Cancer risk management practices of non-carriers within BRCA1/2 mutation positive families in the Kathleen Cunningham Consortium for Research into Familial Breast Cancer (kConFab)

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Background: This study prospectively evaluated risk management practices of true BRCA1/2 negative women. Methods: A questionnaire was mailed to 471 non-carriers from mutation positive families 3 years after their enrolment in the kConFab breast cancer (BC) family cohort study. Women who had received their mutation result had pre-test counselling and result disclosure in one of 16 Family Cancer Clinics nationwide. Undertaking mammography more often than 2 yearly (Australian population guidelines), clinical breast examination (CBE) more often than yearly, breast self-examination (BSE) more often than monthly and any trans-vaginal ultrasound (TVU) or CA-125 was considered over screening. Linear logistic regression was used to identify factors (age, marital status, education, parity, ethnicity, place of residence, time since disclosure of result, family history) associated with over screening. Results: 347 women responded (74%); 260 were excluded from this analysis (self-reported not knowing their mutation status, 207; uninformative screening data due to proximity of result disclosure to questionnaire administration, 47; developed cancer, 3; pregnancy, 3), leaving 87 subjects. Mean follow up was 4.4 years. Proportions over-screening were; mammography 53%, CBE 10%, BSE 11%, TVU 10% and CA125 10%. No measured factor was associated with over-utilization of BC screening. Women with > one relative with OC were significantly more likely to over-utilize TVU (OR 8.1, CI 1.6–42 P=0.01) and CA125 (OR 19.6, CI 3.1–121 P=0.001) compared to women with ≤ one relative with OC. One woman underwent bilateral mastectomy and 1 bilateral oophorectomy; none used chemoprevention. Conclusions: A major benefit of learning one′s negative mutation status is that the intensity of risk management practices can be reduced to that appropriate for the general population. However, non-carriers with a strong family history of OC tend to inappropriately use OC screening. The reasons are unclear but need elucidation given the potential for harm. The reasons for over-utilization of mammography in 53% also warrant further study.

No significant financial relationships to disclose.

Genetic, functional, and histopathological evaluation of two C-terminal BRCA1 missense variants

BACKGROUND

The vast majority of BRCA1 missense sequence variants remain uncharacterized for their possible effect on protein expression and function, and therefore are unclassified in terms of their pathogenicity. BRCA1 plays diverse cellular roles and it is unlikely that any single functional assay will accurately reflect the total cellular implications of missense mutations in this gene.

OBJECTIVE

To elucidate the effect of two BRCA1 variants, 5236G>C (G1706A) and 5242C>A (A1708E) on BRCA1 function, and to survey the relative usefulness of several assays to direct the characterisation of other unclassified variants in BRCA genes.

METHODS AND RESULTS

Data from a range of bioinformatic, genetic, and histopathological analyses, and in vitro functional assays indicated that the 1708E variant was associated with the disruption of different cellular functions of BRCA1. In transient transfection experiments in T47D and 293T cells, the 1708E product was mislocalised to the cytoplasm and induced centrosome amplification in 293T cells. The 1708E variant also failed to transactivate transcription of reporter constructs in mammalian transcriptional transactivation assays. In contrast, the 1706A variant displayed a phenotype comparable to wildtype BRCA1 in these assays. Consistent with functional data, tumours from 1708E carriers showed typical BRCA1 pathology, while tumour material from 1706A carriers displayed few histopathological features associated with BRCA1 related tumours.

CONCLUSIONS

A comprehensive range of genetic, bioinformatic, and functional analyses have been combined for the characterisation of BRCA1 unclassified sequence variants. Consistent with the functional analyses, the combined odds of causality calculated for the 1706A variant after multifactorial likelihood analysis (1:142) indicates a definitive classification of this variant as "benign". In contrast, functional assays of the 1708E variant indicate that it is pathogenic, possibly through subcellular mislocalisation. However, the combined odds of 262:1 in favour of causality of this variant does not meet the minimal ratio of 1000:1 for classification as pathogenic, and A1708E remains formally designated as unclassified. Our findings highlight the importance of comprehensive genetic information, together with detailed functional analysis for the definitive categorisation of unclassified sequence variants. This combination of analyses may have direct application to the characterisation of other unclassified variants in BRCA1 and BRCA2.

Awareness under anesthesia and the development of posttraumatic stress disorder

Failure of general anesthesia to render a patient insensate, termed "awareness," is estimated to affect between 40,000 and 140,000 patients in the US each year. This study investigated the occurrence of post-traumatic stress disorder (PTSD) in subjects who reported a past episode of intraoperative awareness. We inquired about intraoperative and postoperative experiences and studied the relationship between various surgical experiences and currently meeting the diagnosis of PTSD. Sixteen postawareness subjects and 10 postgeneral anesthesia controls completed the Clinician Administered PTSD Scale (CAPS), a standardized clinical rating scale for PTSD, and a questionnaire about peri-operative experiences. Nine of 16 subjects (56.3%), a mean of 17.9 postoperative years, and no controls met diagnostic criteria for current PTSD (X(2)= 8.6, df = 1, P<.01). Common intraoperative experiences included an inability to communicate, helplessness, terror, and pain. Postawareness patients had significant postoperative distress related to feeling unable to communicate, unsafe, terrified, abandoned and betrayed. Perioperative dissociative experiences predicted having current PTSD. Being conscious during surgery is a traumatic event that may result in developing chronic PTSD. Further studies should include prospective designs of prevalence and long-term psychological, social, and overall health effects, and ways of preventing and treating awareness-induced PTSD.

Excretion of (14)C-fumonisin B(1), (14)C-hydrolyzed fumonisin B(1), and (14)C-fumonisin B(1)-fructose in rats

14C-Fumonisin B(1) (FB(1)) was produced by Fusarium proliferatum M-5991 in modified Myro liquid medium and purified to >95% purity with a specific activity of 1.7 mCi/mmol. Nine male and nine female F344/N rats were each dosed by gavage with 0.69 micromol of (14)C-FB(1), (14)C-hydrolyzed FB(1), or (14)C-FB(1)-fructose/kg body weight. Urinary excretion of (14)C-FB(1) and (14)C-FB(1)-fructose was 0.5% and 4.4% of the total dose, respectively, and was similar between male and female rats. Urinary excretion of (14)C-hydrolyzed HFB(1) was significantly greater (P > 0.05) in female rats as compared with male rats (17.3% vs 12.8% of the total dose, respectively). There were no significant (P > 0.05) differences in biliary excretion of the three fumonisin compounds with a mean of 1. 4% of the dose excreted at 4 h after dosing. Lesser amounts continued to be excreted up to 9.25 h after dosing. Although biliary excretion of the (14)C-FB(1), (14)C-hydrolyzed FB(1), and (14)C-FB(1)-fructose was similar, increased urinary excretion of the (14)C-hydrolyzed FB(1) as compared to (14)C-FB(1) and (14)C-FB(1)-fructose indicated a greater absorption of the hydrolyzed form.

Relationship of endogenous sex hormones to lipids and blood pressure in mid-aged women

PURPOSE

The relationship between endogenous sex hormones and blood lipids was examined in a representative sample of 438 Australian-born women 45 to 56 years of age taking part in a longitudinal study of the menopausal transition. Data from 363 women who were taking neither exogenous hormones nor lipid-altering medications, were not diabetic, and who had provided blood samples were available for analysis.

METHODS

Multiple linear regression was used to examine the relationship between sex hormones and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides, and diastolic blood pressure (DBP), taking account of the effects of age, body mass index (BMI), smoking, alcohol intake, and exercise.

RESULTS

There was no significant relationship between estradiol and HDL, LDL, triglyceride, or DBP levels. Free androgen index was positively associated with LDL. However, BMI was an important predictor of all three lipid measures and DBP. HDL was positively associated with age and was highest among women with lowest BMI, high alcohol intake, and in nonsmokers. LDL increased with BMI, free androgen index, and age, but was lower amongst women who exercised more than two or three times per week. Triglyceride also increased with BMI, and was higher among smokers. DBP increased with BMI only.

CONCLUSIONS

The results do not support the view that endogenous sex hormones are strongly associated with cardiovascular risk factors around the time of menopause.

Degree of left hippocampal atrophy correlates with severity of neuropsychological deficits

The relationship between the degree and distribution of hippocampal atrophy measured by volumetric magnetic resonance imaging and severity of memory deficits in 25 patients with temporal lobe epilepsy secondary to mesial temporal sclerosis was assessed. Hippocampal volumes were expressed as a ratio of smaller to larger, normal ratio greater than 0.95. Neuropsychology tests included: subtests of the WAIS-R, Rey Auditory Verbal Learning Task, Rey Figure and the Austin Maze. Degree of left hippocampal atrophy in patients with left temporal lobe epilepsy was associated with severity of verbal memory deficits as measured by RAVLT total recall (P < 0.05), delayed recall (P < 0.001), story recognition (P < 0.001), list recognition (P < 0.001) and final delayed recall (P < 0.001) and recall of the Rey Figure (P < 0.01). There was no association between degree of right hippocampal atrophy and any of the memory tests. Diffuse left hippocampal atrophy was associated with more severe verbal memory deficits than anterior atrophy. We conclude, the association between degree of left hippocampal atrophy and verbal memory provides further evidence of the predominant involvement of the left hippocampus in verbal memory. The finding of a relationship between degree of left hippocampal atrophy and measures of non-verbal function suggests these tests are dependent on verbal memory, or that mesial temporal sclerosis is a bilateral but asymmetrical condition.

Factors in the cycle of violence: gender rigidity and emotional constriction

A sample of 595 men were administered self-report assessments of childhood sexual and physical abuse, perpetration history, gender rigidity and emotional constriction. Including noncontact forms of sexual abuse, 11% of the men reported sexual abuse alone, 17% reported physical abuse alone, and 17% reported both sexual and physical abuse. Of the 257 men in the sample who reported some form of childhood abuse, 38% reported some form of perpetration themselves, either sexual or physical; of the 126 perpetrators, 70% reported having been abused in childhood. Thus, most perpetrators were abused, but most abused men did not perpetrate. Both sexually and physically abused men who perpetrated manifested significantly more gender rigidity and emotional constriction than abused nonperpetrators. Men who reported abuse but not perpetration demonstrated significantly less gender rigidity, less homophobia and less emotional constriction than nonabused men.

Determinants of serum levels of retinol, β-carotene and α-tocopherol in men and women born in Australia, Greece and Italy

Serum retinol, β-carotene and α-tocopherol levels were measured in a volunteer sample of 764 Australian-, Greek- and Italian-born adult residents of Melbourne, Australia. There was no difference among the ethnic groups in mean levels of serum retinol or α-tocopherol. Mean β-carotene levels were between 11 and 22% higher for Australian-born subjects. Serum β-carotene was higher in females, retinol was higher in males. The serum levels of retinol, β-carotene and α-tocopherol were significantly positively associated with serum cholesterol. Serum triglyceride was positively associated with serum retinol and α-tocopherol but negatively associated with serum -β-carotene. A positive association with retinol and an inverse association with β-carotene was found for alcohol consumption. Serum α-tocopherol was positively associated with dietary vitamin E. Serum β-carotene was correlated with carotene intake among subjects who had never smoked. Serum retinol increased with age in women only. These data provide a degree of cross-cultural robustness to previous findings in regard to the determinants of serum retinol, β-carotene and α-tocopherol in healthy men and women.

Intermittent ischaemic arrest and cardioplegia in coronary artery surgery: coming full circle?

OBJECTIVE

To compare the cardioprotective efficacy of cold crystalloid cardioplegia and intermittent ischaemic arrest in patients undergoing elective coronary artery surgery.

DESIGN

Prospective randomised trial.

SETTING

London teaching hospital.

SUBJECTS

20 patients with at least moderately good left ventricular function undergoing elective coronary artery surgery by one experienced surgeon and needing at least two bypass grafts.

INTERVENTIONS

Patients were randomised to cold crystalloid cardioplegia or intermittent ischaemic arrest.

MAIN OUTCOME MEASURES

The primary determinant of the efficacy of myocardial protection was serial measurement (before and at 1, 6, 24, and 72 hours after the end of cardiopulmonary bypass) of cardiac troponin T (cTnT), a highly sensitive and specific marker of myocardial damage.

RESULTS

There was no significant difference in age, ejection fraction, number of grafts, bypass times, or cross clamp times between the two groups. One patient in the cardioplegia group had a perioperative infarct and was excluded from further study. In both groups there was a significant increase in cTnT, with peak concentrations being reached 6 hours after the end of cardiopulmonary bypass and remaining significantly high at 72 hours. At 6 hours the median (75% interquartile range) concentrations of cTnT were similar in both groups (1.8 (1.0-3.6) micrograms/l for cardioplegia v 1.9 (1.0-3.5) micrograms/l for intermittent ischaemic arrest).

CONCLUSION

This trial shows that intermittent ischaemic arrest, even without systemic cooling or venting of the left ventricle, provides a similar level of myocardial protection to cardioplegia in patients with moderate left ventricular function and short ischaemic times.

The treatment-seeking woman at menopause

Recent studies suggest that health care utilisation by women during menopause transition in general is highly idiosyncratic, despite the widespread advocation of prophylactic hormone therapy and increased health vigilance. The Melbourne Women's Midlife Health Study, a community-based cross-sectional study of 2001 urban Australian-born women aged 45-55 years, evaluated women's physical and emotional experiences, past and present health status, attitudes and beliefs about menopause, health behaviours and current menopausal status in a 30-min telephone interview. This paper reports on those factors related to help-seeking and health care utilisation. Findings show that treatment utilisers, in contrast to non-utilisers, reported a wider range of general symptoms, but reports on vasomotor symptoms did not contribute to the regression analysis. Treatment utilisers were further identified as problem-related or prevention-related utilisers. In three-way analyses, the past and present social and physical health of the problem-related treatment user was reportedly worse than either the prevention-related utiliser or non-utiliser. These findings suggest that medical and societal views about the health of middle-aged women during menopausal transition are likely to be based on the experiences of a particular segment of the population only. It is proposed that biased views of menopause as a time of considerable distress and ill-health are being perpetuated and over-generalised. This perspective appears to have little relevance for the majority of middle-aged women.