University of North Carolina Hospitals

Tumor necrosis factor alpha (TNF-alpha) binding to the TNF receptor (TNFR) potentially initiates apoptosis and activates the transcription factor nuclear factor kappa B (NF-kappaB), which suppresses apoptosis by an unknown mechanism. The activation of NF-kappaB was found to block the activation of caspase-8. TRAF1 (TNFR-associated factor 1), TRAF2, and the inhibitor-of-apoptosis (IAP) proteins c-IAP1 and c-IAP2 were identified as gene targets of NF-kappaB transcriptional activity. In cells in which NF-kappaB was inactive, all of these proteins were required to fully suppress TNF-induced apoptosis, whereas c-IAP1 and c-IAP2 were sufficient to suppress etoposide-induced apoptosis. Thus, NF-kappaB activates a group of gene products that function cooperatively at the earliest checkpoint to suppress TNF-alpha-mediated apoptosis and that function more distally to suppress genotoxic agent-mediated apoptosis.

Clostridium difficile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratified depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mild-to-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classification of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI.

squamous cell carcinoma antigen 1 or 2 α1 antitrypsin (α1 proteinase inhibitor) α2 antiplasmin amyloid-β α1 antichymotrypsin antithrombin III monocyte-neutrophil elastase inhibitor ovalbumin plasminogen activator inhibitor type 1 or 2 pigment epithelium-derived factor vascular endothelial growth factor reactive site loop tissue plasminogen activator urokinase plasminogen activator The serpins (serineproteinase inhibitors) are a superfamily of proteins (350–500 amino acids in size) that fold into a conserved structure and employ a unique suicide substrate-like inhibitory mechanism. The serpins were last reviewed in 1994 (1Potempa J. Korzus E. Travis J. J. Biol. Chem. 1994; 269: 15957-15960Abstract Full Text PDF PubMed Google Scholar). More recent studies show: 1) an expanded distribution within the kingdoms of metazoa and plantae, as well as certain viruses, 2) a surprising effect on the covalently bound target proteinase, and 3) novel biochemical and biological functions. Most serpins inhibit serine proteinases of the chymotrypsin family. However, cross-class inhibitors have been identified. The viral serpin CrmA and, to a lesser extent, PI9 (SERPINB9) inhibit the cysteine proteinase, caspase 1 (2Komiyama T. Ray C.A. Pickup D.J. Howard A.D. Thornberry N.A. Peterson E.P. Salvesen G. J. Biol. Chem. 1994; 269: 19331-19337Abstract Full Text PDF PubMed Google Scholar), and SCCA11 (SERPINB3) neutralizes the potent papain-like cysteine proteinases, cathepsins L, K, and S (3Schick C. Pemberton P.A. Shi G.-P. Kamachi Y. Cataltepe S. Bartuski A.J. Gornstein E.R. Bromme D. Chapman H.A. Silverman G.A. Biochemistry. 1998; 37: 5258-5266Crossref PubMed Scopus (259) Google Scholar). In addition, several members no longer function as proteinase inhibitors but perform other roles such as hormone transport (thyroid-binding globulin (SERPINA6), corticosteroid-binding globulin (SERPINA7)), and blood pressure regulation (angiotensinogen (SERPINA8)) (1Potempa J. Korzus E. Travis J. J. Biol. Chem. 1994; 269: 15957-15960Abstract Full Text PDF PubMed Google Scholar). Data base searching provides evidence for ∼500 serpins, with full-length coding sequences known or predicted for about one-half of those (4Irving J.A. Pike R.N. Lesk A.M. Whisstock J.C. Genome Res. 2000; 10: 1845-1864Crossref PubMed Scopus (523) Google Scholar). A phylogenetic analysis divides serpins into 16 clades (see Supplemental Data, Table A) and 10 highly diverged “orphans” (4Irving J.A. Pike R.N. Lesk A.M. Whisstock J.C. Genome Res. 2000; 10: 1845-1864Crossref PubMed Scopus (523) Google Scholar). These data facilitate the construction of a consistent expandable nomenclature (see Supplemental Data for Serpin Nomenclature Guidelines, Table B). The completed DNA sequences of several organisms have yielded insight into the complexity of the family. The Caenorhabditis elegans, Drosophila melanogaster, and Arabidopsis thalianagenomes encode for ∼20,000, 13,000, and 25,000 genes, respectively. However, these three species harbor ∼9, 32, and 13 serpin genes, respectively. The nonlinear relationship among the number of serpin genes, relative to the total gene number, suggests that at least a subset of serpins has evolved divergent functions despite a striking degree of sequence and structural conservation. Serpins adopt a metastable conformation that is required for their inhibitory activity (5Stein P.E. Carrell R.W. Nat. Struct. Biol. 1995; 2: 96-113Crossref PubMed Scopus (398) Google Scholar). This conformation consists of a conserved secondary structure comprised of β-sheets A, B, and C and at least 7 α-helices (most typically have 9, lettered A–I; Fig.1 A). The RSL, which contains the proteinase recognition site, is an exposed, flexible stretch of ∼17 residues tethered between β-sheets A and C. Serpins can undergo major structural rearrangements that involve alternative conformations for the RSL, β-sheet A, and the attached strand 1 of β-sheet C. Considering only intramolecular structural changes, serpins can convert to the more stable latent form (Fig. 1 B). The RSL inserts into the middle of β-sheet A to give a fully antiparallel β-sheet, and s1C is extracted from β-sheet C to provide an exposed “return” from the bottom of the serpin. Serpins in the latent conformation are noninhibitory but can be converted back to the active state by denaturation and refolding. The Tm for unfolding of latent PAI1 (SERPINE1) is 17 °C higher than that for the native state (reviewed in Ref. 6Gettins P.G.W. Patston P.A. Olson S.T. Serpins: Structure, Function and Biology, Molecular Biology Intelligence Unit. R. G. Landes Co., and Chapman & Hall, Austin, TX1996Google Scholar). The most stable state for inhibitory serpins is the RSL-cleaved form, in which the RSL has fully inserted into β-sheet A, as in the latent conformation, but without the need to extract s1C from β-sheet C (Fig. 1 C). Estimates of the Tm for unfolding of such conformations are >120 °C, compared with ∼60 °C for the native state (7Kaslik G. Kardos J. Szabo E. Szilagyi L. Zavodszky P. Westler W.M. Markley J.L. Graf L. Biochemistry. 1997; 36: 5455-5464Crossref PubMed Scopus (104) Google Scholar). The most informative serpin structures, from a mechanistic viewpoint, are those of a Michaelis complex between Serpin 1 and trypsin (Fig.1 D) and of a covalent complex between α1AT (SERPINA1) and trypsin (8Huntington J.A. Read R.J. Carrell R.W. Nature. 2000; 407: 923-926Crossref PubMed Scopus (970) Google Scholar) (Fig. 1 E). This latter structure represents the proteinase after it has been kinetically trapped in the acyl-enzyme intermediate that forms normally along the peptide bond cleavage pathway. Whereas the bound serpin is almost indistinguishable from that of the RSL-cleaved form (Fig. 1 C), the proteinase is grossly distorted (see below). Serpins inhibit serine proteinases by an irreversible suicide substrate mechanism when the interaction proceeds down the inhibitory arm of a branched pathway (Fig. 2) (6Gettins P.G.W. Patston P.A. Olson S.T. Serpins: Structure, Function and Biology, Molecular Biology Intelligence Unit. R. G. Landes Co., and Chapman & Hall, Austin, TX1996Google Scholar). In the inhibitory pathway, the proteinase initially forms a noncovalent Michaelis-like complex (Fig. 1 D) through interactions with residues flanking the scissile bond (P1–P1′). Attack of the active site serine on the scissile bond leads to a covalent ester linkage between Ser-195 of the proteinase and the backbone carbonyl of the P1 residue and cleavage of the peptide bond (6Gettins P.G.W. Patston P.A. Olson S.T. Serpins: Structure, Function and Biology, Molecular Biology Intelligence Unit. R. G. Landes Co., and Chapman & Hall, Austin, TX1996Google Scholar). It is likely that only at this stage, with removal of the restraint, does the RSL start to insert into β-sheet A and transport the covalently bound proteinase with it. Upon complete loop insertion the proteinase is translocated by over 70 Å, and its active site is distorted (Fig. 1 E). The alignment of the active site catalytic triad is altered by as much as 3 Å, and the P1 side chain is removed from the S1 pocket. Also, 40% of the body of the proteinase shows no traceable electron density. Proteinase distortion and hence inactivation results from compression of the proteinase against the base of the serpin as a consequence of the inserted RSL being just the right length. The energy needed to effect the distortion may come from the much greater stability of the cleaved loop-inserted conformation compared with the native-like conformation. The net result of this conformational rearrangement is kinetic trapping of the acyl intermediate due to slowing of the deacylation steps of the normal substrate reaction by 6–8 orders of magnitude (k5 in Fig. 2). Because of the small values for k5 (complex t12≅ hours to weeks), serpin-proteinase complexes in vivowould bind to their receptors and be cleared (complext12 ≅ minutes) long before significant complex decay could occur. The point in transit where the enzyme activity is reduced sufficiently to commit the intermediate to the kinetic trap is not known but in part contributes to the branched nature of the pathway and the ultimate fate of the complex. If, for example, RSL movement is impeded, the enzyme may successfully complete the deacylation step and escape before it is irreversibly trapped. This noninhibitory pathway yields an active proteinase and a cleaved, inactive serpin. The ratio of serpin products (complex versuscleaved) thus reflects a competition between the rate of ester hydrolysis (k3 in Fig. 2) and that of loop insertion (k4 in Fig. 2) to the point of proteinase distortion. This ratio is signified also by the stoichiometry of inhibition, which is defined as (k3 +k4)/k4, i.e.the number of moles of serpin needed to inhibit 1 mol of proteinase as a kinetically trapped complex. This mechanism accounts for the requirements for effective inhibition by serpins, which include a critical RSL length, appropriate residues within the loop that are compatible with rapid and favorable burial into β-sheet A, and the presence of Ser in the proteinase active site (6Gettins P.G.W. Patston P.A. Olson S.T. Serpins: Structure, Function and Biology, Molecular Biology Intelligence Unit. R. G. Landes Co., and Chapman & Hall, Austin, TX1996Google Scholar). Such a mechanism is adaptable to the inhibition of cysteine proteinases by serpins, with the difference being that the kinetically trapped intermediate is a thiol ester rather than an oxy ester. The detection of CrmA, a serpin that inhibits cysteine proteinases of the caspase family, in the loop-inserted cleaved conformation supports the feasibility of a common inhibitory mechanism (9Renatus M. Zhou Q. Stennicke H.R. Snipas S.J. Turk D. Bankston L.A. Liddington R.C. Salvesen G.S. Struct. Fold. Des. 2000; 8: 789-797Abstract Full Text Full Text PDF Scopus (55) Google Scholar), whereas the detection of an SDS-stable complex between SCCA1 and cathepsin S (a cysteine proteinase of the papain family) provides evidence for the formation of a stable, covalent thiol ester-type linkage (3Schick C. Pemberton P.A. Shi G.-P. Kamachi Y. Cataltepe S. Bartuski A.J. Gornstein E.R. Bromme D. Chapman H.A. Silverman G.A. Biochemistry. 1998; 37: 5258-5266Crossref PubMed Scopus (259) Google Scholar). The few convincing reports of reversible inhibition, such as of single-chain uPA by PCI (SERPINA5) (10Schwartz B.S. Espana F. J. Biol. Chem. 1999; 274: 15278-15283Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar) or of chymotrypsin by α2AP (SERPINF2) (11Shieh B.H. Potempa J. Travis J. J. Biol. Chem. 1989; 264: 13420-13423Abstract Full Text PDF PubMed Google Scholar) may represent special cases in which unusual stabilization of the initial noncovalent Michaelis-like complex blocks progression to the substrate reaction. A negative consequence of the need for a metastable conformation in the active state is that natural mutations, either alone or in combination with environmental factors, can promote inappropriate loop insertion. When this occurs between the RSL of one molecule and the β-sheet of another, dimers and higher order oligomers can result. Either through depletion of active serpin or through pathological effects of the polymers themselves, such aggregate formation can lead to disease. The best characterized examples are the emphysema (serpin depletion) and cirrhosis (intracellular inclusions) associated with loop-sheet polymers of the Z or S variants of α1AT (12Elliott P.R. Lomas D.A. Carrell R.W. Abrahams J.P. Nat. Struct. Biol. 1996; 3: 676-681Crossref PubMed Scopus (249) Google Scholar) (see Supplemental Data, Fig. A) and the dementia associated with neuroserpin (SERPINI1) inclusion bodies (see below). Understanding the biologic function of serpins remains an ongoing challenge. For example, the biologic functions for many of the human serpins involved in the clotting and fibrinolytic cascades are well documented. However the role of human serpins in some other types of biologic processes awaits further validation (Fig.3). In 1993 amino acid similarities among chicken ovalbumin (ov), PAI2 (SERPINB2), and MNEI (SERPINB1) led to the identification of a subgroup of the serpin superfamily (13Remold-O'Donnell E. FEBS Lett. 1993; 315: 105-108Crossref PubMed Scopus (217) Google Scholar). The N and C termini of the ov-serpins are shorter than the prototypical serpin α1AT, and they also lack a classical secretory signal peptide. At present, there are 13 human ov-serpins (see Supplemental Data, Table B). They map to 6p25 and 18q21 and fall into two classes based on a single difference in gene structure (14Scott F.L. Eyre H.J. Lioumi M. Ragoussis J. Irving J.A. Sutherland G.A. Bird P.I. Genomics. 1999; 62: 490-499Crossref PubMed Scopus (37) Google Scholar). Like ovalbumin, many of the 18q21 serpin genes have an exon encoding a polypeptide loop between helices C and D (CD loop) that may contribute to accessory functions. Unlike ovalbumin itself, most ov-serpins reside intracellularly with a cytoplasmic or nucleocytoplasmic distribution. However, several ov-serpins (PAI2, megsin (SERPINB7), MNEI, maspin (SERPINB5), and the SCCAs (SERPINB3 and -4)) may function extracellularly as they are released from cells under certain conditions. Release may be facilitated by an embedded, noncleaved hydrophobic N-terminal signal sequence and appears to involve both conventional and non-endoplasmic reticulum-Golgi secretory pathways (15Belin D. Thromb. Haemostasis. 1993; 70: 144-147Crossref PubMed Scopus (40) Google Scholar). Regardless of how ov-serpins are released from cells, those with RSL cysteine or methionine residues are susceptible to oxidative inactivation and are likely to have a limited half-life in the extracellular milieu. With the possible exception of maspin, all human ov-serpins are functional, competitive inhibitors of serine or cysteine proteinases. Several members of the group inhibit more than one proteinase, and dual reactive sites (utilization of more than one P1 residue) have been described for PI6 (SERPINB6), PI8 (SERPINB8), PI9, SCCA1, SCCA2, and MNEI (for example see Ref. 16Riewald M. Schleef R.R. J. Biol. Chem. 1996; 271: 14526-14532Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar). However, the CD loops of the ov-serpins have the potential to interact with other proteins. For example, the CD loop of PAI2 is required for its cell survival function (17Dickinson J.L. Bates E.J. Ferrante A. Antalis T.M. J. Biol. Chem. 1995; 270: 27894-27904Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar) and is a target for transglutamination (18Jensen P.H. Schuler E. Woodrow G. Richardson M. Goss N. Hojrup P. Petersen T.E. Rasmussen L.K. J. Biol. Chem. 1994; 269: 15394-15398Abstract Full Text PDF PubMed Google Scholar). Bomapin (SERPINB10; like the chicken ov-serpin, MENT, see below) carries a nuclear localization signal in its CD loop that presumably interacts with a nuclear importin (19Chuang T.L. Schleef R.R. J. Biol. Chem. 1999; 274: 11194-11198Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar). The physiological functions of ov-serpins are still emerging. PAI2 may play a role in the regulation of extracellular matrix remodeling through the inhibition of uPA, as high PAI2 and low uPA levels correlate with a positive prognosis in breast cancer (20Duggan C. Kennedy S. Kramer M.D. Barnes C. Elvin P. McDermott E. O'Higgins N. Duffy M.J. Br. J. Cancer. 1997; 76: 622-627Crossref PubMed Scopus (66) Google Scholar). Also, PAI2 may have a structural role inside some cells (perhaps keratinocytes) as suggested by its ability to spontaneously polymerize and undergo transglutamination (21Mikus P. Ny T. J. Biol. Chem. 1996; 271: 10048-10053Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar). Many ov-serpins reside in proteinase-secreting cells (22Bird P.I. Immunol. Cell Biol. 1999; 77: 47-57Crossref PubMed Scopus (58) Google Scholar). For example, PI9, a potent inhibitor of granzyme B, is also present in cytotoxic lymphocytes. Because PI9 can protect cells against granzyme B-mediated apoptosis, it probably protects cytotoxic lymphocytes from autodestruction due to misdirected granzyme B. A similar cytoprotective role can be envisaged for PI6, PI8, MNEI, PAI2, and the SCCAs. In addition, endogenous or exogenous ov-serpins may protect bystander cells and tissue from proteolytic damage. Studies in rats show that recombinant MNEI delivered to the airways prevents lung injury by neutrophil proteinases and point to its potential in treating inflammatory lung disease (23Rees D.D. Rogers R.A. Cooley J. Mandle R.J. Kenney D.M. Remold-O'Donnell E. Am. J. Respir. Cell Mol. Biol. 1999; 20: 69-78Crossref PubMed Scopus (43) Google Scholar). The ability of many ov-serpins to inhibit more than one proteinase and their presence in epithelial cells suggest that they play a role in barrier function or host defense against microbial or viral proteinases. For example, PI9 inhibits Bacillussubtilisin, and PI8 inhibits furin, a subtilisin-related enzyme (24Dahlen J.R. Foster D.C. Kisiel W. Biochem. Biophys. Res. Commun. 1997; 238: 329-333Crossref PubMed Scopus (19) Google Scholar,25Dahlen J.R. Jean F. Thomas G. Foster D.C. Kisiel W. J. Biol. Chem. 1998; 273: 1851Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar). Additional functions of ov-serpins include the regulation of: 1) cell growth or differentiation, as exemplified by the role of megsin in megakaryocyte differentiation (26Tsujimoto M. Tsuruoka N. Ishida N. Kurihara T. Iwasa F. Yamashiro K. Rogi T. Kodama S. Katsuragi N. Adachi M. Katayama T. Nakao M. Yamaichi K. Hashino J. Haruyama M. Miura K. Nakanishi T. Nakazato H. Teramura M. Mizoguchi H. Yamaguchi N. J. Biol. Chem. 1997; 272: 15373-15380Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar), 2) tumor cell invasiveness and motility, as shown by the inhibitory role of maspin in breast and prostate tumors (27Zou Z. Anisowicz A. Hendrix M.J. Thor A. Neveu M. Sheng S. Rafidi K. Seftor E. Sager R. Science. 1994; 263: 526-529Crossref PubMed Scopus (842) Google Scholar), and 3) angiogenesis (see below). Grigoryev et al. (28Grigoryev S.A. Bednar J. Woodcock C.L. J. Biol. Chem. 1999; 274: 5626-5636Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar) isolated a novel serpin, MENT, from the nuclei of terminally differentiated chicken hematopoietic cells. MENT is an ov-serpin with a CD loop that contains a nuclear localization signal, a lamin-like chromatin binding domain, and an A-T hook DNA binding motif. The molecule has a relatively high pI (9 versus 5–6.5 for that of other serpins) with the majority of positive charges clustering near the CD loop. Thus, MENT appears to utilize the CD loop to bind tightly to nucleosomes with an apparent stoichiometry of 2:1. MENT is the major non-histone chromatin protein in differentiated nuclei and is concentrated in the heterochromatin. MENT induces higher order chromatin compaction when it is expressed ectopically in cells or added to isolated nuclei in vitro. Although MENT contains a viable RSL, target proteinases have yet to be identified. which inhibits uPA, and growth factor in is from and cells G.A. S. E.P. R. S. M. D.A. J. Biol. Chem. 1997; 272: Full Text Full Text PDF PubMed Scopus Google Scholar). may play a role in the from In a neuroserpin in within the and of the protein reduced the by and the number of cells by M. M. E. D.A. 2000; PubMed Google Scholar). In a form of dementia and neuroserpin Molecular analysis in two and in the C. D. P. J. F. D. M. D.A. B. P.R. Carrell R.W. Lomas D.A. Nature. 1999; PubMed Google Scholar). These are similar to that in α1AT in which an of β-sheet A and the formation of loop-sheet In these polymers and in the normal function is and, to a lesser extent, other serpins are within the of from with one of the most common forms of dementia (reviewed in Ref. S. 1998; 20: PubMed Scopus Google Scholar). Although the of this is the extracellular of may be by binding to low receptors and with appears to facilitate formation by as a for the The peptide inserts into A and C of in which it a conformation. Upon RSL is released into the extracellular in which the peptide is more to is a noninhibitory serpin that isolated from pigment epithelial cells but is also in and (6Gettins P.G.W. Patston P.A. Olson S.T. Serpins: Structure, Function and Biology, Molecular Biology Intelligence Unit. R. G. Landes Co., and Chapman & Hall, Austin, TX1996Google Scholar). This factor the survival and differentiation of and et al. P. H. W. Science. 1999; PubMed Scopus Google Scholar) show that inhibits of the and endothelial cell vitro. In the cell as potent as other angiogenesis inhibitors such as and the effects of the angiogenesis growth growth and in the with the of Thus, and to blood growth in the by and angiogenesis and respectively. maspin, and RSL-cleaved have been shown to with angiogenesis in M. Shi N. Nat. 2000; PubMed Scopus Google S. E. G.A. D.A. J. Biol. Chem. Full Text Full Text PDF PubMed Scopus Google S. J. Science. 1999; PubMed Scopus Google Scholar). However, it has yet to be of these are involved in the or regulation of blood A of function in serpin leads to the and of the E. C. D. M. J.A. Science. 1999; PubMed Scopus Google Scholar). of the pathway proteolytic cleavage of the In leads to an in both and the pathway. appears to in a negative loop by proteinases that Thus, the of and the to be secondary to proteolytic The function of these proteins remains Several studies show that serpins are of serine proteinase H. Rasmussen J. J. Biol. Chem. 2000; Full Text Full Text PDF PubMed Scopus Google Scholar). However, with the exception of a proteinase in conventional serine proteinase are in of the sequence of trypsin as a to classical In studies by et al. K. Y. R.J. B. J. J. Biol. Chem. 2000; Full Text Full Text PDF PubMed Scopus Google Scholar) show that of the with the of the to and on these a role for serpins in host Several of human serpins have been by in cells. of these have to an whereas show and structural as well as (see Supplemental Data, Table C). Serpins are within a number of within the of the and the (see Supplemental Data, Table of the serpins are required for growth in cell the and three highly conserved serpins, and types of proteinases The of the also three serpins, the contains serpin genes and lack serpin of encode serpins with P1 and the and all have a with a P1 residue the have a serpin with a at the P1 For more on serpins see Supplemental The serpins are a superfamily of genes that are the metazoa and Serpin members are by a conserved structure and a unique suicide substrate-like inhibitory mechanism. Serpins reside both intracellularly and extracellularly and are involved in a of biologic functions that the ability of these to irreversibly inhibit target proteinases. The of serpin function biological such as the Biochem. Full Text Full Text PDF PubMed Scopus Google Scholar) and the role that these play in and host

Drug-induced liver injury (DILI) is the most frequent reason cited for the withdrawal of approved drugs from the market and accounts for up to 15% of the cases of acute liver failure. Investigators around the globe have begun to identify and study patients with DILI; several large registries and tissue banks are being established. In order to gain the maximum scientific benefit from these efforts, the definitions and terminology related to the clinical phenotypes of DILI must be harmonized. For this purpose, an international DILI Expert Working Group of clinicians and scientists reviewed current DILI terminology and diagnostic criteria so as to develop more uniform criteria that would define and characterize the spectrum of clinical syndromes that constitute DILI. Consensus was established with respect to the threshold criteria for definition of a case as being DILI, the pattern of liver injury, causality assessment, severity, and chronicity. Consensus was also reached on approaches to characterizing DILI in the setting of chronic liver diseases, including autoimmune hepatitis (AIH).

Importance: Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. Objective: To compare clinical characteristics and outcomes of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). Setting, Design, and Participants: Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. Exposure: SARS-CoV-2. Main Outcomes and Measures: Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. Results: Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference [RD], 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% [95% CI, 5.6%-16.0%]; aRR, 1.43 [95% CI, 1.17-1.76] vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P < .001), higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; P < .001), and lower platelet count (<150 ×103 cells/μL [212/523 {41%} vs 84/486 {17%}, P < .001]). A total of 398 patients (73.8%) with MIS-C and 253 (43.8%) with COVID-19 were admitted to the intensive care unit, and 10 (1.9%) with MIS-C and 8 (1.4%) with COVID-19 died during hospitalization. Among patients with MIS-C with reduced left ventricular systolic function (172/503, 34.2%) and coronary artery aneurysm (57/424, 13.4%), an estimated 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days. Conclusions and Relevance: This case series of patients with MIS-C and with COVID-19 identified patterns of clinical presentation and organ system involvement. These patterns may help differentiate between MIS-C and COVID-19.

BACKGROUND: Numerous studies have associated bladder cancer with exposure to carcinogens present in tobacco smoke and other environmental or occupational exposures. Approximately 50% of all humans inherit two deleted copies of the GSTM1 gene which encodes for the carcinogen-detoxification enzyme glutathione S-transferase M1. Recent findings suggest that the GSTM1 gene may modulate the internal dose of environmental carcinogens and thereby affect the risk of developing bladder cancer. PURPOSE: We investigated whether the absence of the GSTM1 gene affects bladder cancer risk and whether there are racial differences in GSTM1 genotype frequency. METHODS: Using a polymerase chain reaction (PCR)-based method, we examined the frequency of the homozygous deleted genotype (GSTM1 0/0) in 229 patients with transitional cell carcinoma of the bladder and 211 control subjects who were enrolled from the Urology Clinics at Duke University Medical Center and the University of North Carolina Hospitals. Control subjects were urology clinic patients who primarily presented with benign prostatic hypertrophy or impotence, who had no history of any cancer other than nonmelanoma skin cancer, and who were frequency matched to case patients on race, sex, and age (10-year age intervals). In order to explore racial differences in GSTM1 gene frequency, genotype was also determined in a community-based sample of 466 paid, healthy, unrelated volunteers from Durham and Chapel Hill, N.C. The presence or absence of the GSTM1 gene locus was determined by using a differential PCR, a semiquantitative technique in which multiple genes are coamplified. RESULTS: Overall, the GSTM1 0/0 genotype conferred a 70% increased risk of bladder cancer (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2-2.5; P = .004). Absence of the GSTM1 gene encoding the glutathione S-transferase M1 enzyme significantly increased risk to persons with exposure to the carcinogens in tobacco smoke (OR = 1.8; 95% CI = 1.2-3.0; P = .01) but poses little increased risk to persons without such exposure. Persons with smoking exposure of more than 50 pack-years who had the GSTM1 0/0 genotype had a sixfold greater risk relative to persons in the lowest risk group (i.e., nonsmokers who were GSTM1 +/+ or +/0). In the pooled clinic control and community sample groups (677 individuals), the GSTM1 0/0 genotype occurred less frequently among Blacks (35%) than among Whites (49%, P < .001). CONCLUSIONS: These findings support a protective role for the GSTM1 gene in bladder cancer. From these findings, it is estimated that 25% of all bladder cancer may be attributable to the at-risk GSTM1 0/0 genotype.

BACKGROUND AND PURPOSE: The extent of a patient's impairment can be established by comparing measurements of that patient's performance with normative values obtained from apparently unimpaired individuals. Only a few studies have described normative values for muscle strength measured by hand-held dynamometry. The purpose of this study of older adults, therefore, was to obtain normative values of maximum voluntary isometric force using hand-held dynamometers. SUBJECTS: One hundred fifty-six asymptomatic adults (77 men, 70 women) participated in this study. The subjects' mean age was 64.4 years (SD=8.3, range=50-79). The male subjects' mean age was 64.5 years (SD=8.4, range=50-79), and the female subjects' mean age was 64.3 years (SD=8.2, range=50-79). METHODS: Gender, age, dominant side, height, weight, and activity level were recorded. Eight upper-extremity movements (shoulder flexion, extension, abduction, and medial and lateral rotation; elbow flexion and extension; and wrist extension) and five lower-extremity movements (hip flexion and abduction, knee flexion and extension, and ankle dorsiflexion) were resisted by one of three experienced testers using a strain-gauge hand-held dynamometer. RESULTS: Gender, age, and weight were identified as independent predictors of force for all muscle actions on both the dominant and nondominant sides. These variables were used, therefore, to create regression equations and normative values for the force of each muscle action. CONCLUSION AND DISCUSSION: The reference values provided may allow clinicians who follow the described testing protocol to estimate the severity of force-generating impairments in patients aged 50 to 79 years.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the prophylaxis of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis. Main recommendations 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before or after ERCP in all patients without contraindication. In addition to this, in the case of high risk for post-ERCP pancreatitis (PEP), the placement of a 5-Fr prophylactic pancreatic stent should be strongly considered. Sublingually administered glyceryl trinitrate or 250 µg somatostatin given in bolus injection might be considered as an option in high risk cases if nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated and if prophylactic pancreatic stenting is not possible or successful. 2 ESGE recommends keeping the number of cannulation attempts as low as possible. 3 ESGE suggests restricting the use of a pancreatic guidewire as a backup technique for biliary cannulation to cases with repeated inadvertent cannulation of the pancreatic duct; if this method is used, deep biliary cannulation should be attempted using a guidewire rather than the contrast-assisted method and a prophylactic pancreatic stent should be placed. 4 ESGE suggests that needle-knife fistulotomy should be the preferred precut technique in patients with a bile duct dilated down to the papilla. Conventional precut and transpancreatic sphincterotomy present similar success and complication rates; if conventional precut is selected and pancreatic cannulation is easily obtained, ESGE suggests attempting to place a small-diameter (3-Fr or 5-Fr) pancreatic stent to guide the cut and leaving the pancreatic stent in place at the end of ERCP for a minimum of 12 - 24 hours. 4 ESGE does not recommend endoscopic papillary balloon dilation as an alternative to sphincterotomy in routine ERCP, but it may be advantageous in selected patients; if this technique is used, the duration of dilation should be longer than 1 minute.

Purpose We evaluated the combination of talimogene laherparepvec plus ipilimumab versus ipilimumab alone in patients with advanced melanoma in a phase II study. To our knowledge, this was the first randomized trial to evaluate addition of an oncolytic virus to a checkpoint inhibitor. Methods Patients with unresectable stages IIIB to IV melanoma, with no more than one prior therapy if BRAF wild-type, no more than two prior therapies if BRAF mutant, measurable/injectable disease, and without symptomatic autoimmunity or clinically significant immunosuppression were randomly assigned 1:1 to receive talimogene laherparepvec plus ipilimumab or ipilimumab alone. Talimogene laherparepvec treatment began in week 1 (first dose, ≤ 4 mL × 10 6 plaque-forming units/mL; after 3 weeks, ≤ 4 mL × 10 8 plaque-forming units/mL every 2 weeks). Ipilimumab (3 mg/kg every 3 weeks; up to four doses) began week 1 in the ipilimumab alone arm and week 6 in the combination arm. The primary end point was objective response rate evaluated by investigators per immune-related response criteria. Results One hundred ninety-eight patients were randomly assigned to talimogene laherparepvec plus ipilimumab (n = 98), or ipilimumab alone (n = 100). Thirty-eight patients (39%) in the combination arm and 18 patients (18%) in the ipilimumab arm had an objective response (odds ratio, 2.9; 95% CI, 1.5 to 5.5; P = .002). Responses were not limited to injected lesions; visceral lesion decreases were observed in 52% of patients in the combination arm and 23% of patients in the ipilimumab arm. Frequently occurring adverse events (AEs) included fatigue (combination, 59%; ipilimumab alone, 42%), chills (combination, 53%; ipilimumab alone, 3%), and diarrhea (combination, 42%; ipilimumab alone, 35%). Incidence of grade ≥ 3 AEs was 45% and 35%, respectively. Three patients in the combination arm had fatal AEs; none were treatment related. Conclusion The study met its primary end point; the objective response rate was significantly higher with talimogene laherparepvec plus ipilimumab versus ipilimumab alone. These data indicate that the combination has greater antitumor activity without additional safety concerns versus ipilimumab.

BACKGROUND: Falls and their consequences are significant concerns for older adults, caregivers, and health care providers. Identification of fall risk is crucial for appropriate referral to preventive interventions. Falls are multifactorial; no single measure is an accurate diagnostic tool. There is limited information on which history question, self-report measure, or performance-based measure, or combination of measures, best predicts future falls. PURPOSE: First, to evaluate the predictive ability of history questions, self-report measures, and performance-based measures for assessing fall risk of community-dwelling older adults by calculating and comparing posttest probability (PoTP) values for individual test/measures. Second, to evaluate usefulness of cumulative PoTP for measures in combination. DATA SOURCES: To be included, a study must have used fall status as an outcome or classification variable, have a sample size of at least 30 ambulatory community-living older adults (≥65 years), and track falls occurrence for a minimum of 6 months. Studies in acute or long-term care settings, as well as those including participants with significant cognitive or neuromuscular conditions related to increased fall risk, were excluded. Searches of Medline/PubMED and Cumulative Index of Nursing and Allied Health (CINAHL) from January 1990 through September 2013 identified 2294 abstracts concerned with fall risk assessment in community-dwelling older adults. STUDY SELECTION: Because the number of prospective studies of fall risk assessment was limited, retrospective studies that classified participants (faller/nonfallers) were also included. Ninety-five full-text articles met inclusion criteria; 59 contained necessary data for calculation of PoTP. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) was used to assess each study's methodological quality. DATA EXTRACTION: Study design and QUADAS score determined the level of evidence. Data for calculation of sensitivity (Sn), specificity (Sp), likelihood ratios (LR), and PoTP values were available for 21 of 46 measures used as search terms. An additional 73 history questions, self-report measures, and performance-based measures were used in included articles; PoTP values could be calculated for 35. DATA SYNTHESIS: Evidence tables including PoTP values were constructed for 15 history questions, 15 self-report measures, and 26 performance-based measures. Recommendations for clinical practice were based on consensus. LIMITATIONS: Variations in study quality, procedures, and statistical analyses challenged data extraction, interpretation, and synthesis. There was insufficient data for calculation of PoTP values for 63 of 119 tests. CONCLUSIONS: No single test/measure demonstrated strong PoTP values. Five history questions, 2 self-report measures, and 5 performance-based measures may have clinical usefulness in assessing risk of falling on the basis of cumulative PoTP. Berg Balance Scale score (≤50 points), Timed Up and Go times (≥12 seconds), and 5 times sit-to-stand times (≥12) seconds are currently the most evidence-supported functional measures to determine individual risk of future falls. Shortfalls identified during review will direct researchers to address knowledge gaps.

PURPOSE OF REVIEW: This article reviews the evidence demonstrating the importance of contamination of hospital surfaces in the transmission of healthcare-associated pathogens and interventions scientifically demonstrated to reduce the levels of microbial contamination and decrease healthcare-associated infections. RECENT FINDINGS: The contaminated surface environment in hospitals plays an important role in the transmission of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), Clostridium difficile, Acinetobacter spp., and norovirus. Improved surface cleaning and disinfection can reduce transmission of these pathogens. 'No-touch' methods of room disinfection (i.e., devices which produce ultraviolet light or hydrogen peroxide) and 'self-disinfecting' surfaces (e.g., copper) also show promise to decrease contamination and reduce healthcare-associated infections. SUMMARY: Hospital surfaces are frequently contaminated with important healthcare-associated pathogens. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider's hands or gloves that may result in patient-to-patient transmission of nosocomial pathogens. Admission to a room previously occupied by a patient with MRSA, VRE, Acinetobacter, or C. difficile increases the risk for the subsequent patient admitted to the room to acquire the pathogen. Improved cleaning and disinfection of room surfaces decreases the risk of healthcare-associated infections.

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. This elaborate process had been undertaken every 7 years resulting in three prior publications in 1986, 1993, and 2000 of "The ASFA Special Issues." This article is the integral part of the Fourth ASFA Special Issue. The Fourth ASFA Special Issue is significantly modified in comparison to the previous editions. A new concept of a fact sheet has been introduced. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. A detailed description of the fact sheet is provided. The article consists of 53 fact sheets devoted to each disease entity currently categorized by the ASFA. Categories I, II, and III are defined as previously in the Third Special Issue. However, a few new therapeutic apheresis modalities, not yet approved in the United States or are currently in clinical trials, have been assigned category P (pending) by the ASFA Clinical Categories Subcommittee. The diseases assigned to category IV are discussed in a separate article in this issue.

Epidermolysis bullosa acquisita is an acquired chronic blistering disease of the skin, in which separation of the skin occurs in the basement-membrane zone between the epidermis and the dermis. There is evidence that blistering is initiated by an immune process. Using serum samples from nine patients as a source of antibodies, we have identified a major protein of the basement membrane of human skin that serves as the antigen (or target) for autoantibodies in this disorder. This previously unrecognized protein, which consists of two components of 290,000 and 145,000 daltons, is distinct from other known components of the basement membrane. These studies provide evidence that epidermolysis bullosa acquisita is a specific disease that is different from other primary bullous diseases, such as bullous pemphigoid and pemphigus vulgaris, and suggest that the basement-membrane component that has been identified may have a role in normal epidermal-dermal adherence.

To study whether the administration of recombinant human erythropoietin increases the amount of autologous blood that can be collected before surgery, we conducted a randomized, controlled trial of erythropoietin in 47 adults scheduled for elective orthopedic procedures. The patients received either erythropoietin (600 units per kilogram of body weight) or placebo intravenously twice a week for 21 days, during which time up to 6 units of blood was collected. Patients were excluded from donation when their hematocrit values were less than 34 percent. All patients received iron sulfate (325 mg orally three times daily). The mean number of units collected per patient (+/- SE) was 5.4 +/- 0.2 for the erythropoietin group and 4.1 +/- 0.2 for the placebo group. The mean red-cell volume donated by the patients who received erythropoietin was 41 percent greater than that donated by the patients who received placebo (961 vs. 683 ml, P less than 0.05). Only 1 of the 23 patients treated with erythropoietin was unable to donate greater than or equal to 4 units (4 percent) as compared with 7 of the 24 patients who received placebo (29 percent). No adverse effects were attributed to erythropoietin. We conclude that recombinant human erythropoietin increases the ability of patients about to undergo elective surgery to donate autologous blood.

This article theoretically explores the characteristics underpinning quadratic term structure models (QTSMs), which designate the yield on a bond as a quadratic function of underlying state variables. We develop a comprehensive QTSM, which is maximally flexible and thus encompasses the features of several diverse models including the double square-root model of Longstaff (1989), the univariate quadratic model of Beaglehole and Tenney (1992), and the squared-autoregressive-independent-variable nominal term structure (SAINTS) model of Constantinides (1992). We document a complete classification of admissibility and empirical identification for the QTSM, and demonstrate that the QTSM can overcome limitations inherent in affine term structure models (ATSMs). Using the efficient method of moments of Gallant and Tauchen (1996), we test the empirical performance of the model in determining bond prices and compare the performance to the ATSMs. The results of the goodness-of-fit tests suggest that the QTSMs outperform the ATSMs in explaining historical bond price behavior in the United States.

In current practice, gadolinium-based contrast agents have been considered safe when used at clinically recommended doses in patients without severe renal insufficiency. The causal relationship between gadolinium-based contrast agents and nephrogenic systemic fibrosis in patients with renal insufficiency resulted in new policies regarding the administration of these agents. After an effective screening of patients with renal disease by performing either unenhanced or reduced-dose-enhanced studies in these patients and by using the most stable contrast agents, nephrogenic systemic fibrosis has been largely eliminated since 2009. Evidence of in vivo gadolinium deposition in bone tissue in patients with normal renal function is well-established, but recent literature showing that gadolinium might also deposit in the brain in patients with intact blood-brain barriers caught many individuals in the imaging community by surprise. The purpose of this review was to summarize the literature on gadolinium-based contrast agents, tying together information on agent stability and animal and human studies, and to emphasize that low-stability agents are the ones most often associated with brain deposition.

OBJECTIVES: To investigate potential determinants of severe hypoglycaemia, including baseline characteristics, in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial and the association of severe hypoglycaemia with levels of glycated haemoglobin (haemoglobin A(1C)) achieved during therapy. DESIGN: Post hoc epidemiological analysis of a double 2x2 factorial, randomised, controlled trial. SETTING: Diabetes clinics, research clinics, and primary care clinics. PARTICIPANTS: 10 209 of the 10 251 participants enrolled in the ACCORD study with type 2 diabetes, a haemoglobin A(1C) concentration of 7.5% or more during screening, and aged 40-79 years with established cardiovascular disease or 55-79 years with evidence of significant atherosclerosis, albuminuria, left ventricular hypertrophy, or two or more additional risk factors for cardiovascular disease (dyslipidaemia, hypertension, current smoker, or obese). Interventions Intensive (haemoglobin A(1C) <6.0%) or standard (haemoglobin A(1C) 7.0-7.9%) glucose control. MAIN OUTCOME MEASURES: Severe hypoglycaemia was defined as episodes of "low blood glucose" requiring the assistance of another person and documentation of either a plasma glucose less than 2.8 mmol/l (<50 mg/dl) or symptoms that promptly resolved with oral carbohydrate, intravenous glucose, or glucagon. RESULTS: The annual incidence of hypoglycaemia was 3.14% in the intensive treatment group and 1.03% in the standard glycaemia group. We found significantly increased risks for hypoglycaemia among women (P=0.0300), African-Americans (P<0.0001 compared with non-Hispanic whites), those with less than a high school education (P<0.0500 compared with college graduates), aged participants (P<0.0001 per 1 year increase), and those who used insulin at trial entry (P<0.0001). For every 1% unit decline in the haemoglobin A(1C) concentration from baseline to 4 month visit, there was a 28% (95% CI 19% to 37%) and 14% (4% to 23%) reduced risk of hypoglycaemia requiring medical assistance in the standard and intensive groups, respectively. In both treatment groups, the risk of hypoglycaemia requiring medical assistance increased with each 1% unit increment in the average updated haemoglobin A(1C) concentration (standard arm: hazard ratio 1.76, 95% CI 1.50 to 2.06; intensive arm: hazard ratio 1.15, 95% CI 1.02 to 1.21). CONCLUSIONS: A greater drop in haemoglobin A(1C) concentration from baseline to the 4 month visit was not associated with an increased risk for hypoglycaemia. Patients with poorer glycaemic control had a greater risk of hypoglycaemia, irrespective of treatment group. Identification of baseline subgroups with increased risk for severe hypoglycaemia can provide guidance to clinicians attempting to modify patient therapy on the basis of individual risk. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00000620.

Purpose The significance of radiotherapy (RT) -associated cardiac injury for stage III non-small-cell lung cancer (NSCLC) is unclear, but higher heart doses were associated with worse overall survival in the Radiation Therapy Oncology Group (RTOG) 0617 study. We assessed the impact of heart dose in patients treated at our institution on several prospective dose-escalation trials. Patients and Methods From 1996 to 2009, 127 patients with stage III NSCLC (Eastern Cooperative Oncology Group performance status, 0 to 1) received dose-escalated RT to 70 to 90 Gy (median, 74 Gy) in six trials. RT plans and cardiac doses were reviewed. Records were reviewed for the primary end point: symptomatic cardiac events (symptomatic pericardial effusion, acute coronary syndrome, pericarditis, significant arrhythmia, and heart failure). Cardiac risk was assessed by noting baseline coronary artery disease and calculating the WHO/International Society of Hypertension score. Competing risks analysis was used. Results In all, 112 patients were analyzed. Median follow-up for surviving patients was 8.8 years. Twenty-six patients (23%) had one or more events at a median of 26 months to first event (effusion [n = 7], myocardial infarction [n = 5], unstable angina [n = 3], pericarditis [n = 2], arrhythmia [n = 12], and heart failure [n = 1]). Heart doses (eg, heart mean dose; hazard ratio, 1.03/Gy; P = .002,), coronary artery disease ( P < .001), and WHO/International Society of Hypertension score ( P = .04) were associated with events on univariable analysis. Heart doses remained significant on multivariable analysis that accounted for baseline risk. Two-year competing risk-adjusted event rates for patients with heart mean dose < 10 Gy, 10 to 20 Gy, or ≥ 20 Gy were 4%, 7%, and 21%, respectively. Heart doses were not associated with overall survival. Conclusion Cardiac events were relatively common after high-dose thoracic RT and were independently associated with both heart dose and baseline cardiac risk. RT-associated cardiac toxicity after treatment of stage III NSCLC may occur earlier than historically understood, and heart doses should be minimized.

PURPOSE: Plasma circulating tumor human papillomavirus DNA (ctHPVDNA) is a sensitive and specific biomarker of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). We investigated whether longitudinal monitoring of ctHPVDNA during post-treatment surveillance could accurately detect clinical disease recurrence. METHODS AND MATERIALS: A prospective biomarker clinical trial was conducted among patients with nonmetastatic HPV-associated (p16-positive) OPSCC. All patients were treated with curative-intent chemoradiotherapy (CRT). Patients underwent a 3-month post-CRT positron emission tomography/computed tomography scan and were thereafter clinically evaluated every 2-4 months (years 1-2), then every 6 months (years 3-5). Chest imaging was performed every 6 months. Blood specimens were collected every 6-9 months for analysis of plasma ctHPVDNA using a multianalyte digital polymerase chain reaction assay. The primary endpoint was to estimate the negative predictive value (NPV) and positive predictive value (PPV) of ctHPVDNA surveillance. RESULTS: One hundred fifteen patients were enrolled, and 1,006 blood samples were analyzed. After a median follow-up time of 23 months (range, 6.1-54.7 months), 15 patients (13%) developed disease recurrence. Eighty-seven patients had undetectable ctHPVDNA at all post-treatment time points, and none developed recurrence (NPV, 100%; 95% CI, 96% to 100%). Twenty-eight patients developed a positive ctHPVDNA during post-treatment surveillance, 15 of whom were diagnosed with biopsy-proven recurrence. Sixteen patients had 2 consecutively positive ctHPVDNA blood tests, 15 of whom developed biopsy-proven recurrence. Two consecutively positive ctHPVDNA blood tests had a PPV of 94% (95% CI, 70% to 99%). Median lead time between ctHPVDNA positivity and biopsy-proven recurrence was 3.9 months (range, 0.37-12.9 months). CONCLUSION: Detection of ctHPVDNA in two consecutive plasma samples during post-treatment surveillance has high PPV and NPV for identifying disease recurrence in patients with HPV-associated oropharyngeal cancer and may facilitate earlier initiation of salvage therapy.

INTRODUCTION: Cisplatin, a platinum-based antineoplastic agent, is the cornerstone for the treatment of many malignancies. Nephrotoxicity is the primary dose-limiting toxicity, and various hydration regimens and supplementation strategies are used to prevent cisplatin-induced kidney injury. However, evidence-based recommendations on specific hydration regimens are limited. A systematic review was performed to evaluate clinical studies that have examined hydration and supplementation strategies to prevent cisplatin-induced nephrotoxicity. MATERIALS AND METHODS: PubMed and Excerpta Medica databases were searched from 1966 through October 2015 for clinical trials and other studies focused on hydration regimens to prevent nephrotoxicity in cancer patients treated with cisplatin. The University of Oxford Centre for Evidence-Based Medicine criteria were used to grade level of evidence. RESULTS: Among the 1,407 identified studies, 24 were included in this systematic review. All studies differed on type, volume, and duration of hydration. Among the 24 studies, 5 evaluated short-duration hydration, 4 evaluated low-volume hydration, 4 investigated magnesium supplementation, and 7 reviewed forced diuresis with hydration. Short-duration and lower-volume hydration regimens are effective in preventing cisplatin-induced nephrotoxicity. Magnesium supplementation may have a role as a nephroprotectant, and forced diuresis may be appropriate in some patients receiving cisplatin. CONCLUSION: 2017;22:609-619 IMPLICATIONS FOR PRACTICE: The findings contained within this systematic review show that (a) hydration is essential for all patients to prevent cisplatin-induced nephrotoxicity, (b) short-duration, low-volume, outpatient hydration regimens appear to be safe and feasible, even in patients receiving intermediate- to high-dose cisplatin, (c) magnesium supplementation (8-16 milliequivalents) may limit cisplatin-induced nephrotoxicity, and (d) mannitol may be considered for high-dose cisplatin and/or patients with preexisting hypertension. These findings have broad implications for clinical practice and represent best practice principles for the prevention of cisplatin-induced nephrotoxicity.