Comprehensive gene expression profiling and immunohistochemical studies support application of immunophenotypic algorithm for molecular subtype classification in diffuse large B-cell lymphoma: a report from the International DLBCL Rituximab-CHOP Consortium Program Study

Gene expression profiling (GEP) has stratified diffuse large B-cell lymphoma (DLBCL) into molecular subgroups that correspond to different stages of lymphocyte development-namely germinal center B-cell like and activated B-cell like. This classification has prognostic significance, but GEP is expensive and not readily applicable into daily practice, which has lead to immunohistochemical algorithms proposed as a surrogate for GEP analysis. We assembled tissue microarrays from 475 de novo DLBCL patients who were treated with rituximab-CHOP chemotherapy. All cases were successfully profiled by GEP on formalin-fixed, paraffin-embedded tissue samples. Sections were stained with antibodies reactive with CD10, GCET1, FOXP1, MUM1 and BCL6 and cases were classified following a rationale of sequential steps of differentiation of B cells. Cutoffs for each marker were obtained using receiver-operating characteristic curves, obviating the need for any arbitrary method. An algorithm based on the expression of CD10, FOXP1 and BCL6 was developed that had a simpler structure than other recently proposed algorithms and 92.6% concordance with GEP. In multivariate analysis, both the International Prognostic Index and our proposed algorithm were significant independent predictors of progression-free and overall survival. In conclusion, this algorithm effectively predicts prognosis of DLBCL patients matching GEP subgroups in the era of rituximab therapy.

A critical evaluation of HIPE data

Resource allocation and planning of future services is dependent on current volumes, making it imperative that procedural data is accurately recorded. We sought to evaluate the effectiveness of the information gathered by the Hospital Inpatient Enquiry (HIPE) system in recording such activity. Five index vascular procedures (open/endovascular abdominal aneurysm repair, carotid endarterectomy, lower limb angioplasty/bypass) were chosen to reflect activity. The Economic and Social Research Institute (ESRI), and HIPE databases were interrogated to obtain the regional and hospital specific figures for the years 2005, 2006 and 2009, and then compared with the prospective vascular database in St James's hospital. Data for 2006 (the most recent year available) shows significant discrepancies between the HIPE and vascular database figures for St James's hospital. The HIPE and database figures respectively for; open aneurysm 13/30 (-50%), endovascular aneurysm 39/31 (+25%), carotid 62/48 (+29%), angioplasty 242/111 (+100%) and bypass 24/10 (+100%) These inaccuracies are likely to be magnified on a regional and national level when pooling data.

Traumatic injury to the colon and rectum in Scotland: demographics and outcome

AIM

An analysis of a multi-centred database of trauma patients was performed.

METHOD

The study used data from a prospective multi-centre trauma database containing details of 52 887 trauma patients admitted to participating Scottish Hospitals over an 11-year period.

RESULTS

Three hundred and forty (0.64%) of 52 887 trauma patients (284 male) with colorectal injuries were identified; 43.9% of colorectal injuries occurred following blunt trauma and 56.1% following penetrating injury. Patients in the latter group were younger, had less haemodynamic compromise and were less likely to die than those with blunt trauma (P < 0.01). The overall mortality rate was 25.6% and after rectal injury it was 21.2% (P > 0.05). Female gender, increased age, road traffic accidents and those admitted as a result of a blunt traumatic injury were associated with increased mortality. Age > 65 years (P = 0.01), increasing injury severity score (ISS) at presentation (P < 0.001), haemodynamic compromise (P = 0.045) and decreased Glasgow Coma Score (GCS) (P < 0.001) had the strongest independent associations with mortality.

CONCLUSION

Colorectal injury after trauma has a high morbidity. Clinical features associated with death allow stratification of mortality risk.

Integrated Residential Treatment for Persons with Severe and Persistent Mental Illness: Lessons in Recovery

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Single-step separation of platelets from whole blood coupled with digital quantification by interfacial platelet cytometry (iPC)

We report the efficient single-step separation of individual platelets from unprocessed whole blood, enabling digital quantification of platelet function using interfacial platelet cytometry (iPC) on a chip. iPC is accomplished by the precision micropatterning of platelet-specific protein surfaces on solid substrates. By separating platelets from whole blood using specific binding to protein spots of a defined size, iPC implements a simple incubate-and-rinse approach, without sample preparation, that enables (1) the study of platelets in the physiological situation of interaction with a protein surface, (2) the choice of the number of platelets bound on each protein spot, from one to many, (3) control of the platelet-platelet distance, including the possibility to study noninteracting single platelets, (4) digital quantification (counting) of platelet adhesion to selected protein matrices, enabling statistical characterization of platelet subpopulations from meaningfully large numbers of single platelets, (5) the study of platelet receptor expression and spatial distribution, and (6) a detailed study of the morphology of isolated single platelets at activation levels that can be manipulated. To date, we have demonstrated 1-4 of the above list. Platelets were separated from whole blood using iPC with fibrinogen, von Willebrand factor (VWF), and anti-CD42b antibody printed "spots" ranging from a fraction of one to several platelet diameters (2-24 μm). The number of platelets captured per spot depends strongly on the protein matrix and the surface area of the spot, together with the platelet volume, morphology, and activation state. Blood samples from healthy donors, a May-Hegglin-anomaly patient, and a Glanzmann's Thrombasthenia patient were analyzed via iPC to confirm the specificity of the interaction between protein matrices and platelets. For example, the results indicate that platelets interact with fibrinogen spots only through the fibrinogen receptor (αIIbβ3) and, relevant to diagnostic applications, platelet adhesion correlates strongly with normal versus abnormal platelet function. A critical function of platelets is to adhere to regions of damage on blood vessel walls; in contrast to conventional flow cytometry, where platelets are suspended in solution, iPC enables physiologically relevant platelet bioassays based on platelet/protein-matrix interactions on surfaces. This technology should be inexpensive to implement in clinical assay format, is readily integrable into fluidic microdevices, and paves the way for high-throughput platelet assays from microliter volumes of whole blood.

Postmenopausal hormone therapy and cognition: effects of timing and treatment type

SETTING

Hormone therapy used for the management of postmenopausal symptoms in older women appears to result in variable effects on cognitive function, depending on study design, subjects, tests used, and types of therapy.

OBJECTIVE

To determine the effects of estrogen-only and estrogen plus progestogen preparations on cognitive performance (cognitive status, general and working memory) when taken 'early' and 'late' from the onset of menopause.

METHOD

The study consisted of 410 women who were participants in a longitudinal study, first recruited at age 40-80 years. They were tested for change over 5 years as an observational cohort by the Mini-Mental State Examination, National Adult Reading Test and the Wechsler Memory Scale Version 3. Cognitive decline, measured by age-adjusted scores, was defined as >or=10% negative change in each individual woman.

RESULTS

Controlling for age and lifestyle factors, and using the criterion of decrease in score >or=10% over 5 years for 'cognitive decline', 'early start' of hormone therapy (<3 years from menopause) was strongly associated with reduction in risk by the Mini-Mental State Examination (estrogen-only preparation, p = 0.005) but with increase in risk for general memory (with estrogen plus progestogen preparation, p = 0.02). Overall, there were no major effects on subgroups with type/timing of hormone therapy in relation to testing for a negative change in cognitive function.

CONCLUSION

'Early start' of estrogen-only hormone therapy was associated with reduced risk of global cognitive decline, and 'early start' estrogen-only and estrogen/progestogen hormone therapies showed increased risks of general memory decline. Even though this study did not have the power to discriminate between minor and mixed effects, it suggests that cognitive effects of hormone therapies may be mixed, depending on cognitive domain and timing of use/type of preparation.

Comparison of multiple and novel measures of dietary glycemic carbohydrate with insulin resistant status in older women

Background

Previous epidemiological investigations of associations between dietary glycemic intake and insulin resistance have used average daily measures of glycemic index (GI) and glycemic load (GL). We explored multiple and novel measures of dietary glycemic intake to determine which was most predictive of an association with insulin resistance.

Methods

Usual dietary intakes were assessed by diet history interview in women aged 42-81 years participating in the Longitudinal Assessment of Ageing in Women. Daily measures of dietary glycemic intake (n = 329) were carbohydrate, GI, GL, and GL per megacalorie (GL/Mcal), while meal based measures (n = 200) were breakfast, lunch and dinner GL; and a new measure, GL peak score, to represent meal peaks. Insulin resistant status was defined as a homeostasis model assessment (HOMA) value of >3.99; HOMA as a continuous variable was also investigated.

Results

GL, GL/Mcal, carbohydrate (all P < 0.01), GL peak score (P = 0.04) and lunch GL (P = 0.04) were positively and independently associated with insulin resistant status. Daily measures were more predictive than meal-based measures, with minimal difference between GL/Mcal, GL and carbohydrate. No significant associations were observed with HOMA as a continuous variable.

Conclusion

A dietary pattern with high peaks of GL above the individual's average intake was a significant independent predictor of insulin resistance in this population, however the contribution was less than daily GL and carbohydrate variables. Accounting for energy intake slightly increased the predictive ability of GL, which is potentially important when examining disease risk in more diverse populations with wider variations in energy requirements.

Cyclical vomiting syndrome: diagnosis, causes and treatment

Cyclical vomiting syndrome (CVS) is a disorder of unknown cause. Patients experience episodes of sudden violent vomiting that last from a few hours to a few days, which can occur several times a year. CVS affects children and adults yet despite numerous studies the cause of the condition is unknown. The aim of this article is to outline the current theories for the possible causes of CVS and to examine the various treatment options available.

Effect of lifestyle factors and hormone therapy on heart function by serial echocardiography in postmenopausal women

BACKGROUND

There is conflicting information on the effects of oestrogen on the heart in women, especially those using postmenopausal hormone therapy. Whilst some studies reported a beneficial effect, others showed adverse outcomes. The interplay of lifestyle factors and type/timing of therapy remains to be clarified.

AIM

The aim of this study was to determine the effects of lifestyle and hormone therapy on heart function and structure in postmenopausal women.

METHOD

As part of a large longitudinal study of women randomly recruited from an urban population, the study assessed 410 suitable women by echocardiography in Year 1 and Year 5 of the study by two independent cardiologists.

RESULTS

In lifestyle characteristics, the difference in age and body mass (as markers of cardiovascular risk) was in favour of never-users versus hormone therapy-users. Using an arbitrary cut-off > or =15% change for an effect, we found lifestyle factors had minimal effect on the two measured parameters - ejection fraction, left ventricular mass. Effects of hormone therapy were variable and mixed; greatest effect was found for an 'early start' of hormone therapy with oestrogen-only preparation - the risk of reduced ejection fraction was decreased [hazard ratio (HR) 0.42, confidence interval = 0.17-1.03, P = 0.06] and risk of increased left ventricular mass was increased (HR 2.21, 1.09-4.49, P = 0.03).

CONCLUSION

Our findings add to the evidence that oestrogen given to postmenopausal women has a mixed effect on the heart, with effect best shown when started early.

Intake of isoflavone and lignan phytoestrogens and associated demographic and lifestyle factors in older Australian women

The purpose was to determine intake of phytoestrogens in a sample of older Australian women, and to investigate associated lifestyle factors. Subjects were an age-stratified sample of 511 women aged 40-80 y, randomly selected from the electoral roll and participating in the Longitudinal Assessment of Ageing in Women at the Royal Brisbane and Women's Hospital. A cross-sectional study was conducted to assess isoflavone and lignan intake over the past month from food and supplements using a 112-item phytoestrogen frequency questionnaire. Data were also collected on nutrient intakes, physical activity, smoking, alcohol, non-prescription supplements, hormone therapy, education and occupation. Logistic regression was used to evaluate associations between demographic and lifestyle variables and soy/linseed consumption while controlling for age. Isoflavone intakes were significantly higher in the younger compared to older age groups (p<0.001); there were no age-related differences in lignan intake. Forty-five percent of women consumed at least one serve of a soy and/or linseed item and were defined as a soy/linseed consumer. Median (range) intakes by consumers for isoflavones and lignans (3.9 (0-172) mg/d and 2.4 (0.1-33) mg/d) were higher than intakes by non-consumers (0.004 (0-2.6) mg/d and 1.57 (0.44-4.7) mg/d), respectively (p<0.001). Consumers had higher intakes of dietary fibre (p=0.003), energy (p=0.04) and polyunsaturated fat (p=0.004), and higher levels of physical activity (p=0.006), socio-economic position (p<0.001), education (p<0.001) and supplement use (p<0.001). Women who consumed soy or linseed foods differed in lifestyle and demographic characteristics suggesting these factors should be considered when investigating associations with chronic disease outcomes.

Endometrial and vaginal effects of low-dose estradiol delivered by vaginal ring or vaginal tablet

AIMS

The major aims of the study were to compare the safety of a continuous low-dose estradiol-releasing vaginal ring (ESTring) to that of a vaginal estradiol tablet (Vagifem) on the endometrium and the relief of subjective symptoms and signs of urogenital estrogen deficiency. Quality of life and acceptability of treatment delivery were also assessed.

STUDY DESIGN

A prospective, randomized study in which women were assigned in a 2:1 ratio to ESTring and Vagifem and followed for 12 months. The primary endpoint was endometrial safety, based on the results of ultrasound measurement of endometrial thickness and a progestogen challenge test at baseline and week 48. Efficacy was determined by subjective assessment of urogenital estrogen deficiency symptoms at baseline and weeks 3, 12, 24, 36 and 48 and assessment of signs of vaginal epithelial atrophy by the clinician at baseline, 12 and 48 weeks. In addition, pelvic floor strength, vaginal cytological evaluation and pH, bacteruria and patient acceptability were assessed. Quality of life was assessed using a menopause-specific quality-of-life questionnaire and a 2-day bladder diary at baseline and 12 and 48 weeks. The comparability of the two groups was assessed using ANOVA, chi2 or Fisher's exact tests.

RESULTS

A total of 126 women were randomized to ESTring and 59 to Vagifem. There was no statistical difference between the groups in the alleviation of symptoms and signs of urogenital estrogen deficiency. Maturation indices increased in both groups, from generally atrophic at baseline to proliferative or highly proliferative at 48 weeks. After 48 weeks of treatment, there was no statistically significant difference in endometrial thickness between the two groups. A statistically smaller proportion of bleeding/spotting occurred in the ESTring group (n = 0) compared to the Vagifem users (n = 4). Estradiol and total estrone serum levels increased during treatment in both groups but remained within the normal postmenopausal range. General health status in both groups was unchanged but the urogenital component of health burden was significantly improved in both groups. Bladder diary variables showed no differences between treatment groups.

CONCLUSION

Equivalent endometrial safety and efficacy in the relief of the symptoms and signs of urogenital estrogen deficiency were demonstrated for the 12 months' use of a low-dose estradiol-releasing vaginal ring and a vaginal estradiol tablet.

Ca(2+)-calmodulin can activate and inactivate cardiac ryanodine receptors

BACKGROUND AND PURPOSE

Ca(2+)-calmodulin (Ca(2+)CaM) is widely accepted as an inhibitor of cardiac ryanodine receptors (RyR2); however, the effects of physiologically relevant CaM concentrations have not been fully investigated.

EXPERIMENTAL APPROACH

We investigated the effects of low concentrations of Ca(2+)CaM (50-100 nmol.L(-1)) on the gating of native sheep RyR2, reconstituted into bilayers. Suramin displaces CaM from RyR2 and we have used a gel-shift assay to provide evidence of the mechanism underlying this effect. Finally, using suramin to displace endogenous CaM from RyR2 in permeabilized cardiac cells, we have investigated the effects of 50 nmol.L(-1) CaM on sarcoplasmic reticulum (SR) Ca(2+)-release.

KEY RESULTS

Ca(2+)CaM activated or inhibited single RyR2, but activation was much more likely at low (50-100 nmol.L(-1)) concentrations. Also, suramin displaced CaM from a peptide of the CaM binding domain of RyR2, indicating that, like the skeletal isoform (RyR1), suramin directly competes with CaM for its binding site on the channel. Pre-treatment of rat permeabilized ventricular myocytes with suramin to displace CaM, followed by addition of 50 nmol x L(-1) CaM to the mock cytoplasmic solution caused an increase in the frequency of spontaneous Ca(2+)-release events. Application of caffeine demonstrated that 50 nmol x L(-1) CaM reduced SR Ca(2+) content.

CONCLUSIONS AND IMPLICATIONS

We describe for the first time how Ca(2+)CaM is capable, not only of inactivating, but also of activating RyR2 channels in bilayers in a CaM kinase II-independent manner. Similarly, in cardiac cells, CaM stimulates SR Ca(2+)-release and the use of caffeine suggests that this is a RyR2-mediated effect.

Reactivity to autologous serum skin test and relationship with complement levels in chronic idiopathic urticaria and angio-oedema

BACKGROUND

A role for complement in autoantibody-mediated histamine release in urticaria has been suggested but not proven in vivo. Aim. To study serum complement levels in patients with chronic idiopathic urticaria (CIU) and to determine whether there was a relationship with autologous serum skin test (ASST) reactivity.

METHODS

We recruited 35 patients with CIU. Complement (C3, C4) levels and ASST were measured in all patients; additional investigations were undertaken dependent on history and examination.

RESULTS

Complement concentrations were outside the population reference intervals in 19/35 patients, with low C3 noted in 3/35 and low C4 in 18/35. Of 12 patients with a positive ASST, 7 had low complement levels, and 12/23 with a negative ASST had low complement levels. Patients with a positive ASST had a median C3 of 1.24 g/L (range 0.35-1.51) compared with a median of 1.25 g/L in those with a negative ASST (P = 0.36), and a median C4 of 0.20 g/L (range 0.185-0.452) in those with a positive ASST compared with 0.18 g/L in those with a negative ASST (P = 0.88).

CONCLUSIONS

We conclude that both a reduction in C4 and positive ASST are common in CIU and although these immunological abnormalities often coexist, there is no clear relationship between them. Other components of the complement system may be worth exploring.

Positive effects of exercise on falls and fracture risk in osteopenic women

Exercise may affect osteopenic women at risk of falls and fractures. A workstation approach to exercise was evaluated in a randomised study of 98 women. The intervention group improved in measures of balance, strength and bone density. This study supports a preventative exercise approach that aims to reduce risk factors for fractures and falls, in women already at risk, through balance training and weight-bearing activity.

INTRODUCTION

The objective of this study was to determine the effects of a workstation balance training and weight-bearing exercise program on balance, strength and bone mineral density (BMD) in osteopenic women. A single-blinded randomised controlled trial (RCT) was undertaken for 20 weeks with measurements at baseline and completion.

MATERIALS AND METHODS

Ninety-eight (98) community-dwelling osteopenic women aged 41-78 years were recruited through the North Brisbane electoral roll. Subjects were randomised via computer-generated random numbers lists into either a control (receiving no intervention), or exercise group (two one-hour exercise sessions per week for 20 weeks with a trained physiotherapist). Assessments at baseline and post-intervention included balance testing (five measures), strength testing (quadriceps, hip adductors / abductors / external rotators and trunk extensors), and DXA scans (proximal femur and lumbar spine). Baseline assessment showed no significant differences between groups for all demographics and measures except for subjects taking osteoporosis medication. The percentage differences between pre- and post-intervention measurements were examined for group effect by ANOVA using an intention-to-treat protocol.

RESULTS

Ninety-eight women (mean age 62.01 years, SD 8.9 years) enrolled in the study. The mean number of classes attended for the 42 participants in the exercise group who completed the program was 28.2 of a possible 40 classes (71%). At the completion of the trial the intervention group showed markedly significant better performances in balance (unilateral and bilateral stance sway measures, lateral reach, timed up and go and step test) (p < 0.05) with strong positive training effects reflecting improvements of between 10% to 71%. Similarly there were gains in strength of the hip muscles (abductors, adductors, and external rotators), quadriceps and trunk extensors with training effects between 9% and 23%.

CONCLUSIONS

Specific workstation exercises can significantly improve balance and strength in osteopenic women. This type of training may also positively influence bone density although further study is required with intervention over a longer period. A preventative exercise program may reduce the risk of falls and fractures in osteopenic women already at risk.

Age-related changes relevant to health in women: design, recruitment, and retention strategies for the Longitudinal Assessment of Women (LAW) study

OBJECTIVES

The primary aim was to assess the age-related changes that occur in older women. This paper describes the study rationale and methods, recruitment, and retention strategies.

METHODS

The Longitudinal Assessment of Women (LAW) Study was a longitudinal, observational, and multidisciplinary evaluation of a population-based cohort of urban-living women, aged between 40 and 80 years at recruitment and randomly invited from a district in Brisbane (a city in Australia) via the electoral roll. Five hundred eleven women were recruited and stratified into four age groups (40-49, 50-59, 60-69, 70-79 years) and were assessed on three or four occasions each year, using interviews and diagnostic instruments (echocardiography, applination tonometry, dual-energy x-ray absorptiometry [DEXA]) Retention strategies included flexibility, accessibility, personalized attention, and feedback.

RESULTS

From a sample frame of 1598 names, there were 1082 respondents, of whom 511 (47%) were successfully recruited from those eligible to participate. Recruitment was quickest for the oldest age group, 70-79 years, and slowest for the age group 40-49 years; all age groups achieved their required quota. A scheduling program was developed to minimize the number of visits and maximize the use of allocated time. The largest dropout was seen in year 1 of the study, with very few thereafter. Of the 9 deaths, cancer was the cause in 7. The retention rate after 5 years was 95.5%.

CONCLUSIONS

The design of the present study, with careful attention to coordination and a personal approach, facilitated the completion of a 5-year study, enabling a collection of a set of wide-ranging data from almost all the women recruited. The information thus collected will form the basis of cross-linking analysis of the risk factors associated with health problems in aging women.