A man in London appears to be the second person ever cured of HIV, his doctors said.
The man — whose case was first announced a year ago — has now been HIV-free for 30 months without the need for antiviral medications, according to a new report published Tuesday (March 10) in the journal The Lancet HIV.
Previously known only as the “London patient,” the man revealed his identity on Monday (March 9). He is Adam Castillejo, a 40-year-old who was first diagnosed with HIV in 2003, according to The New York Times.
Last year, researchers reported that Castillejo had experienced “long-term remission” from the virus after undergoing a special bone-marrow transplant. At that time, Castillejo had been HIV-free for 18 months. Now, 12 months later, his doctors are more sure that his case does indeed represent a cure.
“We propose that these results represent the second ever case of a patient to be cured of HIV,” study lead author Ravindra Kumar Gupta, a professor of clinical microbiology the University of Cambridge, said in a statement.
The first patient to be cured of HIV — Timothy Brown, also known as the “Berlin patient” — received a similar bone-marrow transplant in 2007 and has been HIV-free for more than a decade.
In the cases of both Castillejo and Brown, stem cells used for their transplants came from a donor who had a relatively rare genetic mutation that confers resistance to HIV.
However, the researchers stressed that such a bone-marrow transplant would not work as a standard therapy for all patients with HIV. Such transplants are risky, and both Castillejo and Brown needed the transplants to treat cancer, rather than for HIV.
In the new report, doctors found no active viral infection in Castillejo’s body. However, they did find “remnants” of HIV’s DNA in some cells. But the authors said these traces of DNA can be thought of as “fossils,” because they are unlikely to allow the virus to replicate. Such remnants were also found in Brown’s case.
Castillejo’s cure “means the first one [in the Berlin patient] wasn’t an anomaly or a fluke,” Gupta told The Guardian.
In patients with gastric cancer who undergo D2 lymphadenectomy, indocyanine green (ICG) helps surgeons harvest more lymph nodes than conventional dissection and reduces the number of nodes that should have been excised, but weren’t, a phase-3 trial reveals.
Drs. Chao-hui Zheng and Chang-Ming Huang of Fujian Medical University Union Hospital in China randomized 266 patients (mean age, about 59; two-thirds men) to ICG tracer-guided or conventional laparoscopic gastrectomy.
As reported in JAMA Surgery, the mean number of lymph nodes retrieved in the ICG group was significantly more than in the non-ICG group (mean, 50.5 vs. 42.0, respectively).
Similarly, significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group, and the mean total number of lymph nodes retrieved with ICG within the scope of the entire procedure was also significantly higher than without ICG (mean, 49.6 vs. 41.7).
Further, the ICG group’s lymph node noncompliance rate was significantly lower than in the non-ICG group: 31.8% vs. 57.4%.
Additional analyses showed that the number of metastatic lymph nodes in each station in the ICG group was not significantly higher than in the non-ICG group, regardless of the resection method. And an analysis of the relationship between the fluorescence lymph nodes and metastatic lymph nodes retrieved in the ICG group indicated that the diagnostic sensitivity and specificity of fluorescence and metastatic lymph nodes were 56.3% and 46.1%, respectively
Notably, no significant between-group differences were found during the postoperative recovery process in the incidence of complications (15.5% vs. 16.3%) or their severity within 30 days after surgery.
“This is a very important study that shows the usefulness of ICG for patients with gastric cancer,” Dr. Marco Giuseppe Patti of the University of North Carolina at Chapel Hill, coauthor of a related editorial, told Reuters Health by email. “The technique is very simple and safe and allows the retrieval of a larger number of lymph nodes. We feel that is even more important for us surgeons in the Western world, as we operate on very few patients with gastric cancer as compared to surgeons in the East.”
“In addition, our patients are often overweight with large amounts of intra-peritoneal fat, which makes the dissection more cumbersome and lengthy,” he noted. “Presently, we feel that infrared fluorescent imaging should be used in any patient with cancer.”
Dr. Amit Bhatt, director of Cleveland Clinic’s Endoluminal Surgery Center in Ohio, commented in an email to Reuters Health, “While there has been interest in the use of ICG tracer with near-infrared fluorescent imaging in gastric cancer for some time, previous studies focused on sentinel node identification or small patient populations. The strengths of the study are the high volume of gastric cancer surgeries involved, and the robust design of the study.”
“Moving forward,” he said, “the two main questions that remain are: 1) Is the long-term survival between these two groups different; and 2) Are these findings translatable to lower surgical volume centers like those in the West where gastric cancer surgery is less common.”
“Despite these questions,” he added, “the use of ICG is simple and should be considered in patients undergoing gastrectomy for gastric cancer.”
Drs. Chao-hui Zheng and Chang-Ming Huang did not respond to requests for comment.
New statistics on colorectal cancer in the United States confirm previously reported trends showing the burden of disease is shifting toward younger adults.
The new data, published online March 5, come from latest edition of Colorectal Cancer Statistics from the American Cancer Society.
During the 2000s, the incidence of CRC has shown a rapid decline in individuals aged 65 and older, but has increased by 1% annually among those aged 50 to 64 years, and increased by 2% annually in those younger than 50 years, the report notes.
CRC death rates from 2008 through 2017 declined by 3% annually in individuals aged 65 years and older, and by 0.6% annually in individuals aged 50 to 64 years, but they have increased 1.3% annually in those aged younger than 50 years.
“As a result of declining [CRC] incidence in older age groups coinciding with increasing incidence in younger individuals, the CRC patient population as a whole is rapidly shifting younger,” conclude the authors, led by Rebecca Siegel, MPH, scientific director, Surveillance Research, American Cancer Society, Atlanta, Georgia.
Commenting on the new figures, Kimmie Ng, MD, MPH, Dana-Farber Cancer Institute, Boston, Massachusetts, who was not involved with the statistical report, said, “The new American Cancer Society statistics reinforce previous trends that demonstrate a very concerning, steady rise in the incidence of young-onset colorectal cancer.”This rising burden on people younger than 50 years old is what keeps me up at night. Dr Kimmie Ng
“This rising burden on people younger than 50 years old is what keeps me up at night, and which is why we have redoubled our efforts to tackle the problem,” Ng told Medscape Medical News.
This effort includes the opening of the Young-Onset Colorectal Cancer Center at her institution a year ago, where Ng serves as the director.
At the center, providers are partnering with patients to address their unique needs and to carry out focused research aimed at identifying those at the highest risk for CRC as well as novel treatment strategies.
“Up until this point, there has been very limited scientific data available on CRC specifically in people younger than 50,” Ng noted.
“And we are working every day to make inroads in decreasing CRC incidence and mortality by raising awareness of what is a potentially preventable cancer, and underscoring the importance of screening tests,” she added.
The increase in CRC incidence among adults younger than 50 has also been seen in other countries, including Australia, New Zealand, Canada, and many across Europe, as reported by Medscape Medical News.
CRC Statistics Reveal a Shift
In terms of overall numbers, the majority of cases are still occurring in older individuals.
The report estimates that the overall number of newly diagnosed CRC patients in 2020 in the US is expected to reach 147,950. Of these, 12% are expected to occur in patients younger than 50. Additionally, the authors estimate there will 53,200 deaths from CRC in 2020; about 7% are expected to occur in patients younger than 50.
Important to note, the authors say, is that there has been a shift toward CRC incidence in younger adults.
This is reflected by the median age at the time of diagnosis, which has dropped from age 72 years in the period 1988-1989 to age 66 years in the period 2015-2016, they add.
The decline in CRC incidence in older adults is explained by the authors as a result of increased screening.
They note that rapid declines seen in the 2000s in the incidence of CRC in people age 50 and older reflect a surge in screening colonoscopy, which tripled from 20% in 2000 to 61% in 2018 in this age group.
More recently, however, the decline in CRC incidence was confined to those aged 65 years and older, among whom CRC incidence rates dropped by 3.3% a year between 2011 and 2016.
This has not held true for patients between the ages of 50 and 64 years. In this age range, the declines in the incidence of CRC of between 2% to 3% a year during the 2000s have now reversed, and increased by 1% a year in the period 2011 through 2016, the researchers note.
“The uptick is similar to the trend in individuals aged younger than 50 years and likely reflects elevated disease risk in generations born since 1950 being carried forward by aging birth cohorts, a phenomenon referred to as a birth cohort effect,” the authors write.
Asked to elaborate on this so-called “birth cohort effect,” Siegel explained that the underlying risk of being diagnosed with CRC exclusive of the impact of screening had been declining for a long time because of changing patterns in risk factors such as a drop in smoking rates and increases in the use of anti-inflammatory drugs.
“However, this changed with people born after the 1950s; their risk of disease is higher and has increased with each subsequent generation,” Siegel told Medscape Medical News in an email.
“People don’t just have a higher risk when they’re young and leave it behind as they age…they carry the elevated risk with them, which is why you see an uptick in CRC incidence over time in increasing age groups,” she explained.
“Since 1950, risk has been increasing for every subsequent generation,” Siegel emphasized.
Indeed, the report shows that CRC incidence rates in patients younger than age 50 have actually been increasing since the mid-1990s, largely driven by rectal tumors.
However, between 2012 and 2016, incidence rates for patients younger than 50 rose by 1.8% a year for tumors in the proximal and distal colon as well as in the rectum, and by 2.2% annually for total colorectum (excluding the appendix).
Alarmingly, “the increased incidence in those aged younger than 50 years is confined to advanced-stage diagnoses and is steepest among non-Hispanic Whites (NHW) [at] 2% per year and American Indian/Alaska Natives (AI/ANs) [at] 2.2% per year,” the researchers note.
As a result of these trends, “CRC incidence rates in NHWs aged 20 to 49 years are now equivalent to those in blacks…despite being 40% higher in blacks during 1995-1996,” they add.
Slightly more than 20% of patients between 45 and 49 years of age availed themselves of screening colonoscopy in 2018, as is now recommended by the American Cancer Society (many other medical associations, however, continue to recommend starting colonoscopy at age 50). There is an ongoing debate about whether the age to start screening for CRC should be lowered in the US. In other countries (eg, the United Kingdom), screening for CRC starts at 60 (using stool tests).
However, the authors also note that “patterns of CRC test use do not appear to explain the rise in early-onset CRC, particularly in light of the preponderance of advanced-stage disease diagnoses.”
Asked what she thinks is driving the shift of CRC incidence in younger patients, Siegel admitted that reasons for the rise are still unknown.
“The obesity epidemic is probably contributing to it but it doesn’t seem to be the sole cause,” she said.
However, diet has a large influence on CRC risk as well; there is considerable interest now in looking at how things like antibiotics influence gut health — specifically their role in determining the microorganisms that make up the microbiome, which could influence CRC risk, Siegel suggested.
Siegel and five other authors of the report are employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the submitted work. Author Andrea Cercek serves on the advisory board for Bayer and Array Biopharma and receives research support from Tesaro, RGenix, and Seattle Genetics, all outside the submitted work.
CA Cancer J Clin. Published online March 5, 2020. Full text
The American Association of Endocrine Surgeons (AAES) has issued a first-of-its-kind set of clinical guidelines for the surgical treatment of thyroid disease, offering evidence-based recommendations on the wide-ranging aspects of thyroidectomy and the management of benign as well as malignant thyroid nodules and cancer.
Whereas various endocrine and thyroid societies issue guidelines on many aspects of management of thyroid disease, the new AAES guidelines are the first focusing specifically on surgical management of thyroid disease in adults.
“These guidelines truly focus on the surgical decision-making and management of thyroid disease; however, there is something for all clinicians who take care of patients with thyroid disease,” lead author Kepal N. Patel, MD, of NYU Langone Health in New York City, told Medscape Medical News.
The guidelines, published this week in the Annals of Surgery,include a total of 66 recommendations from a multidisciplinary panel of 19 experts. The group reviewed medical literature spanning from 1985 to 2018. (The authors of the guidelines report no conflicts of interest, although the article lists several disclosures.)
More than 100,000 thyroidectomies are performed each year in the United States alone, and as surgical indications and treatment paradigms evolve, the need for surgical guidance is more important than ever, Patel said.
“Such transformations have propagated differences in clinical interpretation and management, and as a result, clinical uncertainty and even controversy have emerged,” he said.
“Recognizing the importance of these changes, the AAES determined that evidence-based clinical guidelines were necessary to enhance the safe and effective surgical treatment of benign and malignant thyroid disease.”
Key areas addressed in the guidelines include the addition of new cytologic and pathologic diagnostic criteria, molecular profiling tests, operative techniques and adjuncts, and the nuances surrounding the sometimes challenging newer concept of ‘borderline’ thyroid tumors, Patel noted.
In terms of imaging recommendations, for instance, the guidelines recommend the preoperative use of CT or MRI:
“CT or MRI with intravenous contrast should be used preoperatively as an adjunct to ultrasound in selected patients with clinical suspicion for advanced locoregional thyroid cancer,” the guidelines state, citing the recommendation as being “strong,” with a “low quality of evidence.” (Recommendation 6).
Further diagnostic recommendations cover issues including voice assessment, the risk for vocal fold dysfunction related to thyroid disease and surgery, and the use of fine-needle aspiration biopsy in evaluating suspicious thyroid nodules and lymph nodes.
The guidelines also address the indications for thyroidectomy, with recommendations regarding the extent and outcomes of surgery spanning different categories of thyroid disease.
A key recommendation along those lines, for instance, indicates that, when possible, thyroidectomy should be performed by surgeons who perform a high volume of such procedures.
Approaches for safe and effective perioperative management are also covered, including measures to prevent complications and the use of thyroid tissue diagnosis during surgery, such as core needle biopsy of the thyroid and cervical lymph nodes and incisional biopsy of the thyroid, nodal dissection, and concurrent parathyroidectomy.
Recommendations further address the optimal management of thyroid cancer, with an emphasis on a personalized, evidence-based approach tailored to the patient’s situation and preferences.
The authors underscore that, as technology rapidly evolves, “in the future, this work will certainly and rightly need to be done again.”
In the meantime, the recommendations should be relevant to “the target audience [of] the practicing surgeon in a community hospital, academic center, or training program.”
An AAES press release notes that “the members of the expert panel hope their efforts will meet the need for evidence-based recommendations to ‘define practice, personalize care, stratify risk, reduce healthcare costs, improve outcomes, and identify rational challenges for future efforts.’ ”
The guidelines on minimally invasive pancreas resection (MIPR) were released in January 2020 by the International Study Group on Minimally Invasive Pancreas Surgery (I-MIPS), cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology.
Distal and Central Pancreatectomy
Minimally invasive distal pancreatectomy (MIDP) for benign and low-grade malignant tumors is to be considered over open distal pancreatectomy (ODP), in that it is associated with a shorter hospital stay, reduced blood loss, equivalent complication rates, and better postoperative quality of life.
MIDP for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands.
No evidence exists regarding the use of vascular resection in MIDP.
Both stapler and nonstapler closure can be used in MIDP; outcomes are comparable. Evidence to support routine staple-line reinforcement with any method or material is lacking.
No studies exist specifically comparing spleen-preserving MIDP with spleen-preserving ODP.
Both laparoscopic distal pancreatectomy (LDP) and robotic distal pancreatectomy (RDP) are safe and feasible. The choice of technique should be based on surgeons’ experience and local resources.
Minimally invasive central pancreatectomy has been reported to be feasible, but safety must be confirmed before it can be widely adopted. Comparative data on minimally invasive vs open central pancreatectomy are inadequate.
Minimally invasive enucleation of pancreatic lesions in selected patients is an appropriate alternative to open enucleation.
Pancreatoduodenectomy
Insufficient data exist to recommend minimally invasive pancreatoduodenectomy (MIPD) over open pancreatoduodenectomy (OPD). Both MIPD and OPD are valid approaches for selected patients with adenocarcinoma.
No comparative data exist regarding MIPD vs OPD for the treatment of pancreatic head adenocarcinoma after neoadjuvant therapy.
Limited comparative data exist regarding MIPD vs OPD for the treatment of pancreatic head ductal adenocarcinoma requiring vascular resection. MIPD with vascular resection should be performed only by highly experienced surgeons and in high-volume centers.
No evidence of superiority exists regarding laparoscopic pancreatoduodenectomy (LPD) vs robotic pancreatoduodenectomy (RPD) for the treatment of pancreatic head lesions. Surgeon training, experience, and available resources guide the choice of approach.
Patients and Technique
There are no contraindications for MIPR based on patient age, obesity, or previous abdominal surgery.
The evidence to suggest a relationship between comorbidity and the outcome of MIPR is limited.
No evidence exists that specifically addresses the relative benefits of any particular hemostatic technique in MIPR.
No evidence exists to clearly determine the appropriate timing or indication for conversion in MIPR. Elective conversion should be considered on the basis of surgeon experience, concern for patient safety, or failure to progress.
Training and Implementation
Participation in a structured training program is strongly recommended for all surgeons undertaking MIPR.
Single-surgeon learning curves for MIPR show improvements in operative time, blood loss, lymph node harvest, and complications with increased total volume/experience; the exact number remains to be defined.
No specific studies assess prerequisites for MIPR. Experience in pancreatic surgery, including a formal fellowship training or an established practice as a pancreatic surgeon, is advised. A two-surgeon approach can be beneficial in the learning curve.
Center volume strongly affects outcomes after MIPR; consideration of total pancreas resection volume along with MIPR-specific volume is critical. MIPD should be performed in high-volume centers; mortality (at < 10 MIPD/y) and morbidity (at < 20 MIPD/y) are worse in low-volume settings.
Centers undertaking MIPR should consider the following measures: implementing dedicated individual and team training; having more than one surgeon performing MIPR at the institution; monitoring outcomes of MIPR for quality assurance; and considering surgeon/institution volume of pancreas resections, including MIPR.
Instrumentation
No documented advantages for any specific energy device have been reported.
The development of instruments and enhanced visualization systems for MIPR should be encouraged.
Accountability
Inclusion of patient data into thoughtfully organized and maintained regional, national, and international registries supported by hepatopancreatobiliary organizations is strongly encouraged.
Because outcome monitoring of MIPD is essential for its safe and wide expansion, inclusion into validated regional, national, and international registries is highly recommended.
Development and expansion of MIPR should be encouraged and monitored by national and international societies through the promotion of working groups to drive training and registries.
A new meta-analysis adds further fuel to the controversy over sodium and cardiovascular health, suggesting that reducing dietary sodium lowers blood pressure (BP) even among those whose starting systolic BP is as low as 120 mmHg.
Each 50-mmol reduction in 24-hour sodium excretion was associated with reductions in systolic BP of 0.66, 1.89, and 2.76 mmHg among normotensive patients, a mix of normotensive and hypertensive patients, and hypertensive patients, respectively.
“This is a quite important finding that it is beneficial not only in hypertensive individuals but those with normal blood pressure,” senior author Feng J. He, MD, Queen Mary University of London, United Kingdom, told theheart.org | Medscape Cardiology. “Also, the study showed quite clearly that the lower the salt intake achieved, the lower the blood pressure.”
The World Health Organization recommends a maximum dietary sodium intake of 2 g/day (5 g of salt) as a population-level intervention to reduce cardiovascular disease (CVD) and mortality. Previous studies, however, have reported that sodium reduction is of limited or no value in normotensive individuals.
Further questions were raised following evidence from the PURE study of a J-shaped relationship, in which both higher and lower sodium levels were associated with increased CVD risk.
Unlike the PURE study, which has been criticized for using spot urine tests to estimate sodium excretion, only 24-hour urine collection was used to estimate sodium excretion in the 133 randomized trials in the meta-analysis, He noted.
Among the 12,197 participants, each 50-mmol reduction in 24-hour sodium excretion was associated with a 1.10-mmHg reduction in systolic BP and a 0.33-mmHg reduction in diastolic BP (P = .03).
Falls in systolic BP were present across all subgroups, as classified by age, sex, and race, but were larger among those older than 55 to 65 years (– 3.88; 95% confidence interval [CI], –5.05 to –2.71), women (–1.32; 95% CI, –2.47 to –0.16), and blacks (–4.07; 95% CI, –6.14 to –2.00), the authors report in an article published online February 25 in the BMJ.
Reductions were also found for each group, as classified by mean baseline systolic BP:
<120 mmHg; –0.39 (95% CI, –.061 to –0.18)
≥120 to <130 mmHg; –1.21 (95% CI, –1.87 to –0.55)
≥130 to <140 mmHg; –2.23 (95% CI, –2.89 to –1.57)
≥ 140 to <150 mmHg; –3.23 (95% CI, –3.88 to –2.59)
≥150 to <160 mmHg; –2.68 (95% CI, –3.55 to –1.81)
≥160 mmHg; –2.97 (95% CI, –4.34 to –1.60)
“It seems to me that the blood pressure barely changed in the normotensive individuals, so I think they exaggerate how much benefit there would be to the general population,” Suzanne Oparil, MD, a hypertension expert and director of the vascular biology and hypertension program at the University of Alabama at Birmingham, commented to theheart.org | Medscape Cardiology.
She noted that 24-hour urinary collections can vary, depending on how conscientious the individual is, and that studies involving Russian cosmonauts have shown large variations in 24-hour sodium excretion day to day. “So there’s no gold standard there,” Oparil said.
In addition, Oparil noted that the investigators used casual BP measurements rather than 24-hour ambulatory BP measurements and dismissed data showing that very low sodium intake sometimes stimulates counter-regulatory mechanisms, such as the renin-angiotensin system, which tends to drive blood pressure up.
In addition, the findings are based on study-level rather than patient-level data and do not include CV outcomes, she said.
“Clearly if you have high blood pressure and you eat a lot of salt, decreasing the salt will lower the blood pressure, but for people who have essentially normal or nearly normal blood pressure and are not consuming very much salt, I just don’t believe that reducing the salt intake has demonstrable benefit,” Oparil said.
Senior investigator He said that evidence showing a lack of benefit with sodium reduction in normotensive individuals is based on very short-term studies and that activation of the renin-angiotensin system and adverse metabolic effects linked to large decreases in dietary sodium do not appear to be present in longer-term interventions.
In the meta-analysis, interventions to reduce sodium varied in length from no more than 7 days to more than 6 months.
No overall association was identified between intervention duration and the magnitude of either systolic or diastolic BP reduction, likely because of a lack of statistical power, because only 19% of studies included interventions that lasted longer than 30 days, and only 4% were longer than 6 months, He said.
Nevertheless, the effect of each 50-mmol reduction in 24-hour sodium excretion on systolic BP was approximately twice as large in studies with interventions longer than 14 days vs 14 days or less (2.13 mmHg vs 1.05 mmHg; P = .002).
Long-term reductions in dietary sodium can be difficult for individuals, but positive health benefits have been reported from national programs that combine salt-awareness campaigns and collaboration with food industry, He said.
For example, the investigators previously reported that the United Kingdom’s salt-reduction program, which sets voluntary, incrementally lower salt-reduction targets for more than 85 food categories, led to a 15% reduction in salt intake (from 9.5 g/day in 2003 to 8.1 g/day in 2011), a 2.7-mmHg fall in population systolic BP, and a decrease in mortality from stroke by 42% and ischemic heart disease by 40%.
Going forward, more ambulatory blood pressure monitoring data reflecting different dietary conditions would be useful, Oparil suggested. “It would be worthwhile knowing more about the effects of salt reduction on diurnal variation in blood pressure; we know that out-of-office blood pressure, particularly nocturnal blood pressure, seems to be more associated with outcomes than in-office blood pressure,” she said.
You must be logged in to post a comment.