Tuberculosis and diabetes: increased hospitalisations and mortality associated with renal impairment.

BACKGROUND: Diabetes mellitus (DM) triples a person's risk of active tuberculosis (TB) and is associated with increased mortality. It is unclear whether diabetes status and/or the associated renal dysfunction is associated with poor TB outcomes in New Zealand, which has high diabetes screening. AIM: To characterise the population of TB-DM and TB-alone to assess the effect of diabetes status and renal function on hospitalisation and mortality. METHODS: Clinical records from all adult patients diagnosed with TB in Auckland over a 6-year period (2010-2015) were reviewed. Baseline demographics, clinical presentation and microbiological data were assessed to compare the rates of hospitalisation and mortality between those with TB-DM and TB-alone. Statistical significance was defined as P < 0.05. RESULTS: A total of 701 patients was identified with TB; 120 (17%) had an unknown diabetes status and were excluded, and 135 had co-existing diabetes. The TB-DM and TB-alone groups had similar distribution of TB site and proportions of Mycobacterium tuberculosis culture positivity. Univariate analysis showed TB-DM patients had statistically significantly higher proportions of acute hospitalisation and mortality. Multivariate logistic regression showed only a reduced estimated glomerular filtration rate (eGFR) accounted for the higher rates of hospitalisation, with the odds of hospitalisation increasing by 2% for every unit decrease in eGFR. The odds of mortality increased by 6% for every year increase in age, and the odds of mortality increased by 3% for every unit reduction in eGFR. CONCLUSIONS: Diabetes is associated with higher TB hospitalisation and mortality; however, this is likely mediated by increased age and chronic kidney disease.

Surgical treatment of non-small-cell lung cancer in octogenarians: a single-centre retrospective study.

Lung resection in patients aged ≥80 years is considered high risk and contributes to the low rates of resection in this population. This review of 79 octogenarians who underwent curative surgery for non-small-cell lung cancer demonstrated no intraoperative mortality, 30-day mortality of 1.3% and 12-month mortality of 10%. In this selected cohort of octogenarians, surgery resulted in acceptable short- to medium-term outcomes.

Patients' and doctors' preferences for adjuvant chemotherapy in resected non-small-cell lung cancer: What makes it worthwhile?

BACKGROUND: Adjuvant chemotherapy (ACT) in non-small-cell lung cancer (NSCLC) improves overall survival, but the benefits must be weighed against its harms. We sought to determine the survival benefits that patients and their doctors judged sufficient to make ACT in NSCLC worthwhile. METHODS: 122 patients completed a self-administered questionnaire at baseline and 6 months (before & after ACT, if they had it); 82 doctors completed the questionnaire once only. The time trade-off method was used to determine the minimum survival benefits judged sufficient in four hypothetical scenarios. Baseline survival times were 3 years & 5 years and baseline survival rates (at 5 years) were 50% & 65%. RESULTS: At baseline, the median benefits judged sufficient by patients were an extra 9 months (Interquartile range (IQR) 1-12 months) beyond 3 years & 5 years and an extra 5% (IQR 0.1-10%) beyond 50% & 65%. At 6 months (n=91), patients' preferences had the same median benefit (9 months & 5%) but varied more (IQRs 0-18 months & 0-15%) than at baseline. Factors associated with judging smaller benefits sufficient were deciding to have ACT (P=0.01, 0.02) and better well-being (P=0.01, 0.006) during ACT. Doctors' preferences, compared with patients' preferences, had similar median benefits (9 months & 5%) but varied less (IQR 6-12 months versus 1-12 months, P<0.001; 5%-10% versus 0.1-10%, P<0.001). CONCLUSION: Most patients and doctors judged moderate survival benefits sufficient to make ACT in NSCLC worthwhile, but the preferences of doctors varied less than those of patients. Doctors should endeavour to elicit patients' preferences during discussions about ACT in NSCLC.

Destruction of the bladder by single dose Mitomycin C for low-stage transitional cell carcinoma (TCC)--avoidance, recognition, management and consent.

OBJECTIVES: To identify a cohort of patients under our care who have had significant and in some cases irreparable damage to their bladders after Mitomycin C (MMC) instillation. To highlight the importance of avoidance and recognition of bladder perforations during transurethral resection of bladder tumour (TURBT) and explore the issue of consent regarding MMC given the serious complications that may occur after its instillation. PATIENTS AND METHODS: Patients referred to our tertiary centre for a second opinion to manage their complications after a suspected MMC leak was identified from the departmental database between January 2000 and December 2010. After collection of all the records, we established a cohort of six patients. All patients had their initial tumour resection elsewhere and were referred for specialist management thereafter. Details of the operating surgeon and cystoscopic findings were known only in half of the cases. Retrospective analysis of their notes including documentation from the referring centre was undertaken. This included a review of all the histology and imaging. RESULTS: All patients had immediate severe pelvic pain on instillation of the MMC. Four of the six continue to have chronic pelvic pain. Two patients had urinary retention and three had severe lower urinary tract symptoms. One patient developed a frozen pelvis. Initial treatment was with an indwelling catheter for a period of 2-52 weeks to aid healing. Two patients had reconstructive surgery, one with success and the other with failure, as an intestinal patch failed to close the fistula and he continues with a catheter. One patient had an ileal conduit. No patient was warned of such complications. CONCLUSIONS: Although rare, prophylactic MMC can have devastating consequences. Patients should be aware of such major risks. Strong emphasis should be placed on the quality of the initial TURBT coupled with the judgement of an experienced surgeon before to MMC instillation. The real clinical benefit could be reviewed and intravesical MMC offered only to patients who have a good chance of benefit.

Multiple loci on 8q24 associated with prostate cancer susceptibility.

Previous studies have identified multiple loci on 8q24 associated with prostate cancer risk. We performed a comprehensive analysis of SNP associations across 8q24 by genotyping tag SNPs in 5,504 prostate cancer cases and 5,834 controls. We confirmed associations at three previously reported loci and identified additional loci in two other linkage disequilibrium blocks (rs1006908: per-allele OR = 0.87, P = 7.9 x 10(-8); rs620861: OR = 0.90, P = 4.8 x 10(-8)). Eight SNPs in five linkage disequilibrium blocks were independently associated with prostate cancer susceptibility.

Identification of new genetic risk factors for prostate cancer.

There is evidence that a substantial part of genetic predisposition to prostate cancer (PCa) may be due to lower penetrance genes which are found by genome-wide association studies. We have recently conducted such a study and seven new regions of the genome linked to PCa risk have been identified. Three of these loci contain candidate susceptibility genes: MSMB, LMTK2 and KLK2/3. The MSMB and KLK2/3 genes may be useful for PCa screening, and the LMTK2 gene might provide a potential therapeutic target. Together with results from other groups, there are now 23 germline genetic variants which have been reported. These results have the potential to be developed into a genetic test. However, we consider that marketing of tests to the public is premature, as PCa risk can not be evaluated fully at this stage and the appropriate screening protocols need to be developed. Follow-up validation studies, as well as studies to explore the psychological implications of genetic profile testing, will be vital prior to roll out into healthcare.

Multiple newly identified loci associated with prostate cancer susceptibility.

Prostate cancer is the most common cancer affecting males in developed countries. It shows consistent evidence of familial aggregation, but the causes of this aggregation are mostly unknown. To identify common alleles associated with prostate cancer risk, we conducted a genome-wide association study (GWAS) using blood DNA samples from 1,854 individuals with clinically detected prostate cancer diagnosed at

Primary uretero-iliac fistula: the unusual source of haematuria.

Uretero-iliac fistula is a rare cause of frank haematuria. The aetiology of such fistula is commonly iatrogenic. We present a unique case of a primary aorto-iliac fistula in the absence of an aneurysm or arteriovenous malformation. The diagnosis was demonstrated by ureteroscopy and real-time retrograde ureterogram. Multiple arterial embolisation of the fistula had failed, and the patient underwent a successful ureterolysis and ligation of fistula. We demonstrate the diagnostic difficulties and treatment dilemma of such rare cause of haematuria.

Lung cancer treatment in New Zealand: physician's attitudes.

AIMS: To determine treatment practices of New Zealand physicians who manage non-small cell lung cancer (NSCLC). METHODS: A questionnaire on the treatment of NSCLC was emailed to all respiratory physicians, medical oncologists, and radiation oncologists in New Zealand. Respondents were asked to select the treatment they would offer in six lung cancer case scenarios. RESULTS: Thirty-one (81%) respiratory physicians, 15 (71%) medical oncologists, and 8 (30%) radiation oncologists responded to the questionnaire. Surgery was selected (by all groups) as the best option for early-stage disease NSCLC. Radiotherapy or combination chemo/radiotherapy (for locally advanced disease) was favoured by 37% of respiratory physicians for stage IIIa and 28% for stage IIIb--compared with medical oncologists (100% and 80%) and radiation oncologists (86% and 28%). Chemotherapy for 'fit' patients with advanced disease was favoured by only 11% of respiratory physicians, compared with 67% of medical oncologists and 33% of radiation oncologists. Best supportive care (BSC) was the favoured treatment for patients with advanced disease with poor performance patients. CONCLUSION: This study demonstrates considerable heterogeneity in the choice of treatment for NSCLC between specialities, particularly for locally advanced and advanced disease. These findings suggest international guidelines are not being adhered to, and variations in treatment may potentially have outcome implications for patients.