Immune expression in children with Wilms tumor: a pilot study.

BACKGROUND: Given improvements in multimodality therapy, survival among children with Wilms tumor (WT) exceeds 90%. However, 15% of children with favorable histology and 50% of children with anaplastic WT experience recurrence or progression. Of patients with advanced disease, only 50% survive to adulthood. In adult malignancies (including renal tumors), patient survival has improved with the advent of immunotherapy. However, little is known about the immune microenvironment of WT, making the potential role of immunotherapy unclear. OBJECTIVE: The objective of the study is to perform an exploratory, descriptive analysis of the immune milieu in WT. STUDY DESIGN: Between 2016 and 2017, all pediatric patients with WT, some of whom received neoadjuvant chemotherapy, underwent ex vivo wedge biopsy at the time of nephrectomy. The fresh tumor tissue and peripheral blood samples were analyzed for infiltrating immune infiltrate and effector cells using flow cytometry. Immunohistochemistry was performed for CD4, CD8, and PD-L1 expression. Matched blood samples were obtained for each patient, and circulating immune cells were analyzed by flow cytometry. RESULTS: A total of six patients were enrolled. One patient with neuroblastoma was excluded. The remaining five patients included the following: two with unilateral WT (resected before chemotherapy), two with bilateral WT (resected after neoadjuvant chemotherapy), and one with Denys-Drash syndrome, end-stage renal disease, and history of WT in the contralateral kidney. Immune analysis showed that WT were infiltrated by immune cells regardless of chemotherapy status. CD8 and CD4 T cells were present in the tumor tissue and exhibited an activated phenotype. Elevated levels of natural killer (NK) cells were observed in the tumors (Figure). Immune checkpoint PD-L1 was also found expressed in one of the tumors stained. DISCUSSION: In this pilot study, it was found that WTs were infiltrated by immune cells (CD45+) both before and after chemotherapy. Elevated levels of NK cells infiltrating the tumor specimens, which were quantitatively increased compared with levels of NK cells circulating in the blood, were noted. T cells, particularly CD4+ and CD8+ T cells, were present in tumor specimens. Tumor-infiltrating CD4 and CD8 T cells displayed an activated phenotype as defined by increased expression of human leukocyte antigen-DR isotype (HLA-DR), programmed cell death protein 1 (PD1), and CD57. Together, these findings suggest that WT microenvironment is immune engaged and may be susceptible to immunotherapy similar to other malignancies. CONCLUSIONS: These pilot data suggest an immune-engaged tumor microenvironment is present within WT. This implies that WT may be susceptible to immunotherapy similar to adult renal tumors and other adult malignancies. Follow-up studies are currently underway.

Assessment of pediatric bowel and bladder dysfunction: a critical appraisal of the literature.

OBJECTIVE: Bowel and bladder dysfunction (BBD) is a clinical syndrome defined by the coexistence of constipation and lower urinary tract symptoms. Although BBD is a common condition in pediatric urology and can cause significant stress to patients/parents, clinical diagnosis of BBD has not been standardized. Bowel and bladder dysfunction instruments have gained popularity over the past decade to aid in diagnosis. In this review, the currently published BBD symptom questionnaires were summarized and an analysis on their psychometric validation process was provided. SUBJECTS/PATIENTS: PubMed was searched for articles on BBD symptom questionnaires/instruments/surveys since 2000. Two investigators (R.Y.J. & M.S.K.) conducted the search in duplicate. The search was limited to English language. The included search terms were 'dysfunctional elimination syndrome', 'bowel and bladder dysfunction', 'dysfunctional voiding', 'voiding dysfunction symptom score', and 'dysfunctional voiding symptom scale'. Reference lists of included studies were screened for missed studies. Unpublished abstracts presented at the following scientific meetings were also manually searched for: the American Urological Association, the Society for Pediatric Urology, and the American Academy of Pediatrics Section on Urology. Exclusion criteria included articles in languages other than English, articles not related to BBD questionnaires, and articles not pertaining to pediatric patients. RESULTS: After initial search, a total of 54 articles were obtained. Of the seven questionnaires reviewed, only one did not measure sensitivity or specificity. Almost all questionnaires showed excellent discriminative property with an Area under the curve (AUC) >0.85. Criterion validity was not reported in any of the questionnaires. Known-group validation was used as a common method to evaluate construct validity. Internal consistency was reported in 2 studies, and only 1 study measured questionnaire responsiveness during initial validation. CONCLUSIONS: Although BBD is a common pediatric urology condition; a large amount of heterogeneity exists in the questionnaires' psychometric testing and validation process. To further improve the diagnosis and management of BBD in pediatric patients, there is a need for consensus on the gold standard questionnaire measure.

Environmental Survey of Drinking Water Sources in Kampala, Uganda, during a Typhoid Fever Outbreak.

In 2015, a typhoid fever outbreak began in downtown Kampala, Uganda, and spread into adjacent districts. In response, an environmental survey of drinking water source types was conducted in areas of the city with high case numbers. A total of 122 samples was collected from 12 source types and tested for Escherichia coli, free chlorine, and conductivity. An additional 37 grab samples from seven source types and 16 paired large volume (20 liter) samples from wells and springs were also collected and tested for the presence of Salmonella enterica serovar Typhi. Escherichia coli was detected in 60% of kaveras (drinking water sold in plastic bags) and 80% of refilled water bottles; free chlorine was not detected in either source type. Most jerry cans (68%) contained E. coli and had free chlorine residuals below the WHO-recommended level of 0.5 mg/liter during outbreaks. Elevated conductivity readings for kaveras, refilled water bottles, and jerry cans (compared to treated surface water supplied by the water utility) suggested that they likely contained untreated groundwater. All unprotected springs and wells and more than 60% of protected springs contained E. coli Water samples collected from the water utility were found to have acceptable free chlorine levels and no detectable E. coli While S Typhi was not detected in water samples, Salmonella spp. were detected in samples from two unprotected springs, one protected spring, and one refilled water bottle. These data provided clear evidence that unregulated vended water and groundwater represented a risk for typhoid transmission.IMPORTANCE Despite the high incidence of typhoid fever globally, relatively few outbreak investigations incorporate drinking water testing. During waterborne disease outbreaks, measurement of physical-chemical parameters, such as free chlorine residual and electrical conductivity, and of microbiological parameters, such as the presence of E. coli or the implicated etiologic agent, in drinking water samples can identify contaminated sources. This investigation indicated that unregulated vended water and groundwater sources were contaminated and were therefore a risk to consumers during the 2015 typhoid fever outbreak in Kampala. Identification of contaminated drinking water sources and sources that do not contain adequate disinfectant levels can lead to rapid targeted interventions.

Increased pediatric sub-specialization is associated with decreased surgical complication rates for inpatient pediatric urology procedures.

INTRODUCTION: Increased case volumes and training are associated with better surgical outcomes. However, the impact of pediatric urology sub-specialization on perioperative complication rates is unknown. OBJECTIVES: To determine the presence and magnitude of difference in rates of common postoperative complications for elective pediatric urology procedures between specialization levels of urologic surgeons. The Nationwide Inpatient Sample (NIS), a nationally representative administrative database, was used. STUDY DESIGN: The NIS (1998-2009) was retrospectively reviewed for pediatric (≤18 years) admissions, using ICD-9-CM codes to identify urologic surgeries and National Surgical Quality Improvement Program (NSQIP) inpatient postoperative complications. Degree of pediatric sub-specialization was calculated using a Pediatric Proportion Index (PPI), defined as the ratio of children to total patients operated on by each provider. The providers were grouped into PPI quartiles: Q1, 0-25% specialization; Q2, 25-50%; Q3, 50-75%; Q4, 75-100%. Weighted multivariate analysis was performed to test for associations between PPI and surgical complications. RESULTS: A total of 71,479 weighted inpatient admissions were identified. Patient age decreased with increasing specialization: Q1, 7.9 vs Q2, 4.8 vs Q3, 4.8 vs Q4, 4.6 years, P < 0.01). Specialization was not associated with race (P > 0.20), gender (P > 0.50), or comorbidity scores (P = 0.10). Mortality (1.5% vs 0.2% vs 0.3% vs 0.4%, P < 0.01) and complication rates (15.5% vs 11.7% vs 9.6% vs 10.9%, P < 0.0001) both decreased with increasing specialization. Patients treated by more highly specialized surgeons incurred slightly higher costs (Q2, +4%; Q3, +1%; Q4 + 2%) but experienced shorter length of hospital stay (Q2, -5%; Q3, -10%; Q4, -3%) compared with the least specialized providers. A greater proportion of patients treated by Q1 and Q3 specialized urologists had CCS ≥2 than those seen by Q2 or Q4 urologists (12.5% and 12.2%, respectively vs 8.4% and 10.9%, respectively, P = 0.04). Adjusting for confounding effects, increased pediatric specialization was associated with decreased postoperative complications: Q2 OR 0.78, CI 0.58-1.05; Q3 OR 0.60, CI 0.44-0.84; Q4 OR 0.70, CI 0.58-0.84; P < 0.01. DISCUSSION: Providers with proportionally higher volumes of pediatric patients achieved better postoperative outcomes than their less sub-specialized counterparts. This may have arisen from increased exposure to pediatric anatomy and physiology, and greater familiarity with pediatric techniques. LIMITATION: The NIS admission-based retrospective design did not enable assessment of long-term outcomes, repeated admissions, or to track a particular patient across time. The study was similarly limited in evaluating the effect of pre-surgical referral patterns on patient distributions. CONCLUSIONS: Increased pediatric sub-specialization among urologists was associated with a decreased risk of mortality and surgical complications in children undergoing inpatient urologic procedures.

Associations between hoof shape and the position of the frontal plane ground reaction force vector in walking horses.

AIMS: To determine the frontal plane position of the ground reaction force vector at its centre of pressure under the hoof of walking horses, and its projection through the distal limb joints, and to relate this to hoof geometric measurements. METHODS: Reflective markers were glued to the forelimb hooves and skin of 26 horses, over palpable landmarks representing centres of the coffin, fetlock and carpal joints, and the dorsal toe at its most distal point. A 4-camera kinematic system recorded the position of these markers as the horse walked in hand across a force platform, to generate a frontal plane representation of the ground reaction force vector passing between the markers at the joints. The position of the vector was calculated as the relative distance between the lateral (0%) and medial (100%) markers at each joint. Digital photos were taken of the hoof in frontal and sagittal views to determine hoof geometric measurements. Associations between these and the position of the force vector at each joint were examined using Pearson correlation coefficients. RESULTS: Mean vector position for both forelimbs at the toe, coffin, fetlock and carpal joint was 50.1 (SD 8.9), 53.0 (SD 9.2), 54.6 (SD 11.4) and 50.5 (SD17.3)%, respectively, of the distance between the lateral and medial sides of the joint in the frontal plane. Across all four joints, the vector position was slightly more medial (2-4%) for the right than left limb (p>0.05). Medial hoof wall angle was correlated (p<0.05) with force vector position at the fetlock (r=-0.402) and carpal (r=-0.317) joints; lateral hoof wall angle with vector position at the toe (r=0.288) and carpal (r=-0.34) joint, and medial hoof wall height with vector position at the fetlock (r=-0.306) and carpal (r=-0.303) joints. CONCLUSION: The position of the two-dimensional frontal plane ground reaction force vector at the toe, and at the fetlock and carpal joints was associated with hoof shape. Mediolateral hoof balance has been shown in vitro to affect articular forces, which may be a factor in development of joint disease. The effect of hoof shape needs to be evaluated at faster gaits to determine the potential for joint injury in the presence of larger forces.

Nationwide outbreak of multidrug-resistant Salmonella Heidelberg infections associated with ground turkey: United States, 2011.

On 23 May 2011, CDC identified a multistate cluster of Salmonella Heidelberg infections and two multidrug-resistant (MDR) isolates from ground turkey retail samples with indistinguishable pulsed-field gel electrophoresis patterns. We defined cases as isolation of outbreak strains in persons with illness onset between 27 February 2011 and 10 November 2011. Investigators collected hypothesis-generating questionnaires and shopper-card information. Food samples from homes and retail outlets were collected and cultured. We identified 136 cases of S. Heidelberg infection in 34 states. Shopper-card information, leftover ground turkey from a patient's home containing the outbreak strain and identical antimicrobial resistance profiles of clinical and retail samples pointed to plant A as the source. On 3 August, plant A recalled 36 million pounds of ground turkey. This outbreak increased consumer interest in MDR Salmonella infections acquired through United States-produced poultry and played a vital role in strengthening food safety policies related to Salmonella and raw ground poultry.

Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis.

PURPOSE: The management of the contralateral inguinal canal in children with clinical unilateral inguinal hernia is controversial. Our objective was to systematically review the literature regarding management of the contralateral inguinal canal. METHODS: We searched MEDLINE, EMBASE, and Cochrane databases (1940-2011) using 'hernia' and 'inguinal' and either 'pediatric,' 'infant,' or 'child,' to identify studies of pediatric (age ≤21 years) patients with inguinal hernia. Among clinical unilateral hernia patients, we assessed the number of cases with contralateral patent processus (CPP) and incidence of subsequent clinical metachronous contralateral hernia (MCH). We evaluated three strategies for contralateral management: expectant management, laparoscopic evaluation or pre-operative ultrasound. Pooled estimates of MCH or CPP were generated with random effects by study when heterogeneity was found (I(2) > 50 %, or Cochrane's Q p ≥ 0.10). RESULTS: We identified 2,477 non-duplicated studies, 129 of which met our inclusion criteria and had sufficient information for quantitative analysis. The pooled incidence of MCH after open unilateral repair was 7.3 % (95 % CI 6.5-8.1 %). Laparoscopic examination identified CPP in 30 % (95 % CI 26-34 %). Lower age was associated with higher incidence of CPP (p < 0.01). The incidence of MCH after a negative laparoscopic evaluation was 0.9 % (95 % CI 0.5-1.3 %). Significant heterogeneity was found in studies and pooled estimates should be interpreted with caution. CONCLUSIONS: The literature suggests that laparoscopically identified CPP is a poor indicator of future contralateral hernia. Almost a third of patients will have a CPP, while less than one in 10 will develop MCH when managed expectantly. Performing contralateral hernia repair in patients with CPP results in overtreatment in roughly 2 out of 3 patients.

Evaluation of the United States pediatric urology workforce and fellowships: a series of surveys performed in 2006-2010.

OBJECTIVE: In the US, there has been an evolution in the practice of pediatric urology from a primary academic sub-specialty focused on reconstruction of major congenital genitorurinary abnormalities to a mixed academic and private practice that serves as the primary care giver for all pediatric urologic concerns. The estimated manpower needs were unable to be resolved, due to our inability to determine the impact of sub-specialty certification on referral patterns, along with the failure to embrace the use of physician extenders. Here, we review a series of surveys performed in 2006-2010 regarding the sub-specialty of pediatric urology. MATERIALS AND METHODS: The four surveys focused on workforce needs, appraised the financial impact of educational debt on the pediatric urology community, and evaluated concerns of the current fellows in training. RESULTS: The median financial income for a pediatric urologist, the resident's educational debt load, and a desire of the fellows to have an open dialog with the urologic community regarding the merits of the research year are revealed. CONCLUSION: We have identified that the ability to recruit fellows into our field is dependent upon a combination of factors: interest in the field, job availability in relationship to geographic locations, mentoring, concerns regarding financial/familial hardships encountered during a 2-year fellowship, and the lack of increased financial reimbursement for the extra training required.

Lung transplantation for cystic fibrosis patients with Burkholderia cepacia complex. Survival linked to genomovar type.

The number of cystic fibrosis (CF) patients undergoing lung transplant has risen over the past decade, because of a clear-cut survival benefit. However, patients with Burkholderia cepacia complex are often excluded from transplantation because of increased mortality. To determine the influence of B. cepacia complex genomovar type on transplant outcome, we undertook a retrospective study in 121 CF patients transplanted at UNC. Twenty-one and three patients, respectively, were infected pre- or postoperatively with B. cepacia complex. All posttransplant acquisitions were successfully treated. However, excess mortality occurred over the first 6 postoperative months in those infected preoperatively with B. cepacia complex compared with those not infected (33% versus 12%, p = 0.01). The 1-, 3-, and 5-yr survival were significantly lower in the B. cepacia complex cohort. Of the patients infected preoperatively, genomovar III patients were at the highest risk of B. cepacia complex-related mortality (5 of 12 versus 0 of 8, one isolate not typed; p = 0.035). Each of the B. cepacia complex-related deaths was caused by a unique genotype as determined by pulsed-field gel electrophoresis. All isolates were negative for the cable pilin gene. These results warrant a multicenter analysis of B. cepacia complex-infected patients with genomovar-typing to confirm that genomovar III patients are at highest risk for post-transplant complications.

Characterization and origin of dissolved organic carbon in Yegua ground water in Brazos County, Texas.

Dissolved organic carbon (DOC) concentrations in five shallow (< 20 m) and three deeper wells (27 to 30 m) in the Eocene Yegua Formation (Brazos County in east-central Texas) ranged from 92 to 500 microns. Characterization of high, intermediate, and low molecular weight DOC fractions (HMW > 3000 amu, IMW 1000 to 3000 amu, and LMW 500 to 1000 amu) and combined neutral sugar analyses provide information on organic matter sources in the Yegua aquifers. Combined neutral sugars ranged in concentration from 0.6 to 2.7 mumol/L and comprised 0.8% to 6.7% of DOC in ground water. Glucose was the most abundant neutral sugar, followed by xylose and galactose, arabinose, mannose, rhamnose, and fucose. These combined neutral sugars were more diagenetically altered in shallow, oxic ground water as indicated by high mole % fucose + rhamnose and low neutral sugar yield. The precursors for neutral sugars are most probably angiosperm leaves, which show a similar distribution pattern of neutral sugars. Ground water DOC was depleted in 13C relative to soil-zone organic matter (OM) (-16@1000 to -19@1000). The delta 13C values of bulk DOC and HMW DOC ranged from -24@1000 to -32@1000, whereas LMW and IMW DOC ranged from -32@1000 to -34@1000 and -16@1000 to -28@1000, respectively. This variability in delta 13C values is probably related to microbial processes and selective preservation of OM. Carbon isotope analyses in bulk and different molecular weight DOC fractions imply a predominantly C3 OM source and a low contribution of soil-zone OM to DOC.

Depletion of ovarian oocytes in sublethally exposed mice to gamma radiation and its modification by 2-mercaptopropionylglycine (MPG).

Adult female Swiss albino mice were exposed to 0.6, 1.2 and 2.4 Gy of 60Co gamma radiations in presence and absence of MPG. Quantitative studies were done in serial sections of ovary at 1, 3, 5, 7, 14 and 35 days after exposure. Primary follicles were found to be most radiosensitive. The depletion in the various types of follicles was checked to some extent by prior administration of MPG, but MPG could not prevent the complete elimination of all types of follicles by the last autopsy interval studied.

Radiation response of plasma protein and albumin of peripheral blood and its modification by MPG (2-Mercaptopropionylglycine) in mice.

Changes in the total protein and albumin level in the blood of six week and three week old Swiss albino mice exposed to a sublethal dose of 2.2 Gy of gamma rays after an intraperitoneal injection of 20 mg/kg body weight of the radioprotector drug MPG (2-Mercaptopropionylglycine) were studied. The results were compared with those obtained from animals irradiated with the same dose of gamma rays in the absence of the drug. Animals were sacrificed at one, three, five, seven and 14 days after irradiation. The drug has been found to modify the levels of plasma protein and albumin in the blood of the irradiated animals. The depletion observed was less marked in the drug treated animals than their respective controls. The observations have been discussed in light of relevant literature.

Efficacy of 2-mercaptopropionylglycine (MPG): a radioprotector in modifying the gonadal response of whole body irradiated male Swiss albino mice.

Six week old male Swiss albino mice taken from an inbred colony were irradiated with 0.6 and 1.2 Gy of low 60Co gamma rays in the presence (Experimental) and absence (Control) of MPG. Results indicated the infliction of radiation insult and subsequent repair in the testes to be dose dependent, that is higher the dose greater the damage and sluggish the reparative activity. A greater number of surviving germ cells in the experimental tests with fewer dead cells reflected the protective efficiency of the drug against radiation damage to the cell population. Thus MPG not only protects against radiation induced cell death and depletion but also changes the mitotic rate of the stem cells by which an accelerated recovery was brought about.

Assessment of interference by aspirin with some assays commonly done in the clinical laboratory.

We have assessed the interference of acetylsalicylic acid (aspirin) with some common clinical laboratory assays, because of its widespread use and reported interference. The therapeutic regimens involved ingestion of 10 325-mg tablets daily for three days or eight tablets for five days or two weeks. Twenty-one commonly done determinations were run on control sera, and sera were collected during and after drug therapy. Significant changes in t-test values, indicating the significance of the standard deviation of the difference between controls and specimens drawn after drug therapy, were observed for chloride (increased), and for total protein, calcium, cholesterol, uric acid, bilirubin, and thyroxine (decreased). Aspirin therapy depressed the apparent concentrations of these constituents progressively in the three-day regimen and initially in the long-term regimens, followed by recovery toward zero t-values at the end of the longer regimens.

The effects of therapy for mild hypertension on circulating level of dopamine beta-hydroxylase.

Circulating dopamine beta-hydroxylase levels and norepinephrine excretion were measured in 76 mild hypertensive patients. Levels of dopamine beta-hydroxylase, norepinephrine excretion and blood pressure were obtained both before and after the initiation of therapy. Data from 20 patients exhibiting a diastolic blood pressure decrease of 10 mmHg or more were compared with data from 10 normotensive individuals. Changes in dopamine beta-hydroxylase levels were similar for the two groups and were not related to blood pressure changes. Intra-individual variation was small in both groups. There were no detectable functional relationships between diastolic pressure and urinary norepinephrine, norepinephrine and dopamine beta-hydroxylase or dopamine beta-hydroxylase and diastolic pressure. It dose not seem likely that dopamine beta-hydroxylase levels can replace urinary catecholamines as a commonly used index of sympathetic activity.