Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND

Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS

QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS

The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION

Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

Head and cervical spine posture in behaving rats: implications for modeling human conditions involving the head and cervical spine

The aim of this study was to define the temporal and spatial (postural) characteristics of the head and cervical vertebral column (spine) of behaving rats in order to better understand their suitability as a model to study human conditions involving the head and neck. Time spent in each of four behavioral postures was determined from video tape recordings of rats (n = 10) in the absence and presence of an intruder rat. Plain film radiographic examination of a subset of these rats (n = 5) in each of these postures allowed measurement of head and cervical vertebral column positions adopted by the rats. When single they were quadruped or crouched most (∼80%) of the time and bipedal either supported or free standing for only ∼10% of the time. The introduction of an intruder significantly (P < 0.0001) reduced the proportion of time rats spent quadruped (median, from 71% to 47%) and bipedal free standing (median, from 2.9% to 0.4%). The cervical spine was orientated (median, 25-75 percentile) near vertical (18.8°, 4.2°-30.9°) when quadruped, crouched (15.4°, 7.6°-69.3°) and bipedal supported (10.5°, 4.8°-22.6°) but tended to be less vertical oriented when bipedal free standing (25.9°, 7.7°-39.3°). The range of head positions relative to the cervical spine was largest when crouched (73.4°) and smallest when erect free standing (17.7°). This study indicates that, like humans, rats have near vertical orientated cervical vertebral columns but, in contrast to humans, they displace their head in space by movements at both the cervico-thoracic junction and the cranio-cervical regions.

Abstract P2-19-10: Quality of life following mastectomy and breast reconstruction (QUEST): Learning from two feasibility randomized controlled clinical trials

Background: Breast reconstruction (BRR) aims to improve health related quality of life (HRQL) after mastectomy, but with poor evidence to date informing the optimal type or timing of surgery to guide shared-decision making. Systematic reviews show the paucity of randomised trials (RCT) with only two-singe centre RCTs. Although, an RCT has theoretical advantages, there have been concerns that clinicians may not share clinical equipoise regarding recommending types of BRR surgery that is sensitive to patient preferences. The aim of the QUEST trials (CRUK/08/027) was to determine the optimal types of latissimus dorsi (LD) BRR (Trial A) when there is no expectation for post-mastectomy radiotherapy (PMRT), and timings of LDBRR when PMRT is recommended (Trial B), that would benefit HRQL during five years post-operatively. As this was the first attempt at a multi-centre RCT, the main trial was preceded by a feasibility phase to demonstrate that recruitment was achievable and that randomization was acceptable to patients. An embedded qualitative study, the QUEST Perspective Study (QPS) assessed the perceptions of equipoise of patients and health care professionals (HCPs) for the types of surgery.

Methods: QUEST comprised two parallel phase III multicentre feasibility RCTs to assess HRQL impact of the type of LDBRR when PMRT is unlikely (Trial A, LD - implant assisted (LDI) versus extended autologous LD (ALD)). Trial B evaluated optimal timings of LDBRR comparing staged - delayed ALD (skin-preserving sub-pectoral expander implant then ALD) to immediate ALD when PMRT was likely.

Eligible patients comprised mastectomy recommended for invasive breast cancer or DCIS in the context of technical feasibility for ALD and preferred synchronous breast reduction. The primary endpoint was the proportion of eligible women approached who accepted randomisation. QPS explored patients and HCPs’ acceptability of the trial and randomisation using semi-structured telephone interviews and questionnaires.

Results: The QUEST trials opened in May 2011 with 15 UK centres participating. After 18 months of recruitment, 17 patients had been entered in Trial A and 8 in trial B with acceptance rates of 19% (17/88) and 22% (8/36) for trial A and B respectively. Patient preference was the predominant reason for eligible patients approached about the trial not being randomised with 47 of the 88 (53%) for Trial A and 22 of 36 (61%) eligible for Trial B, declining for that reason. Patient acceptance rates for randomisation increased from 19% during the first 6 months to 29% from 7-12 months for Trial A; corresponding figures for Trial B were 11% and 27%. The recruitment challenges and funding cessation caused the Trial Steering Committee to recommend trial closure in December 2012.

Conclusion: Despite the need for clinical evidence, patients retained strong preferences for breast reconstruction type and timing, amidst ‘standardised’ trial processes. Patient acceptance rates did improve during the trial, but it was not possible to meet target recruitment within the constraints of a feasibility trial.

Funding for this NCRN portfolio trial (92581226) was from Cancer Research UK (CRUK) and BUPA Foundation funding for QPS.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-19-10.

Randomised pilot study of dose escalation using conformal radiotherapy in prostate cancer: long-term follow-up

BACKGROUND

Radical three-dimensional conformal radiotherapy (CFRT) with initial androgen suppression (AS) is a standard management for localised prostate cancer (PC). This pilot study evaluated the role of dose escalation and appropriate target volume margin. Here, we report long-term follow-up.

METHODS

Eligible patients had T1b-T3b N0 M0 PC. After neoadjuvant AS, they were randomised to CFRT, giving (a) 64 Gy with either a 1.0- or 1.5-cm margin and (b) ±10 Gy boost to the prostate alone.

RESULTS

One hundred and twenty-six men were randomised and treated. Median follow-up was 13.7 years. The median age was 66.6 years at randomisation. Median presenting prostate-specific antigen (PSA) was 14 ng ml(-1). Sixty-four out of 126 patients developed PSA failure. Forty-nine out of 126 patients restarted AS, 34 out of 126 developed metastases and 28 out of 126 developed castrate-resistant prostate cancer (CRPC). Fifty-one out of 126 patients died; 19 out of 51 died of PC. Median overall survival (OS) was 14.4 years. Although escalated dose results were favourable, no statistically significant differences were seen between the randomised groups; PSA control (hazard ratio (HR): 0.77 (95% confidence interval (CI): 0.47-1.26)), development of CRPC (HR: 0.81 (95% CI: 0.40-1.65)), PC-specific survival (HR: 0.59 (95% CI:0.23-1.49)) and OS (HR: 0.81 (95% CI: 0.47-1.40)). There was no evidence of a difference in PSA control according to margin size (HR: 1.01 (95% CI: 0.61-1.66)).

INTERPRETATION

Long-term follow-up of this small pilot study is compatible with a benefit from dose escalation, but confirmation from larger trials is required. There was no obvious detriment using the smaller radiotherapy margin.

Selective induction of apoptosis through activation of caspase-8 in human leukemia cells (Jurkat) by dandelion root extract

AIM OF STUDY

Dandelion extracts have been used in traditional Native American Medicine and Traditional Chinese Medicine (TCM) for treatment of leukemia and breast cancer; however, the mechanism of action remains unknown. Today, DRE is mainly marketed for management of gastrointestinal and liver disorders. The current study aims to determine the anti-cancer activity of dandelion root extract (DRE) against human leukemia, and to evaluate the specificity and mechanism of DRE-induced apoptosis.

MATERIALS AND METHODS

The effect of DRE on cell viability was evaluated using the colorimetric-based WST-1 assay. Apoptotic cell death was monitored by nuclear condensation and confirmed by exposure of phosphatidylserine to outer leaflet of plasma membrane. Activation of caspases was detected using a fluorogenic substrate specific to either caspase-8 or -3. Loss of mitochondrial membrane potential was observed by microscopy using JC-1 dye. The apoptotic effect of DRE was also evaluated on a dominant-negative FADD (Fas-associated death domain) cell line and non-cancerous peripheral blood mononuclear cells (PBMCs).

RESULTS

Aqueous DRE effectively induces apoptosis in human leukemia cell lines in a dose and time dependent manner. Very early activation of caspase-8 and the subsequent activation of caspase-3 indicate that DRE may be inducing extrinsic or receptor-mediated apoptosis. Caspase inhibition rendered this extract ineffective, thus DRE-induced apoptosis is caspase-dependent. Moreover, the dominant-negative FADD cells that are unable to form a complete DISC (death-inducing signaling complex) were resistant to DRE treatment, which further confirms our hypothesis that DRE induces receptor-mediated apoptosis. Interestingly, non-cancerous peripheral blood mononuclear cells (PBMCs) exposed to aqueous DRE under the same treatment conditions as leukemia cells were not significantly affected.

CONCLUSION

Our results suggest that aqueous DRE contains components that act to induce apoptosis selectively in cultured leukemia cells, emphasizing the importance of this traditional medicine and thus presents a potential novel non-toxic alternative to conventional leukemia therapy.

What factors predict differences in infant and perinatal mortality in primary care trusts in England? A prognostic model

OBJECTIVE

To identify predictors of perinatal and infant mortality variations between primary care trusts (PCTs) and identify outlier trusts where outcomes were worse than expected.

DESIGN

Prognostic multivariable mixed models attempting to explain observed variability between PCTs in perinatal and infant mortality. We used these predictive models to identify PCTs with higher than expected rates of either outcome.

SETTING

All primary care trusts in England. Population For each PCT, data on the number of infant and perinatal deaths, ethnicity, deprivation, maternal age, PCT spending on maternal services, and "Spearhead" status.

MAIN OUTCOME MEASURES

Rates of perinatal and infant mortality across PCTs.

RESULTS

The final models for infant mortality and perinatal mortality included measures of deprivation, ethnicity, and maternal age. The final model for infant mortality explained 70% of the observed heterogeneity in outcome between PCTs. The final model for perinatal mortality explained 80.5% of the between-PCT heterogeneity. PCT spending on maternal services did not explain differences in observed events. Two PCTs had higher than expected rates of perinatal mortality.

CONCLUSIONS

Social deprivation, ethnicity, and maternal age are important predictors of infant and perinatal mortality. Spearhead PCTs are performing in line with expectations given their levels of deprivation, ethnicity, and maternal age. Higher spending on maternity services using the current configuration of services may not reduce rates of infant and perinatal mortality.

CRISPR analysis of bacteriophage-insensitive mutants (BIMs) of industrial Streptococcus thermophilus--implications for starter design

AIMS

An efficient approach for generation of bacteriophage-insensitive mutants (BIMs) of Streptococcus thermophilus starters was described in our laboratory [Mills et al. (2007) J Microbiol Methods70, 159-164]. The aim of this study was to analyse the phage resistance mechanism responsible for BIM formation.

METHODS AND RESULTS

Three clustered regularly interspaced short palindromic repeat (CRISPR) regions have been identified in Strep. thermophilus, and Strep. thermophilus can integrate novel spacers into these loci in response to phage attack. Characterization of three sets of BIMs indicated that two sets had altered CRISPR1 and/or CRISPR3 loci. A range of BIMs of yoghurt starter CSK938 were generated with the same phage in different phage challenge experiments, and each acquired unique spacer regions ranging between one and four new spacers in CRISPR1. In addition, the BIM that acquired only one new spacer in CRISPR1 also acquired an additional spacer in CRISPR3. A fourth BIM, generated with a different phage, had two spacers deleted from CRISPR1 but acquired two spacers in CRISPR3. Analysis of the Mozzarella starter CSK939 and its associated BIMs indicated that formation of second generation BIMs does not lead to increases in spacer number but to alterations in spacer regions. BIMs of an exopolysaccharide (EPS)-producing strain that lost the ability to produce EPS did not harbour an altered CRISPR, suggesting that phage sensitivity may be related to the EPS-producing phenotype.

CONCLUSIONS

Acquisition/deletion of new spacers in CRISPR loci in response to phage attack generates distinctly individual variants. It also demonstrates that other modifications may be responsible for the phage resistance of Strep. thermophilus BIMs.

SIGNIFICANCE AND IMPACT OF THE STUDY

Isolation of individual BIMs that have unique spacers towards the leader region of the CRISPR locus may be a very useful approach for rotation strategies with the same starter backbone. Upon phage infection, BIMs 'in reserve' can be slotted into the rotation scheme.

A self-administered screening instrument for psychogenic nonepileptic seizures

BACKGROUND

Delay in distinguishing psychogenic nonepileptic seizures (PNES) from epilepsy may result in significant health and economic burdens. Screening tools are needed to facilitate earlier identification of patients with PNES, thereby maximizing cost-effective use of video electroencephalography (VEEG), the expensive gold standard for differentiating PNES from epilepsy. We developed and prospectively validated a self-administered PNES screening questionnaire using variables known to distinguish PNES from epilepsy patients.

METHODS

Adults referred for inpatient VEEG monitoring at two epilepsy centers were prospectively invited to complete a preliminary 209-item questionnaire assessing demographic, clinical, seizure-related, and psychosocial information that appeared in the literature as potentially useful indicators of PNES. A hybrid neural-bayesian classifier was trained to predict PNES using a sample at one center, and was prospectively validated on a separate set of naive patients from both centers.

RESULTS

Of 211 enrolled subjects from the training center, 181 met the study criteria for either PNES (n = 48, 27%), epilepsy (n = 116, 64%), or coexisting PNES and epilepsy (n = 17, 9%). Variable reduction procedures identified 53 questionnaire items that were necessary to accurately predict PNES diagnosis. The hybrid classifier predicted PNES diagnosis with 94% sensitivity and 83% specificity at the training center, and 85% sensitivity and 85% specificity at the second center (n = 46; 17 PNES, 26 epilepsy, 3 with coexisting PNES and epilepsy).

CONCLUSIONS

We developed and prospectively validated a self-administered psychogenic nonepileptic seizure screening questionnaire that could hasten referral for video electroencephalography and reduce the health and economic burdens from delayed diagnosis or misdiagnosis.

Steroid-responsive encephalopathy associated with autoimmune thyroiditis presenting with diffusion MR imaging changes

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) presents with focal or diffuse nonenhancing MR imaging abnormalities in 50% of patients with SREAT during subacute exacerbation. Vasculitic changes in biopsy studies as well as the elevation of antithyroid antibodies and CSF protein suggests an inflammatory cause. We report the case of a patient with SREAT with changes on diffusion-weighted MR imaging, which improved with corticosteroid therapy and plasmapheresis, supporting the theory of inflammatory changes in exacerbation of presumptive SREAT.

Individually-addressable flip-chip AlInGaN micropixelated light emitting diode arrays with high continuous and nanosecond output power

Micropixelated blue (470 nm) and ultraviolet (370 nm) AlInGaN light emitting diode ('micro-LED') arrays have been fabricated in flip-chip format with different pixel diameters (72 microm and 30 microm at, respectively, 100 and 278 pixels/mm(2)). Each micro-LED pixel can be individually-addressed and the devices possess a specially designed n-common contact incorporated to ensure uniform current injection and consequently uniform light emission across the array. The flip-chip micro-LEDs show, per pixel, high continuous output intensity of up to 0.55 microW/microm(2) (55 W/cm(2)) at an injection current density of 10 kA/cm(2) and can sustain continuous injection current densities of up to 12 kA/cm(2) before breakdown. We also demonstrate that nanosecond pulsed output operation of these devices with per pixel onaxis average peak intensity up to 2.9 microW/microm(2) (corresponding to energy of 45pJ per 22ns optical pulse) can be achieved. We investigate the pertinent performance characteristics of these arrays for micro-projection applications, including the prospect of integrated optical pumping of organic semiconductor lasers.

Optical sectioning microscopes with no moving parts using a micro-stripe array light emitting diode

We describe an optical sectioning microscopy system with no moving parts based on a micro-structured stripe-array light emitting diode (LED). By projecting arbitrary line or grid patterns onto the object, we are able to implement a variety of optical sectioning microscopy techniques such as grid-projection structured illumination and line scanning confocal microscopy, switching from one imaging technique to another without modifying the microscope setup. The micro-structured LED and driver are detailed and depth discrimination capabilities are measured and calculated.

Differential response induced by exposure to low-dose ionizing radiation in SHSY-5Y and normal human fibroblast cells

Radiation therapy has been used in the treatment of a wide variety of cancers for nearly a century and is one of the most effective ways to treat cancer. Low-dose ionizing radiation (IR) can interfere with cell division of cancer and normal cells by introducing oxidative stress and injury to DNA. The differences in the response to IR-induced DNA damage and increased reactive oxygen species between normal human fibroblasts (NHFs) and cancerous SHSY-5Y cells were considered. H2AX staining and comet assays revealed that NHF cells responded by initiating a DNA repair sequence whereas SHSY-5Y cells did not. In addition, NHF cells appeared to quench the oxidative stress induced by IR, and after 24 h no DNA damage was present. SHSY-5Y cells, however, did not repair their DNA, did not quench the oxidative stress, and showed characteristic signs that they were beginning to undergo apoptosis. These results indicate that there is a differential response between this cancerous and normal cell line in their ability to respond to low-dose IR, and these differences need to be exploited in order to treat cancer effectively. Further study is needed in order to elucidate the mechanism by which SHSY-5Y cells undergo apoptosis following radiation and why these normal cells are better equipped to deal with IR-induced double-strand breaks and oxidative stress.

Nocardia infections in cats: a retrospective multi-institutional study of 17 cases

OBJECTIVE

To record 17 cases of nocardiosis in cats from eastern Australia and to compare this series with cases previously reported.

DESIGN

Retrospective/prospective study.

RESULTS

Nocardia spp infections were diagnosed in 17 cats over 14 years from the three eastern states of Australia. There were no isolates from dogs during this period, but one isolate from a koala and two from dairy cows. The majority of cats presented with spreading lesions of the subcutis and skin associated with draining sinus tract(s). Early cutaneous lesions consisted of circumscribed abscesses. Infections spread at a variable rate, generally by extension to adjacent tissues. Lesions were generally located in regions subjected to cat bite or scratch injuries, including limbs, body wall, inguinal panniculus and nasal bridge. In some other cases, lesions were situated on distal extremities. The clinical course was variable, from chronic, indolent, initially localised infections to acute fulminating disease. Of the 17 cats, 14 were domestic crossbreds and three were purebreds. There was a preponderance of male cats (12 castrated, 1 entire young adult, 1 entire kitten). Nine of 17 cats were 10 years or older. Interestingly, the majority of infections were attributable to N nova. Immediate and/or predisposing causes could be identified in all cases, and included: renal transplantation [one cat]; chronic corticosteroid administration [three cats]; catabolic state following chylothorax surgery [one cat]; fight injuries [seven cats]; FIV infections [three of seven cats tested]. Of the 17 cats, three were apparently cured. Four were thought to be cured, but infection recurred after several months. Three cats responded partially but were euthanased, while another was improving when it died of unrelated complications. Two died despite treatment and two were euthanased without an attempt at therapy. For two cats there were either insufficient records or the patient was lost to follow up.

CONCLUSION

Nocardiosis is a rare, serious disease. Currently it is more common in cats than dogs. Nocardial panniculitis may be clinically indistinguishable from the syndrome caused by rapidly growing mycobacteria. Although the prognosis is guarded, patients with localised infections caused by N nova often respond to appropriate therapy. If definitive treatment is delayed because of misdiagnosis, the disease tends to become chronic, extensive and refractory. Insufficient duration of therapy leads to disease recurrence.

What do psychotic experiences mean for young men? A qualitative investigation

This study is of a grounded theory analysis of the transcripts of young men talking about their experience of psychosis. Six young men were interviewed twice during the critical period of 3-5 years following their first psychotic episode. The young men were asked to reflect on themselves and their lives before, during, and after having psychotic experiences. The transcripts were considered to have a phenomenological status, in that they represented the participants' perspectives on their experiences. Four themes emerged that were common to all the accounts: experience of psychosis, immediate expression of psychotic experiences, personal and interpersonal changes, and personal explanations. These themes are explored in detail, and their links with existing research and clinical implications are considered.

Infections of the subcutis and skin of dogs caused by rapidly growing mycobacteria

Nine dogs with panniculitis due to rapidly growing mycobacteria (RGM) were examined over 17 years. Dogs were two to 15 years; five were male, four were female. All were obese or in good condition. Antecedent injury, typically a dog bite or vehicular trauma, could be identified in some patients, while one bitch had hyperadrenocorticism. Infections involved different locations, although the cervicothoracic region, dorsum or flank were most often affected. Patients were systemically well, apart from one dog with pyrexia and two with pain or lameness. Cytology demonstrated pyogranulomatous inflammation, but in only one case was it possible to see acid-fast bacilli (AFB) in smears. Histology demonstrated chronic active pyogranulomatous panniculitis and dermatitis; AFB could be detected in only four specimens. Culture of aspirates or resected tissues demonstrated RGM in all cases, comprising six Mycobacterium smegmatis group and three Mycobacterium fortuitum group isolates. Resection of infected tissues, perioperative injectable antimicrobials and long courses of oral antimicrobials chosen according to susceptibility data generally effected a cure, although some cases recurred.

Macaque dendritic cells infected with SIV-recombinant canarypox ex vivo induce SIV-specific immune responses in vivo

Dendritic cells (DCs) infected with recombinant avipox vectors express the introduced genes and activate antigen-specific T cells. DCs exhibit distinct differentiation-dependent immune functions. Moreover, immature DCs are readily infected by canarypox vectors, but undergo tumor necrosis factor (TNF)-alpha-dependent death, while fewer mature DCs get infected and resist dying. A pilot study was performed using the rhesus macaque system to explore whether immature and mature DCs infected with SIV-recombinant canarypox (vCP180) ex vivo could induce primary virus-specific immune responses in vivo. After subcutaneous (sc) reinjection, functional monocyte-derived DCs migrated to lymph nodes (LNs) within 1-2 days and primed T cells in vivo. This was observed by monitoring dye-labeled DCs in the draining LNs and tetanus toxoid (TT)-specific T cell responses after injection of TT-loaded DCs. DCs from simian immunodeficiency virus (SIV)-naïve rhesus macaques were infected with vCP180 (SIVmac142 gag, pol, and env genes), and sc reinjected into donor animals. Low-level SIV-specific T cell proliferation, but little if any interferon (IFN)-gamma production was detected. DCs pulsed with vCP180 in combination with TT and keyhole limpet hemocyanin (KLH) (to activate additional T cells and provide "helper" cytokines) induced SIV-, TT-, and KLH-specific T cell responses, including IFN-gamma responses not seen when vCP180-carrying DCs were used alone. Interleukin (IL)-10 and low-level antibody responses were also observed. This pilot study provides the proof of principle that sc injected ex vivo SIV-recombinant canarypox-infected DCs safely induce low-level SIV-specific immune responses in vivo.

Use of confocal and multiphoton microscopy for the evaluation of micro-optical components and emitters

We report on the application of confocal and multiphoton microscopic techniques for the evaluation of the latest generation of micro optical components. The optical emitting characteristics of arrays of matrix addressable GaN micrometer-sized light emitting diodes (micro-LEDs) have been measured using a commercial confocal microscope utilising the LEDs' own emission along with reflection confocal microscopy to determine the surface structure. Multiphoton induced luminescence from the 10-20-micron diameter emitters has also been used to examine the structure of the device and we compare this with electrically induced emission. In related work, the optical properties of micro lens arrays (10-100-micron diameter) fabricated in SiC, Sapphire, and Diamond have been determined using transmission confocal microscopy. Such optical microscopy techniques offer a simple, non-destructive method to determine the structure and performance of such novel devices.

Attenuated familial adenomatous polyposis presenting as ampullary adenocarcinoma

The risk of periampullary cancer in patients with classic familial adenomatous polyposis (FAP) is significantly increased compared with the general population. However, the incidence of this extracolonic manifestation in attenuated FAP (AFAP) is unknown. We report the case of a 38 year old woman with no known family history of polyposis or colorectal cancer, who presented with ampullary adenocarcinoma. Diagnosis of AFAP was made only after evaluation of the patient's extended family history and genetic testing. This case report suggests that AFAP should be included in the differential diagnosis of patients with ampullary/duodenal tumours.

The importance of social sources of cigarettes to school students

OBJECTIVE

To discover the importance of social sources of tobacco to young people as opposed to commercial sources; to describe the peer market for cigarettes in schools and the consequences for young people of their involvement in it.

STUDY DESIGN

Cross sectional questionnaire survey, one-to-one interviews, and focus groups.

SETTING

Seven schools in Birmingham, UK.

SUBJECTS

All students in two randomly selected classes from each school completed the questionnaire, and never smokers, occasional smokers, and regular smokers were interviewed.

RESULTS

Two thirds of occasional smokers and one quarter of regular smokers obtained cigarettes socially, mostly for free. A few smokers regularly bought their cigarettes from others. Among friendship groups, both smokers and non-smokers were involved in the exchange of cigarettes, often for money, which is a common activity. A few young people use the selling of cigarettes to fund their own smoking. Some young people, smokers and non-smokers, are involved in semi-commercial selling of cigarettes. All school students are aware of where to purchase cigarettes from non-friends, which is only used "in emergency" because of the high price. One school had a strong punishment policy for students caught with cigarettes. In this school, more people bought singles from the peer market and the price was higher.

CONCLUSIONS

The passing and selling of cigarettes in school is a common activity, which from the young persons perspective, ensures that all share cross counter purchases. A few people are prepared to use the peer market for monetary gain and it appears to be responsive to external conditions. The peer market might mean that efforts to control illegal sales of cigarettes are not as effective as hoped.

The change-in-stage and updated smoking status results from a cluster-randomized trial of smoking prevention and cessation using the transtheoretical model among British adolescents

BACKGROUND

The transtheoretical model (TTM) and computer technology are promising technologies for changing health behavior, but there is little evidence of their effectiveness among adolescents.

METHOD

Four thousand two hundred twenty-seven Year 9 (ages 13-14) pupils in 26 schools were randomly allocated to control and 4,125 in 26 schools were allocated to TTM intervention. TTM pupils received three whole class lessons and three sessions with an interactive computer program. Control pupils received no special intervention. Positive change in stage and smoking status was assessed from a questionnaire completed at baseline, 1 year, and 2 years. Random effects logistic regression was used to compare the change in stage and smoking status between the arms.

RESULTS

Eighty-nine percent of the TTM group and 89.3% of the control group were present at 1-year and 86.0 and 83.1%, respectively, were present at 2-year follow-up. The adjusted odds ratio (95% confidence interval) for positive stage movement in the TTM relative to control was 1.13 (0.91-1.41) at 1 year and 1.25 (0.95-1.64) at 2 years and for regular smoking was 1.14 (0.93-1.39) at 1 year and 1.06 (0.86-1.31) at 2 years. Subgroup analysis by initial smoking status revealed no benefit for prevention or cessation.

CONCLUSIONS

The intervention was ineffective.

Distribution analysis of the two chicken estrogen receptor-alpha isoforms and their transcripts in the hypothalamus and anterior pituitary gland

Estrogen plays a key role in the control of reproductive behavior and in the regulation of the neuroendocrine system. To elucidate the mechanisms by which it controls these functions it is important to understand how estrogenic effects are mediated. We have investigated the distribution of the two isoforms of the chicken estrogen receptor alpha (cER-alpha) protein; the previously characterized cER-alpha 66 and a new N-terminal truncated isoform, cER-alpha 61. Immunolocalization demonstrated the presence of cER-alpha 66 protein in hypothalamic areas, principally the nucleus septalis lateralis, bed nucleus striae terminalis medialis, nucleus preopticus medialis, and nucleus infundibuli hypothalami, and in the anterior pituitary gland. When the distribution of ER-alpha immunoreactive cells was compared using the antibodies H 222 (directed against the hormone-binding domain) and ER 221 (directed against the 21-amino acid N-terminus), no apparent differences could be detected. Because this immunocytochemical approach was not able to distinguish whether full-length cER-alpha 66 is the only isoform observed in the ER-positive regions or whether both cER-alpha receptor isoforms are present, SI nuclease assays were performed to compare the relative abundance in these regions of the two distinct classes of cER-alpha mRNA variants (A1-D and A2), which encode the cER-alpha 66 and cER-alpha 61 protein isoforms, respectively. In cockerels and hens, both variants of cER-alpha mRNA are expressed in the anterior pituitary gland and basal hypothalamus with a dominance of the mRNA that encodes cER-alpha 66, whereas the mRNA that encodes cER-alpha 61 was not detectable in the anterior hypothalamus. Therefore, because both receptor isoforms differ in their ability to modulate estrogen target gene expression in a promoter and cell type-specific manner, these differences may mediate the pleiotropic actions of estrogen in reproductive behavior and neuroendocrine functions.

Mutation in Brca2 stimulates error-prone homology-directed repair of DNA double-strand breaks occurring between repeated sequences

Mutation of BRCA2 causes familial early onset breast and ovarian cancer. BRCA2 has been suggested to be important for the maintenance of genome integrity and to have a role in DNA repair by homology- directed double-strand break (DSB) repair. By studying the repair of a specific induced chromosomal DSB we show that loss of Brca2 leads to a substantial increase in error-prone repair by homology-directed single-strand annealing and a reduction in DSB repair by conservative gene conversion. These data demonstrate that loss of Brca2 causes misrepair of chromosomal DSBs occurring between repeated sequences by stimulating use of an error-prone homologous recombination pathway. Furthermore, loss of Brca2 causes a large increase in genome-wide error-prone repair of both spontaneous DNA damage and mitomycin C-induced DNA cross-links at the expense of error-free repair by sister chromatid recombination. This provides insight into the mechanisms that induce genome instability in tumour cells lacking BRCA2.

Nutrition and the Elderly: A Case Manager’s Guide

This article reviews the physiological and nutritional changes associated with aging and provides the case manager with nutrition resources. General information on nutritional factors associated with aging, including common nutrient deficiences, is outlined. The dietitian's role in nutrition assessment, intervention, and outcomes is discussed. A list of resources for case managers interested in accessing a registered dietitian is also included.

The cost effectiveness of including pencils and erasers with self-completion epidemiological questionnaires

It is cheap to process epidemiological data from optical mark read (OMR) questionnaires. Respondents should use a pencil to complete OMR questionnaires, but many will not unless these are supplied. Sending pencils and erasers is expensive. Does sending pencils and erasers increase the response rate as cost-effectively as sending reminders, or does this decrease the error rate and offset data checking costs? We mailed 300 smokers and half were randomised to receive pencils and erasers. The relative risk (95% confidence intervals) for the response rate for the pencil group relative to the non-pencil group was 0.77 (0.46-1.29) and for the error rate was 1.31 (0.78-2.21). Sending pencils and erasers was not cost-effective in sensitivity analysis with any response rate or using the confidence intervals. Including pencils with mailed epidemiological questionnaires probably has no benefit and any plausible benefit does not offset the costs of sending pencils and erasers.

Parents' constructions of professional knowledge, expertise and authority during assessment and diagnosis of their child for an autistic spectrum disorder

This paper presents a discourse analysis of parents' talk about the knowledge, expertise and authority of professionals, during assessment and diagnosis of their child for an autistic spectrum disorder at a Child Development Centre. Focusing on the positional level of analysis, it was suggested that parents' constructions of professional expertise and authority were inherently ambivalent and at times contradictory. It was further argued that this ambivalence is also reflected in an ideological dilemma between equality and expertise, regarding the role and positioning of 'human relations experts'. Discourse analysis was found to be a particularly useful tool in investigating aspects of the parents' talk relating to authority, knowledge and expertise. It is suggested that acknowledging this ambivalence and scrutinizing one's assumptions and practice, rather than denying the authoritarian aspects of health care, would provide the basis for more ethical and respectful clinical practice.

Synthesis and application of submicrometer fluorescence sensing particles for lysosomal pH measurements in murine macrophages

Phagocytosis of bioparticles such as bacteria and viruses by macrophages is a critical component of the immune response against infections. In this paper we describe the synthesis of submicrometer fluorescent particles with pH sensing capability. The particles are used to measure the pH and to monitor the effect of chloroquine, an antimalarial drug, on the pH in the lysosome, the cellular organelle involved in the phagocytosis process. The synthesis of the pH sensing particles is realized by the covalent attachment of amine reactive forms of Oregon Green (pH sensitive dye) and Texas Red (pH insensitive dye) to the surface of amino-modified submicrometer polystyrene particles. The particles are absorbed by J774 Murine Macrophages through phagocytosis and directed to lysosomes. Despite the high lysosomal levels of digestive enzymes and acidity, the absorbed particles remain stable for 12 h in the cells when they are stored in a PBS buffer solution at pH 7.4. The pH dynamic range of the sensing particles is between pH 4.5 and 7 with a sensitivity of 0.1 pH units. Exposure of the cells to chloroquine increases the lysosomal pH from 4.8 to 6.5. The effect is concentration-dependent.

Building your own lifeboat: working-class male offenders talk about economic crime

This study examines the ways in which a group of working-class men serving custodial sentences and probation orders for money-related crimes talk about criminal activity and the implications of this talk for their gender identity. Using a critical social-psychological approach, we carried out nine semi-structured group discussions in probation centres and one open prison and then analyzed the transcripts using a combination of grounded theory and discourse analytic methods. The men critiqued dominant constructions of crime and argued that their criminal activity was justified in two related ways. First, they drew on a discourse of male breadwinning to argue that they were expected to provide for their families. Second, they argued that those now suffering under the broken promises made by the State should not be expected to conform to its rules. For the majority of men, earning through crime was talked about as a last resort and the parameters of 'what they did to whom' were informed by a Robin Hood-type cultural narrative. Finally, the study contextualizes and critically explores these patterns of discourse and their rhetorical use from a historical and structural perspective.

Quality of diagnostic services for cancer: a comparison of open access and conventional outpatient clinics

OBJECTIVE AND STUDY DESIGN

To assess quality of a quick and early diagnosis route (QED) by determining effectiveness and cost-effectiveness of five clinics compared with three conventional outpatient clinics. Prospective economic evaluation. Six-month cohort of all referrals (November 1996-April 1997).

SUBJECTS

All referrals for suspected cancers of: upper gastro-intestinal tract; urinary tract, prostate and testis; skin.

EFFECTIVENESS

Median days saved between GP referral and date of: diagnostic appointment; consultant decision; intervention.

RESULTS

GP referral to diagnostic appointment: QED was effective (median days) for all clinics. Diagnostic appointment to consultant decision: QED was effective for testicular and haematuria clinics. Consultant decision to intervention: QED was effective for haematuria, testicular and melanoma clinics.

COST-EFFECTIVENESS

Extra (incremental) NHS cost per patient diagnosed.

RESULTS

Less than 5 Pounds per day saved between GP referral and diagnostic appointment for: endoscopy; haematuria; prostate; testicular; melanoma. Less than 3 Pounds per day saved between GP referral and consultant decision for: testicular; haematuria. Less than 3 Pounds per day saved between GP referral and intervention for: endoscopy; haematuria; testicular; melanoma.

CONCLUSION

A "quick and early" diagnostic route provides a higher quality service through improved effectiveness and cost-effectiveness compared to conventional outpatients.

Cluster randomised controlled trial of expert system based on the transtheoretical ("stages of change") model for smoking prevention and cessation in schools

OBJECTIVES

To examine whether a year long programme based on the transtheoretical model of behaviour change, incorporating three sessions using an expert system computer program and three class lessons, could reduce the prevalence of teenage smoking.

DESIGN

Cluster randomised trial comparing the intervention to a control group exposed only to health education as part of the English national curriculum.

SETTING

52 schools in the West Midlands region.

PARTICIPANTS

8352 students in year 9 (age 13-14 years) at those schools.

MAIN OUTCOME MEASURES

Prevalence of teenage smoking 12 months after the start of the intervention.

RESULTS

Of the 8352 students recruited, 7444 (89.1%) were followed up at 12 months. The intention to treat odds ratio for smoking in the intervention group relative to control was 1.08 (95% confidence interval 0.89 to 1.33). Sensitivity analysis for loss to follow up and adjustment for potential confounders did not alter these findings.

CONCLUSIONS

The smoking prevention and cessation intervention based on the transtheoretical model, as delivered in this trial, is ineffective in schoolchildren aged 13-14.

Two functionally different protein isoforms are produced from the chicken estrogen receptor-alpha gene

The existence of two forms of the chicken estrogen receptor-alpha protein (ER-alpha) in chicken tissues is demonstrated: the previously reported receptor (cER-alpha form I), which has a size of 66 kDa, and a new form (cER-alpha form II), which lacks the N-terminal 41 amino acids present in form I and thus gives rise to a protein of 61 kDa. Whereas the 66-kDa protein is the translation product of several cER-alpha mRNAs (A1-D), the cER-alpha protein isoform II is encoded by a new cER-alpha mRNA (A2), which is transcribed in vivo from a specific promoter that is located in the region of the previously assigned translation start site of the cER-alpha gene. SI nuclease mapping analysis reveals that cER-alpha mRNA A2 is liver enriched. The resulting cER-alpha forms I and II differ in their ability to modulate estrogen target gene expression in a promoter- and cell type-specific manner. Whereas cER-alpha form I activates or represses in a strictly E2-dependent manner, the truncated form is characterized by a partial transactivating or repressing activity in the absence of its ligand. Comparison of the N-terminal coding regions of different vertebrate ER-alpha reveal a conservation of the translation start methionine of the protein ER-alpha form II in other oviparous species but not in mammals. The expression of two classes of ER-alpha transcripts encoding the two ER-alpha receptor forms in the liver of Xenopus laevis and rainbow trout is demonstrated. Therefore, the existence of two functionally different protein isoforms produced from the ER-alpha gene is probably a common and specific feature in oviparous species.

Novel application of PhastSystem polyacrylamide gel electrophoresis using restriction fragment length polymorphism--internal transcribed spacer patterns of individuals for molecular identification of entomopathogenic nematodes

différences! [editorial] [editorial]onomic way of identifying and assigning nematodes to taxons, which had already been determined either by comparative sequence analysis of nuclear rDNA internal transcribed spacer (ITS) region or by other methods of molecular or conventional taxonomy, is provided. Molecular identification of entomopathogenic nematodes (EPN) can be upgraded by basing it on PhastSystem polyacrylamide gel electrophoresis (PAGE) analysis of restriction fragment length polymorphism (RFLP) patterns of polymerase chain reaction (PCR)-amplified DNA derived from single nematodes of Steinernema or Heterorhabditis spp. Although analysis from single worms has previously been made on agarose gel, the resolution on PhastSystem PAGE gel is much higher. The DNA sequences selected for analysis were those constituting the internal transcribed spacer region between the 18S and 26S rDNA genes within the rRNA operon. RFLP analysis was carried out by gel electrophoresis on the PhastSystem (Pharmacia) as detailed elsewhere (Triga et al., Electrophoresis 1999, 20, 1272-1277. The downscaling from conventional agarose to PhastSystem gels resulted in pattern of DNA fragments differing from those obtained with agarose gel electrophoresis under conventional conditions by increasing the number of detected fragments. The approach supported previous species identifications and was able to identify several unclassified isolates, such as those from Hungary and Ireland, and provides a method for identification of previously unclassified strains. We confirmed that Heterorhabditis "Irish Type", represented by two strains of different geographical origin, comprise a species different from H. megidis. We also confirmed that strain IS5 belongs to the species H. indicus rather than to H. bacteriophora, as had been suggested previously.

Lymphoproliferative disorder of fetal origin presenting as oligohydramnios

Lymphoma involving the placenta or fetus remains a very rare event. All cases reported to date have shown the lymphoma cells to be of maternal origin in that the tumor cells have preferentially involved the intervillous spaces with sparing of the villi and fetal circulation. We report a novel case of a monoclonal primary placental Epstein-Barr virus (EBV)-associated B-cell lymphoma of fetal origin. The placenta of a 20-week stillborn fetus born to a 19-year-old gravida 1 para 0 woman, presenting with oligohydramnios, showed a large cell infiltrate confined within villi and sparing the intervillous spaces, indicative of preferential involvement of the fetal circulation. Necropsy did not show any other site of involvement by malignant lymphoma or other abnormalities. Immunophenotypic studies showed the tumor cells to be of B-cell phenotype with a relatively high proliferation rate. EBV EBER1 RNA was identified in more than 95% of tumor cells, and polymerase chain reaction studies showed EBV EBNA1 strain type A and wildtype EBV LMP1. Analysis of the immunoglobulin heavy chain by polymerase chain reaction showed a monoclonal B-cell population. In situ hybridization studies using a commercially available probe directed at repeated sequences on the human Y chromosome showed a single intense signal within trophoblastic epithelium and lymphoma cells, indicative of male origin. The mother remains in good health 11 months after delivery.

Progesterone secreting adrenal mass in a cat with clinical signs of hyperadrenocorticism

A 7-year-old 7-kg (16-lb) neutered male Himalayan cat had nonpruritic progressive alopecia of 9 months' duration. The cat had hyperglycemia and glucosuria. Physical examination revealed complete alopecia along the abdomen, inguinal area, medial and caudal areas of the thighs, ventral area of the thorax, and axilla. Clinical signs were consistent with endocrine-induced alopecia and hyperadrenocorticism, however, results of diagnostic tests (ACTH stimulation and low-dose dexamethasone suppression) were not supportive of hyperadrenocorticism. Abdominal ultrasonography revealed a mass cranial to the left kidney. Blood samples were obtained before and after ACTH stimulation to measure sex hormone concentrations. Analysis revealed markedly high blood progesterone concentrations before and after ACTH stimulation. An adrenalectomy was performed and histologic examination of the mass revealed a well-differentiated adrenocortical carcinoma. The right adrenal gland could not be viewed during surgery and was assumed to be atrophic. Following surgery, the hyperglycemia and glucosuria resolved. Within 4 months of surgery, the hyperprogesteronemia had resolved, and at 12 months the cat's coat quality appeared normal. Findings suggest that cats with signs of hyperadrenocorticism should be evaluated not only for abnormal cortisol concentrations, but also for sex hormone abnormalities.