Haplotype-Based Association Studies of IGFBP1 and IGFBP3 with Prostate and Breast Cancer Risk: The Multiethnic Cohort

Collective evidence suggests that the insulin-like growth factor (IGF) system plays a role in prostate and breast cancer risk. IGF-binding proteins (IGFBP) are the principal regulatory molecules that modulate IGF-I bioavailability in the circulation and tissues. To examine whether inherited differences in the IGFBP1 and IGFBP3 genes influence prostate and breast cancer susceptibility, we conducted two large population-based association studies of African Americans, Native Hawaiians, Japanese Americans, Latinos, and Whites. To thoroughly assess the genetic variation across the two loci, we (a) sequenced the IGFBP1 and IGFBP3 exons in 95 aggressive prostate and 95 advanced breast cancer cases to ensure that we had identified all common missense variants and (b) characterized the linkage disequilibrium patterns and common haplotypes by genotyping 36 single nucleotide polymorphisms (SNP) spanning 71 kb across the loci ( approximately 20 kb upstream and approximately 40 kb downstream, respectively) in a panel of 349 control subjects of the five racial/ethnic groups. No new missense SNPs were found. We identified three regions of strong linkage disequilibrium and selected a subset of 23 tagging SNPs that could accurately predict both the common IGFBP1 and IGFBP3 haplotypes and the remaining 13 SNPs. We tested the association between IGFBP1 and IGFBP3 genotypes and haplotypes for their associations with prostate and breast cancer risk in two large case-control studies nested within the Multiethnic Cohort [prostate cases/controls = 2,320/2,290; breast cases (largely postmenopausal)/controls = 1,615/1,962]. We observed no strong associations between IGFBP1 and IGFBP3 genotypes or haplotypes with either prostate or breast cancer risk. Our results suggest that common genetic variation in the IGFBP1 and IGFBP3 genes do not substantially influence prostate and breast cancer susceptibility.

Admixture mapping identifies 8q24 as a prostate cancer risk locus in African-American men

A whole-genome admixture scan in 1,597 African Americans identified a 3.8 Mb interval on chromosome 8q24 as significantly associated with susceptibility to prostate cancer [logarithm of odds (LOD) = 7.1]. The increased risk because of inheriting African ancestry is greater in men diagnosed before 72 years of age (P < 0.00032) and may contribute to the epidemiological observation that the higher risk for prostate cancer in African Americans is greatest in younger men (and attenuates with older age). The same region was recently identified through linkage analysis of prostate cancer, followed by fine-mapping. We strongly replicated this association (P < 4.2 x 10(-9)) but find that the previously described alleles do not explain more than a fraction of the admixture signal. Thus, admixture mapping indicates a major, still-unidentified risk gene for prostate cancer at 8q24, motivating intense work to find it.

Haplotype analysis of the HSD17B1 gene and risk of breast cancer: a comprehensive approach to multicenter analyses of prospective cohort studies

The 17beta-hydroxysteroid dehydrogenase 1 gene (HSD17B1) encodes 17HSD1, which catalyzes the final step of estradiol biosynthesis. Despite the important role of HSD17B1 in hormone metabolism, few epidemiologic studies of HSD17B1 and breast cancer have been conducted. This study includes 5,370 breast cancer cases and 7,480 matched controls from five large cohorts in the Breast and Prostate Cancer Cohort Consortium. We characterized variation in HSD17B1 by resequencing and dense genotyping a multiethnic sample and identified haplotype-tagging single nucleotide polymorphisms (htSNP) that capture common variation within a 33.3-kb region around HSD17B1. Four htSNPs, including the previously studied SNP rs605059 (S312G), were genotyped to tag five common haplotypes in all cases and controls. Conditional logistic regression was used to estimate odds ratios (OR) for disease. We found no evidence of association between common HSD17B1 haplotypes or htSNPs and overall risk of breast cancer. The OR for each haplotype relative to the most common haplotype ranged from 0.98 to 1.07 (omnibus test for association: X2 = 3.77, P = 0.58, 5 degrees of freedom). When cases were subdivided by estrogen receptor (ER) status, two common haplotypes were associated with ER-negative tumors (test for trend, Ps = 0.0009 and 0.0076; n = 353 cases). HSD17B1 variants that are common in Caucasians are not associated with overall risk of breast cancer; however, there was an association among the subset of ER-negative tumors. Although the probability that these ER-negative findings are false-positive results is high, these findings were consistent across each cohort examined and warrant further study.

Common Genetic Variation in IGF1 and Prostate Cancer Risk in the Multiethnic Cohort

BACKGROUND

Insulin-like growth factor I (IGF-I) appears to play a role in prostate development and carcinogenesis. We investigated whether genetic variation at the IGF1 locus is associated with prostate cancer risk.

METHODS

We sequenced IGF1 exons in germline DNA from 95 men with advanced prostate cancer to identify missense variants. IGF1 linkage disequilibrium patterns and common haplotypes were characterized by genotyping 64 single-nucleotide polymorphisms (SNPs) spanning 156 kilobases in 349 control subjects. Associations between IGF1 haplotypes and genotypes were investigated among 2320 patients with prostate cancer and 2290 control subjects from the Multiethnic Cohort. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by unconditional logistic regression to determine the association between prostate cancer and IGF1 haplotypes and genotypes. We used permutation testing to correct for multiple hypothesis testing. All statistical tests were two-sided.

RESULTS

No IGF1 missense variants were observed. We identified four blocks of strong linkage disequilibrium and selected a subset of 29 tagging SNPs that could accurately predict both the common IGF1 haplotypes and the remaining SNPs. Haplotype analysis revealed nominally statistically significant associations with prostate cancer risk in each of the four haplotype blocks: haplotype 1B (OR = 1.21, 95% CI = 1.04 to 1.40), haplotype 2C (OR = 1.24, 95% CI = 1.06 to 1.44), haplotype 3C (OR = 1.25, 95% CI = 1.03 to 1.50), and haplotype 4D (OR = 1.19, 95% CI = 1.02 to 1.39). Two SNPs--rs7978742 (Ptrend = .002) and rs7965399 (Ptrend = .002)--were perfectly correlated (correlation coefficient = 1.0) with one another and also associated with prostate cancer risk. These two SNPs were strong proxies for haplotypes 1B, 2C, 3C, and 4D and could account for the haplotype findings. Permutation testing revealed that a similarly strong result would be observed by chance only 5.6% of the time.

CONCLUSION

Inherited variation in IGF1 may play a role in the risk of prostate cancer.

A candidate gene approach to searching for low-penetrance breast and prostate cancer genes

Most cases of breast and prostate cancer are not associated with mutations in known high-penetrance genes, indicating the involvement of multiple low-penetrance risk alleles. Studies that have attempted to identify these genes have met with limited success. The National Cancer Institute Breast and Prostate Cancer Cohort Consortium--a pooled analysis of multiple large cohort studies with a total of more than 5,000 cases of breast cancer and 8,000 cases of prostate cancer--was therefore initiated. The goal of this consortium is to characterize variations in approximately 50 genes that mediate two pathways that are associated with these cancers--the steroid-hormone metabolism pathway and the insulin-like growth factor signalling pathway--and to associate these variations with cancer risk.

Genetic variation in the HSD17B1 gene and risk of prostate cancer

Steroid hormones are believed to play an important role in prostate carcinogenesis, but epidemiological evidence linking prostate cancer and steroid hormone genes has been inconclusive, in part due to small sample sizes or incomplete characterization of genetic variation at the locus of interest. Here we report on the results of a comprehensive study of the association between HSD17B1 and prostate cancer by the Breast and Prostate Cancer Cohort Consortium, a large collaborative study. HSD17B1 encodes 17β-hydroxysteroid dehydrogenase 1, an enzyme that converts dihydroepiandrosterone to the testosterone precursor Δ5-androsterone-3β,17β-diol and converts estrone to estradiol. The Breast and Prostate Cancer Cohort Consortium researchers systematically characterized variation in HSD17B1 by targeted resequencing and dense genotyping; selected haplotype-tagging single nucleotide polymorphisms (htSNPs) that efficiently predict common variants in U.S. and European whites, Latinos, Japanese Americans, and Native Hawaiians; and genotyped these htSNPs in 8,290 prostate cancer cases and 9,367 study-, age-, and ethnicity-matched controls. We found no evidence that HSD17B1 htSNPs (including the nonsynonymous coding SNP S312G) or htSNP haplotypes were associated with risk of prostate cancer or tumor stage in the pooled multiethnic sample or in U.S. and European whites. Analyses stratified by age, body mass index, and family history of disease found no subgroup-specific associations between these HSD17B1 htSNPs and prostate cancer. We found significant evidence of heterogeneity in associations between HSD17B1 haplotypes and prostate cancer across ethnicity: one haplotype had a significant (p < 0.002) inverse association with risk of prostate cancer in Latinos and Japanese Americans but showed no evidence of association in African Americans, Native Hawaiians, or whites. However, the smaller numbers of Latinos and Japanese Americans in this study makes these subgroup analyses less reliable. These results suggest that the germline variants in HSD17B1 characterized by these htSNPs do not substantially influence the risk of prostate cancer in U.S. and European whites.

Steroid hormones such as estrogen and testosterone are hypothesized to play a role in the development of cancer. This is the first substantive paper from the Breast and Prostate Cancer Cohort Consortium, a large, international study designed to assess the effect of variation in genes that influence hormone production and activity on the risk of breast and prostate cancer. The investigators first constructed a detailed map of genetic variation spanning HSD17B1, a gene involved in the production of estrogen and testosterone. This enabled them to efficiently measure common variation across the whole gene, capturing information about both known variants with a plausible function and unknown variants with an unknown function. Because of the results with a large number of study participants, the investigators could rule out strong associations between common HSD17B1 variants and risk of prostate cancer among U.S. and European whites. While this sheds some light on the carcinogenic effects of one enzyme involved in the complex process of steroid hormone production, it remains to be determined whether variants in other genes play a more important role or if the combined effects of several genes within these pathways have a larger impact.

A haplotype-based case-control study of BRCA1 and sporadic breast cancer risk

Rare, highly penetrant germ line mutations in BRCA1 strongly predispose women to a familial form of breast and ovarian cancer. Whether common variants (either coding or noncoding) at this locus contribute to the more common form of the disease is not yet known. We tested common variation across the BRCA1 locus in African American, Native Hawaiian, Japanese, Latino, and White women in the Multiethnic Cohort Study. Specifically, 28 single nucleotide polymorphisms (SNPs) spanning the BRCA1 gene were used to define patterns of common variation in these populations. The majority of SNPs were in strong linkage disequilibrium with one another, indicating that our survey captured most of the common inherited variation across this gene. Nine tagging SNPs, including five missense SNPs, were selected to predict the common BRCA1 variants and haplotypes among the non-African American groups (five additional SNPs were required for African Americans) and genotyped in a breast cancer case-control study nested in the Multiethnic Cohort Study (cases, n = 1,715; controls, n = 2,502). We found no evidence for significant associations between common variation in BRCA1 and risk of breast cancer. Given the large size of our study population and detailed analysis of the locus, this result indicates either that common variants in BRCA1 do not substantially influence sporadic breast cancer risk, or that unmeasured heterogeneity in the breast cancer phenotype or unmeasured interactions with genetic or environmental exposures obscure our ability to detect any influence that may be present.

Demonstrating stratification in a European American population

Population stratification occurs in case-control association studies when allele frequencies differ between cases and controls because of ancestry. Stratification may lead to false positive associations, although this issue remains controversial. Empirical studies have found little evidence of stratification in European-derived populations, but potentially significant levels of stratification could not be ruled out. We studied a European American panel discordant for height, a heritable trait that varies widely across Europe. Genotyping 178 SNPs and applying standard analytical methods yielded no evidence of stratification. But a SNP in the gene LCT that varies widely in frequency across Europe was strongly associated with height (P < 10(-6)). This apparent association was largely or completely due to stratification; rematching individuals on the basis of European ancestry greatly reduced the apparent association, and no association was observed in Polish or Scandinavian individuals. The failure of standard methods to detect this stratification indicates that new methods may be required.

Common genetic variation in the sex steroid hormone-binding globulin (SHBG) gene and circulating shbg levels among postmenopausal women: the Multiethnic Cohort

SHBG transports sex steroid hormones in the blood, and levels in humans are thought to partially be genetically determined. Recently, studies have found a pentanucleotide (TAAAA)n repeat polymorphism in the promoter of the SHBG gene and a missense polymorphism in exon 6 (Asp327Asn) to predict circulating SHBG levels. Based on the potential role of common genetic variation in SHBG to serve as a marker of SHBG levels in the general population, we evaluated the association between the (TAAAA)n repeat polymorphism, Asp327Asn polymorphism, and SHBG levels in a population of African-American, Native Hawaiian, Japanese, Latina, and white healthy postmenopausal women from the Multiethnic Cohort Study (n = 372). Mean SHBG levels were not significantly different between carriers and noncarriers of the Asn327 allele [minor allele frequency range across ethnic groups, 0.02-0.14; Asp/Asn and Asn/Asn genotypes, 33.6 mol/liter; 95% confidence interval (CI), 28.2-40.0; n = 49; Asp/Asp genotype, 30.8 mol/liter (95% CI, 28.7-33.1; n = 296); P = 0.37]. For the repeat polymorphism, we observed six different SHBG repeat alleles segregating in the population (TAAAA6-11), and the distribution of these alleles varied widely across populations. We found suggestive evidence of linkage disequilibrium between the Asn327 allele and the eight-repeat allele in all populations except African-Americans (P > or = 0.08). In analysis of the repeat polymorphism, SHBG levels among carriers of two short alleles (seven or fewer repeats; 31.2 nmol/liter; 95% CI, 27.3-35.6; n = 82) were not statistically different from those of carriers of two long alleles (more than seven repeats; 32.7 nmol/liter; 95% CI, 29.4-36.3; n = 124; P = 0.59). We did, however, observe individual genotypic classes (n = 16) to contribute modestly to the overall prediction of SHBG levels (by analysis of covariance, P = 0.03). Carriers of the six-repeat allele (27.9 nmol/liter; 95% CI, 25.2-30.8; n = 147) were found to have nominally significantly lower SHBG levels than noncarriers (32.4 nmol/liter; 95% CI, 29.7-35.2; n = 202; P = 0.03). This effect was stronger among the subset of women who also carried the Asn327 allele (interaction, P = 0.006). In summary, these results suggest that genetic variation at the SHBG locus may contribute to modest differences in SHBG levels among healthy postmenopausal women, and that much larger studies will be needed to better comprehend the effects of common variations at this locus in predicting circulating SHBG levels.

Systematic evaluation of genetic variation at the androgen receptor locus and risk of prostate cancer in a multiethnic cohort study

Repeat length of the CAG microsatellite polymorphism in exon 1 of the androgen receptor (AR) gene has been associated with risk of prostate cancer in humans. This association has been the focus of >20 primary epidemiological publications and multiple review articles, but a consistent and reproducible association has yet to be confirmed. We systematically addressed possible causes of false-negative and false-positive association in >4,000 individuals from a multiethnic, prospective cohort study of prostate cancer, comprehensively studying genetic variation by microsatellite genotyping, direct resequencing of exons in advanced cancer cases, and haplotype analysis across the 180-kb AR genomic locus. These data failed to confirm that common genetic variation in the AR gene locus influences risk of prostate cancer. A systematic approach that assesses both coding and noncoding genetic variation in large and diverse patient samples can help clarify hypotheses about association between genetic variants and disease.

Common variation in BRCA2 and breast cancer risk: a haplotype-based analysis in the Multiethnic Cohort

It is well established that rare mutations in BRCA2 predispose to familial breast cancer, but whether common variants at this locus contribute more modest risk to sporadic breast cancer has not been thoroughly investigated. We performed a haplotype-based study of BRCA2 among women in the Multiethnic Cohort Study (MEC), genotyping 50 SNPs spanning 109.4 kb of the BRCA2 gene. Twenty-one haplotype-tagging SNPs (including seven missense SNPs) were selected to predict the common BRCA2 haplotypes and were genotyped in a breast cancer case-control study nested in the MEC (cases, n=1715; controls, n=2502). Compared to non-carriers, we observed nominally significant positive associations for homozygous carriers of specific haplotypes in blocks 2 (haplotype 2c: OR=1.50; 95% CI, 1.08-2.09) and 3 (haplotype 3d: OR=1.50; 95% CI, 1.01-2.24). These results could be explained on the basis of a single marker in intron 24 (SNP 42: rs206340) that was correlated with these haplotypes and the homozygous state was associated with a significantly increased risk of breast cancer (AA versus GG genotypes: OR=1.59, 95% CI, 1.18-2.16; nominal P=0.005). This association was modestly stronger among women with advanced disease (OR=2.00, 95% CI, 1.30-3.08; P=0.002). In this exploratory analysis, we found little indication that common variation in BRCA2 dramatically impacts sporadic breast cancer risk. However, a significant elevation in risk was observed among approximately 6% of women who carried a specific haplotype pattern and may harbor a susceptibility allele at the BRCA2 locus.

Assessing the impact of population stratification on genetic association studies

Population stratification refers to differences in allele frequencies between cases and controls due to systematic differences in ancestry rather than association of genes with disease. It has been proposed that false positive associations due to stratification can be controlled by genotyping a few dozen unlinked genetic markers. To assess stratification empirically, we analyzed data from 11 case-control and case-cohort association studies. We did not detect statistically significant evidence for stratification but did observe that assessments based on a few dozen markers lack power to rule out moderate levels of stratification that could cause false positive associations in studies designed to detect modest genetic risk factors. After increasing the number of markers and samples in a case-cohort study (the design most immune to stratification), we found that stratification was in fact present. Our results suggest that modest amounts of stratification can exist even in well designed studies.

Quantitative neuronal c-fos and c-jun expression in Alzheimer's disease

Apoptosis, or programmed cell death, has been proposed as a mechanism of neuropathology in Alzheimer's disease (AD). Activation of immediate early genes (IEG) c-jun and c-fos appears to be required for the initiation of apoptosis. Furthermore, the expression of c-jun is induced in cultured neurons that undergo beta-amyloid-mediated apoptosis suggesting a direct role for c-jun in the apoptosis of AD neurons. Using immunohistochemical methods, we calculated the average number of neuronal profiles per unit area expressing c-Jun and c-Fos within hippocampal regions CA1, CA2/3, and CA4 in postmortem brain samples from AD patients and age-matched non-AD patients. There was an increase in c-Jun-positive and c-Fos-positive neuronal profile density in nearly all AD hippocampal regions examined. In cerebellum there was no evidence of apoptosis as determined by using TUNEL technique, and negligible c-Jun labeling.

Increased peroxidation and reduced antioxidant enzyme activity in Alzheimer's disease

The overall peroxidation activity in brain tissue by region from patients with Alzheimer's disease (AD) and age-matched controls was determined employing the thiobarbituric acid-reactive substances (TBARS) assay, a measure of lipid peroxidation, followed by a determination the activities of the antioxidant enzymes Cu/Zn superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT), in the frontal, temporal, and cerebellar cortex of 10 AD and 9 control brains. The level of TBARS was elevated in all regions, with particular statistical significance in the temporal cortex when compared to age-matched controls. SOD activity was significantly decreased in AD frontal and AD temporal cortex, while catalase activity was significantly decreased in AD temporal cortex. There was no significant difference in GSH-Px activity found in any of the regions examined. This study supports the theory that in AD the brain is affected by increased oxidative stress which, when combined with a decrease in SOD activity, produces oxidative alterations, seen most significantly in temporal cortex in AD, where the pathophysiologic changes are most severe.

Decreased brain glucose metabolism in microvessels from patients with Alzheimer's disease

We studied brain glucose metabolism in patients with Alzheimer's disease and age-matched controls in vivo by PET and assessed brain glucose utilization and the phosphorylation constant K3 for hexokinase. In addition we determined in vitro the binding of 2DG and measured its phosphorylation to 2DG-phosphate in cerebral microvessels obtained at autopsy from subjects with Alzheimer's disease and age-matched controls. In patients with Alzheimer's disease we found a marked decrease in the kinetic constant K3 for the hexokinase, and a marked decrease in the overall metabolism of glucose in our PET studies; in microvessels there was a marked decrease in the affinity of 2DG and a decrease in hexokinase activity. Alzheimer's disease may be related to a complex alteration in brain glucose metabolism.

Dosimetry and cost of imaging osseointegrated implants with film-based and computed tomography

Thermoluminescent dosimeters were used to measure radiation doses at craniofacial sites in a tissue-equivalent phantom during film-based multidirectional tomography with the Tomax Ultrascan (Incubation Industries, Ivyland, Pa.) and during computed tomography with the Elscint Excel 2400 (Elscint Corp., Tel Aviv, Israel). Mean absorbed doses for presurgical mandibular and maxillary canine and molar implant assessments were converted to equivalent doses, which were then multiplied by published weighting factors and summed to give effective doses. The computed tomography device consistently delivered higher doses than the Tomax Ultrascan to all anatomic locations; the differences were most pronounced when only one or two implant sites were evaluated. The reasons for the dose disparities are considered both anatomically and procedurally. A survey of examination cost revealed film-based multidirectional tomography to be less expensive than computed tomography.

Niobium filtration of conventional and high-frequency x-ray generator beams for intraoral radiography. Effects on absorbed doses, image density and contrast, and photon spectra

We have studied the effects of niobium beam filtration on absorbed doses, on image density and contrast, and on photon spectra with conventional and high-frequency dental x-ray generators. Added niobium reduced entry and superficial absorbed doses in periapical radiography by 9% to 40% with film and digital image receptors, decreased the radiation necessary to produce a given image density on E-speed film and reduced image contrast on D- and E-speed films. As shown by increased half-value layers for aluminum, titanium, and copper and by pulse-height analyses of beam spectra, niobium increased average beam energy by 6% to 19%. Despite the benefits of adding niobium on patient dose reduction and on narrowing the beams' energy spectra, the beam can be overhardened. Adding niobium, therefore, strikes the best balance between radiation dose reduction and beam attenuation, with its risks of increased exposure times, motion blur, and diminished image contrast, when it is used at modest thicknesses (30 microns) and at lower kVp (70) settings.

Brain glucose metabolism in Alzheimer's disease

In vitro determination of brain glucose metabolism in the temporal cortex from patients with Alzheimer's disease showed a marked decrease when compared with nondemented, age-matched control subjects. Additional determinations on normal human temporal cortex obtained at autopsy demonstrated an age-dependent decline in the rate of glucose use. These data provide an in vitro correlate for positron emission tomography studies that suggest decreased brain glucose use in Alzheimer's disease.

Alteration of irradiated shuttle vector processing by exposure of human lymphoblast host cells to single or split gamma-ray doses

The repair of damaged DNA by mammalian cells exposed to single or split doses of radiation was probed with shuttle vector pZ189. Human lymphoblast hosts who received a single 120 cGy dose 2 h before transfection with 2500 cGy-damaged pZ189 yielded a two-fold higher frequency of progeny plasmids with mutations in their supF-tRNA target genes than did unirradiated host cells. Delaying transfection for 12 h, however, reduced the mutation frequency by half versus unirradiated controls. Plasmid survival was also affected by the time between host cell irradiation and transfection. Splitting doses of 50-500 cGy into two equal fractions separated by 4 h lowered mutation frequency and increased plasmid survival compared with equivalent acute doses; increasing the interval between dose fractions to 8 h, however, lowered plasmid survival compared with acute doses. Sequence analyses of the target gene in mutant plasmids revealed increased multiple-base substitution mutations among progenies recovered from irradiated hosts, indicating enhanced excision repair. These findings support modulation of mammalian cell DNA repair by ionizing radiation, disclose the transient nature of the effect of radiation on DNA repair, and demonstrate a quantitative difference in the effectiveness of single and split doses.

Dietary aluminum and Alzheimer's disease

Aluminum accumulation has been implicated in the development of Alzheimer's Disease, a hallmark of which is decreased brain glucose metabolism. Dietary sources of aluminum include that which comes from the contact of food with aluminum cook ware, containers, foil, and utensils. Normal aluminum intake from all sources is estimated as 12-14 mg per day. We have evaluated brain glucose metabolism in the presence of physiologically achievable levels of aluminum, in the range 10(-15) to 10(-5) M. Our results indicate no effect of aluminum in the range tested. Thus the contact of food with aluminum cooking utensils cannot alone raise plasma aluminum concentrations to the millimolar levels required to decrease brain glucose metabolism. Non dietary pathophysiological mechanisms are operating which lead to the accumulation of tissue aluminum, since most of dietary aluminum is excreted by the kidney.

Mutation spectrum in gamma-irradiated shuttle vector replicated in ataxia-telangiectasia lymphoblasts

Cells from ataxia-telangiectasia (AT) patients are hypersensitive to the lethal effects of ionizing radiation. To assess radiation mutagenesis in these cells, the SV40-based shuttle vector, pZ189, was used to analyze gamma-ray-induced mutations following the plasmid's replication in AT lymphoblasts. Progenies from the AT line GM2783 exposed to 50 Gy showed a mutation frequency of 7.6 x 10(-3), 63-fold over background; surviving plasmids were 3.4% of control. Both values were essentially the same as those of irradiated plasmids replicated in a normal lymphoblast line, GM606. In addition, pZ189 exposed to 25 Gy of gamma radiation and replicated in another normal lymphoblast line and in cells of two additional AT lymphoblast lines showed similar mutation frequencies and percentages of surviving plasmids. Qualitative comparison of plasmid mutations from AT and normal cells showed no significant differences, indicating that the damaged DNA was repaired with similar fidelity in AT and normal cells. These studies suggest that there is no correlation between the enhanced sensitivity of AT cells to killing by ionizing radiation and gamma-radiation-induced mutagenesis of plasmid DNA processed in these cells.

Dependence of the mutation spectrum in a shuttle plasmid replicated in human lymphoblasts on dose of gamma radiation

The frequencies and types of mutations induced in the target gene, supF-tRNA, of the shuttle vector pZ189 were analysed following the replication of the gamma-irradiated plasmid in the human lymphoblastoid cell line, GM606. The mutation frequency measured in progeny of unirradiated pZ189 was 1.02 x 10(-4), increasing to 17.5 x 10(-4) at 1000 cGy, and to 63.4 x 10(-4) at 5000 cGy, approximately 17- and 62-fold over background levels, respectively. Simultaneously, the number of plasmids capable of replicating in Escherichia coli decreased with increasing radiation dose to 4% of the control value at 5000 cGy. Electrophoresis of the irradiated DNA showed a correlation between increases in mutation frequency and decreases in plasmid survival, and the formation of open-circular and linear DNA. The majority of the spontaneous (69.8%) and induced mutations (85.7%) at 1000 and 79.4% at 5000 cGy) were base substitutions and were generally of similar types among all groups. However, changes at 2500 (12.7%) and 5000 cGy (13.2%) involving A:T base pairs were greater than those in unirradiated controls (3.4%) or those at 1000 cGy (2.0%). This increase in A:T base pair mutations could be a result of reduced repair fidelity when the DNA is extensively damaged by high doses of ionizing radiation.

Cimetidine suppresses chemically induced experimental hepatic porphyria

The ability of cimetidine to reduce the activity of hepatic aminolevulinic acid synthase (ALA-S) was examined in allylisopropyl acetamide (AIA) treated porphyric adult rats. A dose of 20 mg cimetidine/100 gm body weight resulted in a 50% decrease in the AIA-induced hepatic ALA-S activity compared to rats treated with AIA alone. Heme oxygenase activity was decreased 25% compared to rats treated with AIA alone. The effects of AIA and cimetidine on cytochrome P-450 were not additive, suggesting competition for a common site of interaction. The results suggest that cimetidine may prove to be useful in treating porphyria in humans.

Why vitamin B12 deficiency should be managed aggressively

Recent evidence suggests that vitamin B12 deficiency in the elderly is more than classic pernicious anemia. Instead, it is a continuum from negative B12 balance to frank deficiency, which can be detected by low serum B12 levels long before changes occur in hemoglobin levels. Current findings in the literature suggest that subtle B12 deficiency is indeed clinically significant. Treatment may prevent significant neurologic and/or hematologic disease.

Vitamin B12 and geriatrics: unanswered questions

Vitamin B12 is an important area in the interface between geriatrics and hematology. B12 deficiency is more common in the elderly and because its neurologic manifestations overlap very common disorders such as dementia, the diagnosis may be more subtle in the elderly. The critical question is whether early treatment of B12 deficiency can prevent some cases of dementia. If prevention is possible, then all elderly patients should be screened for cobalamin deficiency. Research must be ongoing to determine the most cost-effective strategy for evaluating low B12 levels. In our view careful review of the blood smear is still very useful. Although requiring further study, the Herbert/Herzlich model should prove to be very useful to the clinician evaluating patients for possible B12 deficiency. Finally, although the treatment is lifelong, we would argue that when in doubt the patient should be treated. The cost of therapy is small when balanced against the potential consequences.

Red cell distribution width, mean corpuscular volume, and transferrin saturation in the diagnosis of iron deficiency

The usefulness of the red cell distribution width, mean corpuscular volume, and the transferrin saturation in diagnosing iron deficiency anemia were evaluated in a retrospective study of 247 anemic hospitalized patients, many of whom had chronic liver disease. A red cell distribution width greater than 15% had a sensitivity of 71% and a specificity of 54% for iron deficiency as diagnosed by a low serum ferritin or bone marrow examination. A mean corpuscular volume less than 80 femtoliters had a sensitivity of 53% and a specificity of 84%. Transferrin saturation less than 16% had a sensitivity of 61% and a specificity of 86%. Because the sensitivities and specificities of these tests are less than reported in studies of healthier populations, they cannot be relied on for screening for iron deficiency in sick hospitalized patients.

Gynecologic malignancies of the elderly

Gynecologic malignancies account for over 20,000 deaths in the United States each year, and over half of these occur in elderly women. If discovered in their early stages, each of these cancers is curable, but increasing age usually correlates with more advanced stage of disease. Except for ovarian cancer, these diseases can be detected in asymptomatic women by simple screening procedures. Although elderly women may be more difficult to treat because of intercurrent medical illness, when they are treated aggressively, age usually has no independent prognostic significance.

Cervical cancer screening in women aged 65 and over

Pap smear screening is an accepted method of detecting cervical dysplasia or malignancy, and use of this test has been shown to reduce the incidence of invasive squamous cervical cancer in young and middle aged women. Conflicting recommendations exist concerning the screening of women over the age of 65, and little information is available concerning the results of screening in this population. Elderly women are routinely omitted from screening, as it is generally believed that they usually refuse testing. This paper reports a study attempting to evaluate the feasibility of screening in women over the age of 64 attending a large urban outpatient geriatric clinic. It demonstrates that pap smear screening is acceptable to this population, particularly if performed by the usual primary care provider. It also confirms previous reports that women in this age group have had very little screening in the past, and that screening uncovers a large number of abnormalities. Of note is the high rate of false positive smears in this population.

Low serum B12 levels in a hematologically normal elderly subpopulation

Serum Vitamin B12 levels were determined on 378 patients ranging in age from 56 to 104 years with a median age of 77 for both males and females. A radiodilution method was employed for these determinations. This screening procedure identified 26 patients with low serum B12 levels. Nineteen of these patients had no other symptoms and were hematologically normal. The B12 binding proteins, transcobalamins (TC) I, II, and III were quantitated employing QUSO and DEAE cellulose batch separations. The total number of TC II binding/affinity sites for B12 were elevated in both the normal and low B12 elderly groups. About 17% of the total serum B12 was carried by TC II in the control group while only 4% of the total was carried on TC II in both the normal and low B12 elderly. This was accompanied by an increase in unsaturation in TC II for these two groups. The findings suggest that an alteration in the TC II-B12 delivery system has occurred in the elderly.

Iron deficiency in the elderly

Iron deficiency in the elderly almost always results from blood loss. The loss of iron can be viewed as occurring in four stages, which are reflected in the different tests used to diagnose iron deficiency. Tests used to diagnose iron deficiency have certain limitations regarding their ability to detect iron deficiency before the overt anaemia occurs. The tests which diagnose iron deficiency most accurately are low serum ferritin and reduced iron staining of a bone marrow aspirate. Because iron is present in many metabolic processes besides the production of haemoglobin, iron deficiency results in a variety of defects which are manifested at biochemical, tissue, and functional levels. Iron is a component of several enzymes in the respiratory electron transport chain. Adequate haem and iron levels are necessary to control cytoplasmic and mitochondrial protein synthesis. Iron deficiency results in tissue defects, including those affecting the gastrointestinal tract, and defects of mitochondria and lymphocytes. Normal iron levels seem to be necessary for normal work capacity. A deficiency of iron, independent of the anaemia, results in reduced exercise capacity that can be measured in both physiological and economic terms. Elderly patients complaining of increased fatigue should therefore be screened for iron deficiency. There is evidence to suggest that iron deficiency may predispose individuals to certain infections. Other information points to the promotion of certain bacterial and parasitic infections after rapid correction of iron deficiency. Thus elderly patients having iron replacement therapy should be followed closely. A deficiency of iron has been shown to result in certain behavioural and learning abnormalities. Iron deficiency has been shown to result in impaired control of body temperature, resulting in an increase in catecholamine levels. The impairment in heat-generating ability was shown to result from reduced conversion of T4 to T3 in the peripheral tissues.

Folate and vitamin B12 levels in an urban elderly population with chronic diseases. Assessment of two laboratory folate assays: microbiologic and radioassay

Folate levels of serum and red blood cells (RBC) and vitamin B12 serum levels were investigated in 326 urban chronically ill elderly ambulatory patients and 41 healthy young control subjects. Two laboratory methods were used for investigating the folate levels, the microbiologic assay (MBA) with Lactobacillus casei and radioassay (RA). Serum and RBC samples of 326 patients were tested by the folate MBA and 270 of the same samples by the RIA methods. In the MBA 6.8% of the patients and 12.2% of controls had low levels of folate RBC (less than 200 ng/mL) and 1.8% of patients and 4.8% of controls had low serum folate levels (less than 5 ng/mL). All of the patients with the low folate levels had normal hematologic findings and no clinical symptoms of folate deficiency. In the RIA method, all of the patients and almost all of the control subjects (except one) had normal folate levels. Ten of the patients (3%) had low levels of serum vitamin B12 (less than 200 pg/mL). They were hematologically normal. They had normal Schilling tests and normal vitamin B12 dietary intake. Their RBC folate levels were normal and even somewhat higher. Forty percent of these patients had macular degeneration of the eyes. The data indicate the superiority of the RA method over the MBA and bring into question the accuracy of previous studies. The data furnish further evidence that a low vitamin B12 level in the elderly is not necessarily a true vitamin B12 deficiency and raise the possibility of an association between low B12 serum levels and macular degeneration of the eyes.

Benzene modulation of liver cell structure and heme-cytochrome P-450 metabolism

Rats were treated with subcutaneous benzene, 440 mg/kg, for 3 and 14 days (acute and chronic exposure). Their hepatic cell heme and drug metabolizing enzymes as well as cell morphology by electron microscopy were examined. Electron micrographs of hepatocytes from the benzene-treated rats showed disruption of the mitochondrial membranes and mitochondrial structure. The activity of the rate-limiting enzyme of heme synthesis, delta-aminolevulinic acid synthase was increased 1.5-2-fold in both acutely and chronically exposed animals. In the acutely exposed animals, there was a 50% inhibition of the second enzyme of heme synthesis, delta-aminolevulinic acid dehydratase, while in the chronically exposed there was 70% inhibition. The rate-limiting enzyme of heme degradation, heme oxygenase, was increased more than twofold in both sets of animals. Cytochrome P-450 content was increased 77% in the acutely treated and 35% in the chronic. Associated with this increase in cytochrome P-450 content, there was a twofold increase in both arylhydrocarbon hydroxylase and aminopyrine-N-demethylase activities after acute exposure. During chronic exposure, however, there was a return to normal of the aminopyrine-N-demethylase activity and a decline in arylhydrocarbon hydroxylase induction to 1.25 times control. Results from this study indicate that benzene exposure produces adverse effects on mitochondria and heme metabolism. The precise relationships of these disturbances to benzene toxicity are not clear; however the possible role of heme oxygenase and degree of cytochrome P-450 induction are considered. Finally, the alterations of arylhydrocarbon hydroxylase and aminopyrine-N-demethylase activities point to a potential mechanism of differential toxicity from metabolites of benzene.

Clinical disorders of iron metabolism in the elderly

When iron deficiency occurs in the elderly, it is usually due to bleeding and not to nutritional lack or malabsorption. Iron deficiency early in life may lead to irreversible changes (for example, gastric achlorhydria) that are troublesome in later life. The nonhematologic effects of iron deficiency still need to be studied in the elderly. In particular, the role of iron in brain metabolism would seem important in geriatrics. Although it is important to prevent iron deficiency, indiscriminate use of iron could conceivably lead to iron overload. As with many beneficial compounds, patients must be cautioned against the prolonged ingestion of large amounts of iron salts.

Nutritional needs of the elderly: debate and recommendations

Despite all that has been written, little evidence supports the notion that the American diet for the elderly needs major modifications (table 3). Particularly in counseling and assessing the elderly, physicians must keep in mind that whatever technique older patients used to reach their present age is probably better than what we can recommend. In the last analysis, the most sensible nutritional recommendations we can make are to maintain ideal body weight, reduce animal protein, increase complex carbohydrates and fiber, reduce saturated fats and cholesterol, increase calcium intake, and avoid high doses of supplementary nutrients. If available data are any indication, many community-dwelling elderly persons are now making most of these modifications.

Effect of age on rat liver heme and drug metabolism

Old (24-months) rats have lower activities of hepatic delta-aminolevulinic synthase and the microsomal cytochrome P-450 monooxygenase activities--aminopyrine N-demethylase and aniline hydroxylase--as compared to young (2-months) animals. In contrast, the activity of the heme degradative enzyme, heme oxygenase, is higher in the old rats. Cytochrome P-450 and microsomal heme contents were maintained in the old. When inducibility and inhibition of these enzymes were studied, the old rats responded to the same degree as the young. These results indicate that the ability of the heme synthetic and degradative enzymes to respond to decreasing cellular heme levels is not significantly altered with age. The observations that there is a lower baseline activity of ALA-synthase and good maintenance of microsomal heme and cytochrome P-450 content, in spite of elevated heme oxygenase activity in the old, suggest that, at least in the senescent rat, hepatic heme utilization and degradation are only loosely coupled to heme production. It appears, therefore, that alternate sources of heme for cytochrome P-450 are available in the old animals. Furthermore, it is suggested that the old rat has a baseline change in ALA-synthase, heme oxygenase, and cytochrome P-450 that may be overcome under the appropriate conditions.

Effect of cimetidine on delta-aminolevulinic acid synthase and microsomal heme oxygenase in rat liver

Cimetidine is a well known inhibitor of the heme-containing enzyme cytochrome P-450. We have found that it also inhibits delta-aminolevulinic acid synthase (ALA-S) and microsomal heme oxygenase, the rate-limiting enzymes for heme synthesis and heme degradation respectively. Cytochrome P-450 content was decreased but microsomal heme concentration remained unaltered for a period of 30 min after in vivo cimetidine administration to rats. In vitro incubation of cimetidine with each of the above enzymes revealed no direct effect of cimetidine on ALA-S but about 50% inhibition of heme oxygenase and 20% reduction in cytochrome P-450 content. This suggests that a metabolite of cimetidine inhibits ALA-S activity in vivo, while the drug itself or a metabolite inhibits heme oxygenase both in vivo and in vitro. A rise in ALA-S activity seen after its early inhibition and its return to approximate control values after 60 min suggest a reversible inhibition of ALA-S by a metabolite of cimetidine and may correspond to its clearance from the animal. An elevation in microsomal heme content paralleled the rise in ALA-S activity while microsomal heme oxygenase activity returned to only 65% of control value 60 min after cimetidine treatment. Cytochrome P-450 content did not change after its initial decrease, suggesting that irreversible alteration had occurred.

Salivary and serum IgA levels in a geriatric outpatient population

In two separate studies, specimens of saliva from 57 individuals over the age of 65 years (mean age, 76.7 years) and 37 persons under the age of 40 years (mean age, 28.8 years) were examined for concentrations of IgA as functions of volume, total protein, and electrolyte conductivity; some were also tested for IgG and IgM content. The results show that older persons have higher concentrations of these solutes in their saliva than do younger controls. This suggests that the ability to secrete IgA into saliva does not diminish significantly with aging.

Organic brain syndromes in the elderly. When are they reversible?

Dementia, delirium, and depression are not part of normal aging but are organic brain syndromes that often are reversible. Thus, it is imperative that primary care physicians carefully look for a reversible cause in a patient with one of these disorders. Even an irreversible condition, such as Alzheimer's disease, can be effectively treated with drugs that are carefully chosen to minimize serious side effects. Patients with cognitive impairment deserve to be treated with dignity, and every effort should be made to maintain the highest level of function possible.

Delayed gastric emptying and improvement with domperidone in a patient with anorexia nervosa

A woman with anorexia nervosa who displayed severe bloating after eating was treated with domperidone, a novel compound with prokinetic properties. Both subjective ratings of satiety and assessment of gastric emptying documented improvement.