High-resolution disease maps for cancer control in low-resource settings: A spatial analysis of cervical cancer incidence in Kampala, Uganda.

Background: The global burden of cervical cancer is concentrated in low-and middle-income countries (LMICs), with the greatest burden in Africa. Targeting limited resources to populations with the greatest need to maximize impact is essential. The objectives of this study were to geocode cervical cancer data from a population-based cancer registry in Kampala, Uganda, to create high-resolution disease maps for cervical cancer prevention and control planning, and to share lessons learned to optimize efforts in other low-resource settings. Methods: Kampala Cancer Registry records for cervical cancer diagnoses between 2008 and 2015 were updated to include geographies of residence at diagnosis. Population data by age and sex for 2014 was obtained from the Uganda Bureau of Statistics. Indirectly age-standardized incidence ratios were calculated for sub-counties and estimated continuously across the study area using parish level data. Results: Overall, among 1873 records, 89.6% included a valid sub-county and 89.2% included a valid parish name. Maps revealed specific areas of high cervical cancer incidence in the region, with significant variation within sub-counties, highlighting the importance of high-resolution spatial detail. Conclusions: Population-based cancer registry data and geospatial mapping can be used in low-resource settings to support cancer prevention and control efforts, and to create the potential for research examining geographic factors that influence cancer outcomes. It is essential to support LMIC cancer registries to maximize the benefits from the use of limited cancer control resources.

Aortic remodelling after thoracic endovascular aortic repair in acute and chronic type B aortic dissections.

OBJECTIVES: Type B aortic dissections are routinely treated with thoracic endovascular aortic repair (TEVAR). The timing for TEVAR remains controversial and might have an impact on the remodelling capacity of the aorta. This study analyses and compares aortic remodelling in acute (ABD) and chronic (CBD) type B aortic dissections after TEVAR. METHODS: This retrospective study analysed the preoperative, postoperative and at least 1-year follow-up computed tomography of 53 TEVAR patients (36 ABD, 17 CBD) at a single institution between May 2005 and May 2016. The volumes of aortic lumen (AL), true lumen, false lumen (FL) and perfused FL were measured at the stent graft level (A), from the stent graft to the coeliac trunk (B) and from the coeliac trunk to the bifurcation (C). The absolute volumes, normalized volume changes and FL thrombosis rate of ABD and CBD patients were compared. RESULTS: Absolute AL and FL of segment A were significantly larger in CBD patients compared to ABD patients preoperatively (AL: 354 ± 68 vs 255 ± 51 ml, P = 0.023, FL: 253 ± 56 vs 183 ± 35 ml, P = 0.028) until last follow-up (AL: 462 ± 52 vs 246 ± 52 ml, P = 0.003, FL: 268 ± 202 vs 91 ± 31 ml, P = 0.004). The true lumen in segment A increased more in ABD than in CBD patients preoperatively to postoperatively (112% vs 36% P < 0.001) and within the first year postoperatively (171% vs 80% P < 0.001). FL in segment A decreased more in ABD compared to CBD patients within the first year (-42% vs -13% P < 0.001) and thereafter (-50% vs +6% P = 0.002). In segments B and C, the FL thrombosis rate was higher in ABD than in CBD patients at all time points and significantly higher in segment A after the first year (91% vs 98% P = 0.035). CONCLUSIONS: Aortic remodelling after TEVAR is significantly different in acute and chronic dissection patients. TEVAR promotes aortic remodelling in both acute and chronic dissections in terms of true lumen increase at stent graft level. Nevertheless, significant AL reduction by FL shrinkage is primarily found in ABD.

Predicting Distal Aortic Remodeling After Endovascular Repair for Chronic DeBakey III Aortic Dissection.

BACKGROUND: Chronic DeBakey III aortic dissection is typically managed with open aortic reconstruction. Thoracic endovascular aortic grafting (TEVAR) has been attempted in patients with chronic DeBakey III with improved outcomes over medical management, however with frequent failures. This study investigates factors associated with positive aortic remodeling from a large aortic center. METHODS: Three-dimensional reconstructions (M2S, West Lebanon, NH) of computed tomography angiography scans of 48 patients who underwent TEVAR from 2005 to 2015 were analyzed. The dissection was characterized, and measurements were obtained from preoperative and postoperative scans at four time points. Standard univariate Wilcoxon rank sum and Fisher's exact tests were used to analyze continuous and ordinal/nominal data, respectively. Multivariable logistic regression was performed. RESULTS: In a multivariate logistic model, having fewer than two visceral vessels off the true lumen was a negative predictor of total thrombosis (odd ratio [OR] 0.01, 95% confidence interval [CI]: <0.01 to 0.84, p = 0.04). In a logistic model that predicted total thrombosis in zones 3 and 4, maximum diameter 2 cm above the celiac axis was a significant negative predictor (OR 0.75, 95% CI: 0.57 to 0.99, p = 0.05). In a model that predicted failure of the maximum overall diameter of the descending aorta to regress within 1 year after TEVAR, maximum overall diameter preoperatively (OR 1.19, 95% CI: 1.02 to 1.29, p = 0.03) and tear location on the greater curve (OR 18.1, 95% CI: 1.3 to 243, p = 0.03) were significant positive predictors. CONCLUSIONS: TEVAR is feasible in chronic dissection but is limited by complex dissection-related anatomy. Increasing number of visceral vessels off the false lumen, maximum preoperative aortic size, and location of the primary tear on the greater curve were associated with poorer remodeling.

Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population.

OBJECTIVE: To comprehensively evaluate and compare utilization, outcomes, and especially costs of transfemoral (TF), transapical (TA), and transaortic (TAO) transcatheter aortic valve replacement (TAVR). METHODS: All Medicare fee-for-service patients undergoing TF (n = 4065), TA (n = 691), or TAO (n = 274) TAVR between January 1, 2011, and November 30, 2012, were identified using Health Care Procedure Classification Codes present on Medicare claims. Hospital charges from Medicare claims were converted to costs using hospital-specific Medicare cost-to-charge ratios. RESULTS: TA and TAO patients were similar in age, race, and common comorbidities. Compared with TF patients, TA and TAO patients were more likely to be female and to have peripheral vascular disease, chronic lung disease, and renal failure. Thirty-day mortality rates were higher among TA and TAO patients than among TF patients (TA, 9.6%; TAO, 8.0%; TF, 5.0%; P < .001). Adjusted mortality beyond 1 year did not differ by access. TA patients were more likely to require cardiopulmonary bypass (CPB). Increased adjusted mortality was associated with CPB (hazard ratio, 2.13; P < .01) and increased 30-day cost ($62,000 [interquartile range (IQR)], $45,100-$86,400 versus $48,800 [IQR, $38,100-$62,900]; P < .01). Cost at 30 days was lowest for TF ($48,600) compared with TA ($49,800; P < .01) and TAO ($53,200; P = .03). CONCLUSIONS: For patients ineligible to receive TF TAVR, TAO and TA approaches offer similar clinical outcomes at similar cost with acceptable operative and 1-year survival, except for higher rates of CPB use in TA patients. CPB was associated with worse survival and increased costs.

Cost and contribution margin of transcatheter versus surgical aortic valve replacement.

OBJECTIVE: To compare the cost of and payments for transcatheter aortic valve replacement (TAVR), a novel and expensive technology, and surgical aortic valve replacement (SAVR). METHODS: Medicare claims provided hospital charges, payments, and outcomes between January and December 2012. Hospital costs and charges were estimated using hospital-specific cost-to-charge ratios. Costs and payments were examined in propensity score- matched TAVR and SAVR patients. RESULTS: Medicare spent $215,770,200 nationally on 4083 patients who underwent TAVR in 2012. Hospital costs were higher for TAVR patients (median, $50,200; interquartile range [IQR], $39,800-$64,300) than for propensity-matched SAVR patients ($45,500; IQR, $34,500-$63,300; P < .01), owing largely to higher estimated medical supply costs, including the implanted valve prosthesis. Postprocedure hospital length of stay (LOS) length was shorter for TAVR patients (median, 5 days [IQR, 4-8 days] vs 7 days [IQR, 5-9 days]; P < .01), as was total intensive care unit (ICU) LOS (median, 2 days [IQR, 0-5 days] vs 3 days [IQR, 1-6 days]; P < .01). Medicare payments were lower for TAVR hospitalizations (median, $49,500; IQR, $36,900-$64,600) than for SAVR (median, $50,400; IQR, $37,400-$65,800; P < .01). The median of the differences between payments and costs (contribution margin) was -$3380 for TAVR hospitalizations and $2390 for SAVR hospitalizations (P < .01). CONCLUSIONS: TAVR accounted for $215 million in Medicare payments in its first year of clinical use. Among SAVR Medicare patients at a similar risk level, TAVR was associated with higher hospital costs despite shorter ICU LOS and hospital LOS. Overall and/or medical device cost reductions are needed for TAVR to have a net neutral financial impact on hospitals.

Manipulation of Oat Protoplasts for Transient Expression Assays.

Oat protoplasts are a useful and convenient system to study transient expression using whole cells. Nucleic acid can rapidly be introduced into live cells, and, depending on the assay, results can be collected the same day. Compared to plant tissue, oat cell suspension cultures provide a simple, high yielding, and consistent means to isolate protoplasts. Here, we describe how to generate an oat cell suspension culture from callus grown on solidified medium, and how to maintain the oat cells in cell suspension culture for protoplast preparation. Following the culturing procedure, we describe how to isolate oat protoplasts from cell suspension culture by enzymatic digestion of the cell walls and to transiently express nucleic acid (DNA or RNA) into the cells by electroporation.

At the Root of the Repair Debate: Outcomes After Elective Aortic Root Replacements for Aortic Insufficiency With Aneurysm.

BACKGROUND: There is growing interest in aortic valve-sparing and valve repair operations, but the ideal operation and timing of intervention in these generally younger patients undergoing operations for aortic insufficiency (AI) and dilated ascending aorta remains controversial. METHODS: Root replacements at a single institution from 2002 to 2014 were reviewed. Inclusion criteria were age younger than 70 and presence of moderate or greater aortic insufficiency (AI), with or without aortic aneurysm. Of 1,425 root replacements, 220 patients were considered in the final analysis. RESULTS: Moderate AI was present in 87 patients and severe AI in 133 patients. The 30-day mortality was 0% in moderate AI patients and 2% (n = 3) in severe AI patients (p = 0.3). Freedom from reoperation was 95% at 10 years. Severe preoperative AI was associated with worse long-term survival compared with moderate AI (hazard ratio, 2.6; p = 0.04). Patients undergoing root replacement with moderate AI had similar survival compared with the age- and gender-matched United States population (log-rank p = 0.93), whereas patients with severe AI had significantly worse survival (log-rank p = 0.02). Other multivariable predictors of decreased long-term survival were age (hazard ratio, 1.1; p = 0.01) and preoperative renal failure (hazard ratio, 6.9; p < 0.01). CONCLUSIONS: Elective root replacement operations in patients younger than 70 are associated with low rates of mortality and reoperation, which should be considered the benchmark operation for aortic valve-sparing or repair operations in similar patients. Worse survival was associated with severe AI and older age, suggesting earlier intervention may be an appropriate therapeutic strategy in selected patients.