Conservative management and female gender are associated with increased cancer-specific death in patients with isolated primary urothelial carcinoma in situ.

Our goal was to investigate the effect of patient and disease characteristics on the probability of cancer-specific death (CSD) in cases of isolated urothelial carcinoma in situ (CIS). We performed a retrospective analysis of patients diagnosed with isolated CIS between 1990 and 2010 identified from the Surveillance, Epidemiology, and End Results (SEER) database. Competing risk analysis using Cox proportional hazard model was used to examine the probability of CSD controlling for possible covariates. Overall (n = 1432), patients were mainly male (75%), mean age at diagnosis was 71 years, median survival 47 months, and 65% of the patients had CIS in their upper urinary tract. Caucasians were the predominant race (90%). CIS was the cause of death in 87/1432(6%) of the total cohort; 69/1239 (6%) of patients who underwent surgery, and 18/193 (9%) of the patients who were managed conservatively (CM). On multivariate analysis, CM [hazard ration (HR) = 2.019, CI: 1.189-3.429, P = 0.009] and female gender (HR = 1.690, CI: 1.041-2.741, P = 0.033) were associated with CSD, while age, site, race and year of diagnosis were non-significant predictors. Female gender and conservative management were positively associated with CSD. Multi-institutional collaboration is needed to validate markers for poor prognosis in cases of isolated CIS.

Delivering kidney cancer care in rural Central and Southern Illinois: a telemedicine approach.

There is a growing body of experience and research suggesting that telemedicine (video conferencing, smart phones and online patient portals) could be the solution to addressing gaps in the provision of specialised healthcare in rural areas. The proposed role of telemedicine in providing needed services in hard to reach areas is not new. The United States Telecommunication Act of 1996 provided the initial traction for telemedicine by removing important economic and legal obstacles regarding the use of technology in healthcare delivery. This initial ruling has been supplemented by the availability of federal funding to support efforts aimed at developing telemedicine in underserved areas. In this paper, we explore one aspect of disease disparity pertinent to rural Illinois (kidney cancer incidence and mortality) and describe how we are planning to use an existing telemedicine program at Southern Illinois University School of Medicine (SIUSOM) to improve kidney cancer (Kca) care in rural Illinois. This represents an example of the possible role of telemedicine in addressing healthcare disparities in rural areas/communities and provides a description of general challenges and barriers to the implementation and maintenance of such systems.

Germline single nucleotide polymorphisms associated with response of urothelial carcinoma to platinum-based therapy: the role of the host.

BACKGROUND: Variations in urothelial carcinoma (UC) response to platinum chemotherapy are common and frequently attributed to genetic and epigenetic variations of somatic DNA. We hypothesized that variations in germline DNA may contribute to UC chemosensitivity. PATIENTS AND METHODS: DNA from 210 UC patients treated with platinum-based chemotherapy was genotyped for 80 single nucleotide polymorphisms (SNPs). Logistic regression was used to examine the association between SNPs and response, and a multivariable predictive model was created. Significant SNPs were combined to form a SNP score predicting response. Eleven UC cell lines were genotyped as validation. RESULTS: Six SNPs were significantly associated with 101 complete or partial responses (48%). Four SNPs retained independence association and were incorporated into a response prediction model. Each additional risk allele was associated with a nearly 50% decrease in odds of response [odds ratio (OR) = 0.51, 95% confidence interval 0.39-0.65, P = 1.05 × 10(-7)). The bootstrap-adjusted area under the curves of this model was greater than clinical prognostic factors alone (0.78 versus 0.64). The SNP score showed a positive trend with chemosensitivity in cell lines (P = 0.115). CONCLUSIONS: Genetic variants associated with response of UC to platinum-based therapy were identified in germline DNA. A model using these genetic variants may predict response to chemotherapy better than clinical factors alone.

Suicide in men with testis cancer.

Depression, anxiety and aggression are documented in testis cancer patients and can result in death from suicides; however, their risk of suicide is not defined. We report suicide rates among testis cancer patients in the USA and determine factors associated with higher rates. We used the Surveillance, Epidemiology, and End Results (SEER) database maintained by the National Cancer Institute to identify patients diagnosed with testis cancer between 1995 and 2008. Multivariate analysis was used to assess factors affecting suicide rate. Among 23,381 patients followed for 126,762 person-years, suicide rate was 26.0 per 100,000 person-years, with the average corresponding rate in the US population aged 25-44 years being 21.5 per 100,000 person-years; the calculated standardised mortality ratio for death by suicide was 1.2 [95% confidence interval (CI): 1.1-2.1]. The standardised mortality ratio for suicide was 1.5 (95% CI: 1.1-2.1) in ages less than 30 years, and 1.8 (95% CI: 1.3-2.4) in men of races other than White and Black. Other patient and disease characteristics were not predictive. In conclusion, patients with testis cancer have a 20% increase in the risk of suicide over that of the general population, and races other than White and Black and younger patients may commit suicide at higher rates.

Severity of illness scoring systems in patients with bacteraemic pneumococcal pneumonia: implications for the intensive care unit care.

Severity of illness scoring systems are useful for decisions on the management of patients with community-acquired pneumonia (CAP), including assessing the need for intensified therapy and monitoring, or for intensive care unit (ICU) admission. We compared the accuracy of the Pneumonia Severity Index (PSI), the CURB-65 and CRB-65 score, the modified-American Thoracic Society score (ATS), the IDSA/ATS guidelines and the Pitt Bacteraemia score (PBS) in evaluating severity of illness in 766 patients with bacteraemic pneumococcal pneumonia. We evaluated the sensitivity and specificity, the positive predictive value (PPV) and the negative predictive value (NPV) and the accuracy of the classification in predicting 14-day mortality. The PSI and the IDSA/ATS guidelines were the most sensitive whereas the PBS and modified-ATS scoring systems were the most specific in predicting mortality. The NPV was comparable for all four scoring systems (all above 90%), but the PPV was highest for PBS (54.2%) and lowest for PSI (23.2%). The predictive accuracy and discriminating power as measured by the receiver-operating characteristic (ROC) curve was highest for the PBS. Both the modified-ATS and the PBS scoring systems identified those patients who might benefit most from intensified care and monitoring. The PBS and modified-ATS proved superior to the IDSA/ATS guidelines, CURB-65 and CRB-65 with respect to their specificity and PPV. The low PPV of the PSI rendered it not usable as a parameter for decision-making in severely-ill patients with pneumococcal bacteraemia.

Association of serotypes of Streptococcus pneumoniae with disease severity and outcome in adults: an international study.

BACKGROUND: The introduction of conjugate pneumococcal vaccination for children has reduced the burden of invasive disease due to pneumococcal conjugate vaccine (PCV) types (i.e., serotypes 9V, 14, 6B, 18C, 23F, 19F, and 4) in adults. As nonvaccine serotypes become predominant causes of invasive disease among adults, it is necessary to evaluate the disease severity and mortality associated with infection due to nonvaccine serotypes, compared with PCV serotypes, in adults. METHODS: The association of pneumococcal serotype and host-related variables with disease severity and mortality was statistically examined (with multivariable analysis) in 796 prospectively enrolled, hospitalized adult patients with bacteremia due to Streptococcus pneumoniae. RESULTS: In multivariate analyses of risk in patients with invasive pneumococcal disease, older age (age, > or = 65 years; P = .004), underlying chronic disease (P = .025), immunosuppression (P = .035), and severity of disease (P < .001) were significantly associated with mortality; no association was found between nosocomial infection with invasive serotypes 1, 5, and 7 and mortality. The risk factors meningitis (P = .001), suppurative lung complications (P < or = .001), and preexisting lung disease (P = .051) were significantly associated with disease severity, independent of infecting serotype. No differences were seen in disease severity or associated mortality among patients infected with PCV serotypes, compared with patients infected with nonvaccine serotypes. CONCLUSIONS: Our data support the notion that host factors are more important than isolate serotype in determining the severity and outcome of invasive pneumococcal disease and that these outcomes are unlikely to change in association with nonvaccine serotype infection in the post-conjugate vaccine era.