Vitamin D Deficiency at Diagnosis Increases All-Cause and Prostate Cancer-specific Mortality in Jamaican Men.

BACKGROUND: 25 hydroxyvitamin D [25(OH)D] and serum calcium have been associated with incident prostate cancer (PCa). However, there is limited data on whether these metabolites predict survival in men of African descent, a population disproportionately affected by PCa. We studied the relationship of 25(OH)D at PCa diagnosis with all-cause and cancer-specific mortality among Jamaican men and examined whether serum calcium modified any associations. METHODS: Serum 25(OH)D from 152 Jamaican men with incident PCa within the Prostate Cancer Risk Evaluation (PROSCARE) study were re-evaluated approximately 11 years after enrollment. 25(OH)D analyses were stratified using the using Holick criteria. PCa-specific and all-cause mortality were examined in Kaplan-Meier survival curves and Cox regression models adjusted for age, body mass index (BMI), smoking and Gleason score. Restricted cubic splines evaluated nonlinear associations. Serum calcium was assessed as an effect modifier of the association between 25(OH)D and mortality. RESULTS: Of cases with available 25(OH)D, 64 men with PCa survived, 38 deaths were PCa specific and 36 died of other causes. At baseline, 9.9% of cases were vitamin D deficient and 61.2% were vitamin D sufficient. Compared to 25(OH)D sufficient men, those with 25(OH)D <20.0 ng/mL concentrations were associated with higher PCa-specific mortality (adjusted HR, 4.95; 95% CI, 1.68, 14.63, P = .004) and all-cause mortality (adjusted HR, 2.40; 95%CI, 1.33, 4. 32, P = .003). Serum calcium was not associated with survival and did not modify any associations with 25(OH)D. CONCLUSIONS: 25(OH)D deficiency at PCa diagnosis predicted decreased survival for overall and PCa-specific cancer in Caribbean men of African ancestry.

Both serum 25-hydroxyvitamin D and calcium levels may increase the risk of incident prostate cancer in Caribbean men of African ancestry.

Circulating 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with both higher and lower risk of prostate cancer (PCa), whereas elevated levels of circulating calcium has been related to higher risks. However, there are few studies that account for effects of both calcium and 25(OH)D concentrations on incident PCa in a black population. We examined these relationships in a case-control study of men 40-80 years old with newly diagnosed, histologically confirmed PCa in Jamaica, a tropical country. Mean serum calcium concentrations was higher among cases (2.32 ± 0.19 mmol/L) than controls, (2.27 ± 0.30 mmol/L) (P = 0.023) however, there were no differences in 25(OH)D by cancer status (cases, 33.67 ± 12.71 ng/mL; controls (32.25 ± 12.59 ng/mL). Serum calcium was not correlated with 25(OH)D (partial correlation: r, 0.06; P = 0.287). Multivariable-adjusted models showed a positive linear relationship between PCa and serum calcium (OR, 1.12; CI, 1.00-1.25 per 0.1 nmol/L). Serum 25(OH)D concentration also showed a positive association with PCa (OR, 1.23; CI, 1.01-1.49 per 10 ng/mL). The odds of PCa in men with serum 25(OH)D tertile 2 was OR, 2.18; CI, 1.04-4.43 and OR, 2.47 CI, 1.20-4.90 for tertile 3 (P(trend) = 0.013). Dietary intakes of calcium showed no relationship with PCa. Despite the strong relationship between serum calcium and vitamin D the mechanism by which each affects prostate cancer risk in men of African ancestry needs additional investigation.

A unique strain of community-acquired Clostridium difficile in severe complicated infection and death of a young adult.

BACKGROUND: Clostridium difficile is the major cause of nosocomial antibiotic-associated diarrhoea with the potential risk of progressing to severe clinical outcomes including death. It is not unusual for Clostridium difficile infection to progress to complications of toxic megacolon, bowel perforation and even Gram-negative sepsis following pathological changes in the intestinal mucosa. These complications are however less commonly seen in community-acquired Clostridium difficile infection than in hospital-acquired Clostridium difficile infection. To the best of our knowledge, this was the first case of community-acquired Clostridium difficile infection of its type seen in Jamaica. CASE PRESENTATION: We report a case of a 22-year-old female university student who was admitted to the University Hospital of the West Indies, Jamaica with a presumptive diagnosis of pseudomembranous colitis PMC. She presented with a 5-day history of diarrhoea following clindamycin treatment for coverage of a tooth extraction due to a dental abscess. Her clinical condition deteriorated and progressed from diarrhoea to toxic megacolon, bowel perforation and Gram-negative sepsis. Clostridium difficile NAP12/ribotype 087 was isolated from her stool while blood cultures grew Klebsiella pneumoniae. Despite initial treatment intervention with empiric therapy of metronidazole and antibiotic clearance of Klebsiella pneumoniae from the blood, the patient died within 10 days of hospital admission. CONCLUSIONS: We believe that clindamycin used for coverage of a dental abscess was an independent risk factor that initiated the disruption of the bowel micro-flora, resulting in overgrowth of Clostridium difficile NAP12/ribotype 087. This uncommon strain, which is the same ribotype (087) as ATCC 43255, was apparently responsible for the increased severity of the infection and death following toxic megacolon, bowel perforation and pseudomembranous colitis involving the entire large bowel. K. pneumoniae sepsis, resolved by antibiotic therapy was secondary to Clostridium difficile infection. The case registers community-acquired Clostridium difficile infection as producing serious complications similar to hospital-acquired Clostridium difficile infection and should be treated with the requisite importance.

Dietary patterns as predictors of prostate cancer in Jamaican men.

Studies of diet and prostate cancer have focused primarily on food and nutrients; however, dietary patterns examine the overall diet, particularly foods eaten in combination, and risk of disease. We evaluated the association of dietary patterns and prostate cancer and low- and high-grade subgroups in Jamaican men. In a case-control study, we enrolled 243 incident cases and 273 urology controls in Jamaican clinics, March 2005-July 2007. Dietary patterns were identified using principal component analysis. Four food patterns were identified: a "vegetable and legume" pattern, a "fast food" pattern, a "meat" pattern, and a "refined carbohydrate" pattern. Men in the highest tertile for the refined carbohydrate pattern, characterized by high intakes of rice, pasta, sugar sweetened beverages, and sweet baked foods were at increased risk of total prostate cancer [odds ratio (OR) = 2.02; 95% confidence interval (CI) = 1.05-3.87 (Ptrend = 0.029)] and low-grade disease [OR = 2.91; 95% CI = 1.18-7.13 (Ptrend = 0.019)] compared with men in the lowest tertile. The vegetable and legumes pattern (healthy), meat pattern, or fast food pattern were not associated with prostate cancer risk. These data suggest a carbohydrate dietary pattern high in refined carbohydrates may be a risk factor for prostate cancer in Jamaican men.

Pathological outcome and biochemical recurrence-free survival after radical prostatectomy in African-American, Afro-Caribbean (Jamaican) and Caucasian-American men: an international comparison.

OBJECTIVE: To compare pathological and biochemical outcomes of radical prostatectomy (RP) among African-American (AA), Afro-Caribbean (AC; Jamaican) and Caucasian-American (CA) men using an international cohort of patients who underwent RP in the USA and Jamaica. MATERIALS AND METHODS: A retrospective review was performed of men who underwent RP for clinically organ-confined (OC) prostate cancer between 2000 and 2011 at Columbia University Medical Center (New York, USA) and the University Hospital of the West Indies (Kingston, Jamaica) between 2000 and 2007. Men who had received neoadjuvant or adjuvant (within 3 months) therapy were excluded. Clinicopathological variables were compared among the three groups, focusing on age, stage, PSA level, Gleason sum (GS) and margin status. Multivariate analysis was performed to determine the predictors of biochemical recurrence (BCR; PSA >0.2 ng/mL), and Kaplan-Meier analysis was performed to determine BCR-free survival rates in AA, AC and CA men. RESULTS: A total of 483 men underwent RP for clinically OC disease (CM, n = 309, AA, n = 93 and AC, n = 81). The mean patient age was 59 years, with AA men being younger than CA men (58 vs 60 years, P< 0.05). The mean (range) follow-up was 49 (13-133) months with no significant difference among the groups. The men in the AC cohort had a higher mean PSA level than AA and CA men (8.8 vs 6.2 and 5.0 ng/mL, respectively, P< 0.05) and more clinical GS ≥7 (44%) tumours than AA (8%) and CA men (0%; P< 0.01). On multivariate analysis, controlling for stage, grade, PSA level and margins, AA and AC race were independent predictors of BCR. AA and AC men had significantly lower 5-year BCR-free survival (76 and 74%, respectively) than CA men (98% [P < 0.001]). CONCLUSIONS: This international comparison of clinicopathological outcomes in AA, AC and CA men undergoing RP shows that AA and AC men present similarly with more aggressive disease features than CA men and have lower 5-year BCR-free survival. Both AA and AC race are significant predictors of BCR, independently of stage, grade, PSA level and margin status. Further research is needed to elucidate and correct the mechanisms behind the observed difference in outcome among these populations.

8q24 risk alleles in West African and Caribbean men.

BACKGROUND: Multiple genetic studies have confirmed associations of 8q24 variants with susceptibility to prostate cancer (CaP). However, the magnitude of risk conferred in men living in West Africa is unknown. METHODS: Here we determine the prevalence of 8q24 risk alleles and test for association with CaP risk alleles in West African (WA) descent populations from rural Nigeria, Cameroon, and the Caribbean island of Jamaica. Ten 8q24 SNPs were genotyped in histologically confirmed CaP cases (n = 308) and clinically evaluated controls (n = 469). In addition, unrelated individuals from Sierra Leone (n = 380) were genotyped for comparison of allele frequency comparisons. RESULTS: SNPs rs6983561, rs7008482, and rs16901979 were significantly associated with CaP risk in WAs (P < 0.03). No associations with CaP were observed in our Caribbean samples. Risk alleles for rs6983267, rs7008482, and rs7000448 were highly prevalent (>84%) in West Africa. We also reveal that the A-risk allele for the 'African-specific' SNP bd11934905 was not observed in 1,886 chromosomes from three WA ethnic groups suggesting that this allele may not be common across West Africa, but is geographically restricted to specific ethnic group(s). CONCLUSIONS: We provide evidence of association of 8q24 SNPs with prostate cancer risk in men from Nigeria and Cameroon. Our study is the first to reveal genetic risk due to 8q24 variants (in particular, region 2) with CaP within two WA countries. Most importantly, in light of the disparate burden of CaP in African-Americans, our findings support the need for larger genetic studies in WA descent populations to validate and discern function of susceptibility loci in the 8q24 region.

Associations of whole-blood fatty acids and dietary intakes with prostate cancer in Jamaica.

OBJECTIVE: To investigate the association of whole-blood fatty acids and reported intakes of fats with risk of prostate cancer (PCa). DESIGN: Case-control study of 209 men 40-80 years old with newly diagnosed, histologically confirmed prostate cancer and 226 cancer-free men attending the same urology clinics. Whole-blood fatty acid composition (mol%) was measured by gas chromatography and diet assessed by food frequency questionnaire. RESULTS: High whole-blood oleic acid composition (tertile 3 vs. tertile 1: OR, 0.37; CI, 0.14-0.0.98) and moderate palmitic acid proportions (tertile 2: OR, 0.29; CI, 0.12-0.70) (tertile 3: OR, 0.53; CI, 0.19-1.54) were inversely related to risk of PCa, whereas men with high linolenic acid proportions were at increased likelihood of PCa (tertile 3 vs. tertile 1: OR, 2.06; 1.29-3.27). Blood myristic, stearic and palmitoleic acids were not associated with PCa. Higher intakes of dietary MUFA were inversely related to prostate cancer (tertile 3 vs. tertile 1: OR, 0.39; CI 0.16-0.92). The principal source of dietary MUFA was avocado intake. Dietary intakes of other fats were not associated with PCa. CONCLUSIONS: Whole-blood and dietary MUFA reduced the risk of prostate cancer. The association may be related to avocado intakes. High blood linolenic acid was directly related to prostate cancer. These associations warrant further investigation.

Disseminated trichosporonosis in a burn patient: meningitis and cerebral abscess due to Trichosporon asahii.

A 44-year-old diabetic female presented to a hospital in Jamaica with thermal burns. Trichosporon asahii was isolated from facial wounds, sputum, and a meningeal swab. Dissemination of the fungus was demonstrated in stained histological sections of the meninges and a brain abscess at autopsy. Pure growth of the fungus from patient samples submitted and an environmental isolate obtained from a wash basin in the hospital supported the diagnosis.

Aortic dissection at the University hospital of the West Indies: A 20-year clinicopathological study of autopsy cases.

BACKGROUND: An autopsy study of aortic dissection (AD) at our institution was previously reported. In the approximately 20 years since then, however, many aspects of diagnosis and treatment of this disease have changed, with a fall in mortality reported in many centers around the world. An impression amongst our pathologists that, there might be an increase in the prevalence of AD in the autopsy service at our hospital, since that earlier report, led to this repeated study, in an attempt to validate that notion. We also sought to identify any changes in clinicopathological features between the two series or any occurring during this study period itself. FINDINGS: All cases of AD identified at autopsy, during the 20-year period since the conclusion of the last study, were collected and pertinent clinical and pathological data were analyzed and compared, both within the two decades of this study period and against the results of the last study.Fifty-six cases comprised this study group including 36 males and 20 females, with a mean age of 63.9 years. There were, more patients in the second decade (n = 33; 59%) compared with the first decade (n = 23; 41%). Hypertension as a risk factor was identified in 52 (93%) cases and rupture occurred in 49 (88%) cases. A clinical diagnosis of AD was considered prior to surgery or autopsy in 25 (45%) cases overall, more during the second decade. Surgery was attempted in 25% of all cases with an increase in the second decade compared with the first. CONCLUSIONS: Compared with the earlier review, a variety of changes in the profile of patients with AD in the autopsy service has been noted, including a reversal in the female predominance seen previously. Other observations include an increase in cases where the correct clinical diagnosis was considered and in which surgical treatment was attempted, changes also evident when the second decade of the present study was compared with the earlier decade. Overall, there were many positive trends. However, areas that could still be improved include an increased index of suspicion for the diagnosis of AD and perhaps in the initiation of treatment, earlier, in those cases where the correct diagnosis was considered.

Body size and risk of prostate cancer in Jamaican men.

We investigated the associations between body size and risk of prostate cancer in a hospital-based case-control study in Jamaica. Height, weight, waist, and hip circumference were measured at enrollment, and data collected on medical and lifestyle factors for newly diagnosed cases (n = 243) and controls (n = 275). Compared with men in the normal range of waist-hip ratio (WHR), men with WHR > or =0.95 were at greater risk of total prostate cancer (OR,1.72; CI, 1.01-3.00) and high-grade cancer (OR, 2.02; CI, 1.03-3.96). With additional control for BMI, the association with WHR remained significant for total prostate cancer (OR, 1.90; CI, 1.01-3.53) and high-grade disease (OR, 2.94; CI, 1.34-6.38). There was no association between waist circumference and cancer without control for BMI but after controlling for BMI, waist circumference >90 cm (OR, 2.45; CI, 1.01-5.94) and >102 cm (OR, 5.57; CI, 1.43-18.63) showed a dose-response relationship with high-grade disease. Height and BMI were not associated with risk of prostate cancer. Abdominal obesity may be associated with risk of high-grade prostate cancer. Risk may be greater in those with higher abdominal obesity relative to overall size. The results further highlight the importance of investigating relationships by characteristics of the tumor.

Extramedullary plasmacytoma of the pancreas as an uncommon cause of obstructive jaundice: a case report.

INTRODUCTION: Though uncommon, extramedullary plasmacytoma of the pancreas should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms. This report highlights a case of obstructive jaundice in a 46-year-old West Indian man that resulted from an extramedullary plasmacytoma. CASE PRESENTATION: A 46-year-old West Indian man presented to our hospital with evidence of a significant upper gastrointestinal bleed. He gave a recent history of jaundice, constitutional symptoms and back pain. Ultrasonography revealed a mass in the head of the pancreas with resultant common bile duct dilatation. The patient required urgent surgical intervention for ongoing bleeding at which time a biopsy of the pancreas was taken. Histological analysis revealed a plasmacytoma of the pancreas. A blood film showing rouleaux formation and a skeletal survey demonstrating multiple lytic lesions confirmed multiple myeloma. Before further evaluation or treatment was carried out, the patient defaulted from follow-up and died from his illness seven months later. CONCLUSION: This case represents an example of multiple myeloma with visceral involvement, brought to clinical attention through involvement of the pancreas. The report serves to reaffirm knowledge of the various presentations, the optimal diagnostic tools and the current proposed treatment strategies for extramedullary plasmacytomas of the pancreas.

A 6-year analysis of the clinicopathological profile of patients with prostate cancer at the University Hospital of the West Indies, Jamaica.

OBJECTIVE To document the clinicopathological characteristics of prostate cancer in a public hospital-based population in Jamaica, over a 6-year period, and examine any trends in these characteristics over time, as prostate cancer is the leading cause of cancer in Jamaican men, but there are few published reports documenting the clinicopathological profile of this disease in the Jamaican population. PATIENTS AND METHODS All patients consecutively diagnosed with prostate cancer by transrectal ultrasonography-guided biopsy at the University Hospital of the West Indies, from January 2000 to December 2005, were identified at time of diagnosis, and relevant clinical and pathological data collected from the accompanying histopathology request forms. RESULTS There were 529 cases of prostate cancer diagnosed over the 6 years. The mean (sd) age was 70.66 (8.74) years, with 137 patients aged 70-74 years. A serum prostate-specific antigen (PSA) level was obtained for 490 (92.6%) patients. Of these, an accurate PSA value was available for 456 (86.2%) patients and a 'minimum level' recorded for the remaining 34, all of whom had a PSA level of >100 ng/mL. Of the patients with available PSA information, only 91 (18.5%) had a level of < or =10.0 ng/mL. By contrast, 155 (31.6%) patients had levels of >100 ng/mL. The median (range, interquartile range) serum PSA level for those patients with accurate values was 30.7 (1-14 260, 11.7-109) ng/mL. Histologically, moderately and poorly differentiated cancers accounted for 198 (37.5%) and 160 (30.2%) cases, respectively. Correlation of the variables under investigation confirmed that there was a statistically significant positive and moderate correlation between serum PSA level and Gleason score (Spearman r 0.49; P < 0.001). Statistical analysis of all other variables, including the number of cases of prostate cancer diagnosed annually, showed no significant differences. CONCLUSION Compared with many countries, including some in the Caribbean, prostate cancer in Jamaican men is diagnosed when they are older and these patients have significantly higher PSA levels at diagnosis, suggesting more advanced disease. Despite increasing public awareness of prostate cancer, it appears that there has been no significant change in the profile of patients with prostate cancer, at the time of diagnosis, over the last 6 years, findings consistent with the absence of an organized screening programme for prostate cancer in Jamaica.

Massive multilocular cystic leiomyoma of the uterus: an extreme example of hydropic degeneration.

A 49-year-old woman underwent laparotomy for an undiagnosed, extremely large abdominal mass. At surgery, this was discovered to be a uterine tumor and she was subjected to a subtotal hysterectomy. Pathologic examination of the uterus revealed a multilocular cystic mass containing over 18 L of fluid that was established on histology to be a markedly hydropic leiomyoma. This case describes a very uncommon growth pattern of leiomyoma of the uterus that has only been occasionally described previously. We propose the name multilocular, cystic leiomyoma for this variant.

Primary tumors of the heart: experience at the University Hospital of the West Indies.

BACKGROUND: An analysis of primary cardiac tumors in the English-speaking Caribbean has never been previously conducted. This paper is an attempt to fill this void. METHODS: A retrospective review of autopsy and surgical pathology records of the Department of Pathology at the University Hospital of the West Indies was carried out in search of all primary cardiac tumors. RESULTS: Altogether, 15 patients with primary cardiac tumors were identified. Twelve patients had myxomas, 2 of which were newborn infants. There were 2 cases of fibroma and 1 of rhabdomyoma, also in children. No malignant tumors were identified. Of the 10 adult patients all of whom had myxoma, there were 5 men and 5 women whose ages ranged from 33 to 83 years with a mean of 52 years. Echocardiography was used in making the diagnosis of cardiac tumor in all but one of these cases. All adult patients were symptomatic, with shortness of breath, often accompanied by congestive cardiac failure, being the most common symptom. One patient presented with embolic phenomena. CONCLUSION: This analysis of the clinicopathologic features of primary cardiac neoplasms represents the first of its kind in the English-speaking Caribbean. While the total number of cases was small, there appears to be a disproportionate number of pediatric tumors representing a third of the total. Furthermore, the distribution of tumor types within the pediatric population was dissimilar to that usually seen with only one rhabdomyoma.

E-cadherin polymorphisms and haplotypes influence risk for prostate cancer.

BACKGROUND: The E-cadherin (CDH1) gene has been implicated in prostate cancer (PCA) risk, however, the exact mechanism is unknown. Several polymorphisms, such as the C/A variant -160 base pairs from the transcription start site, in the CDH1 gene promoter region have been associated with cancer risk, mainly in European descent populations. METHODS: We screened the entire coding region and 3.0 kilobases of the CDH1 promoter for polymorphisms in 48 African Americans using dHPLC. Twenty-one (21) polymorphisms were observed. Four polymorphisms, including -160C/A, were genotyped in a genetic association study using incident PCA cases (N = 427) and unaffected controls (N = 337) of similar age from three different ethnic groups consisting of African Americans, Jamaicans, and European Americans. RESULTS: We observed a significantly higher frequency of the -160A allele among European American PCA patients (27.5%) compared to the control group (19.7%) (P = 0.04). More importantly, among men of European ancestry under the age of 65 who possess the -160 A allele there was over three times increased risk for prostate cancer (P = 0.05). Also, the AACT haplotype bearing the -160A allele was significantly associated with PCA in European Americans (P = 0.04). CONCLUSIONS: Our data indicate that CDH1 likely is a low-penetrant PCA susceptibility gene, however, population differences in linkage disequilibrium within the CDH1 gene region may influence the effect of susceptibility alleles such as -160A.

Gleason grading of prostate cancer: level of concordance between pathologists at the University Hospital of the West Indies.

Our aim was to study the level of interobserver concordance in the Gleason scores of prostate needle biopsy specimens reported at 1 institution. A retrospective review of all prostate needle biopsy specimens in which a diagnosis of adenocarcinoma was made during the year 2000 was conducted. Parameters evaluated included the Gleason score, Gleason grades identified, the percentage of Gleason grades 4 and 5, and the percentage of tumor in the biopsy specimen. Our results demonstrated a 60% overall concordance in consensus Gleason scores, which increased to 80% when considered in groups of a Gleason score of less than 7 vs 7 or more. The greatest discordance seemed to be in distinguishing Gleason score 6 from 7 and was more frequent among biopsy specimens with lower tumor volumes, particularly among those with less than 30% involvement. A small percentage of Gleason grade 4 pattern might predict disagreement as well. Strategies for improving accuracy of Gleason score 7 should be devised, and consensus diagnosis for biopsy specimens that demonstrate a low percentage of tumor volume is recommended.

Bilateral synchronous carcinoma of the male breast in a patient receiving estrogen therapy for carcinoma of the prostate: cause or coincidence?

An unusual case of bilateral, synchronous breast cancer in a male patient who had a history of long-term estrogen therapy for prostate cancer is presented. The possible role of estrogen in the development of male breast cancer is revisited.

Use of the Gleason system in international comparisons of prostatic adenocarcinomas in blacks.

BACKGROUND: Comparisons of prostate cancer in blacks living in different countries can shed light on factors responsible for high rates of the disease among blacks in America. Since the prognostic value of the Gleason grading system is well established, we assessed agreement between pathologists in countries where black populations of the African Diaspora reside. METHODS: Three genitourinary pathologists at hospitals in Nigeria, Jamaica, and the US independently assessed sextant biopsies from 12 patients. Gleason sum and percentage involvement were recorded, and a percent-weighted average calculated. Agreement under different groupings was evaluated using the kappa statistic generalized to three raters. RESULTS: Agreement was significant for individual sums (kappa = 0.3317, P = 0.0173), sums grouped as well (2-4), moderately (5-6), and poorly differentiated (7-10) (kappa = 0.2437, P < 0.0001) and other groupings. Agreement between at least two raters was 91.7-100%; complete agreement was 41.7-66.7%. CONCLUSIONS: The Gleason system is feasible and practical for international studies of prostate cancer among blacks from contrasting environments.