Prognostic significance of deregulated dicer expression in breast cancer

BACKGROUND

Dicer, an RNase III-type endonuclease, is the key enzyme involved in RNA interference and microRNA pathways. Aberrant expression of Dicer is reported in several human cancers. Our aim was to assess the prognostic role of Dicer in breast cancer.

METHODS

The entire series comprised 666 invasive breast cancers (IBCs), 480 DCIS cases (397 associated with IBC and 83 pure DCIS) and 305 lymph node metastases. Cytoplasmic Dicer expression by immunohistochemistry was scored as negative (no staining) and positive (weak, moderate or strong staining).

RESULTS

Dicer staining was assessable in 446 IBC, 128 DCIS and 101 lymph node metastases. Expression of Dicer was observed in 33% (145/446) of IBCs, 34% (44/128) of DCIS and 57% (58/101) of lymph node metastases. Dicer expression was increased in nodal metastases compared to primary tumours (p<0.001); and was associated with ER negativity (p<0.001), HER2 positivity (p<0.001), high Ki67 labeling index (p<0.001) and expression of basal-like biomarkers (p = 0.002). Dicer positivity was more frequent in the HER2 overexpressing (p<0.001) and basal-like (p = 0.002) subtypes compared to luminal A subtype. Dicer expression was associated with reduced overall survival (OS) on univariate analysis (p = 0.058) and remained an independent predictor of OS on multivariate analysis (HR 2.84, 95% CI 1.43-5.62, p = 0.003), with nodal status (HR 2.61, 95% CI 1.18-5.80, p = 0.018) and PR (HR 0.28, 95% CI 0.13-0.59, p = 0.001). Further, moderate or strong expression of Dicer was associated with improved disease-free survival in the HER2-overexpressing subtype compared to negative or weak expression (p = 0.038).

CONCLUSION

Deregulated Dicer expression is associated with aggressive tumour characteristics and is an independent prognostic factor for OS. Our findings suggest that Dicer is an important prognostic marker in breast cancer and that its prognostic role may be subtype specific.

Does long-term partial sodium channel blockade alter disease progression in MS? Evidence from a retrospective study

BACKGROUND

There is accumulating evidence that long-term disability and disease progression in multiple sclerosis (MS) are due to prolonged sodium channel opening along demyelinated axons. Despite good evidence in animal models of MS that partial voltage-gated sodium channel (VGSC) blockade reduces disease progression, little is known about its effects in patients, despite widespread use of such agents in the symptomatic management of MS.

OBJECTIVE

To determine if long-term exposure to the VGSC-blocking drug carbamazepine (CBZ) alters disease progression in MS.

METHODS

Using a retrospective chart review of patients diagnosed with MS, we compared progression of disability between patients exposed the VGSC blocker CBZ with those who were not exposed to the drug. Both whole-group and matched case-control analyses were performed after correcting for the influence of age, gender, MS subtype, expanded disability status score at diagnosis, use of disease-modifying therapy, and year of initial therapy. The multiple sclerosis severity scale (MSSS) was used as a measure of disease severity. The primary outcome measure was MSSS score difference between groups.

RESULTS

Four hundred patients were included; 51 received CBZ symptomatic therapy (average duration of therapy 27 months). There was no significant difference in mean MSSS between the two groups in either the whole group comparison (p = 0.63) or the matched analysis (p = 0.12).

CONCLUSION

Despite preclinical evidence suggesting a neuroprotective role of VGSC blockers in animal models of MS, this retrospective study suggests that long-term exposure to the VGSC-blocking drug CBZ fails to alter long-term disability and disease progression in MS patients.

The cost-effectiveness of a structured education pulmonary rehabilitation programme for chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial

OBJECTIVE

To assess the cost-effectiveness of a structured education pulmonary rehabilitation programme (SEPRP) for chronic obstructive pulmonary disease (COPD) relative to usual practice in primary care. The programme consisted of group-based sessions delivered jointly by practice nurses and physiotherapists over 8 weeks.

DESIGN

Cost-effectiveness and cost-utility analysis alongside a cluster randomised controlled trial.

SETTING

32 general practices in Ireland.

PARTICIPANTS

350 adults with COPD, 69% of whom were moderately affected.

INTERVENTIONS

Intervention arm (n=178) received a 2 h group-based SEPRP session per week over 8 weeks delivered jointly by a practice nurse and physiotherapist at the practice surgery or nearby venue. The control arm (n=172) received the usual practice in primary care.

MAIN OUTCOME MEASURES

Incremental costs, Chronic Respiratory Questionnaire (CRQ) scores, quality-adjusted life years (QALYs) gained estimated using the generic EQ5D instrument, and expected cost-effectiveness at 22 weeks trial follow-up.

RESULTS

The intervention was associated with an increase of €944 (95% CIs 489 to 1400) in mean healthcare cost and €261 (95% CIs 226 to 296) in mean patient cost. The intervention was associated with a mean improvement of 1.11 (95% CIs 0.35 to 1.87) in CRQ Total score and 0.002 (95% CIs -0.006 to 0.011) in QALYs gained. These translated into incremental cost-effectiveness ratios of €850 per unit increase in CRQ Total score and €472 000 per additional QALY gained. The probability of the intervention being cost-effective at respective threshold values of €5000, €15 000, €25 000, €35 000 and €45 000 was 0.980, 0.992, 0.994, 0.994 and 0.994 in the CRQ Total score analysis compared to 0.000, 0.001, 0.001, 0.003 and 0.007 in the QALYs gained analysis.

CONCLUSIONS

While analysis suggests that SEPRP was cost-effective if society is willing to pay at least €850 per one-point increase in disease-specific CRQ, no evidence exists when effectiveness was measured in QALYS gained.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN52 403 063.

ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes

OBJECTIVE

Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM.

METHODS

Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (s.d. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used.

DESIGN, COHORT STUDY, AND RESULTS

The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66).

CONCLUSIONS

Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (s.d.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

Effectiveness of a cognitive behavioural therapy-based rehabilitation programme (Progressive Goal Attainment Program) for patients who are work-disabled due to back pain: study protocol for a multicentre randomised controlled trial

Background

Psychologically informed rehabilitation programmes such as the Progressive Goal Attainment Program (PGAP) have the potential to address pain-related disability by targeting known psychological factors that inhibit rehabilitation progress. However, no randomised controlled trials of this intervention exist and it has not been evaluated in the Irish health service context. Our objective was to evaluate the clinical efficacy and cost-effectiveness of the PGAP in a multicentre randomised controlled trial with patients who are work-disabled due to back pain.

Methods and design

Adult patients (ages 18 years and older) with nonmalignant back pain who are work-disabled because of chronic pain and not involved in litigation in relation to their pain were invited to take part. Patients were those who show at least one elevated psychosocial risk factor (above the 50^th percentile) on pain disability, fear-based activity avoidance, fatigue, depression or pain catastrophizing. Following screening, patients are randomised equally to the intervention or control condition within each of the seven trial locations. Patients allocated to the control condition receive usual medical care only. Patients allocated to the PGAP intervention condition attend a maximum of 10 weekly individual sessions of structured active rehabilitation in addition to usual care. Sessions are delivered by a clinical psychologist and focus on graded activity, goal-setting, pacing activity and cognitive-behavioural therapy techniques to address possible barriers to rehabilitation.

The primary analysis will be based on the amount of change on the Roland Morris Disability Questionnaire posttreatment. We will also measure changes in work status, pain intensity, catastrophizing, depression, fear avoidance and fatigue. Outcome measures are collected at baseline, posttreatment and 12-month follow-up. Health-related resource use is also collected pre- and posttreatment and at 12-month follow-up to evaluate cost-effectiveness.

Discussion

This study will be the first randomized controlled trial of the PGAP in chronic pain patients and will provide important information about the clinical and cost effectiveness of the programme as well as its feasibility in the context of the Irish health service.

Trial registration

Current Controlled Trials: ISRCTN61650533

miR-379 regulates cyclin B1 expression and is decreased in breast cancer

MicroRNAs are small non-coding RNA molecules that control gene expression post-transcriptionally, and are known to be altered in many diseases including breast cancer. The aim of this study was to determine the relevance of miR-379 in breast cancer. miR-379 expression was quantified in clinical samples including tissues from breast cancer patients (n=103), healthy controls (n=30) and patients with benign breast disease (n=35). The level of miR-379 and its putative target Cyclin B1 were investigated on all breast tissue specimens by RQ-PCR. Potential relationships with gene expression and patient clinicopathological details were also determined. The effect of miR-379 on Cyclin B1 protein expression and function was investigated using western blot, immunohistochemistry and proliferation assays respectively. Finally, the levels of circulating miR-379 were determined in whole blood from patients with breast cancer (n=40) and healthy controls (n=34). The level of miR-379 expression was significantly decreased in breast cancer (Mean(SEM) 1.9 (0.09) Log₁₀ Relative Quantity (RQ)) compared to normal breast tissues (2.6 (0.16) Log₁₀ RQ, p<0.01). miR-379 was also found to decrease significantly with increasing tumour stage. A significant negative correlation was determined between miR-379 and Cyclin B1 (r=-0.31, p<0.001). Functional assays revealed reduced proliferation (p<0.05) and decreased Cyclin B1 protein levels following transfection of breast cancer cells with miR-379. Circulating miR-379 was not significantly dysregulated in patients with breast cancer compared to healthy controls (p=0.42). This data presents miR-379 as a novel regulator of Cyclin B1 expression, with significant loss of the miRNA observed in breast tumours.

The effectiveness of a structured education pulmonary rehabilitation programme for improving the health status of people with moderate and severe chronic obstructive pulmonary disease in primary care: the PRINCE cluster randomised trial

Objective

To evaluate the effectiveness of a structured education pulmonary rehabilitation programme on the health status of people with chronic obstructive pulmonary disease (COPD).

Design

Two-arm, cluster randomised controlled trial.

Setting

32 general practices in the Republic of Ireland.

Participants

350 participants with a diagnosis of moderate or severe COPD.

Intervention

Experimental group received a structured education pulmonary rehabilitation programme, delivered by the practice nurse and physiotherapist. Control group received usual care.

Main outcome measure

Health status as measured by the Chronic Respiratory Questionnaire (CRQ) at baseline and at 12–14 weeks postcompletion of the programme.

Results

Participants allocated to the intervention group had statistically significant higher mean change total CRQ scores (adjusted mean difference (MD) 1.11, 95% CI 0.35 to 1.87). However, the CI does not exclude a smaller difference than the one that was prespecified as clinically important. Participants allocated to the intervention group also had statistically significant higher mean CRQ Dyspnoea scores after intervention (adjusted MD 0.49, 95% CI 0.20 to 0.78) and CRQ Physical scores (adjusted MD 0.37, 95% CI 0.14 to 0.60). However, CIs for both the CRQ Dyspnoea and CRQ Physical subscales do not exclude smaller differences as prespecified as clinically important. No other statistically significant differences between groups were seen.

Conclusions

A primary care based structured education pulmonary rehabilitation programme is feasible and may increase local accessibility to people with moderate and severe COPD.

Trial registration

ISRCTN52403063.

To what extent does the Health Professions Admission Test-Ireland predict performance in early undergraduate tests of communication and clinical skills? An observational cohort study

BACKGROUND

Internationally, tests of general mental ability are used in the selection of medical students. Examples include the Medical College Admission Test, Undergraduate Medicine and Health Sciences Admission Test and the UK Clinical Aptitude Test. The most widely used measure of their efficacy is predictive validity.A new tool, the Health Professions Admission Test- Ireland (HPAT-Ireland), was introduced in 2009. Traditionally, selection to Irish undergraduate medical schools relied on academic achievement. Since 2009, Irish and EU applicants are selected on a combination of their secondary school academic record (measured predominately by the Leaving Certificate Examination) and HPAT-Ireland score. This is the first study to report on the predictive validity of the HPAT-Ireland for early undergraduate assessments of communication and clinical skills.

METHOD

Students enrolled at two Irish medical schools in 2009 were followed up for two years. Data collected were gender, HPAT-Ireland total and subsection scores; Leaving Certificate Examination plus HPAT-Ireland combined score, Year 1 Objective Structured Clinical Examination (OSCE) scores (Total score, communication and clinical subtest scores), Year 1 Multiple Choice Questions and Year 2 OSCE and subset scores. We report descriptive statistics, Pearson correlation coefficients and Multiple linear regression models.

RESULTS

Data were available for 312 students. In Year 1 none of the selection criteria were significantly related to student OSCE performance. The Leaving Certificate Examination and Leaving Certificate plus HPAT-Ireland combined scores correlated with MCQ marks.In Year 2 a series of significant correlations emerged between the HPAT-Ireland and subsections thereof with OSCE Communication Z-scores; OSCE Clinical Z-scores; and Total OSCE Z-scores. However on multiple regression only the relationship between Total OSCE Score and the Total HPAT-Ireland score remained significant; albeit the predictive power was modest.

CONCLUSION

We found that none of our selection criteria strongly predict clinical and communication skills. The HPAT- Ireland appears to measures ability in domains different to those assessed by the Leaving Certificate Examination. While some significant associations did emerge in Year 2 between HPAT Ireland and total OSCE scores further evaluation is required to establish if this pattern continues during the senior years of the medical course.

An evaluation of Croí MyAction community lifestyle modification programme compared to standard care to reduce progression to diabetes/pre-diabetes in women with prior gestational diabetes mellitus (GDM): study protocol for a randomised controlled trial

BACKGROUND

Universal screening using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria has identified a prevalence of gestational diabetes mellitus (GDM) of 12.4% in women living in Ireland. Women with prior GDM are at increased risk of developing type 2 diabetes later in life. A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes, and medical management. No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM. Through a two-group, parallel randomised controlled trial (RCT), this study aims to assess the clinical impact, cost-effectiveness and psychological experience of the Croí MyAction intensive lifestyle modification programme for women with prior GDM.

METHODS/DESIGN

A total of 54 women with a history of GDM and persistent post-partum glucose dysfunction (impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)), are randomly assigned to a control arm (n=27) or to the Croí MyAction intervention group (n=27). The control arm receives usual health care advice--written information on diet and lifestyle changes for reducing diabetes risks and visits with general practitioners as required. The intervention group receives usual health care as per the control group in addition to attending a 12-week intensive lifestyle modification programme known as Croí MyAction. Croí MyAction involves 2.5 hour sessions once per week (for 12 weeks) comprising a group exercise programme, group health promotion or education seminars, and one-to-one meetings with a multidisciplinary health care team to personalise risk factor reductions. Randomisation and allocation to the intervention arms is carried out by an independent researcher, ensuring that the allocation sequence is concealed from study researchers until the interventions are assigned. The primary analysis is based on glucose dysfunction, comparing a mean reduction in fasting plasma glucose (FPG) levels on a 75 gram oral glucose tolerance test (OGTT) in the two groups at a one-year, post-intervention follow-up. The trial is funded by the Irish Health Research Board (HRB). Ethics approval was obtained on 27 March 2012 from the Clinical Research Ethics Committee, Galway University Hospitals, Health Service Executive of Ireland (Ref: C.A.691).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41202110.

Group follow-up compared to individual clinic visits after structured education for type 1 diabetes: a cluster randomised controlled trial

AIM

To compare the effectiveness of group follow-up with individual follow-up after participation in the Dose Adjustment for Normal Eating (DAFNE) structured education programme.

METHODS

Cluster randomised controlled trial involving 437 adults with type 1 diabetes attending hospital diabetes clinics in Ireland. All participants received DAFNE at baseline. Intervention arm participants received 2 group education sessions post-DAFNE and did not attend clinics. Control arm participants received 2 one-to-one clinic visits post-DAFNE.

RESULTS

We observed no significant difference in the primary outcome (change in HbA1c) at 18 months follow-up (mean difference 0.14%; 95% CI -0.33 to 0.61; p=0.47). Secondary outcomes, including rates of severe hypoglycaemia, anxiety, depression, the burden of living with diabetes and quality of life did not differ between groups. Mean level of HbA1c for the entire sample (regardless of treatment arm) did not change between baseline and 18 month follow-up (p=0.09), but rates of severe hypoglycaemia, diabetes related hospital attendance, levels of anxiety, depression, the burden of living with diabetes, quality of life and treatment satisfaction all significantly improved.

CONCLUSIONS

Our data suggest that group follow-up as the sole means of follow-up after structured education for individuals with type 1 diabetes is as effective as a return to one-to-one clinic visits.

Impact of Lepeophtheirus salmonis infestations on migrating Atlantic salmon , Salmo salar L., smolts at eight locations in Ireland with an analysis of lice-induced marine mortality

Sea lice infestation as a source of marine mortality of outwardly migrating Atlantic salmon smolts has been investigated by treating groups of ranched salmon, prior to release, with a prophylactic sea lice treatment conferring protection from sea lice infestation. A number of studies have been carried out in Ireland using both established ranched populations and groups of hatchery reared fish imprinted for 5-8 weeks in the sites of experimental releases. In this study, data on 352 142 migrating salmon from twenty-eight releases, at eight locations along Ireland's South and West coasts covering a 9-year period (2001 to 2009) are reviewed. Both published and new data are presented including a previously unpublished time series. The results of a meta-analysis of the combined data suggest that while sea lice-induced mortality on outwardly migrating smolts can be significant, it is a minor and irregular component of marine mortality in the stocks studied and is unlikely to be a significant factor influencing conservation status of salmon stocks.

Sea lice levels on wild Atlantic salmon, Salmo salar L., returning to the coast of Ireland

The sea lice population structure, prevalence and intensity of Lepeophtheirus salmonis have been studied over a period extending from 2004 to 2011. Infestation data were collected from the interceptor drift net fishery from 2004 until it was closed in 2006. From 2010, data were collected from the inshore draft net fishery. In all, 34 samples from the drift and draft net fisheries have been analysed to date. Prevalence of infestation with L. salmonis regularly approached 100% in samples of hosts recovered from the offshore drift net fishery. Abundance was variable both within and between years with a maximum mean abundance of 25.8 lice per fish recorded in 2004. The population structure of L. salmonis on hosts recovered in the inshore and estuarine draft net fisheries was different from that observed in the more offshore drift net samples. There is clear evidence of recent infestation with L. salmonis in the draft net samples.

miRNA expressions in rectal cancer as predictors of response to neoadjuvant chemoradiation therapy

INTRODUCTION

Neoadjuvant chemoradiation therapy has been shown to improve the outcome in patients with rectal cancer and is generally accepted as standard care; however, only selected patients would benefit from this treatment. We aimed to identify predictors of response to neoadjuvant chemoradiation therapy in colorectal cancer using formalin-fixed paraffin-embedded (FFPE) tissues as source of genetic materials and microarray analysis as investigation tool.

METHODS

After optimization of RNA extraction methods from FFPE, microarray analysis was carried out on total RNA extracted from 12 pre-treatment FFPE rectal tissues using Megaplex pool A. Microarray data were analysed using an artificial neural network algorithm. Statistical analysis and correlation with clinicopathological data was performed using SPSS software.

RESULTS

A distinct miRNA expression signature predictive of response to neoadjuvant CRT in 12 FFPE pre-treatment rectal cancer tissue samples was identified. These signatures consisted of three miRNA transcripts (miR-16, miR-590-5p and miR-153) to predict complete vs. incomplete response and two miRNA transcript (miR-519c-3p and miR-561) to predict good vs. poor response with a median accuracy of 100 %.

CONCLUSION

Using microarray analysis of pretreatment FFPE rectal cancer tissues, we identified for the first time a group of miRNA predictors of response to neoadjuvant CRT. This, indeed, can lead to a significant improvement in patient selection criteria and personalized rectal cancer management.

Relationship between circulating and tissue microRNAs in a murine model of breast cancer

MiRNAs are key regulators of tumorigenesis that are aberrantly expressed in the circulation and tissue of patients with cancer. The aim of this study was to determine whether miRNA dysregulation in the circulation reflected similar changes in tumour tissue. Athymic nude mice (n = 20) received either a mammary fat pad (n = 8, MFP), or subcutaneous (n = 7, SC) injection of MDA-MB-231 cells. Controls received no tumour cells (n = 5). Tumour volume was monitored weekly and blood sampling performed at weeks 1, 3 and 6 following tumour induction (total n = 60). Animals were sacrificed at week 6 and tumour tissue (n = 15), lungs (n = 20) and enlarged lymph nodes (n = 3) harvested. MicroRNAs were extracted from all samples (n = 98) and relative expression quantified using RQ-PCR. MiR-221 expression was significantly increased in tumour compared to healthy tissue (p<0.001). MiR-10b expression was significantly higher in MFP compared to SC tumours (p<0.05), with the highest levels detected in diseased lymph nodes (p<0.05). MiR-10b was undetectable in the circulation, with no significant change in circulating miR-221 expression detected during disease progression. MiR-195 and miR-497 were significantly decreased in tumour tissue (p<0.05), and also in the circulation of animals 3 weeks following tumour induction (p<0.05). At both tissue and circulating level, a positive correlation was observed between miR-497 and miR-195 (r = 0.61, p<0.001; r = 0.41, p<0.01 respectively). This study highlights the distinct roles of miRNAs in circulation and tissue. It also implicates miRNAs in disease dissemination and progression, which may be important in systemic therapy and biomarker development.

Predictors of quality of life gains among people with type 1 diabetes participating in the Dose Adjustment for Normal Eating (DAFNE) structured education programme

AIMS

To examine predictors of quality of life gains among people with type 1 diabetes following the Dose Adjustment for Normal Eating (DAFNE) self-management training programme.

METHODS

Clinical and questionnaire data were collected from 437 patients from 6 hospital centres before, and 18 months post-DAFNE intervention. Glycated haemoglobin (HbA(1c)), weight, height, and blood pressure levels were recorded by clinicians during clinic appointments. Questionnaires included the Diabetes-Specific Quality of Life Scale (DSQOLS), the Problem Areas in Diabetes Scale (PAID) and the Hospital Anxiety and Depression Scale (HADS). Basic demographics were recorded at baseline. Linear mixed models were fitted to identify predictors of change in quality of life at an 18 month follow-up assessment.

RESULTS

Patients with high levels of diabetes-related distress experienced greatest improvement in DSQOLS quality of life scores (p = 0.001). Patients with poor glycaemic control (higher levels of HbA(1c); p = 0.03) and those with high levels of anxiety (p = 0.001) experienced the greatest reductions in diabetes-related distress.

CONCLUSIONS

Patients with higher baseline levels of anxiety, higher levels of diabetes-related distress and higher baseline levels of HbA(1c) are most likely to experience quality of life gain from participation in self-management programmes such as DAFNE.

Demographic, physiologic and radiographic characteristics of COPD patients taking chronic systemic corticosteroids

Long-term therapy with systemic corticosteroids is not recommended in the treatment of chronic obstructive pulmonary disease (COPD). However, experience demonstrates that some patients receive low dose therapy. Our objective was to describe the demographic, physiologic and radiologic characteristics of COPD patients treated with chronic systemic corticosteroids. We analyzed COPD subjects with GOLD I-IV disease in the COPDGene® study. Subjects were divided into 2 groups based on whether they reported using chronic oral steroids or not; 1264 subjects were included. Fifty-eight (4.5%) reported chronic systemic corticosteroid use. There were no differences in age, race, co-morbid conditions (other than asthma), or body mass index between the groups. There was a greater proportion of GOLD III (41% vs. 26%) and IV (41% vs. 13%) subjects in the group using chronic systemic corticosteroids. This group used more respiratory medications, required more oxygen (2.31 ± 0.21 vs. 0.59 ± 0.05 L/min; p < 0.0001), and walked less distance (245.4 ± 17.4 vs. 367.2 ± 3.9 meters; p < 0.0001). They reported more total (1.7 ± 0.16 vs. 0.62 ± 0.03; p < 0.0001) and severe exacerbations per year (0.41 ± 0.05 vs. 0.18 ± 0.01; p < 0.0001). BODE (5.0 ± 0.3 vs. 2.6 ± 0.1; p < 0.0001), MMRC (3.31 ± 0.19 vs. 1.90 ± 0.04; p < 0.0001) and SGRQ scores (54.9 ± 2.9 vs 53.3 ± 0.6; p < 0.0001) were higher. They also had a higher percentage of emphysema (22.4 ± 1.9 vs. 14.0 ± 0.4;%, p = <0.0001) on CT scan. COPD patients that report using chronic systemic corticosteroids have more severe clinical, physiologic, and radiographic disease.

P1-09-05: A 3′UTR Functional Variant in BRCA1: A Predictor of Poor Outcome in Breast Cancer

Background: MicroRNAs (miRNAs) are class of gene regulators which exert their effects through binding with partial complementarity to sequences in the 3'untranslated region (3'UTR) of the target mRNA. Single nucleotide polymorphisms (SNPs) in the 3'UTR of target mRNA have the potential to disrupt or create new illegitimate miRNA targets and have been associated with cancer predisposition as well as tumor biology. An association between rs8176318 and risk for familial breast and ovarian cancer as well as risk for triple negative breast cancer in African American women has previously been established. We aimed to evaluate the phenotypic effect of rs8176318 in a west of Ireland breast cancer cohort, and also its role as a biomarker of prognosis.

Methods: DNA from 727 unselected breast cancer cases and 387 controls were extracted from whole blood and genotyped for rs8176318 in the 3'UTR of the BRCA1 oncogene. The association with disease specific parameters and outcome were evaluated.

Results: Overall, there was a significant difference in the distribution of the three genotypes between cases and controls (p=0.035). The dominant variant model was predictive of breast cancer (OR=1.4, 95% CI 1.1−1.8). Fifty-two percent of breast cancer cases had the variant, with similar prevalence between subtypes: Luminal A (279 [54%] of 519 cases), Luminal B (37 [43%] of 85 cases), HER2 (21 [53%] of 40 cases) and triple negative breast cancer (41 [49%] of 83 cases). Comparing the prevalence of the variant within respective subtypes with controls however, Luminal A breast cancer was most strongly associated with rs8176318 (OR=1.5, 95%CI 1.1−1.9). The variant was not significantly associated with disease free survival (DFS) in all cancer cases (Log-rank test=0.084). However, rs8176318 was predictive of a poorer DFS (Log-rank test=0.041) in Luminal A patients with a 10-year DFS of 54% (95% CI 0.4−0.7) and 77% (95%CI 0.7−0.9) for the variant versus the non-variant, respectively. In addition, patients with Stage IV disease had a 6-fold increased risk of carrying the variant (p = 0.035), with 17 (73%) of 23 patients with metastasis at presentation positive for the variant compared to 324 (50%) of 642 patients without metastasis (p=0.034). Luminal A patients with Stage IV disease had a 13-fold risk of carrying the variant (p=0.043) in regression analysis, controlling for all other clinicopathological variables. Similarly, the variant was associated with distant metastasis in Luminal A patients, with 11 (92%) of 12 patients with metastasis positive for the variant compared to 242 (52%) of 463 patients without metastasis (p=0.028).

Conclusion: These findings suggest that rs8176318, a variant in the 3'UTR of BRCA1, is a genetic marker for modest breast cancer risk but aggressive tumor biology in breast cancer, and highlights the need for further clinical and biological evaluation of such markers.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-09-05.

P2-12-15: GAINS: A Breast Cancer Prognostic Index Utilizing Lymph Node Ratio

Introduction: Axillary lymph node status is an important predictor of overall survival (OS), hence its inclusion in clinical prognostic tools. The Nottingham Prognostic Index (NPI) which incorporates Lymph Node (LN) stage, tumor size and grade generates a score which predicts a percentage 10-year survival. Despite its status as a benchmark model for breast cancer prognosis, newer prognostic factors do exist. Lymph Node Ratio (LNR) is a superior prognostic indicator compared to absolute positive lymph node number, warranting re-evaluation of breast cancer prognostication. The aims of this study were threefold: identify the strength of LNR as a prognostic indicator compared to LN stage and NPI; establish a new prognostic index (Galway Index of Survival [GAINS]), taking into account the effect of LNR and breast cancer subtype on traditional clinicopathological features in breast cancer prognostication; and evaluate the prognostic efficacy of the new index compared to NPI.

Methods: Two cohorts were used: Galway Cohort-a prospectively compiled cohort of 1668 cases with histologically proven Stage 1, 2 and 3 primary operable breast cancer treated between 1990–2010 in a single institution; and ONCOPOOL-a retrospectively compiled database of 16944 cases treated across 12 European breast cancer units between 1990–1999. A Cox Proportional Hazards model was fitted to evaluate the strength of LNR compared to LN stage (within the NPI model) in both cohorts. The effect of clinicopathological variables on OS was analyzed using multivariable analysis in the Galway cohort. Three models were created (Model 1: Traditional prognostic variables excluding NPI and LNR; Model 2: Model 1 and LNR; Model 3: Model 1 and NPI) and compared using Likelihood-ratio tests.

The prevalence of multimorbidity in primary care and its effect on health care utilization and cost

INTRODUCTION

Multimorbidity is common among the heterogeneous primary care population, but little data exist on its association with health care utilization or cost.

OBJECTIVE

The aim of this observational study was to examine the prevalence and associated health care utilization and cost of patients with multimorbidity.

METHODS

All patients >50 years of age were eligible for the study which took place in three primary care practices in the West of Ireland. Chronic medical conditions and associated health care utilization in primary and secondary care were identified through patient record review.

RESULTS

In a sample of 3309 patients in the community, the prevalence of multimorbidity was 66.2% (95% CI: 64.5-67.8) in those >50 years of age. Health care utilization and cost was significantly increased among patients with multimorbidity (P < 0.001). After multivariate adjustment for age, gender and free medical care eligibility, the addition of each chronic condition led to an associated increase in primary care consultations (P = 0.001) (11.9 versus 3.7 for >4 conditions versus 0 conditions); hospital out-patient visits (P = 0.001) (3.6 versus 0.6 for >4 conditions versus 0 conditions); hospital admissions (P = 0.01) [adjusted odds ratio (OR) of 4.51 for >4 conditions versus 0 conditions] and total health care costs (P < 0.001) (€4,096.86 versus €760.20 for >4 conditions versus 0 conditions) over the previous 12 months.

CONCLUSIONS

Multimorbidity is very common in primary care and in a system with strong gatekeeping is associated with high health care utilization and cost across the health care system. Interventions to address quality and cost associated with multimorbidity must focus on primary as well as secondary care.

Gender differences of airway dimensions in anatomically matched sites on CT in smokers

RATIONALE AND OBJECTIVES

There are limited data on, and controversies regarding gender differences in the airway dimensions of smokers. Multi-detector CT (MDCT) images were analyzed to examine whether gender could explain differences in airway dimensions of anatomically matched airways in smokers.

MATERIALS AND METHODS

We used VIDA imaging software to analyze MDCT scans from 2047 smokers (M:F, 1021:1026) from the COPDGene® cohort. The airway dimensions were analyzed from segmental to subsubsegmental bronchi. We compared the differences of luminal area, inner diameter, wall thickness, wall area percentage (WA%) for each airway between men and women, and multiple linear regression including covariates (age, gender, body sizes, and other relevant confounding factors) was used to determine the predictors of each airway dimensions.

RESULTS

Lumen area, internal diameter and wall thickness were smaller for women than men in all measured airway (18.4 vs 22.5 mm(2) for segmental bronchial lumen area, 10.4 vs 12.5 mm(2) for subsegmental bronchi, 6.5 vs 7.7 mm(2) for subsubsegmental bronchi, respectively p < 0.001). However, women had greater WA% in subsegmental and subsubsegmental bronchi. In multivariate regression, gender remained one of the most significant predictors of WA%, lumen area, inner diameter and wall thickness.

CONCLUSION

Women smokers have higher WA%, but lower luminal area, internal diameter and airway thickness in anatomically matched airways as measured by CT scan than do male smokers. This difference may explain, in part, gender differences in the prevalence of COPD and airflow limitation.

Relationship between CCL5 and transforming growth factor-β1 (TGFβ1) in breast cancer

PURPOSE

Investigate circulating CCL5 in breast cancer patients and healthy controls, along with gene expression levels in corresponding tumour tissue and isolated primary stromal cells. Hormonal control of CCL5, and a potential relationship with TGFβ1, was also investigated.

METHODS

Circulating levels of CCL5 and TGFβ1 were measured in 102 breast cancer patients and 66 controls using ELISA. Gene expression levels (CCL5, CCR5, TGFβ1, TGFβRII) were quantified in corresponding tumour tissue (n = 43), normal tissue (n = 16), and isolated tumour (n = 22) and normal (n = 3) stromal cells using RQ-PCR. CCL5 and circulating menstrual hormones (LH, FSH, Oestradiol, Progesterone) were analysed in serum samples from healthy, premenopausal volunteers (n = 60).

RESULTS

TGFβ1 was significantly higher in breast cancer patients (Mean(SEM) 27.4(0.9)ng/ml) compared to controls (14.9(0.9)ng/ml). CCL5 levels decreased in the transition from node negative (59.6(3.7)ng/ml) to node positive disease (40.5(6.3)ng/ml) and increased again as the number of positive lymph nodes increased (⩾3 positive 50.95(9.8)ng/ml). A significant positive correlation between circulating CCL5 and TGFβ1 (r = 0.423, p<0.0001) was observed, and mirrored at the gene expression level in tumour tissue from the same patients (r = 0.44, p<0.001). CCL5, CCR5 and TGFβ1 expression was significantly higher in tumour compared to normal breast tissue (p < 0.001). A significant negative correlation was observed between circulating CCL5, Oestradiol and Progesterone (r = -0.50, r = -0.39, respectively, p < 0.05).

CONCLUSION

CCL5 expression is elevated in the tumour microenvironment. The data support a role for hormonal control of circulating CCL5 and also highlight a potentially important relationship between CCL5 and TGFβ1 in breast cancer.

The effectiveness of supplementing a standard rehabilitation program with superimposed neuromuscular electrical stimulation after anterior cruciate ligament reconstruction: a prospective, randomized, single-blind study

BACKGROUND

Rehabilitation after anterior cruciate ligament reconstruction is a key determinant affecting patient return to usual activity levels. Neuromuscular electrical stimulation is a treatment that can counteract strength loss and serve as an adjunct to conventional therapy.

PURPOSE

To compare the effect of adding traditional neuromuscular electrical stimulation (Polystim) or a novel garment-integrated neuromuscular electrical stimulation (Kneehab) to a standard postoperative rehabilitation program (control).

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Ninety-six patients, of a total enrolled cohort of 131 patients randomized to 1 of 3 intervention groups, completed a standard rehabilitation program. In addition, the 2 neuromuscular electrical stimulation groups underwent 20-minute sessions of neuromuscular electrical stimulation 3 times a day, 5 days a week, for 12 weeks, in which stimulation was superimposed on isometric volitional contractions. Outcome measures including isokinetic strength of the knee extensors of the injured and uninjured leg at 90 and 180 deg/s, along with functional tests of proprioception, were assessed at baseline and at 6 weeks, 12 weeks, and 6 months postoperatively.

RESULTS

The Kneehab group achieved significantly better results at each time point compared with the Polystim and control groups (P < .001). Extensor strength of the Kneehab group at speeds of 90 and 180 deg/s increased by 30.2% and 27.8%, respectively, between the preoperative measurements and the 6-month follow-up point in the injured leg. The corresponding changes for Polystim were 5.1% and 5%, whereas for the control group they were 6.6% and 6.7%, respectively. The mean single-legged hop test hop score of the Kneehab group improved by 50% between the 6-week and 6-month follow-up, whereas the corresponding changes for the Polystim and control groups were 26.3% and 26.2%, respectively. Although there was no significant difference between the groups with respect to the Tegner score and the International Knee Documentation Committee 2000 knee examination score, the Kneehab group showed a significant difference in mean improvement for the baseline corrected Lysholm score compared with the control group (P = .01; 95% confidence interval, 1.12-8.59) and with the Polystim group (P < .001; 95% confidence interval, 1.34-9.09) with no significant difference evident between Polystim and control groups (P = .97; 95% confidence interval, -4.23 to 3.51).

CONCLUSION

Intensive garment-integrated stimulation combined with standard rehabilitation is effective at accelerating recovery after knee surgery.

Structural magnetic resonance imaging in bipolar disorder: an international collaborative mega-analysis of individual adult patient data

BACKGROUND

There is substantial inconsistency in results of brain structural magnetic resonance imaging studies in adult bipolar disorder. This is likely consequent upon limited statistical power of studies together with their clinical and methodological heterogeneity. The current study was undertaken to perform an international collaborative mega-analysis of regional volumetric measurements of individual patient and healthy subject data, to optimize statistical power, detect case-control differences, assess the association of psychotropic medication usage with brain structural variation, and detect other possible sources of heterogeneity.

METHODS

Eleven international research groups contributed published and unpublished data on 321 individuals with bipolar disorder I and 442 healthy subjects. We used linear mixed effects regression models to evaluate differences in brain structure between patient groups.

RESULTS

Individuals with bipolar disorder had increased right lateral ventricular, left temporal lobe, and right putamen volumes. Bipolar patients taking lithium displayed significantly increased hippocampal and amygdala volume compared with patients not treated with lithium and healthy comparison subjects. Cerebral volume reduction was significantly associated with illness duration in bipolar individuals.

CONCLUSIONS

The application of mega-analysis to bipolar disorder imaging identified lithium use and illness duration as substantial and consistent sources of heterogeneity, with lithium use associated with regionally specific increased brain volume.

The sodium iodide symporter (NIS) and potential regulators in normal, benign and malignant human breast tissue

Introduction

The presence, relevance and regulation of the Sodium Iodide Symporter (NIS) in human mammary tissue remains poorly understood. This study aimed to quantify relative expression of NIS and putative regulators in human breast tissue, with relationships observed further investigated in vitro.

Methods

Human breast tissue specimens (malignant n = 75, normal n = 15, fibroadenoma n = 10) were analysed by RQ-PCR targeting NIS, receptors for retinoic acid (RARα, RARβ), oestrogen (ERα), thyroid hormones (THRα, THRβ), and also phosphoinositide-3-kinase (PI3K). Breast cancer cells were treated with Retinoic acid (ATRA), Estradiol and Thyroxine individually and in combination followed by analysis of changes in NIS expression.

Results

The lowest levels of NIS were detected in normal tissue (Mean(SEM) 0.70(0.12) Log₁₀ Relative Quantity (RQ)) with significantly higher levels observed in fibroadenoma (1.69(0.21) Log₁₀RQ, p<0.005) and malignant breast tissue (1.18(0.07) Log₁₀RQ, p<0.05). Significant positive correlations were observed between human NIS and ERα (r = 0.22, p<0.05) and RARα (r = 0.29, p<0.005), with the strongest relationship observed between NIS and RARβ (r = 0.38, p<0.0001). An inverse relationship between NIS and PI3K expression was also observed (r = −0.21, p<0.05). In vitro, ATRA, Estradiol and Thyroxine individually stimulated significant increases in NIS expression (range 6–16 fold), while ATRA and Thyroxine combined caused the greatest increase (range 16–26 fold).

Conclusion

Although NIS expression is significantly higher in malignant compared to normal breast tissue, the highest level was detected in fibroadenoma. The data presented supports a role for retinoic acid and estradiol in mammary NIS regulation in vivo, and also highlights potential thyroidal regulation of mammary NIS mediated by thyroid hormones.

A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): The PRINCE Study protocol

BACKGROUND

A key strategy in improving care for people with chronic obstructive pulmonary disease (COPD) is the provision of pulmonary rehabilitation programmes. Pulmonary rehabilitation programmes have been successful in improving patients' sense of dyspnoea and Health Related Quality of Life. However, the effectiveness of structured education pulmonary rehabilitation programmes delivered at the level of the general practice on the health status of people with COPD remains uncertain and there is a need for a robust and fair assessment of this. The PRINCE study will evaluate the effectiveness of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), delivered at the level of the general practice, on the health status of people with COPD.

METHODS/DESIGN

The PRINCE Trial is a two-armed, single blind cluster randomised trial conducted in the primary care setting in Ireland. Randomisation to control and intervention is at the level of the General Practice. Participants in the intervention arm will receive a SEPRP and those allocated to the control arm will receive usual care. Delivery of the SEPRP will be by a practice nurse and physiotherapist in the General Practice (GP) site. The primary outcome measure of the study will be health status as measured by the Chronic Respiratory Questionnaire (CRQ). Blinded outcome assessment will be undertaken at baseline and at twelve-fourteen weeks after completion of the programme. A comparison of outcomes between the intervention and control sites will be made to examine if differences exist and, if so, to what extent between control and experimental groups. Sample size calculations estimate that 32 practices with a minimum of 10 participants per practice are required, in total, to be randomised to control and intervention arms for power of at least 80% with alpha levels of 0.05, to determine a clinically significant change of 0.5 units in the CRQ. A cost effectiveness analysis will also be conducted.

DISCUSSION

The results of this trial are directly applicable to primary care settings in Ireland. Should a SEPRP delivered by practice nurses and physiotherapists in primary care be found to be effective in improving patients' sense of dyspnoea and HRQoL, then the findings would be applicable to many thousands of individuals in Ireland and beyond.

Abstract P3-10-02: Circulating miRNA Signature: Potential Screening and Prognostic Tool for Breast Cancer

Introduction: Genetic profiling of breast tumors revolutionized the classification of breast cancer and unravelled the complexity of this phenotypically diverse disease. However there appears to be discordance between the various mRNA-based single sample predictors which stratify tumors into subgroups. Clinical decision making based on a tumor's mRNA expression is therefore concerning. The potential of mi(cro) RNAs as novel tumor markers has been the focus of recent scrutiny due to their tissue specificity, stability and superiority to mRNA in tumor classification. Additionally, the ability to quantify tumor-associated miRNAs in the circulation and their correlations with clinicopathologic variables, highlights their potential to improve upon existing breast tumor classification methods. Systemic miR-195 and let-7a have been shown to hold properties as breast tumor markers. The aim of this study was to identify a larger panel of miRNAs which augment the sensitivity and specificity of circulating miRNAs as diagnostic and prognostic markers for breast cancer.

Methods: The expression levels of 9 miRNAs were evaluated in 345 preoperative cancer patients including 265 breast cancers and 80 non-breast malignancies, and 63 age-matched disease-free controls using RQ-PCR. MiRNA quantification was also performed on tumor tissue from 83 age and stage matched breast cancer patients. Advanced QBase Plus software and SPSS were used for biostatistical analysis of the data and correlation with clinicopathologic variables.

Results: This study confirmed significantly deranged expression levels of systemic miR-195 and let-7a in an independent validation cohort of breast cancer patients (p &lt; 0.001 and p &lt; 0.001 respectively). In addition miR-181c and miR-342 were identified as breast cancer specific biomarkers. Elevated levels of this 4-miRNA signature in breast cancer patients, including those with in-situ carcinoma, increased the discriminatory power of this test for breast cancer (all types) to 94% (P&lt;0.001).

Circulating levels of these 4 miRNAs correlated with tumor miRNA expression, and decreased to basal levels by 2 weeks following curative tumor resection. Additionally circulating miRNA levels correlated with clinicopathological variables such as tumor size and hormone receptor status. A subset of 2 systemic miRNAs was predictive of the Luminal A subtype of breast cancer (ER/PR positive, Her2/neu negative) with 91% accuracy.

Conclusion: This study validates the recent novel finding of dysregulated tumor-specific miRNAs in the circulation of breast cancer patients. Considering that the sensitivity of mammography is 75-90%, this circulating miRNA signature could improve upon existing breast cancer screening methods, given that it was significantly altered even in patients with in-situ carcinoma. These results indicate that circulating miRNA analysis holds immense potential in the future individualized management of breast cancer patients.

Systemic miRNA-195 differentiates breast cancer from other malignancies and is a potential biomarker for detecting noninvasive and early stage disease

PURPOSE

The potential of microRNAs (miRNAs) as novel tumor markers has been the focus of recent scrutiny because of their tissue specificity, stability, and association with clinicopathological parameters. Data have emerged documenting altered systemic miRNA expression across a spectrum of cancers; however, it remains uncertain as to whether circulating miRNAs are tumor specific. Our aim was to assess a panel of cancer-associated miRNAs in the circulation of patients with various malignancies, to determine whether these "oncomirs" were tumor specific, and thus to establish whether systemic miRNA analysis has utility in cancer diagnosis.

PATIENTS AND METHODS

Whole blood samples were prospectively collected from preoperative cancer patients (breast, prostate, colon, and renal cancer and melanoma; n = 163) and healthy age- and sex-matched controls (n = 63). Total RNA was isolated, and a panel of seven miRNAs was quantified by real-time quantitative polymerase chain reaction in each sample.

RESULTS

Differential expression of the general oncomirs let 7a, miR-10b, and miR-155, was observed in the majority of cancer patients in a nonspecific manner. Significantly, elevated circulating miR-195 was found to be breast cancer specific and could differentiate breast cancer from other cancers and from controls with a sensitivity of 88% at a specificity of 91%. A combination of three circulating miRNAs, including miR-195, further enhanced the discriminative power of this test for breast cancer to 94%.

CONCLUSION

These findings suggest that individual cancers display specific systemic miRNA profiles, which could aid in discriminating among cancer types. This finding is of notable clinical consequence because it illustrates the potential of systemic miRNAs as sensitive, specific, noninvasive cancer biomarkers.

Upregulation of DNA methyltransferase-mediated gene silencing, anchorage-independent growth, and migration of colon cancer cells by interleukin-6

Inflammatory bowel disease is characterized by chronic inflammation which predisposes to colorectal cancer. The mechanisms by which inflammation promotes tumorigenesis are not fully known. We aimed to investigate the links between colonic inflammation and tumorigenesis via epigenetic gene silencing. Colon cancer specimens were assessed for the expression of DNA methyltransferase-1 (DNMT-1) using immunohistochemistry. Colorectal carcinoma cell lines were assessed for DNMT1 expression, methylcytosine content, promoter methylation, gene expression, and tumorigenesis in response to interleukin (IL)-6. DNMT1 was expressed at higher levels in both the peritumoral stroma and tumor in inflammatory bowel disease-associated cancers compared with sporadic colon cancers. IL-6 treatment of colon cancer cells resulted in an increase in DNMT1 expression, independent of de novo gene expression. IL-6 increased the methylation of promoter regions of genes associated with tumor suppression, adhesion, and apoptosis resistance. Expression of a subset of these genes was downregulated by IL-6, an effect that was prevented by preincubation with 5-azadeoxycytidine, a DNMT1 inhibitor. Anchorage-independent growth and migration of colon cancer cells was also increased by IL-6 in a 5-azadeoxycytidine-sensitive manner. Our results indicate that DNMT-mediated gene silencing may play a role in inflammation-associated colon tumorigenesis.

Identification of endogenous control genes for normalisation of real-time quantitative PCR data in colorectal cancer

Background

Gene expression analysis has many applications in cancer diagnosis, prognosis and therapeutic care. Relative quantification is the most widely adopted approach whereby quantification of gene expression is normalised relative to an endogenously expressed control (EC) gene. Central to the reliable determination of gene expression is the choice of control gene. The purpose of this study was to evaluate a panel of candidate EC genes from which to identify the most stably expressed gene(s) to normalise RQ-PCR data derived from primary colorectal cancer tissue.

Results

The expression of thirteen candidate EC genes: B2M, HPRT, GAPDH, ACTB, PPIA, HCRT, SLC25A23, DTX3, APOC4, RTDR1, KRTAP12-3, CHRNB4 and MRPL19 were analysed in a cohort of 64 colorectal tumours and tumour associated normal specimens. CXCL12, FABP1, MUC2 and PDCD4 genes were chosen as target genes against which a comparison of the effect of each EC gene on gene expression could be determined. Data analysis using descriptive statistics, geNorm, NormFinder and qBasePlus indicated significant difference in variances between candidate EC genes. We determined that two genes were required for optimal normalisation and identified B2M and PPIA as the most stably expressed and reliable EC genes.

Conclusion

This study identified that the combination of two EC genes (B2M and PPIA) more accurately normalised RQ-PCR data in colorectal tissue. Although these control genes might not be optimal for use in other cancer studies, the approach described herein could serve as a template for the identification of valid ECs in other cancer types.

Characterisation of 17q12-21 – Identification of Novel Therapeutic Targets

Introduction: Over-expression of the HER2/neu oncogene is associated with poorer clinical outcome in breast cancer. Notwithstanding the success achieved with Trastuzumab in treating HER2/neu positive patients, numerous questions remain. In particular, there are concerns regarding accurate identification of HER2/neu positivity and the correct management of these patients in terms of the dosage, timing and optimal combination of Trastzumab with chemotherapeutic regimens. One approach to answering these questions has been to focus on the area of chromosome 17 in which HER2/neu is located in order to identify other genes in the vicinity. As potential therapeutic targets, we examined the amplification and expression patterns of co-localised cancer-associated genes at the HER2/neu amplicon on chromosome 17.Aims: The primary objective of this study was to examine amplification and expression patterns of co-localised genes at 17q12-21. In doing so, we aimed to establish their relationship with HER2/neu positivity, and then to quantify their relative importance in developing a gene panel predictive of HER2/neu status.Methods: Breast tissue from a cohort of patients with HER2/neu positive (n=48) and negative (n=48) tumours was retrieved at time of surgery. Protein and gene expression levels were determined using immunohistochemistry and RQ-PCR, respectively. Results were analysed to detect patterns of amplification among the genes, namely HER2/neu, STARD3, GRB7, TOP2A, TUBG1, RPL19, LASP1, RARA, and ER Alpha, and to identify associations between expression levels and clinical data. A binary logistic approach and classification tree analysis was employed to determine whether the expression levels of our target genes were useful predictors of HER2/neu status.Results: Strong correlation was noted between expression levels of HER2/neu and multiple cancer-associated genes at 17q12-21, including the novel genes LASP1 (p=0.000) and RPL19 (p=0.000). A significant relationship was also noted between TOP2A and the previously unexplored TUBG1 (p=0.000). Analysis of gene expression patterns according to clinicopathological variables revealed significant associations across intrinsic breast cancer subtypes.Conclusion: This study reaffirms the correlation between HER2/neu and its co-localised genes at 17q12-21, including novel candidate genes LASP1 and RPL19. We have also identified a novel relationship between TOP2A and TUBG1. Furthermore, our work represents a tentative step in the development of more accurate means of characterising HER2/neu status. As such, this work has again indicated the central role which this amplicon may play in selection of patients for treatment, not alone for Herceptin and anthracyclines, but also for taxane-based therapies, and as such, has revealed novel pathways for us to follow as we move towards our goal of individually tailored therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3137.

Bilateral Breast Cancer: Analysis of Incidence, Characteristics and Outcome of the Disease

Background: Despite the widespread adoption of breast conservation therapy in breast cancer, there is a dramatic increase in the rate of bilateral mastectomy in USA. The aim of this study was to address the incidence of bilateral breast cancer (BBC) and to investigate its characteristics, survival and outcome compared to unilateral breast cancer.Methods: Data was acquired from the prospectively maintained NUI Galway breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous cancer (after 12 months of first tumour). SPSS was used for data analysis.Results: The incidence of bilateral breast cancer in our population was 4.4% (112 of 2524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (0=0.021) and had smaller size (p=0.001) and earlier stage (p&lt;0.001) tumours at diagnosis. There were no differences in histological type (p=0.630) and grade (p=0.054)). While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (p&gt;0.05), the synchronous bilateral tumour was associated with poor overall survival (p=0.010) and disease free survival (p=0.013) in comparison to metachronous bilateral tumour.Conclusion: We observed significant differences in bilateral tumour characteristics compared to unilateral disease. Although bilateral synchronous tumour was associated with poor outcome and overall survival, patients with metachronous disease do as well as patients with unilateral tumour. The increasing practice of bilateral mastectomy is not supported by this large single centre experience.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5033.

The impact of renal insufficiency and anaemia on survival in patients with cardiovascular disease: a cohort study

Background

The simultaneous occurrence of cardiovascular disease (CVD), kidney disease, and anaemia is associated with increased morbidity and mortality. In the community setting, little data exists about the risk associated with milder levels of anaemia when it is present concurrently with CVD and chronic kidney disease (CKD). The aim of this study was to establish the prevalence of CKD and anaemia in patients with CVD in the community and to examine whether the presence of anaemia was associated with increased morbidity and mortality.

Methods

This study was designed as a retrospective cohort study and involved a random sample of 35 general practices in the West of Ireland. A practice-based sample of 1,609 patients with established cardiovascular disease was generated in 2000/2001 and followed for five years. The primary endpoint was death from any cause. Statistical analysis involved using one-way ANOVA and Chi-squared tests for baseline data and Cox proportional-hazards models for mortality data.

Results

Of the study sample of 617 patients with blood results, 33% (n = 203) had CKD while 6% (n = 37) had CKD and anaemia. The estimated risk of death from any cause, when compared to patients with cardiovascular disease only, was almost double (HR = 1.98, 95% CI 0.99 to 3.98) for patients with both CVD and CKD and was over 4 times greater (HR = 4.33, 95% CI 1.76 to 10.68) for patients with CVD, CKD and anaemia.

Conclusion

In patients with cardiovascular disease in the community, chronic kidney disease and anaemia occur commonly. The presence of chronic kidney disease carries an increased mortality risk which increases in an additive way with the addition of anaemia. These results suggest that early primary care diagnosis and management of this high risk group may be worthwhile.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

OBJECTIVE

To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease.

DESIGN

Cluster randomised controlled multicentre trial.

SETTING

General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems.

PARTICIPANTS

903 patients with established coronary heart disease registered with one of 48 practices.

INTERVENTION

Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care.

MAIN OUTCOME MEASURES

The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12).

RESULTS

At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03).

CONCLUSIONS

Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24081411.

The Irish DAFNE study protocol: a cluster randomised trial of group versus individual follow-up after structured education for type 1 diabetes

BACKGROUND

Structured education programmes for individuals with Type 1 diabetes have become a recognised means of delivering the knowledge and skills necessary for optimal self-management of the condition. The Dose Adjustment for Normal Eating (DAFNE) programme has been shown to improve biomedical (HbA(1c) and rates of severe hypoglycaemia) and psychosocial outcomes for up to 12 months following course delivery. The optimal way to support DAFNE graduates and maintain the benefits of the programme has not been established. We aimed to compare 2 different methods of follow-up of DAFNE graduates in a pragmatic clinical trial delivered in busy diabetes clinics on the island of Ireland.

METHODS

Six participating centres were cluster randomised to deliver either group follow-up or a return to traditional one-to-one clinic visits. In the intervention arm group follow-up was delivered at 6 and 12 months post DAFNE training according to a curriculum developed for the study. In the control arm patients were seen individually in diabetes clinics as part of routine care. Study outcomes included HbA(1c) levels, self-reported rates of severe hypoglycaemia, body weight and measures of diabetes wellbeing and quality of life. These were measured at 6, 12 and 18 months after recruitment. Generalisability (external validity) was maximised by recruiting study participants from existing DAFNE waiting lists in each centre, by using broad inclusion criteria (including HbA(1c) values less than 13 percent with no lower limit) and by using existing clinic staff to deliver the training and follow-up. Internal validity and treatment fidelity were maximised by quality assuring the training of all DAFNE educators, by external peer review of the group follow-up sessions and by striving for full attendance at follow-up visits. Assays of HbA(1c) were undertaken in a central laboratory.

DISCUSSION

This pragmatic clinical trial evaluating group follow-up after a structured education programme has been designed to have broad generalisability. The results should inform how best to manage the well educated patient with Type 1 diabetes in the real world of clinical practice

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79759174.

Research activity and capacity in primary healthcare: the REACH study: a survey

Background

Despite increased investment in primary care research and development (R&D), the level of engagement of primary healthcare professionals with research remains poor. The aim of this study is to assess the level of research activity and capacity for research among primary healthcare professionals in a health authority of over one million people in a mixed urban/rural setting in the West of Ireland.

Methods

A questionnaire, incorporating the R+D Culture Index, was sent to primary healthcare professionals in the HSE Western Region. Baseline characteristics were analysed with the use of one-way ANOVA and Chi-square test and the dependence of R&D Culture Index score on all sixteen available covariates was examined using multiple regression and regression tree modelling.

Results

There was a 54% response rate to the questionnaire. Primary healthcare professionals appeared to have an interest in and awareness of the importance of research in primary care but just 15% were found to be research active in this study. A more positive attitude towards an R&D culture was associated with having had previous research training, being currently involved in research and with not being a general practitioner (GP) (p < 0.001), but much variability in the R&D culture index score remained unexplained.

Conclusion

Despite awareness of the importance of R&D in primary care and investment therein, primary healthcare professionals remain largely unengaged with the R&D process. This study highlights the issues that need to be addressed in order to encourage a shift towards a culture of R&D in primary care: lack of research training particularly in basic research skills and increased opportunities for research involvement. The use of the R&D Culture Index may enable groups to be identified that may be more research interested and can therefore be targeted in any future R&D strategy.

Optimal time-of-day and consolidation of learning in younger and older adults

The current study investigated the relationship between intraindividual variability and associative learning in younger and older adults. The authors hypothesized that higher levels of intraindividual variability would be associated with a reduction in the benefits of practice during learning, and that nonoptimal testing times would magnify these effects. Results indicated that older adults showed an increase in reaction time (RT) standard deviation (SD) relative to mean RT in the evening. Although time-of-day did not have a significant effect on rate of learning or total learning, intraindividual variability did predict learning rate of younger adults at nonoptimal testing times. Results are discussed in light of theoretical models of aging and learning.

Fluid and electrolyte balance in elite gaelic football players

The aim of this study was to investigate fluid and electrolyte balance in elite Gaelic Football players (n=20) during a typical training session in a warm environment (16 to 18 degrees C, 82-88% humidity). Pre-training urine samples were used to determine hydration status. Sweat sodium concentration was collected from four body site locations using absorbent patches. The mean sweat rate per hour was 1.39 l x h(-1) and mean body mass loss was 1.1%. Mean sweat sodium concentrations were 35 mmol x l(-1) (range 19-52 mmol x l(-1)). On average, players did not drink enough fluid to match their sweat rates (p<0.001) and this fluid deficit was not related to pre-training hydration status (p= 0.67). A single hydration strategy based on published guidelines may not be suitable for an entire team due to variations in individual sweat rates. Maximising player performance could be better achieved by accurate quantification of individual fluid and electrolyte losses.