centers in the United States.

Incidence and survival rates for female malignant germ cell tumors.

OBJECTIVE: To evaluate 30-year, population-based trends in incidence and survival rates for malignant germ cell tumors originating within the female genital tract. METHODS: Surveillance, Epidemiology, and End Results data were used to identify malignant germ cell tumors (1973-2002). Overall and 5-year incidence rates, estimated annual percentage change, and survival rates were calculated and compared by age at diagnosis, race, stage, and histology. RESULTS: Of 1,262 cases, there were 414 (32.8%) dysgerminomas, 449 (35.6%) immature teratomas, 37 (2.9%) mature teratomas with malignant degeneration, and 362 (28.7%) mixed germ cell tumors. The 30-year, age-adjusted incidence rate per 100,000 women-years was 0.338, decreasing by 29.4% for dysgerminomas (P = .18) and by 31.5% for mixed germ cell tumors (P = .22). Other nonwhites had higher rates than whites and blacks, but dysgerminoma rates were higher in whites and other nonwhites than in blacks. Using the registries for expanded races, rates were higher for Asian/Pacific Islanders (P = .059) and Hispanics (P = .07). By age at diagnosis, 15-19 year olds had the highest rates and the only significant change in rates (37.5% increase, P = .008). The 5-year relative survival was 83.9%. Survival rates improved significantly over calendar time and varied by histologic subtype, race, stage of disease, and age at diagnosis. CONCLUSION: Over the past 30 years, germ cell tumor incidence rates have declined in women and differ from rising trends reported for testicular tumors. Survival rates have improved but were lower for older women and for nondysgerminoma subtypes.

Gestational trophoblastic neoplasia in American Indians.

OBJECTIVE: To analyze gestational trophoblastic neoplasia (GTN) trends among American Indians (AI) using population-based data. STUDY DESIGN: GTN incidence, by race and age, was calculated using data collected by the New Mexico Tumor Registry over 29 years (1973-2001). Live birth, pregnancy and women at risk were tabulated using data derived from the state's vital record annual reports and from the registry. Statistical methods included trends analysis and Poisson regression. There is no national registry in the United States for all GTN. Therefore, the Surveillance, Epidemiology and End Results (SEER) database was used to identify choriocarcinoma cases in American Indians between 1973 and 1999. RESULTS: Within New Mexico, 1,082 cases of GTN were identified among 752,374 live births and 904,831 pregnancies, with ratios of 1:695 and 1:836, respectively, affecting 234 AI, 355 non-Hispanic whites (NHW), 463 Hispanic whites (HW) and 30 other nonwhites. Ratios per live births (pregnancy), respectively, were significantly higher in AI (AI 1:439 [1:487], NHW 1:739 [1:949], HW 1:783 [1:903]), as was age-adjusted incidence per 100,000 woman-years (AI 10.62, NHW 3.53, HW 5.15; all P<.0001). Using Poisson models with live birth and woman-year denominators, AI were found to be at increased risk for all GTN histologic subsets (complete, partial and invasive hydatidiform mole and choriocarcinoma). Of 524 total gestational choriocarcinoma cases identified within SEER, 8 (1.8%) affected American Indians; of them, 7 were from New Mexico. CONCLUSION: In New Mexico, AI continue to be at higher risk of GTN than are other groups. Given the rarity of choriocarcinoma within SEER, especially among AI, the New Mexico dataset provides the best available estimate of trends in U.S. AI GTN risk.

The effect of race on disease activity in systemic lupus erythematosus.

OBJECTIVE: To determine and contrast the disease activity and clinical variables between Hispanic and Caucasian patients with systemic lupus erythematosus (SLE) in New Mexico. METHODS: Socioeconomic-demographic and clinical data were collected from 125 SLE patients by an interview-administered questionnaire. The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity. RESULTS: Seventy-four Hispanics (H) and 40 Caucasians (C) were compared. Demographics including age, gender, disease duration, marital status, and cigarette smoking were similar between the 2 groups. However, education and income were higher in the Caucasian group compared to the Hispanic group. There was no significant difference between the 2 groups in overall disease activity as measured by the SLEDAI. However, when individual components of the SLEDAI were compared, Hispanics had an increased prevalence of arthritis (77% vs 51%, p = 0.01) and depressed complement levels (40% vs 18%, p = 0.02). Moreover, corticosteroid use was higher among the Hispanics compared to the Caucasian population (p = 0.03). CONCLUSION: We found similar levels of overall disease activity in Hispanic and Caucasian patients with SLE. However, Hispanics used more corticosteroids, had a greater prevalence of arthritis, and had depressed complement levels indicating increased SLE disease activity highly restricted to specific domains. It remains to be determined whether these restricted but discrete differences are genetic in origin, or are related cultural or environmental factors.

Trends in gestational choriocarcinoma: a 27-year perspective.

OBJECTIVE: To evaluate trends in incidence and survival rates for gestational choriocarcinoma with the use of population-based data. METHODS: Overall and 5-year average age-adjusted incidence rates were computed with the Surveillance, Epidemiology, and End Results program public-use database. Differences by age at diagnosis, race, stage, registry, and over calendar time were compared by Poisson regression, and survival censored for deaths other than choriocarcinoma by log-rank tests and Cox's proportional hazard ratios. RESULTS: Between 1973 and 1999, 450 cases were recorded. The annualized age-adjusted incidence rate for choriocarcinoma was 0.133 per 100,000 woman-years and decreased by 49.7% (2.8% per year). By race (whites, blacks, and others), incidence rates declined by 62.3%, 27.2%, and 54.3%, respectively. In the Poisson model evaluating incidence rates, age, race, registry, and stage were significant main effects. Compared with whites, the relative risk was higher for blacks (2.14, 95% confidence interval [CI] 1.60, 2.86) and others (2.30, 95% CI 1.67, 3.18). Rates were highest in Utah and lowest in Iowa. By age at diagnosis, rates were higher in 20-39-year-olds. The 5-year relative survival rate was 89.5%. Censored survival was significantly lower among blacks (whites 92.4%, blacks 84.9%, others 87.1%, P = .045), for advanced disease (localized 94.5%, regional 92.9%, distant 87.1%, P = .02), and with increasing age at diagnosis (P = .017). Age and calendar time significantly influenced censored survival independent of stage and registry. CONCLUSION: Gestational choriocarcinoma incidence rates have declined and survivals have improved, but blacks continue to have higher incidence and lower survival rates.