Diagnostic Work-Up of Contralateral Breast Cancers Has Not Improved over Calendar Period

Background: Contralateral breast cancer (CBC) is diagnosed in 1-2.6 % of all breast cancer patients directly at diagnosis, after that the risk still remains high (0.7% per year) throughout life of the patient. Breast cancer patients are followed up by palpation and clinical mammography after their diagnosis, partly to be able to diagnose a possible CBC. The aim of this study is to investigate if the diagnostic work-up of patients with breast cancer has improved over the last thirty years and resulted in earlier CBC diagnosis.Materials and Methods: Synchronous contralateral breast cancer is here defined as two cancers occurring maximum 3 months apart, cancers with longer latency time are defined as metachronous. The study population is restricted to patients with maximum three years between the two cancer diagnoses. In this study we used two cohorts; all CBCs in Sweden 1976-2004 (N: 3260), and all CBCs in Stockholm during 1976-2005 (N: 688), the smaller cohort had more detailed information. The study participants were selected from two population-based registers (Sweden Cancer Register and Stockholm Breast Cancer Register). With logistic regression we calculated the odds ratio of being diagnosed synchronously, as compared to metachronously, adjusted for calendar period and age at first diagnosis.Results: The risk of synchronous diagnosis was increased by 27% per each 5-year period, the change was statistically significant. We then investigate if this risk increase by calendar period was due to improved clinical work-up, by including detection mode in the model. We found that the risk estimates for calendar period persisted, thus giving no evidence for improvement of clinical work-up during the study period. This result did not change when stratifying the study population by age at first diagnosis (below/above 55). Next, we instead included adjuvant therapy for the first cancer in the model and the association with calendar period decreased to non-significant levels. We also showed that the proportion of CBCs detected trough clinical work-up has not increased over calendar period (p=0.89), neither when including, nor excluding, screening mammography as part of the work-up. The mean tumour size of the contralateral breast cancer was 16.0 mm and has not decreased over the study period (p:0.62)Discussion: We found an increase in the proportion of synchonous CBCs compared to metachronous over calendar period, this change is not associated with clinical work-up, but with adjuvant therapy. This study gives no indications of any improvement in diagnostic work-up of contralateral breast cancer over the last thirty years. Such an improvement would potentially be very important for survival of the growing population of (first) breast cancer survivors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4011.

Childbirth Following Breast Cancer: An Evaluation of the 'Healthy Mothers' Excess Mortality Risk

Background: The favorable outcome of mothers giving birth after breast cancer compared to those who do not, has been attributed to a healthy mother effect. Mainly former breast cancer patients with excellent health status and outlook proceed to having children after their disease. This study evaluates the excess mortality risk among these 'healthy mothers' and factors modifying this risk.Methods: By linking the Singapore Birth Registry (319'437 individuals) and Swedish Multi-Generation Cohort (11 million women) with the respective national cancer registries we identified all 509 women who gave birth >12 months after a breast cancer diagnosis. We calculated excess absolute mortality risks and Standardized Mortality Ratios (SMRs). We used Poisson regression analysis to calculate relative risks of death by country, period of follow up and interval between cancer diagnosis and subsequent birth.Results: The overall 15-year cumulative mortality was 18.2% (95% CI: 13.3 – 20.7%) which is substantially higher than that of the background population (SMR 13.3, 95%CI: 10.4-16.9). Excess mortality risks remained constant over follow up time and were comparable between Sweden and Singapore. Mortality risks decreased significantly with increasing interval between diagnosis and subsequent birth.Conclusion: Despite being 'healthy mothers', women who give birth after a diagnosis of breast cancer have a substantially higher risk of death than the background population. This information may be useful in a woman's decision whether to have a(another) child after breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3173.

Impact of Older Age on Presentation and Management of Breast Cancer in the Multi-Ethnic Population of Singapore

Background: Studies in Caucasian populations have shown that older breast cancer patients are less likely to be treated according to standard guidelines and that this under-treatment is strongly associated with impaired survival. In Asia, where population sizes and life expectancy rates are rising, the number of older women developing breast cancer is growing rapidly. This study aims to evaluate characteristics and treatment patterns of older breast cancer patients in the multi-ethnic population of Singapore, where breast cancer rates have tripled over the past three decades.Methods: This study includes all 2547 women, diagnosed with breast cancer between 1995 and 2006 at the National University Hospital in Singapore. Patients were classified into younger (< 65 years, n=2220) and older (>= 65 years, n=327). Differences in patient and tumor characteristics and treatment between older and younger age groups were explored using multivariate logistic regression models.Results: Even though older Singapore breast cancer patients had more favorable tumor characteristics than younger ones (better tumor differentiation, more often expressing estrogen and progesterone receptors), they presented significantly more often with stage III (adjusted Odds Ratio [ORadj] 1.57, 95%CI 1.0-2.4) and metastatic disease (ORadj 4.3, 95%CI 2.9-6.5). Elderly women were at increased risk not to receive breast surgery (ORadj 1.61, 95%CI 1.0-2.6) and axillary clearance (ORadj 1.74, 95%CI 1.2-2.6). In case of stage I disease, older women were significantly less likely than younger women to be treated with breast conserving surgery (ORadj 0.31, 95%CI 0.2-0.5).Conclusion: Similar to their Caucasian counterparts, older Asian breast cancer patients in Singapore are diagnosed at a later stage and receive less often standard treatment than younger women. Further studies are being undertaken to estimate the impact of these discrepancies on outcome.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3078.

Brain MRI in neurodegeneration with brain iron accumulation with and without PANK2 mutations

BACKGROUND AND OBJECTIVE

Patients with a clinical diagnosis of neurodegeneration with brain iron accumulation (NBIA, formerly called Hallervorden-Spatz syndrome) often have mutations in PANK2, the gene encoding pantothenate kinase 2. We investigated correlations between brain MR imaging changes, mutation status, and clinical disease features.

METHODS

Brain MRIs from patients with NBIA were reviewed by 2 neuroradiologists for technical factors, including signal intensity abnormalities in specific brain regions, presence and location of atrophy, presence of white matter abnormality, contrast enhancement, and other comments. PANK2 genotyping was performed by polymerase chain reaction amplification of patient genomic DNA followed by automated nucleotide sequencing.

RESULTS

Sixty-six MR imaging examinations from 49 NBIA patients were analyzed, including those from 29 patients with mutations in PANK2. All patients with mutations had the specific pattern of globus pallidus central hyperintensity with surrounding hypointensity on T2-weighted images, known as the eye-of-the-tiger sign. This sign was not seen in any studies from patients without mutations. Even before the globus pallidus hypointensity developed, patients with mutations could be distinguished by the presence of isolated globus pallidus hyperintensity on T2-weighted images. Radiographic evidence for iron deposition in the substantia nigra was absent early in disease associated with PANK2 mutations. MR imaging abnormalities outside the globus pallidus, including cerebral or cerebellar atrophy, were more common and more severe in mutation-negative patients. No specific MR imaging changes could be distinguished among the mutation-negative patients.

CONCLUSION

MR imaging signal intensity abnormalities in the globus pallidus can distinguish patients with mutations in PANK2 from those lacking a mutation, even in the early stages of disease.

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Images

MR detectability and appearance of small experimental intracranial hematomas at 1.5 T and 0.5 T. A 6-7-month follow-up study

PURPOSE

To investigate the detectability and appearance of small experimental intracranial hemorrhages on MR at 0.5 T and 1.5 T in a long-term follow-up.

MATERIAL AND METHODS

Autologous blood (1 ml) was injected into the brain of 7 rabbits to create intraparenchymal hematomas. The injected blood leaked partially into the cerebrospinal fluid (CSF) spaces. MR imaging at 0.5 T and 1.5 T were performed immediately before and after hematoma creation, at 2 weeks and monthly up to 6 or 7 months using T1-, proton density- and T2-weighted (w) spin-echo (SE), FLAIR and T2*-w gradient echo (GE) pulse sequences.

RESULTS

Blood was detected both in the brain and in the CSF spaces of all animals during the first hours after hematoma creation at 1.5 T. In the last examination after 6-7 months, the T2*-w GE sequences still showed residues of the intraparenchymal hematomas in all the rabbits at 1.5 T, but the signal pattern was not specific for the age of the hematomas. SE and FLAIR sequences were insensitive. The histopathology revealed iron deposits in all brains.

CONCLUSION

Residues of small intraparenchymal hematomas can be seen for months with T2*-w GE sequences on brain MR imaging at 1.5 T. The age of the microhematomas cannot be estimated with MR imaging.

MR detectability and appearance of small experimental intracranial hematomas at 1.5 T and 0.5 T. A 6-7-month follow-up study

PURPOSE

To investigate the detectability and appearance of small experimental intracranial hemorrhages on MR at 0.5 T and 1.5 T in a long-term follow-up.

MATERIAL AND METHODS

Autologous blood (1 ml) was injected into the brain of 7 rabbits to create intraparenchymal hematomas. The injected blood leaked partially into the cerebrospinal fluid (CSF) spaces. MR imaging at 0.5 T and 1.5 T were performed immediately before and after hematoma creation, at 2 weeks and monthly up to 6 or 7 months using T1-, proton density- and T2-weighted (w) spin-echo (SE), FLAIR and T2*-w gradient echo (GE) pulse sequences.

RESULTS

Blood was detected both in the brain and in the CSF spaces of all animals during the first hours after hematoma creation at 1.5 T. In the last examination after 6-7 months, the T2*-w GE sequences still showed residues of the intraparenchymal hematomas in all the rabbits at 1.5 T, but the signal pattern was not specific for the age of the hematomas. SE and FLAIR sequences were insensitive. The histopathology revealed iron deposits in all brains.

CONCLUSION

Residues of small intraparenchymal hematomas can be seen for months with T2*-w GE sequences on brain MR imaging at 1.5 T. The age of the microhematomas cannot be estimated with MR imaging.

Cost-effectiveness analysis of a psoriasis care instruction programme with dithranol compared with UVB phototherapy and inpatient dithranol treatment

BACKGROUND

This study was part of a large national cost-effectiveness analysis, and was funded by the National Fund for Investigational Medicine of the Health Care Insurance Board.

OBJECTIVE

To compare the costs of treatment of moderate to severe psoriasis by dithranol short contact therapy in a care instruction programme (short contact therapy) with ultraviolet B phototherapy (UVB) and inpatient dithranol treatment (inpatient treatment), and relate these costs to treatment effectiveness.

METHODS

An open randomized controlled multicentre study was performed. The costs (both medical and non-medical) were calculated for the following periods: during treatment, per month during remission, after a relapse, and following an unsuccessful treatment. The effectiveness measures were the clinical response rate and the number of clearance days during follow-up.

RESULTS

The data from 216 patients were analysed. The mean overall costs per patient during treatment were euro;1641, euro;1258 and euro;7706 for short contact treatment, UVB and inpatient treatment, respectively. During the clearance period the mean costs per month per patient were euro;19, euro;5 and euro;25, respectively. The clinical response rates were 57%, 57% and 85%, respectively. The mean number of clearance-days after short contact treatment was 160 [median 119; interquartile range (0-357)], which was not significantly different from the other two strategies: 211 clearance-days after inpatient treatment [241 (99-350)] and 136 clearance-days after UVB [81 (0-266)].

CONCLUSIONS

Short contact treatment is an attractive alternative for patients with moderate to severe psoriasis currently treated by inpatient treatment, as the costs of short contact treatment were significantly lower and the number of clearance days was comparable. Considering the higher costs, short contact treatment is not a first choice treatment when compared with UVB.

Prognostic value of platelet derived growth factor alpha receptor expression in grade 2 astrocytomas and oligoastrocytomas

OBJECTIVE

To determine whether the expression of platelet derived growth factor alpha receptor (PDGFRalpha) in low grade astrocytomas and oligoastrocytomas is associated with survival.

METHODS

Formalin fixed and paraffin embedded tumour samples of 40 consecutive patients with supratentorial diffuse astrocytomas and oligoastrocytomas of WHO grade 2, resected between 1986 and 1993, were used for immunohistochemical staining. The fraction of tumour cells expressing PDGFRalpha protein was quantified and entered into univariate and multivariate survival analyses. Changes in PDGFalpha expression over time were analysed in seven patients in whom reoperations had been performed.

RESULTS

Patients with a relatively high fraction of PDGFRalpha expressing cells had a more favourable outcome in both univariate (p = 0.04) and multivariate analyses (p = 0.02). Expression of PDGFRalpha was greater in oligoastrocytomas than in astrocytomas (p = 0.05). In four reoperated patients with histologically confirmed malignant transformation, there was a marked decrease in the number of cells expressing the receptor.

CONCLUSIONS

There is an association between high PDGFRalpha expression and long survival time in patients with grade 2 astrocytomas and oligoastrocytomas. The findings suggest that expression of the receptor may be a useful prognostic marker in such patients.

Economic evaluation of ventilation tubes in otitis media with effusion

OBJECTIVE

To determine the costs and effectiveness of treatment with ventilation tubes as compared with watchful waiting in children with persistent otitis media with effusion.

DESIGN

Randomized controlled trial.

SETTING

Institutional practice.

PATIENTS

A total of 187 young children (19 months old) with persistent bilateral otitis media with effusion.

INTERVENTIONS

Treatment with ventilation tubes or watchful waiting.

MAIN OUTCOME MEASURES

The time without effusion, language development, and the costs from a societal perspective during 1-year follow-up.

RESULTS

The mean duration of effusion was 9.2 months in the watchful waiting group and 4.7 months in the ventilation tube group. The language development was comparable in both groups (0.7 month of improvement difference [95% confidence interval, -0.3 to 1.7 months] after correction for confounding variables). Because no statistically significant differences were found in the language development between the treatment groups, we performed a cost minimization analysis. The mean costs per child during 1 year of follow-up were 454 US dollars in the ventilation tube group and 120 US dollars in the watchful waiting group. On average, an additional investment of 334 US dollars per patient was needed for ventilation tube treatment.

CONCLUSION

In the absence of differences in language development and in view of higher costs, treatment with ventilation tubes is not recommended as standard treatment in all young children with persistent otitis media with effusion traced by a population-based screening program.

Positron emission tomography (11)C-methionine and survival in patients with low-grade gliomas

BACKGROUND

Considerable numbers of patients with low-grade gliomas experience an early malignant course and may benefit from aggressive treatment. These patients are difficult to identify using established prognostic factors. A retrospective study was performed to determine whether the (11)C-methionine uptake in tumor is a survival factor in adult patients with supratentorial gliomas classified as World Health Organization Grade 2.

METHODS

The authors identified 89 patients with histologically confirmed low-grade gliomas in whom an (11)C-methionine positron emission tomography (PET) scan had been performed as part of the diagnostic tumor investigation from 1983 to 1998. Clinical data were collected, and the PET scans were re-evaluated according to a fixed protocol. The (11)C-methionine uptake in the tumor and relevant clinical parameters were entered into univariate and multivariate survival analyses.

RESULTS

At the end of the study, 49 patients (55.1%) had died. The median overall survival was 5.7 years. Low methionine uptake was significantly favorable in the multivariate survival analysis (P = 0.04) along with oligodendroglioma (P = 0.003). In the histologic subgroups, (11)C-methionine uptake was an important survival factor among patients with astrocytomas (P = 0.05) and oligodendrogliomas (P = 0.03). Tumor resection was a favorable prognostic factor in patients with high methionine uptake (P = 0.01) but not in patients with low uptake.

CONCLUSIONS

Baseline (11)C-methionine PET is a prognostic indicator in patients with low-grade gliomas. The results imply that PET is a valuable tool in the clinical management of these patients and may assist in the selection of patients for therapy.

Accounting for age differences on the Wisconsin Card Sorting Test: decreased working memory, not inflexibility

Two experiments examined the role of cognitive inflexibility and reduced working memory in age-related declines on the Wisconsin Card Sorting Test. Both standard scoring procedures and newly developed scores were used to measure each construct, and modifications of the test further evaluated the role of working memory. Results indicated that age differences are not due to cognitive inflexibility but that for a subset of older adults errors are associated with a reduction in the amount of information that can be stored or processed in working memory. These age differences disappear, however, when visual cues provide information about the immediately preceding sort. The authors conclude by proposing a decline in updating working memory as the explanation that can best account for the entire pattern of age differences on this test.

Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study

OBJECTIVE

To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial.

METHODS

Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX.

RESULTS

Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively).

CONCLUSION

Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.

Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study

OBJECTIVE

To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial.

METHODS

Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX.

RESULTS

Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively).

CONCLUSION

Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.

Meningioma treated with interferon-alpha, evaluated with [(11)C]-L-methionine positron emission tomography

PURPOSE

In meningioma patients with postoperative residual masses, recurrent or primarily inoperable tumors, positron emission tomography (PET) with [(11)C]-L-methionine was used to evaluate treatment efficacy of IFN-alpha.

EXPERIMENTAL DESIGN

Twelve patients were treated with IFN-alpha at a dose of 1.5-5 million IU s.c. daily. PET, computed tomography, and/or magnetic resonance imaging were performed in all patients before and, at regular intervals, during IFN-alpha treatment. The ratio of tumor hot-spot uptake to cerebellar uptake or to cortex uptake was calculated. This ratio estimates the relative methionine accumulation in the tumor and presumably the proliferative activity in the tumor.

RESULTS

During IFN-alpha treatment, PET demonstrated a mean relative percentage of reduction in the uptake ratio (MRelR) of 22.3% in the meningiomas. In nine patients who were considered responders, defined as patients with a positive MRelR, the MRelR was 30.4%. For the three nonresponders, defined as patients with a negative MRelR, the MRelR was -1.8%. Three patients were followed for a long time: two patients for 8 years and one patient for 4 years and 6 months; the two patients followed for 8 years are still on IFN. The volumes of these tumors were constant or showed a slight decrease. No correlation was found between histopathological diagnosis (PAD) WHO grading I-III of meningiomas and response to IFN-alpha treatment.

CONCLUSIONS

PET was judged a useful method to predict which patients are suitable for long-term treatment with IFN-alpha and also for dose finding. In five patients treated from 9 months to 8 years, IFN-alpha seemed to be an effective oncostatic drug. The clinical usefulness of IFN-alpha, taking adverse reactions into account, must be evaluated in a larger series of patients.

Effect of folic or folinic acid supplementation on the toxicity and efficacy of methotrexate in rheumatoid arthritis: a forty-eight week, multicenter, randomized, double-blind, placebo-controlled study

OBJECTIVE

To study the effect of folates on discontinuation of methotrexate (MTX) as single-drug antirheumatic treatment due to toxicity, to determine which type of adverse events are reduced, to study the effects on the efficacy of MTX, and to compare folic with folinic acid supplementation in a 48-week, randomized, double-blind, placebo-controlled trial.

METHODS

Patients with active RA (n = 434) were randomly assigned to receive MTX plus either placebo, folic acid (1 mg/day), or folinic acid (2.5 mg/week). The initial MTX dosage was 7.5 mg/week; dosage increases were allowed up to a maximum of 25 mg/week for insufficient responses. Folate dosages were doubled once the dosage of MTX reached 15 mg/week. The primary end point was MTX withdrawal because of adverse events. Secondary end points were the MTX dosage and parameters of efficacy and toxicity of MTX.

RESULTS

Toxicity-related discontinuation of MTX occurred in 38% of the placebo group, 17% of the folic acid group, and 12% of the folinic acid group. These between-group differences were explained by a decreased incidence of elevated liver enzyme levels in the folate supplementation groups. No between-group differences were found in the frequency of other adverse events or in the duration of adverse events. Parameters of disease activity improved equally in all groups. Mean dosages of MTX at the end of the study were lower in the placebo group (14.5 mg/week) than in the folic and folinic acid groups (18.0 and 16.4 mg/week, respectively).

CONCLUSION

Both folate supplementation regimens reduced the incidence of elevated liver enzyme levels during MTX therapy, and as a consequence, MTX was discontinued less frequently in these patients. Folates seem to have no effect on the incidence, severity, and duration of other adverse events, including gastrointestinal and mucosal side effects. Slightly higher dosages of MTX were prescribed to obtain similar improvement in disease activity in the folate supplementation groups.

Human peripheral blood eosinophils express stem cell factor

Stem cell factor (SCF) or c-Kit ligand is a cytokine associated with the differentiation, survival, and activation of mast cells. Eosinophils have pleiotropic functions in several diseases and, together with mast cells, are key cells in allergy. Mast cell-eosinophil interactions can take place during the late and chronic phases of allergy. It was, therefore, investigated whether eosinophils can produce SCF and consequently influence mast cells. Human peripheral blood eosinophils variably expressed mRNA for the soluble and uncleaved forms of SCF (reverse transcription-polymerase chain reaction) and produced the 18.5-kd protein backbone of SCF (Western blot analysis). After overnight incubation in medium, eosinophils also produced SCF of higher molecular weight (42-45 kd) that might represent its glycosylated forms. Eosinophils expressed cytoplasmic SCF that colocalized with major basic protein (confocal laser microscopy). Freshly isolated eosinophils contained 8.9 +/- 1.7 pg SCF/10(6) (mean +/- SEM; enzyme-linked immunosorbent assay). Although overnight incubation of the eosinophils in either culture medium or in phorbol 12-myristate 13-acetate-calcium ionophore did not cause the secretion of SCF, the addition of chymase induced SCF release. In summary, it was demonstrated that human peripheral blood eosinophils are a source of SCF. These results may contribute to a better understanding of the interactions between eosinophils and mast cells in allergic inflammation.

No association between IL-10 promoter gene polymorphism and heart failure or rejection following cardiac transplantation

Expression of interleukin (IL)-10 influences the frequency of rejection events after organ transplantation. Therefore, 70 heart transplant patients were genotyped for three single nucleotide polymorphisms and a microsatellite polymorphism in the promotor region of the IL-10 gene. The promoter region was amplified by polymerase chain reaction and genotyped by a colorometric oligo ligation assay and gene scan analysis, respectively. Patient groups consisted of patients suffering from dilated cardiomyopathy or ischaemic heart disease. Cardiac donors served as control group. No correlation was found between genotypes and heart failure or rejection after heart transplantation. This may indicate that in heart transplantation, the total balance of cytokine production is more important for post-transplant rejection activities than the levels of IL-10 as such.

ets-2 is a target for an akt (Protein kinase B)/jun N-terminal kinase signaling pathway in macrophages of motheaten-viable mutant mice

The transcription factor ets-2 was phosphorylated at residue threonine 72 in a colony-stimulating factor 1 (CSF-1)- and mitogen-activated protein kinase-independent manner in macrophages isolated from motheaten-viable (me-v) mice. The CSF-1 and ets-2 target genes coding for Bcl-x, urokinase plasminogen activator, and scavenger receptor were also expressed at high levels independent of CSF-1 addition to me-v cells. Akt (protein kinase B) was constitutively active in me-v macrophages, and an Akt immunoprecipitate catalyzed phosphorylation of ets-2 at threonine 72. The p54 isoform of c-jun N-terminal kinase-stress-activated kinase (JNK- SAPK) coimmunoprecipitated with Akt from me-v macrophages, and treatment of me-v cells with the specific phosphatidylinositol 3-kinase inhibitor LY294002 decreased cell survival, Akt and JNK kinase activities, ets-2 phosphorylation, and Bcl-x mRNA expression. Therefore, ets-2 is a target for phosphatidylinositol 3-kinase-Akt-JNK action, and the JNK p54 isoform is an ets-2 kinase in macrophages. Constitutive ets-2 activity may contribute to the pathology of me-v mice by increasing expression of genes like the Bcl-x gene that promote macrophage survival.

Does binge eating play a role in the self-regulation of moods?

Self-reported emotional experiences and eating behaviors were studied in college students in an attempt to determine what types of emotional experiences precede and follow binge eating and how specific types of compensatory behaviors modify these experiences. First-year male and female students (N=390) were surveyed for depression, anxiety, health status, life satisfaction, and eating attitudes (EAT-26). Those reporting recurrent binge eating episodes were asked to describe their emotional feelings before and after bingeing and before and after compensatory activities. EAT-26 scores corresponding to scores previously reported for eating disordered patients were found in 9.7% of students. Binge eating was nearly twice as frequent among females (16.4%) as males (8.6%). Among females, positive relationships were found between specific EAT-26 factors scores and both anxiety and depression scores. The emotional antecedents and consequences of binge eating and of compensatory activities were compared in three sub-groups of individuals who reported recurrent bingeing with loss of self-control during binges. The three sub-groups consisted of individuals who reported, 1) bingeing without engaging in compensatory activities, 2) bingeing and compensating by means other than vomiting (fasting, exercising, or use of laxatives or diuretics), and 3) bingeing and compensating by vomiting. Regardless of the type of activity, those individuals who engaged in compensatory activities reported greater negative affect preceding binge episodes than those who did not compensate. In addition, contrary to expectations, negative affect did not decrease, but instead increased significantly, following binge episodes and decreased immediately before and after compensatory activities.

Minor head injury: predicting follow-up after discharge from the Emergency Department

BACKGROUND

Up to 50% of ED patients discharged within a minor head injury (MHI) will develop postconcussive syndrome (PCS) within 1 month of injury. The follow-up visit is an important opportunity to identify and treat PCS before it becomes persistent.

OBJECTIVE

To identify factors predictive of follow-up (FU) after ED discharge in patients presenting with MHI.

METHODS

Prospective, observational study of a convenience sample of 71 MHI presenting within 24 hours of injury to the ED of a university teaching hospital between February 1996 and October 1997. MHI defined as loss of consciousness not greater than 10 minutes or amnesia, GCS 15, no skull fracture on PE, no new focality to neurologic exam and no brain injury on CT if one was done. Neurobehavioural test scores, clinical information and demographic data collected via use of standardized patient encounter form. All patients were discharged with written instructions to FU with their private physician within 1-2 weeks. Patients without a follow-up physician were assigned one. At 1 month post-injury, all patients were telephoned to determine if they had followed-up.

ANALYSIS

Stepwise, multivariate, logistic regression.

RESULTS

Thirty one out of 71 (43.7%) reported FU with a physician within 1 month. Factors associated with FU were performance of a head CT in the ED (OR = 3.58, 95% CI = 1.12-11.37), associated laceration (OR = 8.84, 95% CI = 1.69-42.55), female gender (OR = 3.19, 95% CI = 1.04-9.82), and African-American race (OR = 0.36, 95% CI = 0.13-0.99).

CONCLUSIONS

Several factors predict FU after ED discharge for MHI. Patients unlikely to FU may benefit from an assessment of PCS risk before they leave the ED.

MUC1 isoform specific monoclonal antibody 6E6/2 detects preferential expression of the novel MUC1/Y protein in breast and ovarian cancer

The products of the MUC1 gene are known to be highly expressed in human breast cancer cells. The best characterized MUC1 protein is a polymorphic, type 1 transmembrane molecule containing a large extracellular domain composed primarily of a variable number of 20 amino acid tandem repeats. We have recently identified a novel protein product of the MUC1 gene, the MUC1/Y protein, that is also a transmembrane protein but is devoid of the tandem repeat array and its immediate flanking sequences. To analyze its expression in tumor cells we generated monoclonal antibodies directed against the MUC1/Y extracellular domain (anti-MUC1/Yex MAbs). Epitope mapping identified the MAb, 6E6, which recognized the MUC1/Y isoform with exquisite specificity- the repeat-array-containing MUC1 isoform could not compete out this immunoreactivity. A 30mer peptide which is unique for MUC1/Y and corresponds to the "join" region generated by the MUC1/Y specific splice, abrogated all 6E6 MAb immunoreactivity towards MUC1/Y. Immunoprecipitation of the MUC1/Y protein with 6E6 MAbs revealed that, in contrast with the proteolytic cleavage of the tandem-repeat-array-containing MUC1 isoform, MUC1/Y is not cleaved. Flow cytometry analyses using the 6E6 MAbs demonstrated that the MUC1/Y isoform is expressed on the cell surface of both MCF-7 breast cancer cells and malignant epithelial cells present in effusions obtained from breast and ovarian cancer patients. Our results unequivocally establish that the MUC1/Y protein is expressed on the surface of breast cancer cells and cells of other epithelial malignancies. The anti-MUC1/Y MAbs described here can target MUC1/Y expressing tumor cells in vivo and are likely to be important reagents both for epithelial tumor diagnosis and immunotherapy.

Predictors of hospital mortality in type A aortic dissections: a retrospective analysis of 148 consecutive surgical patients

Reports in the literature frequently concern miscellaneous types of dissections. This makes correct interpretation of data difficult. In order to assess the determinants of hospital mortality, the results of 148 consecutive patients over a 23-year period, all operated on for a type A dissection, were reviewed. Mean(s.d.) age was 56(13.1) years, 64% were male. An acute dissection (surgery within 14 days after onset of symptoms) was performed in 139 patients. Stigmata of the Marfan syndrome were present in 6.1% (n = 9). Peripheral vascular ischaemic complications were observed in 27.7%. Nowadays, diagnosis is primarily confirmed using transoesophageal echocardiography (75 correct diagnoses among 76 performed). Operation consisted of repair or replacement of the ascending aorta. Resuspension of the aortic valve was performed in 74 patients, and arch replacement in 25. In 74 patients, distal repair was done under deep hypothermic circulatory arrest. Hospital mortality rate was 23.6% (35 patients), though mortality rate calculated over the period 1990-1993 was 17.4% (P = n.s.). Univariate analysis revealed the following variables to be statistically significant predictors of hospital mortality (P < 0.05): preoperative ischaemic complications, preoperative resuscitation, haemopericardium, postoperative neurological complications, rethoracotomy, renal insufficiency and intestinal ischaemia. Multivariate stepwise logistic regression indicated preoperative resuscitation, postoperative haemodialysis and postoperative neurological complications as the only independent predictors of hospital death. Dissections arising from a primary intimal tear in the descending aorta had a more favourable outcome (P = 0.06, odds ratio 0.1). Although hospital mortality has declined over the past few years, no decline was seen in operative mortality since gelatine-resourcine-formol (GRF) glue is used as a routine. Transoesophageal echocardiography is the first choice in confirming diagnosis. Early operation is advocated, with careful haemostasis, before the development of cardiac tamponade or end-organ ischaemia, as the cornerstone of a successful treatment of a type A dissection. Reduction of neurological complications will further improve the results.

Effect of delayed intervention with ACE-inhibitor therapy on myocyte hypertrophy and growth of the cardiac interstitium in the rat model of myocardial infarction

The effectiveness of angiotensin-converting enzyme (ACE)-inhibitor therapy in attenuating ventricular remodeling when initiated immediately following myocardial damage is clearly established. Less information, however, is available on the impact of late therapy on the remodeling process, especially its influence on the cellular components of these structural changes. The purpose of this study was to examine the effects of converting enzyme inhibitor therapy commenced 28 days following infarction in the rat on changes in cardiac myocyte dimension and the interstitium. At 28 days following infarction, myocyte cell length (153.9+/-7.3 v 131.1+/-5.9 micron, P=0.0002) and cell volume in the free wall of the left ventricle (38. 5+/-5.0 x 10(3) v31.4+/-3.1 x 10(3), P=0.009) had increased compared with sham-operated rats. Similar changes were noted in the septum and right ventricle. Captopril therapy administered between 28 and 56 days attenuated a further increase in cell length noted in an untreated group in the left ventricle (153.5+/-15.3 v 167.3+/-13.7 micron, P=0.02), right ventricle (153.8+/-20.5 v 173.8+/-2.3 micron, P=0.01) and septum (158.0+/-20.2 v 179.1+/-16.6 micron, P=0.004). There was an increase in hydroxyproline content in the right ventricle and a similar trend in the left ventricle in the untreated myocardial infarction groups. These changes were not altered by captopril therapy. In summary, even late therapy with captopril attenuates progressive myocyte remodeling, which may contribute to the ability of ACE-inhibitor therapy to slow progressive chamber enlargement following infarction.

The effect of delayed reperfusion following infarction in the rat on structural changes in viable myocardium

OBJECTIVE

Evidence indicates that patency of the infarct related artery following the completion of myocardial necrosis can attenuate ventricular remodeling. Data have also demonstrated that inhibition of infarct expansion contributes to the anti-remodeling effect of delayed reperfusion. However, the influence of a patent artery on components of the remodeling process in the viable myocardium is poorly understood.

METHODS

Myocyte morphometrics (isolated cell technique) and collagen content (hydroxyproline analysis) were assessed 28 days following experimental myocardial infarction from rats with permanently ligated left coronary vessels (NRP; n = 10) compared with rats who underwent reperfusion 150 minutes after ligation (RP; n = 11) and a sham-operated group (n = 10).

RESULTS

Analysis of infarct size (planimetry) in a separate group of rats demonstrated that reperfusion at this late time point did not reduce infarct size (NRP: 33 +/- 3 vs. RP: 35 +/- 5%). Myocyte length in RP rats was less than in NRP rats in viable, non-infarcted left ventricular tissue (155 +/- 3 vs. 167 +/- 4 microns, p = 0.02), in the right ventricle (154 +/- 4 vs. 167 +/- 3 microns, p = 0.02) and in the septum (158 +/- 4 vs. 169 +/- 4 microns, p = 0.05). Reperfusion also attenuated the expected increase in cell volume compared with NRP rats (left ventricle 39.4 +/- 1.7 x 10(3) vs. 44.1 +/- 1.6 x 10(3) micron 3, p = 0.06; right ventricle 36.7 +/- 1.6 x 10(3) vs. 42.7 +/- 2.0 x 10(3) micron 3, p = 0.02; septum 41.0 +/- 1.6 x 10(3) vs. 44.2 +/- 1.8 x 10(3) micron 3, p = 0.19). Hydroxyproline content increased in the viable left ventricular tissue in both the reperfused and non-reperfused groups.

CONCLUSION

Reperfusion without myocardial salvage attenuates the increase in myocyte length and volume that occurs in remodeling myocardium following infarction in the rat, with no effect on the increase in collagen content. These data indicate that patency of the infarct vessel, which is known to have an inhibitory effect on infarct expansion, also has an anti-remodeling effect remote from the area perfused by this artery.

Somatic mutations in the human homologue of Drosophila patched in primitive neuroectodermal tumours

The naevoid basal cell carcinoma syndrome (NBCCS) is an autosomal dominant disorder characterized by multiple developmental defects and cancer susceptibility, in particular to basal cell carcinomas (BCCs). Medulloblastomas, primitive neuroectodermal tumours (PNETs) arising in childhood, occur in about 3-5% of NBCCS patients and a subset of PNETs was previously found with allelic imbalance at 9q22-q23, the region containing the gene for NBCCS (PTCH). We have analysed tumour DNA samples from 37 unrelated patients with sporadic PNETs and five medulloblastoma cell lines for PTCH mutations using an exon-by-exon single strand conformation polymorphism assay. We found three missense mutations, which affect conserved residues in transmembrane domains of the gene product and in the extracellular loop implicated in binding sonic hedgehog, one 2 bp deletion and an exon skipping splice site mutation. Most mutations were associated with the absence of the wild-type allele and were found in tumours exhibiting loss of heterozygosity (LOH) at loci flanking PTCH. The finding of LOH at 9q22-q23 in most mutated tumours while present in only three out of 26 tumours, in which a mutation was not identified, implicates PTCH as the target gene in PNETs with LOH at 9q22-q23 and deficient PTCH in the development of a subset of these tumours. Since all observed mutations were absent in the germ-line, a sporadic medulloblastoma developing as the first symptom of NBCCS is likely to be a very uncommon event.

Aging and interference: evidence from indirect memory tests

Four experiments examined age differences on indirect memory tests as a function of (a) the status of a stimulus as target or distractor and (b) the degree of predictability of a stimulus from context. No differences between young and old adults were found when targets were clearly designated as such. In this situation, participants showed priming for unexpected but not expected stimuli whether these words appeared as targets or distractors. In contrast, age differences emerged when there was initial uncertainty on each trial as to which stimulus was the target. It is concluded that aging is associated with a decrease in the efficiency of mechanisms involved in selection.

Hyaluronan in human cerebrospinal fluid

We studied the concentration of hyaluronan in cerebrospinal fluid (CSF) in various diseases and attempted to define its reference interval. A radioassay utilizing cartilage proteins with affinity for hyaluronan was used in determining the concentration of 200 lumbar and 27 ventricular CSF specimens and 11 brain cyst fluids. Molecular weight distributions were determined by gel chromatography and localization in brain tissue by histochemistry. The hyaluronan level of lumbar CSF showed an increase with age; comparatively healthy children had (mean +/- SD) 50 +/- 41 micrograms/L (n = 40) and adults 166 +/- 77 micrograms/L (n = 9); i.e. significantly different values. The highest level was recorded in a patient with meningitis (> 8000 micrograms/L). More than 4000 micrograms/ L was noted in a patient with tumour metastasis in the cerebellum. Significantly elevated levels were especially found with spinal stenosis, head injury and cerebral infarction, but also in inflammatory medical disorders, hydrocephalus and encephalitis. We found no significant increase in multiple sclerosis and some other neurological diseases. Ventricular CSF of adults contained significantly less hyaluronan (53 +/- 73 micrograms/L; n = 16) than lumbar CSF. Hyaluronan in cyst fluids varied from 31 to 25,000 micrograms/L. Weight average molecular weight of hyaluronan in CSF was 2.9-3.0 x 10(5) and in brain tumour cyst fluid 2.4 x 10(6). In search for the origin of hyaluronan in CSF it was found that its concentration in the choroid plexus and leptomeninges was low, but that hyaluronan was accumulated in the superficial layer of the cerebral cortex. Continued screening for hyaluronan in CSF may be valuable in cases of inflammatory diseases, tumours and obstruction to CSF flow.

Divided attention and indirect memory tests

Attentional state during acquisition is an important determinant of performance on direct memory tests. In two experiments we investigated the effects of dividing attention during acquisition on conceptually driven and data-driven indirect memory tests. Subjects read a list of words with or without distraction. Memory for the words was later tested with an indirect memory test or a direct memory test that differed only in task instructions. In Experiment 1, the indirect test was category-exemplar production (a conceptually driven task) and the direct test was category-cued recall. In Experiment 2, the indirect test was word-fragment completion (a data-driven task) and the direct test was word-fragment cued recall. Dividing attention at encoding decreased performance on both direct memory tests. Of the indirect tests, category-exemplar production but not word-fragment completion was affected. The results indicate that conceptually driven indirect memory tests, like direct memory tests, are affected by divided attention, whereas data-driven indirect tests are not. These results are interpreted within the transfer-appropriate processing framework.

Sex and sociocultural correlates of urinary incontinence in Israeli preschool children

Urinary incontinence in children aged 2 to 6 years whose mothers varied in ethnic descent, in level of education, and in immigration status was studied in Israel. Mothers of 302 children were interviewed in well-baby clinics regarding primary and secondary urinary incontinence of their children. A significant age trend was found for attaining primary urinary continence. However, various interactions between mothers' ethnic descent, mothers' level of education, and mothers' immigration status were associated with different rates of primary and secondary urinary incontinence in their children. Moreover, sex differences in rates of primary and secondary urinary incontinence were also associated with mothers' ethnic descent and level of education. It is suggested that different levels of maternal emotional availability to the child in the various subgroups can account for most of the findings.

Occasional memory cytotoxic T-cell responses of patients with human papillomavirus type 16-positive cervical lesions against a human leukocyte antigen-A *0201-restricted E7-encoded epitope

Most cervical carcinoma (Cxca) cells constitutively express human papillomavirus type 16 (HPV16) E6 and E7 oncoproteins. These proteins are, therefore, attractive targets for T cell-based immunotherapy. Previously, we identified HVP16 E7-encoded CTL epitopes. In patients with cervical intraepithelial neoplasia or Cxca, little is known concerning T-cell activity against viruses in general and against HPV16 in particular. Here, we have screened the blood of 10 healthy donor controls and of 22 patients with HPV16+ cervical lesions for the presence of CTLs directed against HPV16 E7- and control influenza virus matrix-derived epitopes presented by HLA-A *0201. We detected influenza virus-specific CTLs in all donors and in the majority of patients, indicating that most patients have functioning T-cell responses despite their lesions or therapeutic interventions. Moreover, we show that patients with HPV16+ lesions occasionally have memory CTLs against a HPV16 E7-encoded epitope (sequence YMLD-LQPETT), providing evidence for natural CTL immunity against HPV16 in patients with cervical lesions. Combined, these findings raise possibilities for vaccination with HPV16 E7-encoded peptides to induce or augment CTL responses for treatment or prevention of Cxca.

Common sense, insight, and neuropsychological test performance in schizophrenia patients

We report an exploratory study examining the interrelationships among common sense, insight into psychosis, and performance on a battery of neuropsychological tests in 32 patients with schizophrenia evaluated at the time of discharge from involuntary hospitalization at a State psychiatric hospital. Common sense, as measured by the Social Knowledge Questionnaire, was associated with better performance across tests measuring parietal lobe functioning and vocabulary. In addition, patients with more common sense were more likely to say that they were ill and needed treatment. A global measure of insight, the Insight and Treatment Attitudes Questionnaire (ITAQ), was related to performance on a test of left parietal lobe function. However, the responses to the ITAQ item that may best reflect current awareness of mental illness in patients at the time of discharge ("After you are discharged, is it possible you may have mental problems again?") were related to performance on tests of the functioning of the prefrontal lobes and the right and left parietal lobes. These results add to the growing evidence that some of the deficits in awareness of illness among patients with schizophrenia are related to the neuropsychological dysfunction commonly seen in patients with this disorder.

Coexpression of platelet-derived growth factor alpha and beta receptors on medulloblastomas and other primitive neuroectodermal tumors is consistent with an immature stem cell and neuronal derivation

Medulloblastomas and related childhood primitive neuroectodermal tumors (PNET) are currently thought to originate from a multipotent stem cell that can give rise to a variety of different tumor types, representing different lines of differentiation and stages of maturation of the original stem cell. The proliferation and differentiation of different cell types in the central nervous system are influenced by growth factors, such as platelet-derived growth factor (PDGF). In this study, we investigated the expression of the two types of PDGF receptors, alpha and beta, on 14 cases of PNET by immunohistochemistry and in situ hybridization. To characterize the tumor cells according to their differentiation and maturation, we performed immunohistochemistry with Ab against several members of the intermediate filament family, such as neurofilament, glial fibrillary acidic protein, vimentin, and the embryonal marker nestin. For the cerebral PNET, we found that the phenotype of multidirectional differentiation (with coexpression of neurofilament, glial fibrillary acidic protein, vimentin, and in some cases nestin) was associated with the expression of both PDGF alpha and beta receptors on the tumor cells. Medulloblastomas (i.e., cerebellar PNET), however, often showed the phenotype of partially committed neuron-like precursor cells, and this was associated with the predominant expression of PDGF alpha receptors on the tumor cells. Our findings show that the PDGF alpha receptor, previously known to play a role in the normal development of cells of the glial lineage, either exclusively or in combination with the PDGF beta receptor, is expressed on tumor cells of neuronal derivation. This "aberrant" expression of PDGF alpha receptors on PNET may reflect a feature of the malignant phenotype of these tumors. Further studies are needed to study the biologic effects of PDGF-A and its receptor in PNET.

Aging and interference: evidence from indirect memory tests

Four experiments examined age differences on indirect memory tests as a function of (a) the status of a stimulus as target or distractor and (b) the degree of predictability of a stimulus from context. No differences between young and old adults were found when targets were clearly designated as such. In this situation, participants showed priming for unexpected but not expected stimuli whether these words appeared as targets or distractors. In contrast, age differences emerged when there was initial uncertainty on each trial as to which stimulus was the target. It is concluded that aging is associated with a decrease in the efficiency of mechanisms involved in selection.

Detection of TP53 gene mutation in human meningiomas: a study using immunohistochemistry, polymerase chain reaction/single-strand conformation polymorphism and DNA sequencing techniques on paraffin-embedded samples

Mutations in the TP53 tumor suppressor gene have been studied in different types of brain tumors. Little is known about this genetic event in human meningioma, a mostly benign tumor. To investigate the frequency of TP53 gene mutations in human tumors derived from meningeal tissues, paraffin-embedded tissues from 30 cases (including 2 malignant and 4 atypical meningiomas, as well as 2 hemangioblastomas and 3 hemangiopericytomas) were screened by immunohistochemistry. Polymerase chain reaction/single strand conformational polymorphism (PCR/SSCP) and direct DNA sequencing were thereafter performed in selected cases. Nuclear p53 staining was not seen in any of the 19 benign meningiomas tested, while atypical meningiomas, hemangioblastomas, and hemangiopericytomas displayed nuclear staining in a subpopulation of tumor cells in 4 out of 5, 2 out of 2, and 3 out of 3 cases, respectively. One malignant meningioma showed an intense nuclear staining and a band shift in SSCP. In this case, we identified a mutation in the TP53 gene at codon 161 changing GCC to ACC and resulting in an alteration of alanine to threonine in this position. Our results indicate that TP53 gene mutation may be considered as a marker for malignant transformation in meningioma. p53 immunoreactivity, even in the absence of detectable gene mutation, is also associated with atypia and does not appear in regular benign meningiomas.