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Parastomal hernias (PHs) are common and contribute to significant patient morbidity. Despite 45 years of evolution, mesh-based PH repairs continue to be challenging to perform and remain associated with high rates of postoperative complications and recurrences. In this article, the authors summarize the critical factors to consider when evaluating a patient for PH repair. The authors provide an overview of the current techniques for repair, including both open and minimally invasive approaches. The authors detail the mesh-based repair options and review the evidence for choice of mesh to use for repair.
Subject(s)
Herniorrhaphy , Postoperative Complications , Humans , Postoperative Complications/etiologyABSTRACT
This article describes advances that are leading to a resurgence in surgeon interest and adoption of laparoscopic common bile duct exploration, making an innovation out of an old technique.
Subject(s)
Cholecystectomy, Laparoscopic , Choledocholithiasis , Gallstones , Laparoscopy , Humans , Choledocholithiasis/surgery , Gallstones/surgery , Common Bile Duct/surgery , Retrospective Studies , Cholangiopancreatography, Endoscopic RetrogradeABSTRACT
OBJECTIVE: Liver lesion characterization is limited by the lack of an established gold standard for precise correlation of radiologic characteristics with their histologic features. The objective of this study was to demonstrate the feasibility of using an ex vivo MRI-compatible sectioning device for radiologic-pathologic co-localization of lesions in resected liver specimens. METHODS: In this prospective feasibility study, adults undergoing curative partial hepatectomy from February 2018 to January 2019 were enrolled. Gadoxetic acid was administered intraoperatively prior to hepatic vascular inflow ligation. Liver specimens were stabilized in an MRI-compatible acrylic lesion localization device (27 × 14 × 14 cm3) featuring slicing channels and a silicone gel 3D matrix. High-resolution 3D T1-weighted fast spoiled gradient echo and 3D T2-weighted fast-spin-echo images were acquired using a single channel quadrature head coil. Radiologic lesion coordinates guided pathologic sectioning. A final histopathologic diagnosis was prepared for all lesions. The proportion of successfully co-localized lesions was determined. RESULTS: A total of 57 lesions were identified radiologically and sectioned in liver specimens from 10 participants with liver metastases (n = 8), primary biliary mucinous cystic neoplasm (n = 1), and hepatic adenomatosis (n = 1). Of these, 38 lesions (67%) were < 1 cm. Overall, 52/57 (91%) of radiologically identified lesions were identified pathologically using the device. Of these, 5 lesions (10%) were not initially identified on gross examination but were confirmed histologically using MRI-guided localization. One lesion was identified grossly but not on MRI. CONCLUSIONS: We successfully demonstrated the feasibility of a clinical method for image-guided co-localization and histological characterization of liver lesions using an ex vivo MRI-compatible sectioning device. KEY POINTS: ⢠The ex vivo MRI-compatible sectioning device provides a reliable method for radiologic-pathologic correlation of small (< 1 cm) liver lesions in human liver specimens. ⢠The sectioning method can be feasibly implemented within a clinical practice setting and used in future efforts to study liver lesion characterization. ⢠Intraoperative administration of gadoxetic acid results in enhancement in ex vivo MRI images of liver specimens hours later with excellent image quality.
Subject(s)
Cysts , Liver Neoplasms , Adult , Humans , Contrast Media/pharmacology , Prospective Studies , Gadolinium DTPA , Liver/diagnostic imaging , Liver/surgery , Liver/pathology , Liver Neoplasms/diagnostic imaging , Liver Neoplasms/surgery , Magnetic Resonance Imaging/methods , Cysts/pathologyABSTRACT
PURPOSE: Current diagnostic and treatment modalities for pancreatic cysts (PCs) are invasive and are associated with patient morbidity. The purpose of this study is to develop and evaluate machine learning algorithms to delineate mucinous from non-mucinous PCs using non-invasive CT-based radiomics. METHODS: A retrospective, single-institution analysis of patients with non-pseudocystic PCs, contrast-enhanced computed tomography scans within 1 year of resection, and available surgical pathology were included. A quantitative imaging software platform was used to extract radiomics. An extreme gradient boosting (XGBoost) machine learning algorithm was used to create mucinous classifiers using texture features only, or radiomic/radiologic and clinical combined models. Classifiers were compared using performance scoring metrics. Shapely additive explanation (SHAP) analyses were conducted to identify variables most important in model construction. RESULTS: Overall, 99 patients and 103 PCs were included in the analyses. Eighty (78%) patients had mucinous PCs on surgical pathology. Using multiple fivefold cross validations, the texture features only and combined XGBoost mucinous classifiers demonstrated an area under the curve of 0.72 ± 0.14 and 0.73 ± 0.14, respectively. By SHAP analysis, root mean square, mean attenuation, and kurtosis were the most predictive features in the texture features only model. Root mean square, cyst location, and mean attenuation were the most predictive features in the combined model. CONCLUSION: Machine learning principles can be applied to PC texture features to create a mucinous phenotype classifier. Model performance did not improve with the combined model. However, specific radiomic, radiologic, and clinical features most predictive in our models can be identified using SHAP analysis.
Subject(s)
Machine Learning , Pancreatic Cyst , Algorithms , Humans , Pancreatic Cyst/diagnostic imaging , Retrospective Studies , Tomography, X-Ray Computed/methodsABSTRACT
BACKGROUND: Unidimensional size is commonly used to risk stratify pancreatic cysts (PCs) despite inconsistent performance. The current study aimed to determine if unidimensional size, demonstrated by maximum axial diameter (MAD), is an appropriate surrogate measurement for volume and surface area. METHODS: Patients with cross-sectional imaging of PCs from 2012 to 2013 were identified. Cyst MAD, volume, and surface area were measured using quantitative imaging software. Non-pseudocystic PCs >1 cm were selected for inclusion to assess MAD correlation with volume and surface area. Cysts imaged twice >1 year apart were selected to evaluate volumetric growth rate. RESULTS: In total, 195 cysts were included. Overall, MAD was strongly correlated with volume (r = 0.83) and surface area (r = 0.93). However, cysts 1-2 cm and 2-3 cm were weakly correlated with volume and surface area: r = 0.78, 0.57 and 0.82, 0.61, respectively. Cyst volumes and surface areas varied widely within unidimensional size groups with 51% and 40% of volumes and surface areas overlapping unidimensional size groups, respectively. Estimated changes in volume poorly predicted measured changes in volume with 42% of cysts having >100% absolute percent difference. CONCLUSIONS: Pancreatic cyst volume and surface area may be useful adjunct measurements to risk stratify patients and surveil cyst changes and deserves further study.
Subject(s)
Pancreatic Cyst , Humans , Pancreatic Cyst/diagnostic imagingABSTRACT
BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are often indolent; however, identifying patients at risk for rapidly progressing variants is critical, particularly for those with small tumors who may be candidates for expectant management. Specific growth rate (SGR) has been predictive of survival in other malignancies but has not been examined in PNETs. METHODS: A retrospective cohort study of adult patients who underwent PNET resection from 2000 to 2016 was performed utilizing the multi-institutional United States Neuroendocrine Study Group database. Patients with ≥ 2 preoperative cross-sectional imaging studies at least 30 days apart were included in our analysis (N = 288). Patients were grouped as "high SGR" or "low SGR." Demographic and clinical factors were compared between the groups. Kaplan-Meier and log-rank analysis were used for survival analysis. Cox proportional hazard analysis was used to assess the impact of various clinical factors on overall survival (OS). RESULTS: High SGR was associated with higher T stage at resection, shorter doubling time, and elevated HbA1c (all P ≤ 0.01). Patients with high SGR had significantly decreased 5-year OS (63 vs 80%, P = 0.01) and disease-specific survival (72 vs 91%, P = 0.03) compared to those with low SGR. In patients with small (≤ 2 cm) tumors (N = 106), high SGR predicted lower 5-year OS (79 vs 96%, P = 0.01). On multivariate analysis, high SGR was independently associated with worse OS (hazard ratio 2.67, 95% confidence interval 1.05-6.84, P = 0.04). CONCLUSION: High SGR is associated with worse survival in PNET patients. Evaluating PNET SGR may enhance clinical decision-making, particularly when weighing expectant management versus surgery in patients with small tumors.
Subject(s)
Neuroendocrine Tumors , Pancreatic Neoplasms , Humans , Neoplasm Staging , Neuroendocrine Tumors/pathology , Neuroendocrine Tumors/surgery , Pancreatic Neoplasms/pathology , Pancreatic Neoplasms/surgery , Retrospective Studies , Survival Rate , United States/epidemiologyABSTRACT
Radiologic characterization of pancreatic lesions is currently limited. Computed tomography is insensitive in detecting and characterizing small pancreatic lesions. Moreover, heterogeneity of many pancreatic lesions makes determination of malignancy challenging. As a result, invasive diagnostic testing is frequently used to characterize pancreatic lesions but often yields indeterminate results. Computed tomography texture analysis (CTTA) is an emerging noninvasive computational tool that quantifies gray-scale pixels/voxels and their spatial relationships within a region of interest. In nonpancreatic lesions, CTTA has shown promise in diagnosis, lesion characterization, and risk stratification, and more recently, pancreatic applications of CTTA have been explored. This review outlines the emerging role of CTTA in identifying, characterizing, and risk stratifying pancreatic lesions. Although recent studies show the clinical potential of CTTA of the pancreas, a clear understanding of which specific texture features correlate with high-grade dysplasia and predict survival has not yet been achieved. Further multidisciplinary investigations using strong radiologic-pathologic correlation are needed to establish a role for this noninvasive diagnostic tool.
Subject(s)
Pancreatic Neoplasms/diagnostic imaging , Radiographic Image Interpretation, Computer-Assisted , Tomography, X-Ray Computed , Disease-Free Survival , Humans , Neoplasm Grading , Pancreatic Neoplasms/mortality , Pancreatic Neoplasms/therapy , Predictive Value of Tests , Risk Assessment , Risk FactorsABSTRACT
BACKGROUND: Insurance status predicts access to medical care in the USA. Previous studies have shown uninsured patients with some malignancies have worse outcomes than insured patients. The impact of insurance status on patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is unclear. PATIENTS AND METHODS: A retrospective cohort study of adult patients with resected GEP-NETs was performed using the US Neuroendocrine Tumor Study Group (USNETSG) database (2000-2016). Demographic and clinical factors were compared by insurance status. Patients ≥ 65 years were excluded, as these patients are almost universally covered by Medicare. Kaplan-Meier and log-rank analyses were used for survival analysis. Logistic regression was used to assess factors associated with overall survival (OS). RESULTS: The USNETSG database included 2022 patients. Of those, 1425 were aged 18-64 years at index operation and were included in our analysis. Uninsured patients were more likely to have an emergent operation (7.9% versus 2.5%, p = 0.01) and less likely to receive postoperative somatostatin analog therapy (1.6% versus 9.9%, p = 0.03). OS at 1, 5, and 10 years was significantly higher for insured patients (96.3%, 88.2%, and 73.8%, respectively) than uninsured patients (87.7%, 71.9%, and 44.0%, respectively) (p < 0.01). On Cox multivariate regression analysis controlling for T/M stage, tumor grade, ASA class, and income level, being uninsured was independently associated with worse OS [hazard ratio (HR) 2.69, 95% confidence interval (CI) 1.32-5.48, p = 0.006]. CONCLUSIONS: Insurance status is an independent predictor of survival in patients with GEP-NETs. Our study highlights the importance of access to medical care, disparities related to insurance status, and the need to mitigate these disparities.
Subject(s)
Insurance Coverage , Neuroendocrine Tumors , Adolescent , Adult , Health Services Accessibility/economics , Health Services Accessibility/statistics & numerical data , Humans , Insurance Coverage/statistics & numerical data , Medically Uninsured/statistics & numerical data , Middle Aged , Neuroendocrine Tumors/economics , Neuroendocrine Tumors/mortality , Neuroendocrine Tumors/pathology , Neuroendocrine Tumors/surgery , Retrospective Studies , United States/epidemiology , Young AdultABSTRACT
BACKGROUND: Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective. OBJECTIVE: To assess patient-rated complication severity and determine concordance with existing grading systems. METHODS: A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked. RESULTS: One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest. CONCLUSION: Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.
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BACKGROUND: Packed red blood cell (PRBC) transfusion has been associated with worse survival in multiple malignancies but its impact on pancreatic neuroendocrine tumors (PNETs) is unknown. The aim of this study was to determine the impact of PRBC transfusion on survival following PNET resection. METHODS: A retrospective cohort study of PNET patients was performed using the US Neuroendocrine Tumor Study Group database. Demographic and clinical factors were compared. Kaplan-Meier and log-rank analyses were performed. Factors associated with transfusion, overall (OS), recurrence-free (RFS) and progression-free survival (PFS) were assessed by logistic regression. RESULTS: Of 1129 patients with surgically resected PNETs, 156 (13.8%) received perioperative PRBC transfusion. Transfused patients had higher ASA Class, lower preoperative hemoglobin, larger tumors, more nodal involvement, and increased major complications (all p < 0.010). Transfused patients had worse median OS (116 vs 150 months, p < 0.001), worse RFS (83 vs 128 months, p < 0.01) in curatively resected (n = 1047), and worse PFS (11 vs 24 months, p = 0.110) in non-curatively resected (n = 82) patients. On multivariable analysis, transfusion was associated with worse OS (HR 1.80, p = 0.011) when controlling for TNM stage, tumor grade, final resection status, and pre-operative anemia. CONCLUSION: PRBC transfusion is associated with worse survival for patients undergoing PNET resection.
Subject(s)
Neuroendocrine Tumors , Pancreatic Neoplasms , Blood Transfusion , Disease-Free Survival , Humans , Neoplasm Recurrence, Local , Neuroendocrine Tumors/surgery , Pancreatic Neoplasms/surgery , Retrospective Studies , Survival RateABSTRACT
BACKGROUND: In a changing health care environment where patient outcomes will be more closely scrutinized, the ability to predict surgical complications is becoming increasingly important. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) online risk calculator is a popular tool to predict surgical risk. This paper aims to assess the applicability of the ACS NSQIP calculator to patients undergoing surgery for pancreatic neuroendocrine tumors (PNETs). METHODS: Using the US Neuroendocrine Tumor Study Group (USNET-SG), 890 patients who underwent pancreatic procedures between 1/1/2000-12/31/2016 were evaluated. Predicted and actual outcomes were compared using C-statistics and Brier scores. RESULTS: The most commonly performed procedure was distal pancreatectomy, followed by standard and pylorus-preserving pancreaticoduodenectomy. For the entire group of patients studied, C-statistics were highest for discharge destination (0.79) and cardiac complications (0.71), and less than 0.7 for all other complications. The Brier scores for surgical site infection (0.1441) and discharge to nursing/rehabilitation facility (0.0279) were below the Brier score cut-off, while the rest were equal to or above and therefore not useful for interpretation. CONCLUSION: This work indicates that the ACS NSQIP risk calculator is a valuable tool that should be used with caution and in coordination with clinical assessment for PNET clinical decision-making.
Subject(s)
Neuroendocrine Tumors/surgery , Pancreatic Neoplasms/surgery , Pancreaticoduodenectomy/methods , Postoperative Complications/epidemiology , Quality Improvement , Risk Assessment/methods , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Retrospective StudiesABSTRACT
BACKGROUND: Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings. METHODS: Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories. RESULTS: Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes. CONCLUSIONS: We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.
Subject(s)
Congresses as Topic , General Surgery/methods , Randomized Controlled Trials as Topic/methods , Research Design , Humans , Qualitative Research , SurgeonsABSTRACT
INTRO: Chromogranin A (CgA) may be prognostic for patients with neuroendocrine tumors; however, the clinical utility of this test is unclear. METHODS: Patients undergoing resection for pancreatic neuroendocrine tumors (pNET) were selected from the eight institutions of the US Neuroendocrine Tumor Study Group database. Cox regression was used to identify pre-operative variables that predicted recurrence-free survival (RFS), and those with p < 0.1 were included in a risk score. The risk score was tested in a unique subset of the overall cohort. RESULTS: In the entire cohort of 287 patients, median follow-up time was 37 months, and 5-year RFS was 73%. Cox regression analysis identified four variables for inclusion in the risk score: CgA > 5x ULN (HR 4.3, p = 0.01), tumor grade 2/3 (HR 3.7, p = 0.01), resection for recurrent disease (HR 6.2, p < 0.01), and tumor size > 4 cm (HR 4.5, p = 0.1). Each variable was assigned 1 point. Risk-score testing in the unique validation cohort of 63 patients revealed a 95% negative predictive value for recurrence in patients with zero points. DISCUSSION: This simple pre-operative risk scoring system resulted in a high degree of specificity for identifying patients at low-risk for tumor recurrence. This test can be utilized pre-operatively to aid informed decision-making.
Subject(s)
Biomarkers, Tumor/blood , Chromogranin A/blood , Clinical Decision Rules , Neoplasm Recurrence, Local/diagnosis , Neuroendocrine Tumors/surgery , Pancreatic Neoplasms/surgery , Preoperative Care/methods , Adolescent , Adult , Aged , Aged, 80 and over , Clinical Decision-Making/methods , Databases, Factual , Disease-Free Survival , Female , Follow-Up Studies , Humans , Male , Middle Aged , Neoplasm Recurrence, Local/blood , Neoplasm Recurrence, Local/etiology , Neuroendocrine Tumors/blood , Neuroendocrine Tumors/diagnosis , Pancreatic Neoplasms/blood , Pancreatic Neoplasms/diagnosis , Predictive Value of Tests , Prognosis , Proportional Hazards Models , Retrospective Studies , Risk Assessment , Sensitivity and Specificity , Young AdultABSTRACT
Multidisciplinary management of chronic wounds using comprehensive wound centers improves outcomes. With an increasing need for wound providers, little is known about surgeons' roles in wound centers. An online survey of two national surgical organization members covered demographics, wound center characterization, and surgeons' perspectives of wound centers and wound care. Surgeon perspectives were compared by age, gender, and relationship status. Three hundred sixty-four surgeons responded. Respondents were mostly older than 50 years, male, in practice older than 10 years, and used wound centers. Most respondents reported favorable experiences with wound centers but uncertainty about financial details. Most respondents were interested in formal wound care certification and participation in a wound practice, particularly as a transition to the retirement option for older surgeons. Surgeons are interested in pursuing a career focus in wound care. Further efforts are needed to educate surgeons and create a pathway for surgeons to become wound center directors. In a nationwide survey, surgeon perspectives on wound centers and wound specialization were positive, although financial understanding was limited. The importance of this finding is the support of wound care pathways for surgeons.
Subject(s)
Surgeons/statistics & numerical data , Trauma Centers , Wounds and Injuries/therapy , Adult , Attitude of Health Personnel , Career Choice , Female , Humans , Male , Middle Aged , Surveys and Questionnaires , Trauma Centers/economics , Trauma Centers/statistics & numerical data , United States , Wounds and Injuries/surgeryABSTRACT
BACKGROUND: Congenital Trypanosoma cruzi transmission is now estimated to account for 22% of new infections, representing a significant public health problem across Latin America and internationally. Treatment during infancy is highly efficacious and well tolerated, but current assays for early detection fail to detect >50% of infected neonates, and 9-month follow-up is low. METHODS: Women who presented for delivery at 2 urban hospitals in Santa Cruz Department, Bolivia, were screened by rapid test. Specimens from infants of infected women were tested by microscopy (micromethod), quantitative PCR (qPCR), and immunoglobulin (Ig)M trypomastigote excreted-secreted antigen (TESA)-blots at birth and 1 month and by IgG serology at 6 and 9 months. RESULTS: Among 487 infants of 476 seropositive women, congenital T. cruzi infection was detected in 38 infants of 35 mothers (7.8%). In cord blood, qPCR, TESA-blot, and micromethod sensitivities/specificities were 68.6%/99.1%, 58.3%/99.1%, and 16.7%/100%, respectively. When birth and 1-month results were combined, cumulative sensitivities reached 84.2%, 73.7%, and 34.2%, respectively. Low birthweight and/or respiratory distress were reported in 11 (29%) infected infants. Infants with clinical signs had higher parasite loads and were significantly more likely to be detected by micromethod. CONCLUSIONS: The proportion of T. cruzi-infected infants with clinical signs has fallen since the 1990s, but symptomatic congenital Chagas disease still represents a significant, albeit challenging to detect, public health problem. Molecular methods could facilitate earlier diagnosis and circumvent loss to follow-up but remain logistically and economically prohibitive for routine screening in resource-limited settings.
Subject(s)
Chagas Disease/congenital , Chagas Disease/diagnosis , Early Diagnosis , Endemic Diseases , Trypanosoma cruzi/immunology , Adult , Antibodies, Protozoan/blood , Antigens, Protozoan/blood , Antigens, Protozoan/immunology , Chagas Disease/immunology , Chagas Disease/transmission , Enzyme-Linked Immunosorbent Assay/methods , Female , Humans , Immunoglobulin G/blood , Immunoglobulin M/blood , Infant , Infant, Low Birth Weight , Infant, Newborn , Infectious Disease Transmission, Vertical , Male , Mothers , Parasite Load , Real-Time Polymerase Chain Reaction , Trypanosoma cruzi/geneticsABSTRACT
Heparan sulfate (HS) is an essential component of the extracellular matrix (ECM), which serves as a barrier to tumor invasion and metastasis. Heparanase promotes tumor growth by cleaving HS chains of proteoglycan and releasing HS-bound angiogenic growth factors and facilitates tumor invasion and metastasis by degrading the ECM. HS mimetics, such as PG545, have been developed as antitumor agents and are designed to suppress angiogenesis and metastasis by inhibiting heparanase and competing for the HS-binding domain of angiogenic growth factors. However, how PG545 exerts its antitumor effect remains incompletely defined. Here, using murine models of lymphoma, we determined that the antitumor effects of PG545 are critically dependent on NK cell activation and that NK cell activation by PG545 requires TLR9. We demonstrate that PG545 does not activate TLR9 directly but instead enhances TLR9 activation through the elevation of the TLR9 ligand CpG in DCs. Specifically, PG545 treatment resulted in CpG accumulation in the lysosomal compartment of DCs, leading to enhanced production of IL-12, which is essential for PG545-mediated NK cell activation. Overall, these results reveal that PG545 activates NK cells and that this activation is critical for the antitumor effect of PG545. Moreover, our findings may have important implications for improving NK cell-based antitumor therapies.
Subject(s)
Antineoplastic Agents/pharmacology , Heparitin Sulfate/pharmacology , Killer Cells, Natural/immunology , Lymphocyte Activation/drug effects , Lymphoma/drug therapy , Saponins/pharmacology , Toll-Like Receptor 9/physiology , Animals , Cell Line, Tumor , Humans , Interleukin-12/biosynthesis , Lymphoma/immunology , Lysosomes/metabolism , Mice , Mice, Inbred BALB C , Mice, Inbred C57BL , Myeloid Differentiation Factor 88/physiology , Oligodeoxyribonucleotides/pharmacologyABSTRACT
BACKGROUND: We studied women and their infants to evaluate risk factors for congenital transmission and cardiomyopathy in Trypanosoma cruzi-infected women. METHODS: Women provided data and blood for serology and quantitative polymerase chain reaction (PCR). Infants of infected women had blood tested at 0 and 1 month by microscopy, PCR and immunoblot, and serology at 6 and 9 months. Women underwent electrocardiography (ECG). RESULTS: Of 1696 women, 456 (26.9%) were infected; 31 (6.8%) transmitted T. cruzi to their infants. Women who transmitted had higher parasite loads than those who did not (median, 62.0 [interquartile range {IQR}, 25.8-204.8] vs 0.05 [IQR, 0-29.6]; P < .0001). Transmission was higher in twin than in singleton births (27.3% vs 6.4%; P = .04). Women who had not lived in infested houses transmitted more frequently (9.7% vs 4.6%; P = .04), were more likely to have positive results by PCR (65.5% vs 33.9%; P < .001), and had higher parasite loads than those who had lived in infested houses (median, 25.8 [IQR, 0-64.1] vs 0 [IQR, 0-12.3]; P < .001). Of 302 infected women, 28 (9.3%) had ECG abnormalities consistent with Chagas cardiomyopathy; risk was higher for older women (odds ratio [OR], 1.06 [95% confidence interval {CI}, 1.01-1.12] per year) and those with vector exposure (OR, 3.7 [95% CI, 1.4-10.2]). We observed a strong dose-response relationship between ECG abnormalities and reported years of living in an infested house. CONCLUSIONS: We hypothesize that repeated vector-borne infection sustains antigen exposure and the consequent inflammatory response at a higher chronic level, increasing cardiac morbidity, but possibly enabling exposed women to control parasitemia in the face of pregnancy-induced Th2 polarization.
Subject(s)
Chagas Disease/epidemiology , Chagas Disease/transmission , Infectious Disease Transmission, Vertical , Insect Vectors/growth & development , Parasitemia/epidemiology , Trypanosoma cruzi/isolation & purification , Adolescent , Adult , Animals , Antibodies, Protozoan/blood , Bolivia , Chagas Disease/congenital , Chagas Disease/immunology , DNA, Protozoan/blood , Electrocardiography , Female , Humans , Infant , Infant, Newborn , Middle Aged , Parasitemia/immunology , Polymerase Chain Reaction , Pregnancy , Risk Assessment , Serologic Tests , Th2 Cells/immunology , Trypanosoma cruzi/immunology , Young AdultABSTRACT
Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) with donor lymphocyte infusion is the mainstay of treatment for many types of hematological malignancies, but the therapeutic effect and prevention of relapse is complicated by donor T-cell recognition and attack of host tissue in a process known as graft-versus-host disease (GvHD). Cytotoxic myeloablative conditioning regimens used prior to Allo-HSCT result in the release of endogenous innate immune activators that are increasingly recognized for their role in creating a pro-inflammatory milieu. This increased inflammatory state promotes allogeneic T-cell activation and the induction and perpetuation of GvHD. Here, we review the processes of cellular response to injury and cell death that are relevant following Allo-HSCT and present the current evidence for a causative role of a variety of endogenous innate immune activators in the mediation of sterile inflammation following Allo-HSCT. Finally, we discuss the potential therapeutic strategies that target the endogenous pathways of innate immune activation to decrease the incidence and severity of GvHD following Allo-HSCT.