Prognostication of uveal melanoma is simple and highly predictive using The Cancer Genome Atlas (TCGA) classification: A review

Purpose: The cancer genome atlas (TCGA) is a comprehensive project supported by the National Cancer Institute (NCI) in the United States to explore molecular alterations in cancer, including uveal melanoma (UM). This led to TCGA classification for UM. In this report, we review the American Joint Committee on Cancer (AJCC) classification and TCGA classification for UM from the NCI's Center for Cancer Genomics (NCI CCG) (based on enucleation specimens [n = 80 eyes]) and from Wills Eye Hospital (WEH) (based on fine needle aspiration biopsy [FNAB] specimens [n = 658 eyes]). We then compare accuracy and predictability of AJCC versus (vs.) TCGA. Methods: Review of published reports on AJCC and TCGA classification for UM was performed. Outcomes based on AJCC 7th and 8th editions were assessed. For TCGA, UM was classified based on chromosomes 3 and 8 findings including disomy 3 (D3), monosomy 3 (M3), disomy 8 (D8), 8q gain (8qG), or 8q gain multiple (8qGm) and combined into four classes including Class A (D3/D8), Class B (D3/8qG), Class C (M3/8qG), and Class D (M3/8qGm). Outcomes of metastasis and death were explored and a comparison (AJCC vs. TCGA) was performed. Results: In the NCI CCG study, there were 80 eyes with UM sampled by enucleation (n = 77), resection (n = 2), or orbitotomy (n = 1) and analysis revealed four distinct genetic classes. Metastasis and death outcomes were subsequently evaluated per class in the WEH study. The WEH study reviewed 658 eyes with UM, sampled by FNAB, and found Class A (n = 342, 52%), B (n = 91, 14%), C (n = 118, 18%), and D (n = 107, 16%). Comparison by increasing class (A vs. B vs. C vs. D) revealed older mean patient age (P < 0.001), worse entering visual acuity (P < 0.001), greater distance from the optic disc (P < 0.001), larger tumor diameter (P < 0.001), and greater tumor thickness (P < 0.001). Regarding outcomes, more advanced TCGA class demonstrated increased 5-year risk for metastasis (4% vs. 20% vs. 33% vs. 63%,P < 0.001) with corresponding increasing hazard ratio (HR) (1.0 vs. 4.1, 10.1, 30.0,P= 0.01 for B vs. A andP < 0.001 for C vs. A and D vs. A) as well as increased 5-year estimated risk for death (1% vs. 0% vs. 9% vs. 23%,P < 0.001) with corresponding increasing HR (1 vs. NA vs. 3.1 vs. 13.7,P= 0.11 for C vs. A andP < 0.001 for D vs. A). Comparison of AJCC to TCGA classification revealed TCGA was superior in prediction of metastasis and death from UM. Conclusion: TCGA classification for UM is simple, accurate, and highly predictive of melanoma-related metastasis and death, more so than the AJCC classification.

Development and Assessment of an Online Computer- Assisted Instruction Method.

Objectives: The purposes of this study were to develop an online computer-assisted instruction method and assess its efficiency in terms of propriety, feasibility, accuracy and utility standards. Method: The sample consisted of third-year medical students and critical care nurses, who volunteered to join the study. Research tools included online activities and student assessments, open-ended questionnaires and students' record profiles. Data was analysed using the percentage, mean, standard deviation, correlation coefficient and t-test. Results: A total of 83 out of 116 third-year medical students (71.55%) and 35 out of 56 critical care nurses (62.50%) registered through the website, and completed the learning courseware. Results of the system efficiency assessment through the tests and open-ended questionnaires showed that it was highly appropriate for use in communicating for learning; it was also found that the system was highly feasible in stimulating learners to continuously plan for self-directed learning and for system accuracy. It appeared that the system had objectivity, construct validity, concurrent validity, and internal reliability; and for system utility, it was found that learners gained high learning achievement and growth scores. Online record profiles revealed that 63 medical students and 35 nurses appreciated the significance of the developed online learning system as fair to full. Conclusion: The online computer-assisted instruction method was highly efficient. Through selfdirected learning, the students were stimulated to apply problem-solving strategies, individual help seeking strategies, and self-regulation, as well as develop critical thinking with discretion for selfassessment and continue learning with a sense of self-actualization and self-esteem.

Effect of severity of pulmonary disease on nitrous oxide washin and washout characteristics.

The influence of chronic obstructive pulmonary disease (COPD) on the nitrous oxide (N2O) washin and washout characteristics was evaluated in 90 (ASA II-III) males undergoing elective peripheral surgery under general anaesthesia with controlled ventilation. Patients were classified by preoperative bedside pulmonary function testing into three groups. Group I (n = 30), patients without COPD (FEV1/FVC > 80% predicted values; control group); Group II (n = 30), patients with mild COPD (FEV1/FVC = 65-79% of predicted values); and Group III (n = 30), patients with moderate COPD (FEV1/FVC = 50-64% of predicted values). The anaesthetic technique was standardized for all patients. The Datex Capnomac Ultima monitor was used to measure the inspired and expired concentrations of nitrous oxide (N2O), carbon dioxide (CO2), and isoflurane. The duration of both N2O washin (time from start of N2O administration to equilibrium of inspired and expired N2O concentrations) and 5 per cent washout (time from discontinuation of N2O to an expired N2O concentration of 5 per cent of the equilibrium value) were recorded. The duration of N2O washin and washout were significantly prolonged in Groups II and III (P < 0.001) as compared to the control group (Group I). The end-tidal CO2 concentration decreased significantly during N2O washout without causing oxygen desaturation (SpO2 < 90%). We conclude that the duration of N2O washin and washout were significantly prolonged in anaesthetized patients with COPD which may delay the induction and recovery from N2O anaesthesia.

Effects of nebulized beta 2-adrenergic agonists on pulmonary mechanics in anesthetized patients with chronic obstructive pulmonary disease.

We evaluated the effects of nebulized beta 2-adrenergic agonists on pulmonary mechanics in patients with COPD undergoing peripheral surgery with a standardized general anesthetic technique. Thirty males with COPD were randomized into one of three groups. Group I (control group; n = 10) received nebulized saline 3 ml, Group II (n = 10) received nebulized albuterol (2.5 mg in 3 ml), and Group III (n = 10) received nebulized metaproterenol (15 mg in 3 ml). At 20 min after tracheal intubation, the study drugs were nebulized over 20 min. Datex Capnomac Ultima monitor was used to measure pulmonary mechanics on a breath-by-breath basis. There was no difference between the three groups with respect to demographic data and preoperative respiratory parameters. A similar degree of DPH occurred with the initiation of mechanical ventilation in all three groups. Patients receiving nebulized bronchodilators (Groups II and III) displayed a significant decrease in DPH and an increase in total dynamic compliance. However, there were no differences in DPH and total dynamic compliance between Groups II and III. We conclude that nebulization of either albuterol or metaproterenol can alleviate DPH resulting from mechanical ventilation in anesthetized patients with COPD.

Preoperative autologous blood collection and haemodilution with gelatin solution (gelifundol).

Autologous blood collection and haemodilution with gelatin solution had an effect on the decrease in red blood cells, haemoglobin, haemotocrit, fibrinogen and platelets; however, this technique had no effect on coagulograms, platelet function and haemostasis. In conclusion, this technique is suitable and possibly practical in obtaining sufficient blood for elective surgical patients and is without any undesirable side effects.

A comparative study of isobaric and hyperbaric solution of bupivacaine for spinal anaesthesia in caesarean section.

Though hyperbaric solution of bupivacaine following intrathecal injection had satisfactory spread of analgesia, it regressed rapidly with more side effects. Isobaric bupivacaine seemed to provide a slow regression of analgesia with fewer undesirable effects except for its inadequate spread of analgesia. As a result, if the dosages as well as the time of administration of isobaric solution are well adjusted, we believe that it is safe and reliable with an excellent level of analgesia for caesarean section.

The use of nebulized salbutamol in patients with bronchospasm during anaesthesia: a clinical trial.

The 2.5 mg salbutamol in 2.5 ml normal saline (Ventolin nebules) was used in 22 patients with unexpected bronchospasm via a nebulizer connected to an inspired limb of an anaesthetic machine. Recording of cardiovascular effects, specific notes of breath sound according to symptom severity (clinical lung score), arterial blood gases and airway pressure, was made every 5 minutes up to 30 minutes. The PaCO2 decreased and a/A ratio appeared to increase (improved shunt effect) significantly. However, the cardiovascular effects showed no statistical significance. The airway pressure as well as the clinical lung score appeared to decrease significantly to normal limits 20 minutes after the therapy. We conclude that the use of nebulized beta 2 selective bronchodilator is suitable in the treatment of unexpected bronchospasm without any cardiovascular disturbances.

Bedside evaluation of the respiratory function in abdominal surgery with a simplified instrument a controlled study.

Though total prevention of postoperative pulmonary abnormalities after upper abdominal surgery does not seem to be possible, appropriate application of treatment to restore VC and FRC. The pulmonary function test helps the physician to predict postoperative respiratory disorders. Nevertheless, by using a simple respirometer and mini Wright's peak flow meter to evaluate the pulmonary functions perioperatively, it shows close relationship to the conventional test. Both FRC and SVC decreased to approximately 50-55 per cent of the preoperative values one day after surgery and yet, they increased significantly to 70-75 per cent of the preoperative levels on the fifth postoperative day. It is evident from this study that this simple test can serve as a reliable screen of pulmonary function. It can be performed economically and does not require complex equipment.

.5 per cent plain bupivacaine for spinal anaesthesia effects of posture.

0.5 per cent plain bupivacaine following intrathecal injection in the lateral position seems to be lower than that in the sitting position. The dosages of the drug according to the patients' height and the time for injection were shown to yield a desirable spread of analgesia. Provided that strict attention is paid to volume replacement, the technique is safe quick and reliable and provides excellent analgesia. It is satisfactory for use in orthopaedic surgery and abdominal surgery that does not take more than 2 hours.