Molecular biology of cholangiocarcinoma and its implications for targeted therapy in patient management.

Cholangiocarcinoma (CCA) remains a devastating malignancy and a significant challenge to treat. The majority of CCA patients are diagnosed at an advanced stage, making the disease incurable in most cases. The advent of high-throughput genetic sequencing has significantly improved our understanding of the molecular biology underpinning cancer. The identification of 'druggable' genetic aberrations and the development of novel targeted therapies against them is opening up new treatment strategies. Currently, 3 targeted therapies are approved for use in CCA; Ivosidenib in patients with IDH1 mutations and Infigratinib/Pemigatinib in those with FGFR2 fusions. As our understanding of the biology underpinning CCA continues to improve it is highly likely that additional targeted therapies will become available in the near future. This is important, as it is thought up to 40 % of CCA patients harbour a potentially actionable mutation. In this review we provide an overview of the molecular pathogenesis of CCA and highlight currently available and potential future targeted treatments.

Decoy receptors block TRAIL sensitivity at a supracellular level: the role of stromal cells in controlling tumour TRAIL sensitivity.

Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) is a death ligand cytokine known for its cytotoxic activity against malignantly transformed cells. TRAIL induces cell death through binding to death receptors DR4 and DR5. The inhibitory decoy receptors (DcR1 and DcR2) co-expressed with death receptor 4 (DR4)/DR5 on the same cell can block the transmission of the apoptotic signal. Here, we show that DcRs also regulate TRAIL sensitivity at a supracellular level and thus represent a mechanism by which the microenvironment can diminish tumour TRAIL sensitivity. Mathematical modelling and layered or spheroid stroma-extracellular matrix-tumour cultures were used to model the tumour microenvironment. By engineering TRAIL to escape binding by DcRs, we found that DcRs do not only act in a cell-autonomous or cis-regulatory manner, but also exert trans-cellular regulation originating from stromal cells and affect tumour cells, highlighting the potent inhibitory effect of DcRs in the tumour tissue and the necessity of selective targeting of the two death-inducing TRAIL receptors to maximise efficacy.

Postlaryngectomy vocal rehabilitation: assessment using a validated questionnaire in 51 patients.

BACKGROUND: This study aimed to assess valved speech and related issues in total laryngectomy patients with the help of the validated Voice Prosthesis Questionnaire (VPQ). PATIENTS AND METHODS: We identified 61 patients who had undergone a surgical voice restoration with a valve following total laryngectomy and who were sent the VPQ by mail. RESULTS: Fifty-one patients (37 males) completed the questionnaire giving a response rate of 83.6%. Fifty-three percent of the patients (n = 27) were fully aware of the dimensions of their valve including the length and diameter, whilst 25% (n = 13) were aware of only one of the two. There was a strong correlation between the patient's perception of tone and their gender with the tone scores significantly lower in women as compared to men (Mann-Whitney test, p = 0.04). Ten patients (19.6%) had had leakage-related issues during the previous 7 days. CONCLUSIONS: This questionnaire provided a significant amount of valuable data. Based on our experience, we recommend the VPQ for prospective use in the serial monitoring and audit of total laryngectomy patients.

Early diagnosis of cystic fibrosis in the newborn period and risk of Pseudomonas aeruginosa acquisition in the first 10 years of life: A registry-based longitudinal study.

OBJECTIVE: Controlled clinical trial data have suggested that identifying asymptomatic cystic fibrosis (CF) patients through newborn screening improves health outcomes of affected children in the first decade of life. However, it is unclear whether these improvements also include a reduction in risk for bronchial infection, the major determinant of CF morbidity. The authors therefore investigated the association between early CF diagnosis and acquisition of Pseudomonas aeruginosa, the major bronchial pathogen, in the first decade of life. METHODOLOGY: Longitudinal data on 3625 CF patients diagnosed between 1982 and 1990 and before 36 months of age were ascertained from the National Cystic Fibrosis Patient Registry. We compared P aeruginosa acquisition in the first 10 years of life among 4 groups: EAD (early asymptomatic diagnosis)-<6 weeks, by pre/neonatal screening, genotype, family history (n = 157); ESD (early symptomatic diagnosis) (n = 227); LAD (late asymptomatic diagnosis)-6 weeks to 36 months (n = 161); and LSD (late symptomatic diagnosis) (n = 3080). P aeruginosa acquisition was determined from yearly sputum and/or bronchoscopy cultures. Children whose CF diagnoses followed meconium ileus or whose cultures were obtained only from nasal samples were excluded from the study. RESULTS: Kaplan Meier analyses for P aeruginosa acquisition were conducted for each diagnostic group. Regression models were used to generate adjusted relative hazards with EAD as the referent group. Relative hazards were 0.9 (95% confidence interval [CI]: 0.7-1.2) for ESD, 0.8 (95% CI: 0.6-1.2) for LAD, and 1.0 (95% CI: 0.7-1.2) for LSD. The risk of acquiring P aeruginosa was therefore not significantly different between children diagnosed early, late, asymptomatically, or symptomatically. CONCLUSIONS: These data suggest that, despite improvements in other health outcomes from newborn screening for CF, early asymptomatic diagnosis of CF does not affect P aeruginosa acquisition.

Type 1 diabetes in offspring of parents with type 1 diabetes: the tip of an autoimmune iceberg?

The objective of the present study was to examine the prevalence of self-reported autoimmune diseases among offspring of type 1 fathers, type 1 diabetic mothers, and non-diabetic parents. Type 1 diabetic probands (n=265; mean age=42 yr), who were ascertained from the Children's Hospital of Pittsburgh Registry for 1950-1964, recently participated in the Familial Autoimmune and Diabetes Study. Non-diabetic probands (n=96), identified from voter registration lists and matched by age, race, median income, and duration of residence in the Pittsburgh area, were also enrolled. Offspring of type 1 diabetic probands were more likely to have a reported autoimmune disease (5.8% vs. 2.4%; p=0.067) than offspring of non-diabetic probands. Half the cases in the diabetic families were disorders other than type 1 diabetes, (e.g., rheumatoid arthritis, Crohn's disease, etc.). Stratification by parental gender revealed a marginally higher risk for type 1 diabetes among offspring of type 1 diabetic fathers compared to mothers (4.9% vs. 3.4%; p=0.38, respectively, through age 20 yr). However, the risk for other autoimmune disorders was statistically significantly increased among offspring of type 1 diabetic mothers (0% vs. 6.2%; p=0.02, respectively, through age 20 yr). These data suggest that offspring of type 1 diabetic parents may be at high risk of developing other autoimmune disorders during childhood, with pediatric diabetes representing the 'tip of an autoimmune iceberg'. The observed risk differences by parental gender, which have also been reported for other autoimmune disorders, warrant further investigation.

Generation and analysis of GluR5(Q636R) kainate receptor mutant mice.

The physiological significance of RNA editing of transcripts that code for kainate-preferring glutamate receptor subunits is unknown, despite the fact that the functional consequences of this molecular modification have been well characterized in cloned receptor subunits. RNA editing of the codon that encodes the glutamine/arginine (Q/R) site in the second membrane domain (MD2) of glutamate receptor 5 (GluR5) and GluR6 kainate receptor subunits produces receptors with reduced calcium permeabilities and single-channel conductances. Approximately 50% of the GluR5 subunit transcripts from adult rat brain are edited at the Q/R site in MD2. To address the role of glutamate receptor mRNA editing in the brain, we have made two strains of mice with mutations at amino acid 636, the Q/R-editing site in GluR5, using embryonic stem cell-mediated transgenesis. GluR5(RloxP/RloxP) mice encode an arginine at the Q/R site of the GluR5 subunit, whereas GluR5(wt(loxP)/wt(loxP)) mice encode a glutamine at this site, similar to wild-type mice. Mutant animals do not exhibit developmental abnormalities, nor do they show deficits in the behavioral paradigms tested in this study. Kainate receptor current densities were reduced by a factor of six in acutely isolated sensory neurons of dorsal root ganglia from GluR5(RloxP/RloxP) mice compared with neurons from wild-type mice. However, the editing mutant mice did not exhibit altered responses to thermal and chemical pain stimuli. Our investigations with the GluR5-editing mutant mice have therefore defined a set of physiological processes in which editing of the GluR5 subunit is unlikely to play an important role.

How accurate is male recall of reproductive information?

The purpose of this study was to determine how well men recall reproductive information. By using a questionnaire, the authors surveyed men who had undergone orchiopexy for undescended testes and a group of matched control men, all of whom had had surgery at the Children's Hospital of Pittsburgh in Pittsburgh, Pennsylvania (n = 77), and their spouses. Subjects were a random subset of a larger (n = 1,212) male fertility study, which has been ongoing since 1992. In 1994, the spouses of men who participated in the study completed a short telephone survey that contained questions previously asked of their partners. Pearson correlations and kappa statistics were calculated to evaluate the accuracy of male recall of reproductive information. For the continuous measures, such as time to conception and frequency of intercourse, the correlations were high to moderate (r = 0.84 (p < 0.001) and r = 0.45 (p < 0.001), respectively). Agreement between the men and their spouses on the majority of bivariate (yes/no) questions, such as those concerning the use of birth control, as measured by the kappa statistic, was moderate to very good (K ranged from 0.14 to 0.69). Statistics were similar for formerly cryptorchid and control men. Male participants' responses to questions about their reproductive histories were accurate as compared with the responses given by their spouses. In this sample from a large cohort study, men appeared to recall reproductive information with acceptable accuracy.

Hashimoto's thyroiditis and insulin-dependent diabetes mellitus: differences among individuals with and without abnormal thyroid function.

Insulin-dependent diabetes mellitus probands from the Familial Autoimmune and Diabetes Study were evaluated for autoimmune thyroid disease (n = 265). The prevalence of Hashimoto's thyroiditis was 26.6%; 42.0% of these individuals were euthyroid, and 58.0% were hypothyroid. There was a female predominance among hypothyroid and euthyroid Hashimoto's cases compared to those with no thyroid disease (75% vs. 72.4% vs. 41.6%; P < 0.001). Insulin-dependent diabetes mellitus patients with hypothyroid Hashimoto's thyroiditis were more likely to report another autoimmune disease compared to euthyroid Hashimoto's patients or individuals with no thyroid disease (30.8% vs. 17.2% vs. 13.9%; P < 0.01). Sex-specific analysis revealed that this difference was significant for men but not for women. Both euthyroid and hypothyroid Hashimoto's cases were more likely to have a family history of the disease (66.7% vs. 69.2% vs. 47.7%; P < 0.05). No differences were observed in the prevalence of DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302 across the three groups. Body mass index, lipid levels, glycemic control, and diabetes complications were also similar. However, euthyroid Hashimoto's women were more likely to report spontaneous abortions than those with hypothyroid Hashimoto's thyroiditis or no thyroid disease (23.8% vs. 61.5% vs. 29.1%; P < 0.05). These data suggest that gender-specific risk factors may be primary determinants of Hashimoto's thyroiditis and other autoimmune diseases among women. However, disease-specific determinants may also increase susceptibility to other autoimmune diseases.

Time to conception after orchidopexy: evidence for subfertility?

OBJECTIVE: To determine whether time to conception is increased among men who were formerly bilaterally or unilaterally cryptorchid compared with a group of matched control men. DESIGN: Retrospective cohort study. SETTING: Human volunteers in an academic research environment. PATIENT(S): Men who underwent orchidopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh (n = 547) and a group of matched control men (n = 463) were surveyed by questionnaire. RESULT(S): Of the men who attempted paternity, the mean time to conception for the bilateral cases, unilateral cases, and control men was 33.90, 11.11, and 8.78 months, respectively. Kaplan-Meier survival analysis showed a significantly longer time to conception among bilateral cases compared with unilateral cases and controls, but not between unilateral cases and control men. Adjustment for confounders and covariates using a Cox Proportional Hazards model showed that former bilaterally cryptorchid men were 68% (95% CI = 55% to 81%) less likely than former unilaterally cryptorchid men or controls to conceive per month of unprotected intercourse. CONCLUSION(S): Time to conception was increased among former bilaterally cryptorchid men compared with both former unilaterally cryptorchid and control men. However, there were no significant differences in time to conception between the unilateral cryptorchid men and the control men.

Paternity after bilateral cryptorchidism. A controlled study.

OBJECTIVE: To compare paternity among men with former bilateral cryptorchidism (referred to as the bilateral group) with a group of men with former unilateral cryptorchidism (referred to as the unilateral group) and a control group. DESIGN: Epidemiologic survey of study cohort. SETTING: Large urban pediatric hospital. SUBJECTS: Men with former bilateral and unilateral cryptorchidism who underwent orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh, Pittsburgh, Pa, and a group of control men have been surveyed by questionnaire concerning paternity and factors related to paternity. MAIN OUTCOME MEASURE: Paternity. RESULTS: Among the married men who had bilateral cryptorchidism, 50% had fathered children, compared with 76% in the control group and 74% in the unilateral group. Data were similar when the men who were cohabitating were included with the married men. When men who had married and had attempted paternity were evaluated, 62% of the men in the bilateral group had been able to father children compared with 94% of the control group and 89% of the men in the unilateral group. No relationship was noted between the age of orchiopexy or lifestyle factors and paternity. Paternity among all groups was related to female-related infertility factors and to the presence of varicoceles. CONCLUSIONS: Paternity was compromised after bilateral cryptorchidism when compared with men with former unilateral cryptorchidism and a control group. Among the bilateral group, infertility is about 3.5 times as frequent than the unilateral group and more than 6 times as frequent among the control group. No correlation was found between age of orchiopexy and paternity for either group.

Association of retinol binding protein in multiple-case families with insulin-dependent diabetes.

We performed a family study to investigate the heritability of reduced serum retinol levels observed in type 1 diabetes cases. Diet and serum factors, including retinol, total carotene, malondialdehyde, and retinol binding protein levels, were measured in 11 multiple-case families. The mean serum retinol level of the diabetics (46 ug/dl) was significantly less than the mean serum retinol level of the nondiabetics (60.9 ug/dl). The level of retinol binding protein was also significantly lower in diabetics (6.2 mg/dl) than in nondiabetics (7.6 mg/dl). The serum values of retinol binding protein were closely related within families, including both diabetic and nondiabetic family members. A characteristic shared between diabetics and one-third of their family members was a low ratio of serum retinol to total carotene, suggesting a low conversion of dietary carotene into retinol. Analysis of food frequency reports showed no difference between dietary retinol or total carotene level in diabetics or their relatives. This study offers evidence that heritability and the reduced conversion of carotene may play a role in the level of serum retinol in type 1 diabetes cases.

Paternity after unilateral cryptorchidism: a controlled study.

OBJECTIVE: To determine if paternity is decreased among formerly unilateral cryptorchid men compared with a control group of men. SUBJECTS AND METHODS: Formerly unilateral cryptorchid men who had orchiopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh and a group of control men have had their medical records reviewed and have been surveyed by questionnaire. RESULTS: Among the men who had ever married and had attempted paternity, significantly more of the unilateral cryptorchid men had been unable to father children (10.5%) than among the control group (5.4%). No difference was found when the groups were compared for the duration of regular intercourse without contraception to conception of their first child. There was no relationship between the age of orchiopexy or lifestyle factors and paternity or between the age of orchiopexy and months of regular unprotected intercourse to conception. Paternity among both groups was related to female-related infertility factors and to the presence of varicoceles. CONCLUSION: When compared with a control group, paternity was compromised after unilateral cryptorchidism. Infertility is about twice as frequent among the unilateral group. There was no evidence of subfertility requiring a longer exposure of regular intercourse without contraception among the fertile subgroup. No correlation was found between age of orchiopexy and paternity.

Paternity after cryptorchidism: lack of correlation with age at orchidopexy.

OBJECTIVE: To determine whether paternity is decreased among men who were formerly unilaterally or bilaterally cryptorchid and to ascertain whether paternity is related to their age at orchidopexy. SUBJECTS AND METHODS: Men who underwent orchidopexy between 1955 and 1969 at the Children's Hospital of Pittsburgh (363) and a group of age-matched control men (336) were surveyed by questionnaire and their medical records reviewed. RESULTS: Of the married men, significantly more of the unilateral cryptorchid (75%) and control (76%) groups had fathered children than had the bilateral cryptorchid group (P < 0.005). Furthermore, when the groups were compared during the period of regular intercourse with no contraception until conception of their first child, the bilateral group had relatively fewer conceptions during the first year and more after the first year. When the unilateral and bilateral groups were analysed separately, there was no relationship between either age at orchidopexy and paternity or between the age at orchidopexy and the duration of regular unprotected intercourse before conception. CONCLUSIONS: Compared with a control group, paternity was compromised after bilateral, but not unilateral, cryptorchidism. Age at orchidopexy was not correlated with paternity.

An epidemiologic study of paternity after cryptorchidism: initial results.

Paternity has been studied among married men who were formerly cryptorchid. Forty-one of 52 formerly unilateral cryptorchid men were married, 10 of 11 bilaterally cryptorchid and 36 of 42 control men. Thirty-two of the 41 of the unilateral group (78%) had fathered children, 6 of 10 in the bilateral group (60%) and 24 of 36 controls (67%). These limited data from the initial phase of this study of paternity after cryptorchidism do not show any correlation between paternity or time of unprotected intercourse to conception and age of surgery or pretreatment testicular size or location. However, these data suggest that paternity is not decreased after unilateral cryptorchidism.

Familial and sporadic insulin-dependent diabetes: evidence for heterogeneous etiologies?

Heterogeneity within insulin-dependent diabetes mellitus (IDDM) has been hypothesized, but few studies have focused on differences which may exist between familial and sporadic IDDM cases. Presenting characteristics for 330 white, newly diagnosed IDDM cases were evaluated. Familial cases were older (10.2 +/- 5.1 years vs 7.9 +/- 4.2 years, P = 0.010) and had, on average, less severe metabolic disturbances at presentation, as demonstrated by lower mean hemoglobin A1 (12.6 +/- 2.4% vs 14.4 +/- 2.6%, P = 0.001) and mean insulin dose at discharge (0.62 +/- 0.35 U/kg/day vs 0.85 +/- 0.29 U/kg/day, P less than 0.001), and higher mean plasma bicarbonate concentrations (19.3 +/- 3.9 mmol/l vs 15.8 +/- 5.9 mmol/l, P = 0.023) and mean plasma C-peptide levels (0.35 +/- 0.36 pmol/ml vs 0.14 +/- 0.15 pmol/ml, P less than 0.001). Further analyses on a subset of IDDM cases (n = 100) indicated that initial differences in metabolic indices observed at diagnosis were no longer apparent at one-year post-diagnosis. These results suggest that the etiology of familial and sporadic IDDM is similar and that the less severe presentation observed at diagnosis in the familial cases may be due to earlier identification of the disease, reflecting increased parental knowledge of diabetic symptoms and/or frequent testing for diabetes.

Lead exposure at uncovered outdoor firing ranges.

Excessive lead exposure in shooting instructors at indoor firing ranges and covered outdoor firing ranges has been documented. The City of Los Angeles assessed exposure of its full-time shooting instructors at uncovered outdoor ranges via air monitoring and blood lead-level measurements. Results of these tests revealed that significant lead exposure and absorption can occur at outdoor firing ranges. The use of copper-jacketed ammunition may decrease air lead levels and decrease lead absorption by range instructors.

Parental occupational exposures and risk of childhood cancer: a review.

We reviewed the literature in order to summarize the present knowledge on the association between parental occupational exposures to chemicals and the risk of childhood malignancy. The 32 studies pertaining to this topic were evaluated by considering various study qualities such as sample size, specificity of outcome, confounding, exposure specificity, and control selection. When evaluating the findings from any epidemiologic study, the potential sources of bias have to be considered. The selection of subjects, misclassification of exposure or outcome, and confounding from extraneous factors can contribute to a biased estimate of effect. Studies done to minimize these potential biases will be more valid, and these studies should be given the most weight when parental occupational exposures are evaluated as risk factors for childhood malignancy. We conclude that the preponderance of evidence supports the hypothesis that occupational exposure of parents to chemicals increases the risk of childhood malignancy. The parental occupational exposures implicated in childhood malignancy risk are exposure to chemicals including paints, petroleum products, solvents (especially chlorinated hydrocarbons) and pesticides, and exposure to metals. The available data do not allow the identification of specific etiologic agents within these categories of compounds. Future epidemiologic and toxicologic studies should be designed to pursue these leads.

Evolution of the Pittsburgh studies of the epidemiology of insulin-dependent diabetes mellitus. Pittsburgh Diabetes Epidemiology and Etiology Research Group.

The Pittsburgh project evaluating the epidemiology and etiology of insulin-dependent diabetes mellitus (IDDM) is currently one of the large ongoing studies of childhood diabetes. This paper traces the evolution of the project, from the initial basic epidemiologic approach in the early 1980s, to the current thrust where complex molecular genetic approaches are being incorporated into population-based research. The epidemiology models employed in the Pittsburgh project are similar to those that could be used in many areas of chronic disease research. The integration of immunogenetics into epidemiology produces a powerful approach for understanding the complex interaction of host susceptibility and environmental agents that contribute to the development of IDDM.