Clinical observed performance evaluation: a prospective study in final year students of surgery

We report a prospective study of clinical observed performance evaluation (COPE) for 197 medical students in the pre-qualification year of clinical education. Psychometric quality was the main endpoint. Students were assessed in groups of 5 in 40-min patient encounters, with each student the focus of evaluation for 8 min. Each student had a series of assessments in a 25-week teaching programme. Over time, several clinicians from a pool of 16 surgical consultants and registrars evaluated each student by direct observation. A structured rating form was used for assessment data. Variance component analysis (VCA), internal consistency and inter-rater agreement were used to estimate reliability. The predictive and convergent validity of COPE in relation to summative OSCE, long case, and overall final examination was estimated. Median number of COPE assessments per student was 7. Generalisability of a mean score over 7 COPE assessments was 0.66, equal to that of an 8 × 7.5 min station final OSCE. Internal consistency was 0.88-0.97 and inter-rater agreement 0.82. Significant correlations were observed with OSCE performance (R = 0.55 disattenuated) and long case (R = 0.47 disattenuated). Convergent validity was 0.81 by VCA. Overall final examination performance was linearly related to mean COPE score with standard error 3.7%. COPE permitted efficient serial assessment of a large cohort of final year students in a real world setting. Its psychometric quality compared well with conventional assessments and with other direct observation instruments as reported in the literature. Effect on learning, and translation to clinical care, are directions for future research.

Short communication: Genetic and nongenetic factors influencing Ostertagia ostertagi antibodies in UK Holstein-Friesian cattle

The purpose of this study was to estimate and discuss the genetic variation, heritability, and effects of nongenetic factors on the ability of Holstein-Friesian cows to produce an immune response by producing IgG antibodies to Ostertagia ostertagi. Total IgG (IgG(1) and IgG(2)) antibody levels were determined using an ELISA and measured using optical density ratio (ODR=OD(sample) - OD(negative control)/OD(positive control) - OD(negative control)) from milk samples collected from 1,276 Holstein-Friesian cattle in 229 commercial dairy farms from 2002 to 2004 during their first (82%) and other (2 to 12) lactations. A sire (n=461) model was fitted to the ODR data using ASREML software, and variance components were estimated. The ability to produce O. ostertagi antibodies as measured by ODR had a heritability of 0.13+/-0.12, and both season of sample and herd had a significant effect on total IgG levels. To conclude, this study has ascertained that genetic variation is present in the ability of dairy cows to mount an immune response to the parasite O. ostertagi. Inasmuch as evidence exists that IgG is linked to protective immunity against the parasite via a reduction in its reproductive ability, this trait may be of potential interest to genetic selection programs as an aid to reduce the effect of O. ostertagi in dairy herds.

Colonic perforation secondary to migrated biliary stent. Case report of an unusual complication, and literature review

Endoscopic stents are widely used to facilitate biliary drainage in hepatic, biliary and pancreatic conditions. Migration of the stent is a potentially serious complication. We report a case of migration of a biliary stent to the sigmoid colon at which point the stent perforated the colon and become lodged subcutaneously. The patient was managed successfully by local exploration to retrieve the stent without bowel resection. We also review the literature on complications caused by migrated biliary stents.

Expression signature developed from a complex series of mouse models accurately predicts human breast cancer survival

PURPOSE

The capability of microarray platform to interrogate thousands of genes has led to the development of molecular diagnostic tools for cancer patients. Although large-scale comparative studies on clinical samples are often limited by the access of human tissues, expression profiling databases of various human cancer types are publicly available for researchers. Given that mouse models have been instrumental to our current understanding of cancer progression, we aimed to test the hypothesis that novel gene signatures possessing predictability in clinical outcome can be derived by coupling genomic analyses in mouse models of cancer with publicly available human cancer data sets.

EXPERIMENTAL DESIGN

We established a complex series of syngeneic metastatic animal models using a murine breast cancer cell line. Tumor RNA was hybridized on Affymetrix MouseGenome-430A2.0 GeneChips. With the use of Venn logic, gene signatures that represent metastatic competency were derived and tested against publicly available human breast and lung cancer data sets.

RESULTS

Survival analyses showed that the spontaneous metastasis gene signature was significantly associated with metastasis-free and overall survival (P < 0.0005). Consequently, the six-gene model was determined and showed statistical predictability in predicting survival in breast cancer patients. In addition, the model was able to stratify poor from good prognosis for lung cancer patients in most data sets analyzed.

CONCLUSIONS

Together, our data support that novel gene signature derived from mouse models of cancer can be used for predicting human cancer outcome. Our approaches set precedence that similar strategies may be used to decipher novel gene signatures for clinical utility.

Abstract A25: Array-based comparative genomic hybridization of hepatocellular carcinoma reveals a unique genomic aberration pattern in tumors with poor prognosis

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide. Like most solid tumors, HCC is very heterogenous in its clinical presentation and genetic makeup, due to genomic instability. The poor survival of HCC patients is partly due to inefficient treatment regimens and the lack of accurate prognostic subgroup stratifications. The discovery of genomic changes in other cancer types has led to the development of novel specific therapies, underscoring the importance of understanding molecular mechanism and tumor biology to provide the best therapy for each cancer patient. To this end, we performed high-resolution array-based comparative genomic hybridization of 76 HCC clinical specimens (cohort1) to search for genetically disrupted genes associated with outcome. In agreement with previous publications, recurrent gains and losses were associated with 1q, 6p, 8q and 4q, 8p, 13q, 16, 17p, respectively. However, only deletions of a few distinct loci on 1p,4q, 8p and 9p were associated with survival (FDR&lt;0.05). Of the 419 genes which mapped to regions of loss, analysis of cohort1 revealed that gene expression and DNA copy number of 134 genes (31.98%) were significantly correlated (Pearson coefficient r&gt;0.3, p&lt;0.001). Next, we built a 10-gene-survival signature based on the expression of these 134 genes utilizing cohort1 as a training and testing set with validation in an independent cohort2 (N=180). Kaplan-Meier survival analysis revealed that the 10-gene signature was able to predict survival outcome in tumor tissue (log-rank p=0.008) but not in paired non-tumor samples of cohort2 (log-rank p=0.421). Cox proportional hazards regression analysis controlling for potentially confounding clinical covariates showed that the 10-gene signature was significantly associated with a 2.1-fold increased risk of death. In addition, the 10-gene signature was able to predict survival in three publicly available breast cancer cohorts. In this study, we found a 10-gene signature that allows for the stratification of patients with poor prognosis in HCC and breast cancer. Ongoing functional analysis of the genes in this signature may lead to the discovery of HCC subtype-specific drugs that might be used for personalized therapy.

Citation Information: Cancer Res 2009;69(23 Suppl):A25.

Joint Practice Guidelines for Radionuclide Lymphoscintigraphy for Sentinel Node Localization in Oral/Oropharyngeal Squamous Cell Carcinoma

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision of whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method for determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histologic nodal staging and avoids overtreating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This document is designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. Preparation of this guideline was carried out by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial (SENT) Committee.

The Tensin-3 protein, including its SH2 domain, is phosphorylated by Src and contributes to tumorigenesis and metastasis

In cell lines from advanced lung cancer, breast cancer, and melanoma, endogenous tensin-3 contributes to cell migration, anchorage-independent growth, and tumorigenesis. Although SH2 domains have not been reported previously to be phosphorylated, the tensin-3 SH2 domain is a physiologic substrate for Src. Tyrosines in the SH2 domain contribute to the biological activity of tensin-3, and phosphorylation of these tyrosines can regulate ligand binding. In a mouse breast cancer model, tensin-3 tyrosines are phosphorylated in a Src-associated manner in primary tumors, and experimental metastases induced by tumor-derived cell lines depend on endogenous tensin-3. Thus, tensin-3 is implicated as an oncoprotein regulated by Src and possessing an SH2 domain with a previously undescribed mechanism for the regulation of ligand binding.

Inhibitory effect of Ginkgo biloba extract on human platelet aggregation

The effect of pure flavonoids and Gingko biloba extract (GBE) on human platelet aggregation was investigated. Most of the flavonoids and vitamin E did not affect platelet aggregation in platelet-rich plasma (PRP); however some of these flavonoids inhibited platelet aggregation in gel-filtered platelets (GFP). GBE inhibited both ADP- and collagen-induced platelet aggregation in PRP, GFP and in whole blood in a dose-dependent manner. GBE at very low concentrations inhibited whole blood aggregation induced by ADP compared with those used for PRP or GFP. Flavonoids and GBE decreased the production of TxA(2) induced by collagen and ADP in PRP. However, no correlation was observed between the inhibition of platelet aggregation and the decrease of TxA(2) synthesis. GBE and flavonoids did not affect platelet membrane fluidity. However, the incubation of PRP with GBE increased cAMP levels in platelets, which is known to inhibit platelet activation by lowering intracellular Ca2+ levels. GBE is a mixture of many compounds, including flavonoids and gingkoglides, which affect metabolism of cAMP, TxA(2) and Ca2+ in platelets. It is effective in the inhibition of platelet aggregation, both in PRP and whole blood, and thus may be potentially used as an effective oral anti-platelet therapeutic agent.

Evaluation of pulsed high intensity focused ultrasound exposures on metastasis in a murine model

High intensity focused ultrasound (HIFU) may be employed in two ways: continuous exposures for thermal ablation of tissue (> 60 degrees C), and pulsed-exposures for non-ablative effects, including low temperature hyperthermia (37-45 degrees C), and non thermal effects (e.g. acoustic cavitation and radiation forces). Pulsed-HIFU effects may enhance the tissue's permeability for improved delivery of drugs and genes, for example, by opening up gaps between cells in the vasculature and parenchyma. Inducing these effects may improve local targeting of therapeutic agents, however; concerns exist that pulsed exposures could theoretically also facilitate dissemination of tumor cells and exacerbate metastases. In the present study, the influence of pulsed-HIFU exposures on increasing metastatic burden was evaluated in a murine model with metastatic breast cancer. A preliminary study was carried out to validate the model and determine optimal timing for treatment and growth of lung metastases. Next, the effect of pulsed-HIFU on the metastatic burden was evaluated using quantitative image processing of whole-lung histological sections. Compared to untreated controls (2/15), a greater number of mice treated with pulsed-HIFU were found to have lungs "overgrown" with metastases (7/15), where individual metastases grew together such that they could not accurately be counted. Furthermore, area fraction of lung metastases (area of metastases/area of lungs) was approximately 30% greater in mice treated with pulsed-HIFU; however, these differences were not statistically significant. The present study details the development of an animal model for investigating the influence of interventional techniques or exposures (such as pulsed HIFU) on metastatic burden.

Metabolic effects of sustained activation of the GLP-1 receptor alone and in combination with background GIP receptor antagonism in high fat-fed mice

AIM

Enzyme-resistant glucagon-like peptide-1 (GLP-1) receptor agonists and GIP receptor antagonists have been proposed to have therapeutic potential for the treatment of type 2 diabetes. Such benefits are based on actions mediated primarily through stimulation of insulin secretion or alleviation of insulin resistance respectively. This study examined the long-term actions of the stable GLP-1 receptor agonist (D-Ala(8))GLP-1 and the GIP receptor antagonist (Pro(3))GIP alone and in combination in high fat-fed mice.

METHODS

Mice on high-fat diet for 155 days were injected once daily with (D-Ala(8))GLP-1 or (Pro(3))GIP (25 nmol/kg body weight) for 24 days. In the following 24-day period, half of the (Pro(3))GIP-treated mice were administered an additional dose of (D-Ala(8))GLP-1 (25 nmol/kg body weight), while the remaining mice continued their original treatment regimes.

RESULTS

Daily intraperitoneal injections of (D-Ala(8))GLP-1 or (Pro(3))GIP restored glycaemic control to normal levels and significantly (p < 0.05) improved glucose tolerance compared with high-fat controls by day 24. Food intake and body weights were not affected. On day 48, all treatment groups displayed significantly improved glucose tolerance (p < 0.05) and insulin sensitivity (p < 0.001) compared with high-fat controls on day 48. HDL cholesterol levels were significantly increased in mice treated with (D-Ala(8))GLP-1 alone (p < 0.05) or in combination with (Pro(3))GIP (p < 0.01) compared with normal chow-fed controls.

CONCLUSIONS

These results illustrate efficacy of (Pro(3))GIP and (D-Ala(8))GLP-1 for treatment of glucose intolerance and insulin resistance caused by high-fat feeding. Combination therapy appeared to have little benefit over either treatment alone.

Grey matter magnetization transfer ratio independently correlates with neurological deficit in secondary progressive multiple sclerosis

Although there is substantial brain grey matter pathology in secondary progressive multiple sclerosis (MS), there has been limited investigation of its contribution to disability.This study investigated the correlation of magnetization transfer ratio (MTR) measures taken from brain grey matter, normal appearing white matter (NAWM) and lesions with neurological deficit and disability in 113 people with secondary progressive MS. In order to adjust for the potential effects of focal white matter lesions and global brain atrophy, T2 lesion volume and normalized brain volume (NBV) were also calculated for each subject. Clinical measures included the expanded disability status scale (EDSS) and the multiple sclerosis functional composite (MSFC) scores. Linear regression analysis was used to assess the age- and gender-adjusted correlation of MTR histogram mean, peak height and peak location with the MSFC and individual component measures. Logistic regression analysis was used to determine whether imaging measures could be used to predict if subjects were in the higher disability group (EDSS > or = 6.5).Significant correlations were detected between MSFC composite and mean MTR in (i) normal appearing white matter (NAWM; r = 0.327, p < 0.0001), (ii) grey matter (r = 0.460, p < 0.0001) and (iii) lesions (r = 0.394, p < 0.0001). Although NBV and T2 lesion volume correlated significantly with MSFC, grey matter histogram mean emerged as the best predictor of MSFC score. None of the MRI measures significantly predicted higher EDSS.These results suggest that brain grey matter pathology plays an important role in determining neurological impairment. The apparent paucity of correlation between MRI measures and EDSS is likely to represent the relative insensitivity of the latter measure in this study group.

Genetic variation in SIPA1 in relation to breast cancer risk and survival after breast cancer diagnosis

Genetic variation in SIPA1, signal-induced proliferation-associated gene 1, has been proposed to be associated with aggressive breast tumor characteristics related to metastasis and worse prognosis in humans and rodents. To test this hypothesis, we genotyped 3 single nucleotide polymorphisms (SNP) located at -3092 (A<G, rs931127), exon 3-135 (C>T, rs3741378), and exon 14 + 14 (C>T, rs746429), and examined them in relation to breast cancer risk and overall survival, stratified by tumor characteristics in 2 independent case-control studies conducted in Poland (1,995 cases, 2,296 controls) and in Britain (2,142 cases, 2,257 controls). Vital status (n = 396 deaths) was available for 911 Polish and 1,919 British breast cancer cases with an average follow-up time of 5.5 years. Overall, we found no significant associations between genetic variants of SIPA1 SNPs and breast cancer risk (per allele odds ratios, 95% confidence intervals (CI): rs931127-0.99, 0.93-1.06; rs3741378-1.03, 0.94-1.13; and, rs74642-0.98, 0.92-1.04). In both studies, SIPA1 polymorphisms were not related to overall mortality (per allele hazard ratios, 95% CI: 1.02, 0.88-1.17; 0.90, 0.72-1.11; 1.04, 0.90-1.21, respectively). Our results do not support a relationship between SIPA1 polymorphisms and breast cancer risk or subsequent survival.

Determining the cost of genital warts: a study from Ireland

OBJECTIVES

To determine the average cost of a case of genital warts, for both males and females, with a view to informing the current debate as to which Human papillomavirus vaccine would have maximum cost-effectiveness in the Irish population.

METHODS

Contact time between patients and healthcare professionals was prospectively measured at five genitourinary medicine clinics in the south-west of Ireland, over a period of 3 weeks. By identifying all those with genital warts, it was possible to calculate the proportion of total time taken by patients with this condition, and from this to calculate a cost per incident case, by gender.

RESULTS

A total of 25.5% of attendances were for genital warts, and these patients used 26.2% of total clinic time (CI 25.4 to 27.0%). The average cost calculated for genital warts was 335 euros per incident case, and by gender 300 euros per male case and 366 euros per female case.

CONCLUSIONS

There are considerable costs associated with the treatment of genital warts, with female cases representing a higher cost than males. By vaccinating with the quadrivalent HPV vaccine, there are significant savings to be made.

Ex utero intrapartum treatment (EXIT) procedure and simultaneous excision of oral teratoma

We report a case of a large oral teratoma in a foetus diagnosed on antenatal ultrasound. Due to the anticipated difficulty in securing the airway at birth an ex-utero intrapartum treatment (EXIT) procedure was planned. In this case simultaneous excision of the tumour mass was carried out while on placental support this allowed safe procurement of the airway and successful delivery of an otherwise healthy infant. This case highlights the challenge presented by such unusual cases and illustrates the successful treatment of this condition.

Comparison of the metabolic effects of GIP receptor antagonism and PYY(3-36) receptor activation in high fat fed mice

Glucose-dependent insulinotropic polypeptide (GIP) and peptide YY (PYY) are secreted from the intestinal K- and L-cells, respectively, following a meal. Both peptides are believed to play a key role in glucose homeostasis and energy expenditure. This study investigated the effects of daily administration of the stable and specific GIP-R antagonist, (Pro(3))GIP (25 nmol/kg) and the endogenous truncated form of PYY, PYY(3-36) (50 nmol/kg), in mice fed with a high fat diet. Daily i.p. injection of (Pro(3))GIP, PYY(3-36) or combined peptide administration over 24 days significantly (P<0.05-0.01) decreased body weight compared with saline-treated controls without change in food intake. Plasma glucose levels and glucose tolerance were significantly (P<0.05) lowered by (Pro(3))GIP treatment alone, and in combination with PYY(3-36). These changes were accompanied by a slight improvement of insulin sensitivity in all of the treatment groups. (Pro(3))GIP treatment significantly reduced plasma corticosterone (P<0.05), while combined administration with PYY(3-36) significantly lowered serum glucagon (P<0.05). No appreciable changes were observed in either circulating or glucose-stimulated insulin secretion in all treatment groups. (Pro(3))GIP-treated mice had significantly (P<0.01) lowered fasting glucose levels and an improved (P<0.05) glycemic response to feeding. These comparative data indicate that chemical ablation of GIP receptor action using (Pro(3))GIP provides an especially effective means of countering obesity and related abnormalities induced by consumption of high fat energy rich diet.

Host genetics influence tumour metastasis

The complexity of the metastatic process has made it difficult to gain a full understanding of the origins of this most lethal aspect of cancer. Many factors probably have an important role, including somatic mutation, epigenetic modulations, interactions with normal stroma, and environmental stimuli. Additionally, recent evidence implies a significant role for germline polymorphisms in cancer progression. The existence of inherited metastasis risk factors (or prospective metastatic biomarkers) has potentially significant implications for our models of metastasis, clinical prognosis and the development of tailored treatment. Further investigations into the inherited components of metastasis might help resolve many of the questions that remain about tumour progression.

The Intersection of Inheritance and Metastasis: The Role and Implications of Germline Polymorphism in Tumor Dissemination

Metastasis is an enormously complex process that involves both spatial and temporal barriers. Metastatic cells must not only acquire all of the characteristics of a primary tumor, but additionally must be capable of invasion, survival during transit and in the secondary site, interact productively with a novel microenvironment and proliferate to form a clinically relevant lesion.(1) Adding complexity to the process is the fact that it can be years or even decades after diagnosis of the primary tumor before the secondary tumors are apparent. A number of models have been proposed to explain the origins of metastasis. However, while all of the models can account for some aspects of the experimental observations, suggesting they may be at least in part true, none adequately explain all of the data. This implies that the existing models are likely to be too simplistic and additional factors must be considered to adequately account for existing and newly emerging data.