Attitudes to Prophylactic Surgery and Chemoprevention in Australian Women at Increased Risk for Breast Cancer

BACKGROUND

Because of the uncertain efficacy of breast cancer screening in women at increased risk of developing breast cancer, bilateral prophylactic oophorectomy and mastectomy are considered management options for high-risk women. Data on the attitudes to prophylactic strategies of high-risk women who have not attended specialist clinics are needed to ascertain the need for patient education and provide the basis for planning of support services.

METHODS

Three hundred seventy-one women unaffected by cancer and with unknown mutation status from families with a dominantly inherited susceptibility to breast cancer, recruited through a large Australian population-based, epidemiological study, were assessed using a mailed self-administered questionnaire with validated measures of psychological outcome.

RESULTS

Sixteen percent of women reported considering prophylactic mastectomy, and 1% had already had the procedure. Among women with a family history of breast/ovarian cancer, 33% had considered and 5% had already had a prophylactic oophorectomy. Twenty-three percent of women reported considering taking tamoxifen if it were shown to prevent breast cancer. Consideration of prophylactic oophorectomy (OR = 1.51 for a 10% change in perceived risk, 95% CI 1.14-1.99, p = 0.0045) and tamoxifen (OR = 1.14 for a 10% change in perceived risk, 95% CI 1.002-1.30, p = 0.047) were positively associated with perceived cancer risk.

CONCLUSIONS

Attitudes to prophylactic surgery and psychological distress levels in high-risk women participating in an epidemiological study appear to be comparable to those of women attending familial cancer clinics and indicate that women attending high-risk clinics may be representative of the larger population of women at increased risk.

Variables in the spread of tumor cells to trocars and port sites during operative laparoscopy

BACKGROUND

Port-site recurrences have delayed the uptake of laparoscopic colectomy, but the etiology of these is incompletely understood. These studies were designed to investigate variables such as the size of the tumor inoculum and the volume and pressure of the insufflated gas during operative laparoscopy that might affect the deposition of these cells in relation to trocars and port sites.

METHODS

Radiolabeled human colon cancer cells were injected into the peritoneal cavity of pigs. Three trocars were inserted, and the abdomen was insufflated with carbon dioxide. The movement of cells within the abdomen was traced on a gamma camera. After 2 h, the trocars were removed and the port sites excised. Two studies were performed. In the first study, tumor inocula were varied from 1.5 x 10(5) to 120 x 10(5). In the second study, insufflation pressure was varied, with pressures 0, 4, 8 and 12 mmHg were studied.

RESULTS

When larger tumor inocula were injected, the contamination of both trocars (p = 0.005, Kendall's rank correlation) and trocar sites (p = 0.04, Kendall's rank correlation) increased. The deposition of cells on a trocar site was linked to contamination of its trocar (p = 0.03, chi-square), but the contamination of trocars did not always result in trocar-site contamination (p = 0.5, chi-square). Increased volumes of gas insufflation caused increased intraabdominal movement of tumour cells (p = 0.01, Kendall's rank correlation), although this did not lead to greater contamination of trocars or port sites (p = 0.82, Kendall's rank correlation). Decreased insufflation pressures resulted in increased contamination of trocars and port sites (p = 0.01, Kendall's rank correlation).

CONCLUSIONS

If clinical situations parallel this study, strategies such as increasing insufflation pressure, reducing episodes of desufflation and gas leaks, and using frequent intraabdominal lavage may help to reduce the numbers of viable tumor cells displaced to port sites during laparoscopic surgery for intraabdominal malignancy. This may reduce the rate of port-site metastases.

Psychological impact of genetic testing in women from high-risk breast cancer families

Psychological adjustment in 90 women (30 carriers and 60 non-carriers) who had undergone genetic testing for mutations in BRCA1 and BRCA2 breast/ovarian cancer susceptibility genes was compared with that of 53 women who were not offered genetic testing. Women were assessed prior to genetic testing and 7-10 days, 4 and 12 months after carrier status disclosure using self-administered questionnaires. Compared with women not offered testing, mutation carriers had significantly higher breast cancer distress 7-10 days (t=2.80, P=0.005) and 12 months (t=2.01, P=0.045) post-notification. Non-carriers showed a significant decrease in state anxiety 7-10 days post-notification (t=2.27, P=0.024) and in depression 4 months post-notification (t=2.26, P=0.024), compared with women not offered testing. These data show that non-carriers derive psychological benefits from genetic testing. Women testing positive may anticipate a sustained increase in breast cancer distress following disclosure, although no other adverse psychological outcomes were observed in this group.

Tailoring communication in consultations with women from high risk breast cancer families

This multicentre study examined the influence of patient demographic, disease status and psychological variables on clinical geneticists/genetic counsellors (consultants) behaviours in initial consultations with women from high-risk breast cancer families. One hundred and fifty-eight women completed a pre-clinic self-report questionnaire. The consultations were audiotaped, transcribed verbatim and coded. Consultants did not vary their behaviour according to women's expectations. However, significantly more aspects of genetic testing were discussed with women who were affected with breast cancer (P<0.001), screening and management with unaffected women (P=0.01) and breast cancer prevention with younger women (P=0.01). Prophylactic mastectomy was discussed more frequently with women with medical and allied health training (P=0.02), and prophylactic oophorectomy with women affected with breast cancer (P=0.03), those in non-professional occupations (P=0.04) and with a family history of breast and ovarian cancer (P<0.001). Consultants used significantly more behaviours to facilitate understanding with women who were in non-professional occupations (P=0.04); facilitated active patient involvement more with women affected with breast cancer (P<0.001) and used more supportive and counselling behaviours with affected women (P=0.02). This study showed that patient demographics were more likely to predict consultants' communication behaviours than the woman's psychological status. Methods to facilitate assessment of psychological morbidity are needed to allow more tailored communication.

Infected compartment syndrome after acupuncture

We present a case of septicaemia and compartment syndrome of the leg in a diabetic patient, following acupuncture to his calf. An emergency decompression fasciotomy was performed on the patient and gram-positive cocci were grown from the posterior compartment wound swab cultures and group A streptococcus from his blood cultures. He remained in the Intensive Therapy Unit postoperatively, requiring inotropic support and intravenous antibiotics for his septicaemia. We would like to remind acupuncturists, to consider the possibility of heightened risks in immunocompromised patients.

Psychological impact of prophylactic oophorectomy in women at increased risk of developing ovarian cancer: a prospective study

OBJECTIVES

The objectives of this study were twofold: to prospectively assess whether expressed intention to undergo prophylactic oophorectomy translated into uptake and to evaluate the psychological impact of the procedure in a sample of unaffected women with a strong family history of breast/ovarian cancer.

METHODS

Ninety-five women, initially assessed at the time of their first attendance at a familial cancer clinic, were followed-up 3 years later. A total of 22 women (23.2%) in this study had undergone a prophylactic oophorectomy. Ten women (10.5%) who had undergone a prophylactic oophorectomy during the 3-year follow-up period were compared to 73 women (76.9%) who did not have a prophylactic oophorectomy. Twelve women (12.6%) who had the procedure prior to study entry were also assessed for psychological adjustment and associated information needs.

RESULTS

Age emerged as a significant predictor of uptake of prophylactic oophorectomy (chi(2) = 7.13, P = 0.009). Among those who had the procedure after study entry, a significant reduction in ovarian cancer anxiety was observed (Z = -2.19, P = 0.029). Of the 22 women who had undergone a prophylactic oophorectomy in total (both before and after study entry), 86.4% reported a high degree of satisfaction with their decision to have the procedure. A low level of screening uptake was also reported by women who did not have a prophylactic oophorectomy but for whom screening was recommended.

CONCLUSION

Findings demonstrate that prophylactic oophorectomy is successful in reducing anxiety about ovarian cancer. The results also suggest that women perceive that the benefit of anxiety reduction may outweigh the potentially adverse effects of the procedure, given that women expressed a high level of satisfaction with their decision.

Neurotrophin modulation of voltage-gated potassium channels in rat through TrkB receptors is time and sensory experience dependent

The whole-cell configuration of the patch-clamp technique, immunoprecipitation experiments and unilateral naris occlusions were used to investigate whether the voltage-gated potassium channel Kv1.3 was a substrate for neurotrophin-induced tyrosine phosphorylation and subsequent functional modulation of current properties in cultured rat olfactory bulb (OB) neurons. Membrane proteins of the OB included all three Trk receptor kinases, but the truncated form of the receptor, lacking an intact kinase domain, was the predominant form of the protein for TrkA and TrkC, while TrkB was predominantly found as the full-length receptor. Acute (15 min) stimulation of OB neurons with bath application of 50 ng ml(-1) brain-derived neurotrophic factor (BDNF), which is a selective ligand for TrkB, caused suppression of the whole-cell outward current and no changes in the kinetics of inactivation or deactivation. Acute stimulation with either nerve growth factor or neurotrophin-3 failed to evoke any changes in Kv1.3 function in the OB neurons. Chronic exposure to BDNF (days) caused an increase in the magnitude of Kv1.3 current and speeding of the inactivation and deactivation of the channel. Acute BDNF-induced activation of TrkB receptors significantly increased tyrosine phosphorylation of Kv1.3 in the OB, as shown using a combined immunoprecipitation and Western blot analysis. With unilateral naris occlusion, the acute BDNF-induced tyrosine phosphorylation of Kv1.3 was increased in neurons lacking odour sensory experience. In summary, the duration of neurotrophin exposure and the sensory-dependent state of a neuron can influence the degree of phosphorylation of a voltage-gated ion channel and its concomitant functional modulation by neurotrophins.

Experimental study of the material composition of laparoscopic ports on tumour cell adherence

BACKGROUND

Laparoscopic resection of intra-abdominal malignancies has yet to be widely adopted, partly because of concerns over the possible increase in the rate of port-site metastasis. The aetiology of these is unclear, but the laparoscopic instrumentation used may influence the deposition of tumour cells at the port sites during operation. An in vitro model to examine tumour cell adherence to laparoscopic ports and to port sites was developed to examine this hypothesis.

METHODS

A pilot study (study 1) was performed in which six smooth plastic, six ribbed plastic and six metal ports were introduced through the shaved abdominal wall of a cadaveric sheep and suspended in a water-bath containing radiolabelled LIM 1215 human colonic cancer cells for 30 min. Radioactivity on both ports and port sites was measured and the number of cells adherent to each structure was calculated. The study was expanded to include a further 36 smooth plastic ports and 36 metal ports (study 2).

RESULTS

In study 1 metal ports were found to have significantly more adherent cells than plastic ports (P = 0.004), as did ribbed ports when compared with smooth ports (P < 0.05). In study 2 increased numbers of cells were again detected on metal ports (P < 0.001) when compared with plastic ports. Significantly greater numbers of cells were also detected on the sites through which metal ports had passed than on sites through which plastic ports had passed (P = 0.03).

CONCLUSION

In this model, the use of metal ports as opposed to plastic ports resulted in increased deposition of tumour cells on both ports and port sites.

The effect of lavage on intraabdominal cell burden

BACKGROUND

Abdominal lavage is a common surgical practice, but few studies have been conducted to assess its efficacy at removing cells from the abdominal cavity, particularly during laparoscopic surgery.

METHODS

After three 12-mm trocars were inserted into six female 30-kg pigs at the umbilicus left and right iliac fossae, the abdomen was insufflated with carbon dioxide. The pelvis of each pigs was injected with 6 million radiolabeled LIM 1215 cells. Then the abdominal cavity was irrigated with either 500 ml 0.9% saline, 500 ml 10% betadine solution, or 1 L 0.9% saline. A maximum of 5 L of solution was used for each animal. The lavage fluid was suctioned into separate containers after each aliquot, and each container was measured for radioactivity.

RESULTS

Significantly greater numbers of cells were removed by lavage by the first to third lavage cycle; however, after four lavage cycles, relatively few cells were removed by each further cycle. No difference was observed between 500-ml and 1-L aliquots. Additionally, the mechanical efficacy of 0.9% saline and 10% betadine solution appeared similar.

CONCLUSION

These findings suggest that optimal lavage consists of four irrigation/suction cycles utilizing 500-ml aliquots.

Psychological impact of genetic counselling and testing in women previously diagnosed with breast cancer

BACKGROUND

The recent discovery of susceptibility genes relating to breast cancer, BRCA1 and BRCA2, now allows women with breast cancer and a family history of breast/ovarian cancer to undergo genetic testing to identify a causative germ-line mutation. The present study assessed the psychological status over time of women affected by breast cancer requesting genetic testing (cases; n = 32) compared with matched controls (n = 28).

METHODS

Subjects were recruited through two Sydney-based hospitals. Data were collected via questionnaire and telephone interview at baseline, and 2 weeks and 3-6 months following counselling.

RESULTS

Genetic test results were not received by the subjects within the study period. Cases showed a greater increase in knowledge of cancer genetics following counselling compared with controls, and this was maintained over time. Psychological symptoms remained stable over the study period and there were no differences between groups.

CONCLUSIONS

Increased knowledge following genetic counselling was not accompanied by an increase in anxiety or depression. Further assessment will be required in the long term to determine the psychological impact of receiving a genetic test result.

Long-term outcomes of genetic counseling in women at increased risk of developing hereditary breast cancer

This multicenter study evaluated the impact of genetic counseling in 218 women at risk of developing hereditary breast cancer. Women were assessed prior to counseling and 12-month post-counseling using self-administered, mailed questionnaires. Compared to baseline, breast cancer genetics knowledge was increased significantly at follow-up, and greater increases in knowledge were associated with educational level. Breast cancer anxiety decreased significantly from baseline to follow-up, and these decreases were associated with improvements in perceived risk. A significant decrease in clinical breast examination was observed at the 12-month follow-up. Findings suggest that women with a family history of breast cancer benefit from attending familial cancer clinics as it leads to increases in breast cancer genetics knowledge and decreases in breast cancer anxiety. The lowered rates of clinical breast examination indicate that the content of genetic counseling may need to be reviewed to ensure that women receive and take away the right message.

The frequency of founder mutations in the BRCA1, BRCA2, and APC genes in Australian Ashkenazi Jews: implications for the generality of U.S. population data

BACKGROUND

Several studies have shown that Ashkenazi Jews in the United States and Israel have a high prevalence of the founder mutations BRCA1 185delAG, BRCA1 5382insC, BRCA2 6174delT, and APC I1307K at frequencies of 1.0--1.1%, 0.2--0.3%, 0.6--1.4%, and 6.1--7.0%, respectively. The objective of this study was to compare the prevalence of these alleles in the Australian Jewish population with that of U.S. Jews. Australian Jews have a different history of migration, with less opportunity for changes in allele frequency due to conversion or intermarriage with non-Jewish Australians. The results obtained therefore can be used to assess whether U.S. data can be generalized to other Jewish populations. SUBJECTS AND METHODS. Subject samples were ascertained through a screening program for Tay-Sachs disease as part of a community-based screening program in New South Wales and Victoria. DNA extracted from 1200 deidentified blood samples was tested using amplification refractory mutation system polymerase chain reaction.

RESULTS

The allele frequencies found were as follows: BRCA1 185delAG 1.25% (95% confidence interval [CI], 0.62--1.88%), BRCA1 5382insC 0.25% (95% CI, 0--0.53%), BRCA2 6174delT 1.08% (95% CI, 0.50--1.67%), and APC I1307K 8.67% (95% CI, 7.07--10.26%). The prevalence of breast carcinoma predisposition alleles therefore is greater than 2.5% in Australian Ashkenazim.

CONCLUSIONS

There were no significant differences between the allele frequencies in Australian Ashkenazim and those identified in other studies with similar ascertainment strategies, despite the different migration patterns of Australian Jews. This suggests the broad applicability of the U.S. and Israeli data, not only to Australian Ashkenazim, but also to Ashkenazi communities throughout the world.

Cultural aspects of cancer genetics: setting a research agenda

BACKGROUND

Anecdotal evidence suggests that people from non-Anglo-Celtic backgrounds are under-represented at familial cancer clinics in the UK, the USA, and Australia. This article discusses cultural beliefs as a potential key barrier to access, reviews previous empirical research on cultural aspects of cancer genetics, draws implications from findings, and sets a research agenda on the inter-relationships between culture, cancer genetics, and kinship.

METHODS

The CD-ROM databases MEDLINE, PsychLIT, CINAHL, and Sociological Abstracts were searched from 1980 onwards.

RESULTS

Cultural aspects of cancer genetics is the focus of an emerging body of publications. Almost all studies assessed African-American women with a family history of breast cancer and few studies included more diverse samples, such as Americans of Ashkenazi Jewish background or Hawaiian- and Japanese-Americans. Our analysis of published reports suggests several directions for future research. First, an increased focus on various Asian societies appears warranted. Research outside North America could explore the extent to which findings can be replicated in other multicultural settings. In addition, control group designs are likely to benefit from systematically assessing culture based beliefs and cultural identity in the "majority culture" group used for comparative purposes.

CONCLUSION

More data on which to base the provision of culturally appropriate familial cancer clinic services to ethnically diverse societies are needed. Empirical data will assist with culturally appropriate categorisation of people from other cultures into risk groups based on their family histories and provide the basis for the development of culturally appropriate patient education strategies and materials.

Familial adenomatous polyposis: more evidence for disease diversity and genetic heterogeneity

Familial adenomatous polyposis (FAP) is characterised by the presence of profuse colonic carpeting of adenomas throughout the entire colon and rectum. The genetic basis of FAP has been shown to be primarily associated with germline mutations in the APC gene. Notwithstanding, several reports have been published indicating that there is genetic heterogeneity in FAP and that the most likely explanation is the existence of another gene. In this report we further delineate the genotype/phenotype correlation in families that harbour germline mutations in the APC gene and identify some previously unreported changes in the APC gene which predispose to an attenuated disease phenotype. From 53 index patients diagnosed with either FAP or attenuated FAP, 27 harboured changes in the APC gene. The remaining 26 patients were further subgrouped according to their colonic phenotype. There were nine patients with a mixed hyperplastic/adenomatous colonic phenotype and there were 17 patients with an adenomatous colonic phenotype. Evaluation of the disease characteristics of these patients and their families is presented which may aid in the identification of new genes associated with colonic polyposis.

Alcohol drinking determines the effect of the APOE locus on LDL-cholesterol concentrations in men: the Framingham Offspring Study

BACKGROUND

The effect of alcohol drinking on LDL-cholesterol concentrations is unclear. The reported variability may be due to interactions between genetic factors and alcohol intake.

OBJECTIVE

The purpose of the study was to examine whether variation at the apolipoprotein E gene (APOE) locus modulates the association between alcohol drinking and LDL cholesterol.

DESIGN

We used a cross-sectional design in a healthy population-based sample of 1014 men and 1133 women from the Framingham Offspring Study.

RESULTS

In male nondrinkers (n = 197), LDL cholesterol was not significantly different across APOE allele groups [APOE*E2 (E2), APOE*E3 (E3), and APOE*E4 (E4)]. However, in male drinkers (n = 817), differences were observed (P: < 0.001); those with the E2 allele had the lowest concentrations. LDL cholesterol in men with the E2 allele was significantly lower in drinkers than in nondrinkers but was significantly higher in drinkers than in nondrinkers in men with the E4 allele. This APOE-alcohol interaction remained significant (P < 0.001) after age, body mass index, smoking status, and fat and energy intakes were controlled for. In women, the expected effect of APOE alleles on LDL cholesterol occurred in both drinkers (n = 791; P < 0.001) and nondrinkers (n = 342; P < 0.001). Multiple linear regression models showed a negative association (P < 0.05) between alcohol and LDL cholesterol in men with the E2 allele but a positive association in men with the E4 allele. No significant associations were observed in men or women with the E3 allele.

CONCLUSION

In men, the effects of alcohol intake on LDL cholesterol are modulated in part by variability at the APOE locus.

Sexual dimorphism and developmental expression of signal-transduction machinery in the vomeronasal organ

We have explored the use of a new model to study the transduction of chemosignals in the vomeronasal organ (VNO), for which the functional pathway for chemical communication is incompletely understood. Because putative vomeronasal receptors in mammalian and other vertebrate models belong to the superfamily of G-protein-coupled receptors, the objective of the present study was to define which G-protein subunits were present in the VNO of Sternotherus odoratus (stinkpot or musk turtle) in order to provide directionality for future functional studies of the downstream signaling cascades. The turtle vomeronasal epithelium (VNE) was found to contain the G-proteins G(beta) and G(alphail-3) at the microvillar layer, the presumed site of signal tranduction in these neurons, as evidenced by immunocytochemical techniques. G(alphao) labeled the axon bundles in the VNE and the somata of the vomeronasal sensory neurons but not the microvillar layer. Densitometric analysis of Western blots indicated that the VNO from females contained greater concentrations of G(alphai1-3) compared with males. Sexually immature (juvenile) turtles showed intense immunolabeling for all three subunits (G(beta), G(alphai1-3), and G(alphao)) in the axon bundles and an absence of labeling in the microvillar layer. Another putative signaling component found in the microvilli of mammalian VNO, transient receptor potential channel, was also immunoreactive in S. odoratus in a gender-specific manner, as quantified by Western blot analysis. These data demonstrate the utility of Sternotherus for discerning the functional signal transduction machinery in the VNO and may suggest that gender and developmental differences in effector proteins or cellular signaling components may be used to activate sex-specific behaviors.

Hereditary nonpolyposis colorectal cancer in 95 families: differences and similarities between mutation-positive and mutation-negative kindreds

Hereditary nonpolyposis colorectal cancer (HNPCC) describes the condition of a disparate group of families that have in common a predisposition to colorectal cancer in the absence of a premalignant phenotype. The genetic basis of this disease has been linked to mutations in genes associated with DNA mismatch repair. A large proportion of families harbor changes in one of two genes, hMSH2 and hMLH1. Approximately 35% of families in which the diagnosis is based on the Amsterdam criteria do not appear to harbor mutations in DNA-mismatch-repair genes. In this report we present data from a large series of families with HNPCC and indicate that there are subtle differences between families that harbor germline changes in hMSH2 and families that harbor hMLH1 mutations. Furthermore, there are differences between the mutation-positive group (hMSH2 and hMLH1 combined) of families and the mutation-negative group of families. The major findings identified in this study focus primarily on the extracolonic disease profile observed between the mutation-positive families and the mutation-negative families. Breast cancer was not significantly overrepresented in the hMSH2 mutation-positive group but was overrepresented in the hMLH1 mutation-positive group and in the mutation-negative group. Prostate cancer was not overrepresented in the mutation-positive groups but was overrepresented in the mutation-negative group. In age at diagnosis of colorectal cancer, there was no difference between the hMSH2 mutation-positive group and the hMLH1 mutation-positive group, but there was a significant difference between these two groups and the mutation-negative group.

Human enamel as a substrate for in vitro acid dissolution studies: influence of tooth surface and morphology

The variation in susceptibility of enamel to acid dissolution has been quantitatively assessed in vitro by examination of different surfaces of both maxillary and mandibular teeth of different morphology obtained from a pool of sound human teeth. The lingual/palatal surfaces of all teeth showed greater susceptibility to acid dissolution than the corresponding labial/buccal surfaces. The palatal surface of the maxillary teeth appeared more susceptible to acid than the lingual surface of the corresponding teeth in the mandible. The palatal surfaces of the maxillary teeth showed least variation in acid susceptibility, whilst the lingual surfaces of mandibular teeth and buccal/labial surfaces of teeth from both jaws showed much more variation between teeth of different morphology. These differences in susceptibility to acid dissolution probably reflect both developmental differences and post-eruptive changes in enamel and may contribute to the clinical presentation of dental disease. Importantly, the data indicates that careful selection of teeth for in vitro study of enamel dissolution processes is essential to minimise inter-sample variation. For such purposes, the palatal surface of the maxillary teeth appears to be most suitable.

Intention to undergo prophylactic bilateral mastectomy in women at increased risk of developing hereditary breast cancer

PURPOSE

To assess intention to undergo prophylactic bilateral mastectomy and psychologic determinants in unaffected women at increased risk of developing hereditary breast cancer.

PATIENTS AND METHODS

Three hundred thirty-three women who were awaiting their initial appointments for risk assessment, advice about surveillance, and prophylactic options at one of 14 familial cancer clinics participated in a cross-sectional, questionnaire-based survey.

RESULTS

Nineteen percent of women would consider and 47% would not consider a prophylactic mastectomy, should genetic testing identify a mutation in a breast cancer-predisposing gene, whereas 34% were unsure and 1% had already undergone a prophylactic mastectomy. In a bivariate analysis, women at a moderately increased risk of developing breast cancer had the highest proportion of subjects reporting that they would consider a prophylactic mastectomy (25%), compared with women at high risk (16%) (chi(2) = 7.79; P =.051). In multivariate analyses, consideration of prophylactic mastectomy strongly correlated with high levels of breast cancer anxiety (odds ratio [OR] = 17.4; 95% confidence interval [CI], 4.35 to 69.71; P =. 0001) and overestimation of one's breast cancer risk (OR = 3.01; 95% CI, 1.43 to 6.32; P =.0036), whereas there was no association with objective breast cancer risk (P =.60).

CONCLUSION

A significant proportion of women at increased risk of developing hereditary breast cancer would consider prophylactic mastectomy. Although prophylactic mastectomy may be appropriate in women at high risk of developing breast cancer, it is perhaps less so in those who have a moderately increased risk. Such moderate-risk women are likely to benefit from interventions aimed at reducing breast cancer anxiety and correcting exaggerated breast cancer risk perceptions.

Brain insulin receptor causes activity-dependent current suppression in the olfactory bulb through multiple phosphorylation of Kv1.3

Insulin and insulin receptor (IR) kinase are found in abundance in discrete brain regions yet insulin signaling in the CNS is not understood. Because it is known that the highest brain insulin-binding affinities, insulin-receptor density, and IR kinase activity are localized to the olfactory bulb, we sought to explore the downstream substrates for IR kinase in this region of the brain to better elucidate the function of insulin signaling in the CNS. First, we demonstrate that IR is postnatally and developmentally expressed in specific lamina of the highly plastic olfactory bulb (OB). ELISA testing confirms that insulin is present in the developing and adult OB. Plasma insulin levels are elevated above that found in the OB, which perhaps suggests a differential insulin pool. Olfactory bulb insulin levels appear not to be static, however, but are elevated as much as 15-fold after a 72-h fasting period. Bath application of insulin to cultured OB neurons acutely induces outward current suppression as studied by the use of traditional whole-cell and single-channel patch-clamp recording techniques. Modulation of OB neurons is restricted to current magnitude; IR kinase activation does not modulate current kinetics of inactivation or deactivation. Transient transfection of human embryonic kidney cells with cloned Kv1.3 ion channel, which carries a large proportion of the outward current in these neurons, revealed that current suppression was the result of multiple tyrosine phosphorylation of Kv1.3 channel. Y to F single-point mutations in the channel or deletion of the kinase domain in IR blocks insulin-induced modulation and phosphorylation of Kv1.3. Neuromodulation of Kv1.3 current in OB neurons is activity dependent and is eliminated after 20 days of odor/sensory deprivation induced by unilateral naris occlusion at postnatal day 1. IR kinase but not Kv1.3 expression is downregulated in the OB ipsilateral to the occlusion, as demonstrated in cryosections of right (control) and left (sensory-deprived) OB immunolabeled with antibodies directed against these proteins, respectively. Collectively, these data support the hypothesis that the hormone insulin acts as a multiply functioning molecule in the brain: IR signaling in the CNS could act as a traditional growth factor during development, be altered during energy metabolism, and simultaneously function to modulate electrical activity via phosphorylation of voltage-gated ion channels.

Localization to Xq27 of a susceptibility gene for testicular germ-cell tumours

Testicular germ-cell tumours (TGCT) affect 1 in 500 men and are the most common cancer in males aged 15-40 in Western European populations. The incidence of TGCT has risen dramatically over the last century. Known risk factors for TGCT include a history of undescended testis (UDT), testicular dysgenesis, infertility, previously diagnosed TGCT (ref. 7) and a family history of the disease. Brothers of men with TGCT have an 8-10-fold risk of developing TGCT (refs 8,9), whereas the relative risk to fathers and sons is fourfold (ref. 9). This familial relative risk is much higher than that for most other types of cancer. We have collected samples from 134 families with two or more cases of TGCT, 87 of which are affected sibpairs. A genome-wide linkage search yielded a heterogeneity lod (hlod) score of 2.01 on chromosome Xq27 using all families compatible with X inheritance. We obtained a hlod score of 4.7 from families with at least one bilateral case, corresponding to a genome-wide significance level of P=0.034. The proportion of families with UDT linked to this locus was 73% compared with 26% of families without UDT (P=0.03). Our results provide evidence for a TGCT susceptibility gene on chromosome Xq27 that may also predispose to UDT.

Breast cancer screening uptake in women at increased risk of developing hereditary breast cancer

This multicenter study assessed breast cancer screening uptake in 461 unaffected women at increased risk of developing breast cancer on the basis of family history who approached familial cancer clinics for advice about surveillance options. At the time of attending the clinic, 89% and 90% of participants were vigilant with respect to age- and risk-specific recommendations for mammography and clinical breast examination, respectively, and 51% reported practicing breast self-examination monthly or more frequently. The degree to which health outcomes are perceived to be under one's personal control (chi2 = -2.09, p = 0.0037) and breast cancer anxiety (chi2 = 8.11, p = 0.044) were both associated with monthly or more frequent breast self-examination, while there were no associations with sociodemographic characteristics. A significantly lower percentage (56%) of women aged <30 were vigilant with respect to mammography recommendations, compared to 77%, 96% and 98% of women aged 30-39, 40-49 and >50, respectively (chi2 = 37.2, p < 0.0001). These relatively low rates of mammographic screening in young women may reflect concerns about increased cancer risk associated with early and repeated radiation exposure or lack of sensitivity in young women with radiographically dense breasts. If mammographic screening is ultimately shown to lower mortality in women at high risk, there will be a strong case to promote screening in young women. The need for regular mammographic screening would then need to be highlighted and reinforced amongst young women and their referring physicians. Awareness amongst general practitioners, who are largely responsible for referral to screening services, would also need to be increased.

Dietary patterns and blood pressure in African Americans

Hypertension is a highly prevalent risk factor for vascular disease, particularly among African Americans. The Dietary Approaches to Stop Hypertension (DASH) study demonstrated that providing diets with 8-10 fruits and vegetables and 2-3 low-fat dairy foods per day significantly lowered blood pressure. A recent reanalysis showed even stronger effects for African Americans. Studies are needed to translate these findings into methods of effecting dietary change in high-risk populations.

Attitudes toward prophylactic oophorectomy and screening utilization in women at increased risk of developing hereditary breast/ovarian cancer

OBJECTIVES

The aim of this study was to evaluate ovarian cancer screening uptake and attitudes toward prophylactic oophorectomy in women at risk of developing hereditary breast/ovarian cancer.

STUDY METHODS

Ninety-five unaffected women, who approached 1 of 14 familial cancer clinics for advice about their breast/ovarian cancer risk and surveillance and prophylactic options, were assessed in a cross-sectional design when they attended the clinic.

RESULTS

Among high-risk women ages 30 and over who had not had a prophylactic oophorectomy, 48% reported ever having had an ovarian ultrasound, and among women ages 50 and over 23% had had a serum CA 125 test. Twenty-three percent of women would consider, and 27% would not consider, a prophylactic oophorectomy should the genetic test indicate a germline mutation associated with hereditary breast/ovarian cancer, while 38% were unsure. Twelve percent had already undergone a prophylactic oophorectomy. Interest in prophylactic oophorectomy was associated with increased breast/ovarian cancer anxiety (chi(2) = 5.14, P = 0.023), but not objective cancer risk (chi(2) = 0.40, P = 0.53).

CONCLUSION

Findings demonstrate that breast/ovarian cancer anxiety, rather than objective risk, is the major factor which determines women's attitude to prophylactic oophorectomy. Women are likely to benefit from interventions aimed at reducing breast/ovarian cancer anxiety. Research on the impact of prophylactic oophorectomy would be helpful in the development of educational strategies and decision aids to assist women who are trying to make a decision under conditions of uncertainty.

Eosinophil influx to the nasal airway after local, low-level LPS challenge in humans

BACKGROUND

Recent observations show that atopic asthmatic subjects have increased sensitivity to respirable endotoxin (or LPS) compared with normal persons. In vitro studies demonstrate that LPS enhances eosinophil survival. These observations suggest that the effects of inhaled LPS in asthmatic subjects may include increases in the number of airway eosinophils.

OBJECTIVE

We sought to determine whether low-level nasal LPS challenge causes an increase in eosinophil numbers in the nasal airways of atopic or normal subjects.

METHODS

Sixteen volunteers (10 atopic asthmatic subjects and 6 normal subjects) underwent 2 nasal challenge sessions. In one session, one nostril was challenged with saline and the other with 0. 1 microg of LPS. During the second session, 0.3 microg and 1.0 microg of LPS was delivered to each nostril, respectively. Nasal lavage fluid was obtained from each nostril before challenge, as well as 4 and 24 hours after challenge, and examined for the percent of total cells that were eosinophils and neutrophils, as well as cytokine levels.

RESULTS

LPS (1.0 microg) increased the percent of eosinophils in nasal lavage fluid 4 hours after challenge in atopic subjects only. There was also a correlation between constitutive nasal GM-CSF and eosinophil response to LPS in atopic subjects.

CONCLUSION

LPS challenge increases eosinophils in the airways of atopic subjects.

Pulse oximetry

Pulse oximetry is one of the most commonly applied technologies in acute and critical care. It has the potential to continuously monitor pulmonary function, avoid unnecessary blood gases, and alert clinicians to hypoxemic events that are not readily apparent by physical assessment. Due to these advantages, pulse oximetry has a firm place in health care. Unfortunately, pulse oximetry will not usually have a major impact on reducing hospital resources. In addition, oximetry has the potential to be misused owing to its widespread application. In order to obtain the maximum benefits from this technology, clinicians must be educated about the strengths and limitations of oximetry. If this education effectively changes clinicians' behavior, pulse oximetry will provide an excellent clinical advantage in patient assessment as well as moderate cost benefits.

Effect of storage temperature on sperm cryopreservation

OBJECTIVE

To evaluate the influence of cryopreservation temperature on human sperm motility and morphology.

DESIGN

Controlled study, investigator was blinded to the type of cryopreservation.

SETTING

University-based andrology laboratory.

PATIENT(S)

Sixteen semen samples with normal motility and sperm count from men after a fertility work up.

INTERVENTION(S)

Semen aliquots were either stored in a mechanical freezer at -70 degrees C or in liquid nitrogen at -196 degrees C for 7 days or 3 months. Test yolk buffer was used as a cryoprotectant. With use of a programmable freezing unit, all samples were cooled at a controlled rate.

MAIN OUTCOME MEASURE(S)

Sperm motility and morphology.

RESULT(S)

After 7 days of cryopreservation, there was a greater decrease in sperm motility among specimens maintained at -70 degrees C than among those maintained at -196 degrees C (47% versus 39% decrease). The difference in sperm motility was even greater after 3 months of cryopreservation (72% versus 39% decrease). No difference in postthaw sperm morphology was detected among sperm preserved at -70 degrees C versus -196 degrees C.

CONCLUSION(S)

Sperm cryopreservation at -196 degrees C is superior to cryopreservation at -70 degrees C. Sperm can be stored at -70 degrees C for a short period of time with a relatively modest loss of motility.

Intraoperative scintigraphic localization and laparoscopic excision of accessory splenic tissue

The recent advent of laparoscopic splenectomy for the treatment of refractory idiopathic thrombocytopenic purpura (ITP) has been embraced by surgeons and hematologists in many institutions. However, the occurrence of accessory splenic tissue in a proportion of such splenectomies, either concurrently or later, raises the question of how to deal with this problem when it arises. We report that the laparoscopic approach, facilitated by lateral positioning, can be successfully used for the treatment of an accessory spleen causing recurrent ITP. The use of intraoperative nuclear imaging can greatly aid the localization and provide confirmation of complete excision of the nuclear focus, especially for a very small accessory spleen.

Cancer in the family. Part 2

This second article follows on from 'Cancer in the family--guidelines for general practice' (AFP, May, 1997). It reviews the current knowledge for bowel cancer, breast-ovarian cancer and melanoma, from a genetic perspective.

Cancer in the family. Guidelines for general practice

In the past 2 years the major genes for inherited breast-ovarian cancer, bowel cancer and melanoma have been identified. Relatives of cancer patients frequently perceive themselves to be at high risk of cancer. Appropriate assessment of the family history permits the identification of those at particularly high risk who may benefit from special programs of prevention, screening and surveillance. In certain cases, genetic testing and prophylactic surgery may be indicated. This article looks at the general issues involved. A follow-up article next month will look at specific diseases.

Epidemic optic and peripheral neuropathy in Cuba: a unique geopolitical public health problem

During 1992 and 1993 an epidemic of optic and peripheral neuropathy affected over 50,000 Cubans. This occurred in the unique setting of a communist country which had a widespread health care network and wherein sudden changes in the economy affected most of the population. Although nutritional factors appeared to play a key role in the pathogenesis of the epidemic neuropathy, viral, toxic, and genetic factors were investigated by Cuban and North American scientists. The authors, representing different disciplines and different groups that visited Cuba during the epidemic, review and reflect on the clinical and laboratory findings which became available through their own experience and through reviewing the literature. The recent Cuban epidemic is compared to similar outbreaks of optic and peripheral neuropathy which have occurred in the past.

The use of epidemiologic approaches and meta-analysis to determine mineral element requirements

With a new focus on long-term health effects of nutrient intake as well as the traditional concerns of preventing deficiency and maintaining tissue saturation, epidemiologic studies which identify diet and health relationships have become important to debates on defining nutrient requirements. Epidemiologic studies include descriptive surveys, case-control studies, cohort studies, and intervention studies. National dietary intake survey data have always played a role in defining intake amounts which are feasible and which are associated with no clearly apparent health problem. A growing number of large epidemiologic cohort studies have provided new evidence of preventive effects of specific nutrients on chronic diseases. The question of how that information should be used in setting requirements is still unresolved. Because one epidemiologic study alone cannot prove a causal relationship, and because small studies often lack sufficient power to clearly establish statistical significance, meta-analysis is sometimes used to combine results from many studies to obtain an overall quantitative result. It has been most effectively used with sets of clinical trials. Meta-analysis of multiple observational studies is usually difficult because of variations in design, methodology of data collection and form of the variables; its use has been seriously challenged. Careful review of the totality of epidemiologic studies completed on specific nutrient and health or functional outcome is important to defining future research priorities and designs, and can inform the definition of nutrient requirements when used carefully and in conjunction with the wider body of scientific evidence.

Overweight and leanness in adulthood: prospective study of male participants in the Normative Aging Study

OBJECTIVE

Our objective was to examine the stability of body habitus over 15 years in Boston area adult males enrolled in the Normative Aging Study (NAS) and to examine stability as a function of initial leanness or obesity, age and reported body habitus at age 18.

DESIGN

Prospective observational study of anthropometric/clinical measures initiated in 1961-1970, follow-up examinations at regular three and five year intervals. Subjects with complete data at entry, 5, 10 and 15 years.

SUBJECTS

The 2280 Boston area subjects were aged 21-80 years (mean = 42 y) at entry. A subset (n = 350) with complete data for weight (WT) and height (HT) at four points over 15 years provided estimates of body habitus continuity. The prevalence of obesity and age of those studied were comparable to the complete sample of enrolled men (n = 1403) with any missing follow-up measures.

MEASUREMENTS

Obesity was defined as body mass index (BMI) (weight in kg/height in m2) > or = 27.8 and leanness as BMI < 24.0. Three age categories at baseline (young = 25-39 y; middle = 40-49 y and old = 50-74 y) were used to examine secular and longitudinal changes. Obesity prevalence rates during late adolescence, based on self-reported weights at age 18, were compared with measured prevalence rates at entry and follow-up. Individual changes in BMI over time for each subject were estimated by linear regression and were combined to measure change in age and BMI groups.

RESULTS

Weights and BMI at entry were highly correlated with 18 year values and 15 year follow-up values. New cases of obesity, defined on the basis of BMI, increased over time while the numbers of subjects classified as lean and intermediate decreased. Among oldest subjects both the lean and obese had slight but significant decreases in mean BMI. Among the lean, only the young showed consistent increments.

DISCUSSION

Our results suggest consistency in body habitus among young and middle-aged obese subjects. There was little evidence of long-term reduction. In agreement with previous observations, the current findings of long-term duration in obesity suggest that preventive efforts should be focused on early years.

Evaluation of four methods for determining energy intake in young and older women: comparison with doubly labeled water measurements of total energy expenditure

The accuracy and precision of four different food intake assessment methods were evaluated in young and older women by comparing reported energy intakes with doubly labeled water measurements total energy expenditure (TEE). A study lasting 8 d was conducted in 10 young women aged 25.2+/-1.1 y (-x+/-SEM) and in 10 older women aged 74.0+/-1.4 y. Free-living TEE was measured over 7 d and food consumption was determined from weighed food intake data (7 d), a 24-h food recall (in duplicate), and two different food-frequency questionnaires [Fred Hutchinson Cancer Research Center (FHCRC)/Block and Willett, both in duplicate]. In addition, body composition was determined by using hydrodensitometry, and strenuous physical activity and the extent of dietary restraint were determined by questionnaire. In young women, 24-h recall gave mean energy intakes that were closest to measures of TEE (-0.34+/-3.71 MJ/d compared with TEE, P=0.178), and energy intakes by food-frequency questionnaires were the only intake data that correlated significantly with individual values for TEE (P<0.05). In older women, food-frequency questionnaires gave mean energy intakes that were closest to measured TEE (+0.53+/-2.95 MJ/d with the Willett questionnaire and -1.19+/-3.02 MJ/d with FHCRC/Block questionnaire). No energy intake data from this group correlated significantly with values for TEE. The 7-d weighed dietary intakes were significantly lower than measured TEE in both young and older women (-2.0 MJ/d in young and older women combined, P<0.001), and did not correlate significantly with values for TEE, although they did most closely mirror the mean difference in TEE between the young and older women (2.30 MJ/d for TEE and 2.11 MJ/d for 7-d weighed intake). These data suggest that none of the methods studied gave accurate estimates of the usual energy requirements of individual subjects. In addition, the results suggest that for some types of studies, simple methods for assessing group mean dietary intake may actually give more accurate information than weighed dietary intakes.

Relations of vitamin B-12, vitamin B-6, folate, and homocysteine to cognitive performance in the Normative Aging Study

We investigated the relations between plasma concentrations of homocysteine and vitamins B-12 and B-6 and folate, and scores from a battery of cognitive tests for 70 male subjects, aged 54-81 y, in the Normative Aging Study. Lower concentrations of vitamin B-12 (P=0.04) and folate (P=0.003) and higher concentrations of homocysteine (P=0.0009 ) were associated with poorer spatial copying skills. Plasma homocysteine was a stronger predictor of spatial copying performance than either vitamin B-12 or folate. The association of homocysteine with spatial copying performance was not explained by clinical diagnoses of vascular disease. Higher concentrations of vitamin B-6 were related to better performance on two measures of memory (P=0.03 and P=0.05). The results suggest that vitamins (and homocysteine) may have differential effects on cognitive abilities. Individual vitamins and homocysteine should be explored further as determinants of patterns of cognitive impairment.

Assessment of dietary phylloquinone intake and vitamin K status in postmenopausal women

OBJECTIVE

To examine the relationship between dietary phylloquinone intake and vitamin K status of postmenopausal Caucasian women.

DESIGN

Cross-sectional study, in which dietary intake was estimated using weighed record techniques and vitamin K status was measured by a single plasma phylloquinone concentration and 24-h urinary gamma-carboxyglutamic acid (Gla) excretion.

SETTING

The metabolic research unit at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA.

SUBJECTS

402 healthy postmenopausal Caucasian women who were participating in a randomized trial to determine the effect of calcium supplementation on bone loss. Of the original group, 362 had complete weighed diet records, 358 had corresponding plasma phylloquinone concentrations, and 346 had corresponding urinary Gla measurements.

RESULTS

There was a significant correlation (r = 0.13, P = 0.01) between total dietary intake of phylloquinone (geometric mean = 89 micrograms/day) and plasma phylloquinone levels (mean = 1.12 nmol/l). Dietary intake was neither correlated with urinary Gla excretion (mean = 4.0 mumol/mmol creatinine) nor did it vary by season. The ratio of intra- to interindividual variance in phylloquinone intake was 2.6, from which it was estimated that 5 days of independent recording is necessary to estimate true usual dietary intake, assuming a correlation of 0.8.

CONCLUSIONS

A weighed record has the potential to be a reliable method for estimating dietary intakes of vitamin K which relate to plasma phylloquinone levels used as an indicator of vitamin K status in postmenopausal Caucasian women.

Body habitus changes among adult males from the normative aging study: relations to aging, smoking history and alcohol intake

The Normative Aging Study (NAS) recruited 2280 Boston area healthy males aged 21 to 80 in 1961 through 1970. Clinical exams have continued at 3- to 5-year intervals. Obesity was not an exclusion criterion. Stability in weight and body habitus among 867 adult participants in the NAS was evaluated at 5- and 15-year follow-ups. At study entry, age was linearly related to central adiposity [abdominal circumference (AC) and ratio of AC/Hip Breadth (HB)] throughout the entire age range (30 to 78 years) and linearly and quadratically related to weight (WT) and Body Mass Index (BMI) (kg/m2) with maximal values at age 50. Over 15 years, changes in adiposity were strongly related to age; the greatest increases were among those initially 30 to 44 years of age with decrements in several adiposity measures (BMI, AC) only among the oldest subjects (60+ at entry); significant quadratic effects of age for BMI (p < .001), WT (p < .02) and AC (p < .01). There were major secular differences; men born later were heavier and fatter at the same ages as men born earlier. Men who gained (> 1 BMI) were younger while men who lost (> 1 BMI) had greater initial central adiposity than others. Smoking cessation was independently associated with increments in both central and peripheral adiposity. Moderate alcohol intake was associated with lower gains in AC/HB ratios at 15 years compared with little or high consumption. In general, aging was associated with trends towards central adiposity which tended to plateau or decrease at the oldest ages.

Segmental analysis of resting echocardiographic function and stress scintigraphic perfusion: implications for myocardial viability

In 73 patients with coronary artery disease, we performed segmental analysis of resting two-dimensional echocardiography and stress thallium-201 single photon emission computed tomographic scintigraphy with 24-hour delayed imaging to test the hypotheses that (1) combined analysis of stress thallium-201 scintigraphy (with 24-hour redistribution) and echocardiography provides an evaluation of the viability of most myocardial segments; and (2) the severity of the scintigraphic perfusion abnormality in a given segment is equivalent to the severity of its echocardiographically determined functional impairment. Scintigraphy showed 14% of the 1168 segments analyzed to have fixed severe defects. Echocardiography showed 11% of the 1070 segments analyzed to be akinetic or dyskinetic. However, with combined analysis, only 62 (5%) segments showed no evidence of viability by either imaging technique. We conclude that in this group of patients, 95% of segments have evidence of viability by one of these two conventional imaging techniques.

Household headship and child nutrition: a case study in western Kenya

The effect of female household headship on child nutrition has been hypothesized by some to be negative, based on the assumption that mothers alone will be poorer and will have greater demands on their time and resources. On the other hand, there is some evidence in Kenya that the nutritional status of children of female heads may be better than that of children of male heads, suggesting that when women have more control over resources, more goes to the children. In Kenya, de facto female headship is common due to male labor migration. This study examines the relationship between child nutrition and de facto female vs male household headship in western Kenya through the examination of family income and decision making patterns. Women in male-headed households had greater financial responsibility for household maintenance. Female heads assumed more farming responsibilities and had higher remittances from husbands. Husbands of female heads purchased food and other goods in the city for use by the household. Male headed households produced more food crops and used a larger proportion of them for home consumption. In this study, children of female heads consumed a greater variety of foods. Despite a greater prevalence of stunting, there was a lower prevalence of low weight for age among children of female heads. However, in statistical analyses, headship did not relate significantly to nutritional intake or status. In attempting to understand the possible factors influencing the relationship between headship and nutritional status, we found trade-offs in the ways families were coping, which appeared to balance some of the negative and positive effects of each situation.