The long-term risk of malignancy following a diagnosis of coeliac disease or dermatitis herpetiformis: a cohort study

BACKGROUND

People with coeliac disease are known to be at increased risk of malignancy; however, long-term risks of malignancy beyond 10-15 years are largely unstudied.

AIM

To estimate how long an increased risk of malignancy among coeliac disease patients persists following diagnosis and treatment, using data from a cohort with an average follow-up of 25 years.

METHODS

People with coeliac disease diagnosed in the Lothian region of Scotland, United Kingdom, were followed up from January 1970 or the date of coeliac disease diagnosis (whichever was later) until the first occurrence of death, emigration, cancer diagnosis or the end of 2004. Standardised incidence ratios were calculated to compare the cancer incidence rates among this group with those from the population of Scotland.

RESULTS

Overall, the risk of any malignancy in coeliac disease patients compared with the general population was increased 40% [standardised incidence ratio (SIR) = 1.41; 95% CI 1.09-1.78]. An increased risk for cancer overall persisted for up to 15 years, beyond which no overall increase in malignancy risk was observed, although the risk of non-Hodgkin's lymphoma remained raised beyond 15 years (SIR = 5.15; 95% CI 1.40-13.2). In total, there were 14 non-Hodgkin's lymphomas in the cohort, providing an overall incidence of 1.3 per 1000 person-years.

CONCLUSIONS

The overall risk of malignancy in coeliac patients declines with time after diagnosis and is not significantly increased after 15 years. Most of the increased risk can be attributed to the development of haematological malignancies, despite their very low absolute rate of occurrence.

No difference in mortality in undetected coeliac disease compared with the general population: a UK cohort study

BACKGROUND

Studies of mortality in undetected coeliac disease compared with the general population give contradictory findings, suggesting it is either increased fourfold compared with the general population or not at all.

AIM

To establish all-cause and cause-specific mortality in undiagnosed coeliac disease, identified by anti-endomysial antibody (EMA) positivity, in the Cambridge GP Health Survey cohort.

METHOD

This cohort was recruited in 1990 from the general population aged 45-76 years. All deaths were ascertained from the Office for National Statistics. Mortality rates were calculated per 1000 person years and adjusted for age, gender, smoking and socioeconomic group using multivariate Cox regression to estimate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

There were 117,914 patient years of follow-up (median 16.8 years) from 7527 participants. Eighty-seven had undetected coeliac disease, their all-cause mortality rate was 9.4 per 1000 person years (95% CI 5.4-16.1) compared with 12.7 (95% CI 12.1-13.4) in EMA-negative participants. The adjusted all-cause mortality HR was 0.98 (95% CI 0.57-1.69). Death due to cancer and circulatory diseases was not increased, adjusted HR were 1.27 (95% CI 0.57-2.85) and 1.39 (95% CI 0.66-2.92) respectively.

CONCLUSIONS

We observed no excess overall mortality in people aged over 45 years with undetected coeliac disease compared with the general population, nor any increase in deaths related to circulatory disease or cancer. Our findings do not support screening the general population aged over 45 years, for coeliac disease for the purpose of improving life expectancy.

Abnormal liver tests in people aged 75 and above: prevalence and association with mortality

BACKGROUND

Despite their common use the occurrence and consequences of abnormal liver tests remain unclear.

AIMS

To estimate the prevalence and mortality associated with abnormal liver tests in people aged 75 years and above.

METHODS

A cohort study on 13,276 people aged 75 years and above, registered with general practices, with a valid measurement of one or more liver test, calculating the prevalence of abnormal aspartate transaminase (AST), alkaline phosphatase (ALP) or bilirubin. Hazard ratios (HRs) were calculated for all-cause and cause-specific mortality comparing elderly patients with abnormal liver tests to elderly patients with normal liver tests.

RESULTS

At least one abnormal liver test was found in 2175 subjects (16.1%, 95% CI [15.4%, 16.7%]). The prevalence of a single abnormal liver test was 3.3% (95% CI [3.0%, 3.7%]) for AST, 9.2% (95% CI [8.8%, 9.7%]) for ALP and 5.4% (95% CI [5.1%, 5.9%]) for bilirubin. Abnormal AST, ALP and bilirubin were associated with increased risks of all-cause mortality; adjusted HRs, 1.27(95% CI [1.09, 1.47]), 1.47(95% CI [1.35, 1.61]) and 1.15(95% CI [1.02, 1.30]), respectively. Abnormal AST and ALP were associated with sevenfold and sixfold increased risk of death from liver disease, respectively. Two or more abnormal liver tests were associated with 2-fold and 17-fold increased risk of death from cancer and liver disease, respectively. Of the causes examined, absolute mortality rates were highest for cardiovascular disease in subjects with and without abnormal liver tests.

CONCLUSIONS

Abnormal liver tests occur commonly in elderly people and are associated with a modest increase in all-cause mortality. There was a strong association with liver disease; however, the majority of deaths were not due to this cause.

The rising incidence of idiopathic pulmonary fibrosis in the U.K

BACKGROUND

Previous studies have shown that the incidence of idiopathic pulmonary fibrosis (IPF) is rising in the U.K. and U.S.A. Death registrations and primary care data were used to determine the current trends in IPF incidence in the U.K. Because routine clinical data sets were used, the term IPF clinical syndrome (IPF-CS) is used to describe individuals in this study.

METHODS

Age- and stratum-specific death registration rates between 1968 and 2008 were calculated and these were applied to the 2008 population to generate annual standardised expected number of deaths. Annual mortality rate ratios were calculated using Poisson regression. Computerised primary care records were used to determine incidence rates of IPF-CS between 2000 and 2008 stratified by age, sex and geographical region, and survival rates between calendar periods were compared.

RESULTS

Annual death certificate recording of IPF-CS rose sixfold across the study period from 0.92 per 100,000 in the 1968-1972 calendar periods to 5.10 per 100,000 in the 2006-2008 calendar period, and were higher in men and the older age groups. The incidence of IPF-CS in primary care increased by 35% from 2000 to 2008, with an overall incidence rate of 7.44 per 100,000 person-years (95% CI 7.12 to 7.77). Incidence was higher in men, the older population and in Northwest England.

CONCLUSIONS

The incidence of IPF-CS in primary care and registered deaths from this cause in the U.K. continues to rise in the 21st century. The current findings suggest that there are >5000 new cases diagnosed each year in the U.K.

Microarray studies in pulmonary arterial hypertension

Microarray studies have been performed on lung tissue, freshly isolated circulating cells and cells cultured from patients with idiopathic, hereditary and secondary forms of pulmonary arterial hypertension (PAH). These studies have provided a wealth of information on the characteristics of end-stage disease, but information about the origin of disease is only clear in hindsight. The central conclusions that can be drawn from these studies are that end-stage disease includes a massive but currently poorly defined inflammatory response, induction of angiogenesis genes for an as yet remaining unknown purpose, suppression of the BMP pathway even in idiopathic and secondary cases, and a host of more subtle changes, including mitochondrial and actin organisation changes. Moreover, the same physiologic endpoints can be achieved through use of any of multiple genes, and so specific genes are usually less important than the pathways they lie in; the exception to this rule must lie in as yet undefined critical nodes. Finally, the lack of consistency in methodologies of analysis makes cross-experiment comparisons difficult, and likely means that there is data collected in these studies that await interpretation.

First Report of Fusarium Wilt Caused by Fusarium oxysporum f. sp. canariensis on Canary Island Date Palm in Texas and South Carolina

Canary Island date palm (Phoenix canariensis) is native to the Canary Islands and widely grown throughout the world as an ornamental. At a home site in Austin, TX in May 2008 and a commercial site near Charleston, SC in December 2009, declining Canary Island date palms were observed. Symptoms included individual leaves with chlorotic or necrotic leaflets on one side of the leaf blade (one-sided wilt or death) and a distinct reddish brown stripe along the petiole and rachis. Cross-sections through the petiole or rachis exhibited discoloration of internal tissue. Fusarium oxysporum was isolated from the internal petiole or rachis tissue of each palm sample onto one-quarter-strength potato dextrose agar (PDA). Typical macroconidia in pale orange sporodochia, microconidia in false heads on short monophialides, and chlamydospores were observed (2). Macroconidia were mostly 3-septate, slightly curved, and ranged from 3.8 to 4.2 × 42.9 to 46.5 μm. Microconidia were single cell, oval to reniform, and ranged from 2.5 to 2.9 × 7.2 to 7.8 μm. Single-spore isolates grown on full-strength PDA (12-h light and 26°C) produced abundant white-to-pale lavender mycelia with a purple pigment in the agar. One isolate from each location (PLM-385B from Texas and PLM-511A from South Carolina) was selected for pathogenicity tests and molecular characterization. The translation elongation factor 1-α gene (EF-1α) was amplified in each isolate by PCR using the ef1 and ef2 primers (1). Products were sequenced and queried for similarity against the NCBI database and the FUSARIUM-ID database ( http://isolate.fusariumdb.org/index.php ) (1) using the BLAST search tool. In both databases, both isolates matched F. oxysporum f. sp. canariensis strain NRRL 26035 (GenBank Accession No. AF008485; FD_01211) at 100% sequence similarity. Sequences for PLM-385B and PLM-511A have been deposited in the NCBI database (GenBank Accession Nos. HM591537 and HM591538, respectively). Pathogenicity of these two isolates was tested on three-leaf Canary Island date palm seedlings. There were five replicate palms per isolate and control treatment. All potting mix was shaken from the roots and three groups of five seedlings were placed in small buckets. Twenty-five milliliters of a 10⁶ conidia ml^-1 suspension was pipetted down among the leaf bases and the excess drained onto the roots. Control palms received sterile water. Seedlings were covered with plastic for 48 h and then transplanted into separate growing containers. Ten weeks after inoculation, initial symptoms of a leaf wilt (off-color and folded over) were observed on some of the inoculated palms. After 4 months, all palms inoculated with PLM-511A were dead and three of the five palms inoculated with PLM-385B were dead. The pathogen was reisolated from diseased palms. All five control palms remained healthy. While the symptomatic palm in Texas had been in the home site approximately 2 years, which implied the palm could have been already infected when transplanted, the palm in South Carolina had been planted in 1990. To our knowledge, this is the first report of Fusarium wilt of Canary Island date palm in Texas and South Carolina. Previously in the United States, the disease had only been noted in California, Florida, and Nevada. References: (1) D. M. Geiser et al. Eur. J. Plant Pathol. 110:473, 2004. (2) J. F. Leslie and B. A. Summerell. The Fusarium Laboratory Manual. Blackwell Publishing, Ames, IA, 2006.

Effective treatments for PAH will require detailed knowledge of molecular aetiology

Therapies for idiopathic pulmonary arterial hypertension will need to address the underlying molecular defects, or they will be incapable of halting progression. Identification of the familial PAH gene, BMPR2, and determinants of penetrance in families with BMPR2 mutation, has provided a mechanism for discovering this underlying aetiology not just in those with BMPR2 mutation, but in all patients. These studies suggest that the fundamental defects are in cytoskeletal organization, energy metabolism, and inflammation, with mode of estrogen metabolism acting as the most significant modifier. A detailed understanding of these defects, and a determination of the correct points for intervention, will be required to produce effective treatments for idiopathic PAH.

The rate of decompensation and clinical progression of disease in people with cirrhosis: a cohort study

BACKGROUND

We lack population-based estimates of the rate of decompensation in people with compensated cirrhosis as well as estimates of the manner in which the disease progresses once identified.

AIM

To determine the rate of decompensation and clinical progression of disease in patients with cirrhosis based upon clinical symptoms recorded electronically in general practice data.

METHODS

Using Cox proportional hazards regression, we modelled the rate of decompensation for patients from the UK General Practice Research Database with a diagnosis of cirrhosis between 1987 and 2002. We determined the clinical progression in the first year following diagnosis and subsequently categorizing patients through time according to a simple clinical staging system agreed at the Baveno IV consensus conference.

RESULTS

The rate of decompensation in patients with compensated cirrhosis was found to be 11% overall. The rate of decompensation was higher in the first year (at 31% compared with 7.3% afterwards) and in patients with an alcoholic aetiology. Patients with compensated cirrhosis had a 1-year probability of proceeding directly to death of 7% compared with 20% in patients with decompensated cirrhosis.

CONCLUSIONS

Using data recorded in general practice records, it is possible to determine the rate of decompensation and the clinical progression of disease in people with cirrhosis.

BMPR2 mutation alters the lung macrophage endothelin-1 cascade in a mouse model and patients with heritable pulmonary artery hypertension

Macrophage derived-endothelin-1 (ET-1) has been suggested to contribute to a number of chronic lung diseases. Whether the ET-1 cascade from non-vascular sources (inflammatory cells) also contributes to pulmonary artery hypertension (PAH) and in particular to heritable PAH (HPAH) with known bone morphogenetic protein type 2 receptor (BMPR2) mutations is not known. We tested this notion using bone marrow-derived macrophages (BMDM; precursors of tissue macrophages) isolated from ROSA26rtTAXTetO(7)-tet-BMPR2(R899X) mice (model of PAH with universal expression of a mutated BMPR2 gene) with and without activation by LPS and in human lung tissue from HPAH with BMPR2 mutations and idiopathic PAH (IPAH). At baseline ET(A) and ET(B) receptors and endothelin converting enzyme (ECE) gene expression was reduced in BMPR2 mutant BMDM compared with controls. In control BMDM, LPS resulted in increased ppET-1 gene expression and ET-1 in culture media, whereas ET(A) and ET(B) receptor and ECE gene expression was decreased. These findings were more severe in BMPR2 mutant BMDM. Antagonism of the ET(B) receptor resulted in increased ET-1 in the media, suggesting that decreased ET-1 uptake by the ET(B) receptor contributes to the elevation. While ET-1 expression was demonstrated in lung macrophages from controls and IPAH and HPAH patients, ET(A) and ET(B) expression was decreased in the HPAH, but not IPAH, patients compared with controls. We conclude that reduced expression of macrophage ET-1 receptors in HPAH increases lung ET-1 and may contribute to the pathogenesis and maintenance of HPAH. This is the first description of protein expression that distinguishes HPAH from IPAH in patients.

Diagnostic and Therapeutic Applications of Nanotechnology

The increasing capability to manipulate matter at the nanoscale is generating new materials with unique properties that promise to address unmet medical needs for future generations. As an example, metal nanoshells are a relatively new class of nanoparticles with highly tunable optical properties. Metal nanoshells consist of a dielectric core nanoparticle such as silica surrounded by an ultrathin metal shell, usually composed of gold for biomedical applications. Depending on the size and composition of each layer of the nanoshell, particles can be designed to either absorb or scatter light over much of the visible and infrared regions of the electromagnetic spectrum, including the near infrared region where penetration of light through tissue is maximal. These particles are also easily conjugated to antibodies and other biomolecules for specific targeting. Further, the biocompatibility of these particles is excellent. One can envision a myriad of potential applications of such tunable particles. Several potential biomedical applications are under development, including immunoassays, modulated drug delivery, photothermal cancer therapy, and imaging contrast agents. For example, in photothermal cancer therapy, nanoshells can be injected intravenously, accumulate at tumor sites due to the enhanced permeability and retention (EPR) effect and/or molecular targeting, then generate heat upon illumination with near infrared light, leading to destruction of the tumor. This has shown very promising results in several animal models. For example, in a mouse colon carcinoma model, we demonstrated 100% survival of nanoshell treated mice at 1 year. These materials are now in phase I human clinical trials. For use in diagnostics and imaging, nanoshells can be designed to strongly scatter near infrared light. Molecularly targeted nanoshells have been used as optical contrast agents for cancer imaging with sub-cellular resolution. For example, anti-HER2 conjugated nanoshells allow near infrared imaging of HER2+ breast carcinoma cells. Furthermore, integrated imaging and therapy applications have been accomplished with nanoshells designed to provide both absorption and scattering, potentially enabling “see-and-treat” approaches to cancer therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr MS1-1.

Peroxisome proliferator-activated receptor-g agonist treatment increases septation and angiogenesis and decreases airway hyperresponsiveness in a model of experimental neonatal chronic lung disease

Chronic lung disease (CLD) affects premature newborns requiring supplemental oxygen and results in impaired lung development and subsequent airway hyperreactivity. We hypothesized that the maintenance of peroxisome proliferator-activated receptor gamma (PPARgamma) signaling is important for normal lung morphogenesis and treatment with PPARgamma agonists could protect against CLD and airway hyperreactivity (AHR) following chronic hyperoxic exposure. This was tested in an established hyperoxic murine model of experimental CLD. Newborn mice and mothers were exposed to room air (RA) or moderate hyperoxia (70% oxygen) for 10 days and fed a standard diet or chow impregnated with the PPARgamma agonist rosiglitazone (ROSI) for the duration of study. Following hyperoxic exposure (HE) animals were returned to RA until postnatal day (P) 13 or P41. The accumulation of ROSI in neonatal and adult tissue was confirmed by mass spectrometry. Analyses of body weight and lung histology were performed on P13 and P41 to localize and quantitate PPARgamma expression, determine alveolar and microvessel density, proliferation and alpha-smooth muscle actin (alpha-SMA) levels as a measure of myofibroblast differentiation. Microarray analyses were conducted on P13 to examine transcriptional changes in whole lung. Pulmonary function and airway responsiveness were analyzed at P55. ROSI treatment during HE preserved septation and vascular density. Key array results revealed ontogeny groups differentially affected by hyperoxia including cell cycle, angiogenesis, matrix, and muscle differentiation/contraction. These results were further confirmed by histological evaluation of myofibroblast and collagen accumulation. Late AHR to methacholine was present in mice following HE and attenuated with ROSI treatment. These findings suggest that rosiglitazone maintains downstream PPARgamma effects and may be beneficial in the prevention of severe CLD with AHR.