Socioeconomic Factors Influencing BRCA 1/2 Mutation Carriers To Choose Risk Reduction Surgery in Community Cancer Genetics Program

Background: Mutations in the BRCA 1/2 genes predispose women to increased risk of breast and ovarian cancer. Prophylactic mastectomy (PM) reduces the risk of breast cancer by approximately 90% while prophylactic salpingo-oophorectomy (PSO) reduces the risk of both breast and ovarian cancer. Yet, there is a paucity of data to determine if mutation carriers avail themselves of these risk reducing surgeries in the community setting.Purpose: This study evaluates if particular socioeconomic factors influence BRCA 1/2 mutation carriers to elect risk reduction surgery (RRS), either PM or PSO or both.Method: Of 129 BRCA1/2 positive patients identified by a community-based cancer genetics program outside Philadelphia from 1998 to 2008, 44 were excluded due to personal history of ovarian cancer, loss of follow-up, male gender, or deceased status. The 85 remaining patients were asked to complete a questionnaire addressing: age at diagnosis, ethnicity, religion, parity, education level, marital status, occupation, number of first degree relatives with breast or ovarian cancer, personal history of breast cancer, and use of oral contraceptives, tobacco, and alcohol. A chart review was performed on all responders.Results: Forty-nine patients (58%) completed the questionnaire. Of these, 68% (34/49) had RRS. Of those who did not have RRS, 63% (10/15) stated they definitely plan for RRS in the future. More than half of the women planning RRS in the future (6/10) were younger than 30 years old. Therefore, of all responders, 90% (44/49) stated they had or definitely plan to have RRS. The mean age of women with RRS versus those without was 43.9 and 35.6 years, respectively (p=.0102). Women age 40-64 had the highest rate of RRS (26/34; 84%; p=0.004). Most women (88%) with RRS had children (30/34; p=0.0493). Sixty-five percent (32/49) of women responders were college graduates; 24% were high school graduates (12/49). Of women who had RRS, 68% were college graduates. College graduates age > 40 were the group most likely to have RRS (17/18; 94%; p= .00029). Only 63% of high school graduates age > 40 (5/8; p=1.0) had RRS. Eight-five percent (11/13) of Ashkenazi Jewish women had RRS versus 67% (18/27) of non-Jewish Caucasian women. This was not statistically significant (p=0.2925). There was also no statistical difference for women choosing RRS with respect to occupation, birth control pill use, history of breast cancer, or family history of breast or ovarian cancer. Only 3/49 smoked cigarettes (>more than 1 pack per week) and none drank alcohol (>1 drink/day).Discussion: Women who presented to this community based genetics program had a high rate of RRS, were likely to be college educated, non-smokers, and non-drinkers. Age older than 40, completion of child bearing, and attainment of a college degree were the most significant factors associated with BRCA 1/2 mutation carriers having RRS. Further studies should explore barriers to genetic testing services, as well as evaluate reasons why BRCA1/2 mutation carriers decline RRS.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4076.

Adding gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty

BACKGROUND

Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration.

METHODS

After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain.

RESULTS

Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05).

CONCLUSIONS

A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

Localization of P. gingivalis in preterm delivery placenta

Increasing evidence suggests an association between periodontal disease and adverse pregnancy outcomes. Although infection is considered as a risk factor for preterm delivery, the localization of oral bacteria or their antigens in chorioamnionitis placental tissue has never been demonstrated. This study was devised to test the hypothesis that periodontal pathogens may be present and affect human placenta in cases of chorioamnionitis. Using immunocytochemistry, we have identified the presence of Porphyromonas gingivalis antigens in placental tissues. The antigens were detected in the placental syncytiotrophoblasts, chorionic trophoblasts, decidual cells, and amniotic epithelial cells, as well as the vascular cells. There was a substantial increase in immunostaining intensity of the tissues sectioned from women with chorioamnionitis compared to those experiencing normalterm pregnancy, p < 0.019 (Mann-Whitney test). These results suggest that P. gingivalis may commonly colonize placental tissue, and that the presence of the organism may contribute to preterm delivery.

Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

Subcutaneous IGF-1 is not beneficial in 2-year ALS trial

BACKGROUND

Previous human clinical trials of insulin-like growth factor type I (IGF-1) in amyotrophic lateral sclerosis (ALS) have been inconsistent. This phase III, randomized, double-blind, placebo-controlled study was undertaken to address whether IGF-1 benefited patients with ALS.

METHODS

A total of 330 patients from 20 medical centers were randomized to receive 0.05 mg/kg body weight of human recombinant IGF-1 given subcutaneously twice daily or placebo for 2 years. The primary outcome measure was change in their manual muscle testing score. Secondary outcome measures included tracheostomy-free survival and rate of change in the revised ALS functional rating scale. Intention to treat analysis was used.

RESULTS

There was no difference between treatment groups in the primary or secondary outcome measures after the 2-year treatment period.

CONCLUSIONS

Insulin-like growth factor type I does not provide benefit for patients with amyotrophic lateral sclerosis.

Risk factors for sternal wound infection in children undergoing cardiac surgery: a case-control study

SUMMARY

Complex and prolonged cardiovascular operations are increasingly performed on young infants and children. The aims of this study were to define the incidence, causative bacterial pathogens and risk factors for sternal wound infections (SWIs) in infants and children undergoing cardiac surgery. The study group included all children who underwent cardiac surgery by median sternotomy at a tertiary paediatric centre from 1999 to 2003 and who were diagnosed with a postoperative SWI. Charts were reviewed for pre-, intra- and postoperative variables. The findings were compared with control patients operated on immediately before and after the cases and analysed by a stepwise logistic regression model. Of the 1821 children who underwent cardiac surgery, 49 (2.69%) had SWI; full data were available for 47. Twenty-nine (61.7%) had superficial wound infection and 18 (38.3%) deep wound infection. The main bacterial pathogens were Staphylococcus aureus in 14 patients (39%) and Pseudomonas aeruginosa in 12 (33%). Three variables emerged as significant independent risk factors for SWI: young age (odds ratio: 0.63; 95% confidence interval: 0.47-0.85; P<0.001 for each additional year), cyanotic heart disease (4.93; 1.98-12.3; P<0.001), and central venous catheter (CVC) dwell time (1.15; 1.06-1.24; P<0.001 for each additional day). Gram-negative infections were significantly associated with preoperative oxygen treatment (P=0.007) and prolonged urinary catheter dwell time (P=0.004). This study confirms younger age as risk factor for SWI and adds cyanotic heart disease and duration of CVC as new independent risk factors. Specific risks for Gram-negative infections are identified and should help to introduce new preventive strategies to decrease the incidence and severity of SWI.

Isoflavones and gamma irradiation inhibit cell growth in human salivary gland cells

We studied the effects of isoflavones and irradiation on cell cycle in a human salivary gland cell line (HSG). Genistein and a soy isoflavone conjugate (NS) inhibited DNA synthesis. Cells deconjugated the glucoside form of isoflavones in NS to the aglycones genistein and daidzein. NS, genistein and IR increased phosphorylation of p53 and p21 CIP1 at serine 15 (phos-p53). Irradiation and NS also increased levels of p21 CIP1. In a cologenic survival assay, cells in log phase growth had high radio-sensitivity with 2 Gy causing a reduction in survival (SF2=0.45).

CONCLUSION

isoflavones and radiation may interact to sensitize cancer cells to radiation.

The effect of maternal micronutrient supplementation on early neonatal morbidity in rural Nepal: a randomised, controlled, community trial

OBJECTIVE

Micronutrient deficiencies during pregnancy may be linked to poor newborn health and poor host defences against infection. We assessed newborn morbidity to determine the effect of four combinations of antenatal micronutrient supplements.

DESIGN

Cluster-randomised, double-masked, controlled trial.

SETTING

Rural community in Nepal.

INTERVENTIONS

Women received daily supplements from early pregnancy through to 3 months postpartum of vitamin A alone (control) or vitamin A with folic acid, folic acid plus iron, folic acid plus iron plus zinc or a multiple micronutrient supplement containing these and 11 other nutrients.

MAIN OUTCOME MEASURES

Infants were visited in their home at birth (n = 3927) and for each of 9 days thereafter to elicit a 24-h history of nine infant morbidity symptoms, measure infant respiratory rate and axial temperature, and assess the infant for chest indrawing. At 6 weeks of age, infants were visited again in their homes to elicit a 30-day and 7-day history of 10 morbidity symptoms using parental recall.

RESULTS

Maternal micronutrient supplementation had no effect on 10-day morbidity or morbidity 30-day and 7-day morbidity assessed at 6 weeks of age all relative risks were close to 1. Symptoms of birth asphyxia increased by about 60% (p<0.05) in infants of women who received the multiple micronutrient supplement compared with the control. Symptoms of combinations of sepsis, preterm and birth asphyxia were associated with 8- to 14-fold increased odds of 6-month infant mortality.

CONCLUSIONS

None of the combinations of antenatal micronutrient supplements tested improved symptoms of neonatal morbidity in the first 10 days of life or at 6 weeks of age. Further research is needed to elucidate the association and mechanism of increased risk of birth asphyxia following maternal multiple micronutrient supplementation.

TRIAL REGISTRATION NUMBERS

NCT00115271.

Miscarriage but not stillbirth rates are higher among younger nulliparas in rural Southern Nepal

PURPOSE

To examine the impact of young maternal age on miscarriages and stillbirths in rural Southern Nepal.

METHOD

Pregnancies, miscarriages, and stillbirths were prospectively identified in two randomized trials of maternal micronutrient supplementation. This analysis included 5861 women of parity 0 (nulliparas) and 4459 of parity 1 (primiparas) who were <26 years of age.

RESULTS

Among nulliparous women, 5.7% and 4.6% of pregnancies ended in miscarriage and stillbirth. The adjusted relative risk of miscarriage was 2.07 for girls <15 (95% confidence interval [CI] = 1.17-3.66) compared with those 18 and 19 years, and was 1.40 (95% CI = 1.06-1.84) among those 15-17 years. Stillbirth rates did not differ significantly by maternal age. There were no differences in miscarriage or stillbirth rates by maternal age among primiparas.

CONCLUSION

Young maternal age increased the risk of miscarriages but not stillbirths for nulliparas. Miscarriages and stillbirths did not differ by maternal age for primiparous women.

Chronic ulcerative stomatitis: Diagnostic and management challenges—four new cases and review of literature

Chronic ulcerative stomatitis (CUS) is a recently described mucocutaneous disease characterized by involvement of mucosal surfaces and skin. The disease usually presents in the form of painful oral ulcers and has been seen predominantly among older women. Clinically, CUS patients may exhibit erosive or ulcerative lesions of oral mucosa resembling erosive lichen planus and/or other vesiculobullous lesions. Routine histology may exhibit features of lichenoid mucositis and is often nondiagnostic. Direct immunofluorescence studies of mucosal or skin biopsies usually reveal a unique pattern of IgG bound to nuclei of keratinocytes of the basal and parabasal cell layers. Chronic ulcerative stomatitis exhibits a unique resistance to standard treatments available, including topical and systemic corticosteroids and immunomodulatory medications. However, long-lasting favorable clinical responses may be achieved with hydroxychloroquine pharmacotherapy. We present the clinicoimmunopathologic findings of four cases of CUS and discuss the varied clinical, microscopic spectrum, and treatment for this chronic, debilitating, and often recalcitrant condition. A systematic review of the literature, including 35 previously reported cases, is presented.

Unilateral 6-hydroxydopamine lesion of dopamine neurons and subchronic L-DOPA administration in the adult rat alters the expression of the vesicular GABA transporter in different subsets of striatal neurons and in the substantia nigra, pars reticulata

The loss of dopamine neurons combined or not with the subsequent administration of L-DOPA in patients with Parkinson's disease or in experimental models of the disease results in altered GABAergic signaling throughout the basal ganglia, including the striatum and the substantia nigra, pars reticulata. However, the molecular mechanisms involved in altered GABA neurotransmission remain poorly understood. In order to be released from synaptic vesicles, newly synthesized GABA is transported from the cytosol into synaptic vesicles by a vesicular GABA transporter. The objective of this study was to examine the hypothesis that expression of the vesicular GABA transporter (vGAT) is altered in the unilateral 6-hydroxydopamine model of Parkinson's disease. Our results provide evidence that a unilateral 6-hydroxydopamine lesion results in increased and decreased vGAT mRNA levels in striatopallidal and striatonigral neurons, respectively. These two subsets of neurons were identified by the co-expression or lack of co-expression of preproenkephalin, a marker of striatopallidal neurons, using double-labeling in situ hybridization histochemistry. Such changes occurred in the striatum ipsilateral to the 6-hydroxydopamine lesion and were paralleled by decreased vGAT protein levels in the substantia nigra, pars reticulate (SNr). On the other hand, the subchronic systemic administration of L-DOPA increased vGAT mRNA levels in preproenkephalin-negative neurons on the side ipsilateral and, to a lesser extent, the side contralateral to the 6-hydroxydopamine lesion. Systemic L-DOPA also increased vGAT protein levels in the ipsi- and contralateral SNr. As a whole, the results provide original evidence that vGAT expression is altered in the 6-hydroxydopamine model of Parkinson's disease. They also suggest that the behavioral effects induced by a subchronic administration of L-DOPA to 6-hydroxydopamine-lesioned rats involve an increase in the vesicular release of GABA by striatonigral neurons.

The impact of a small steady stream of income for women on family health and economic well-being

Our primary aim to evaluate the impact of a small steady stream of income on family health and well-being among rural women employed part-time in a health project in Sarlahi district, Nepal. All 870 women applying for the job of distributing nutritional supplements in their villages completed a questionnaire prior to selection for employment, 350 of whom were hired and 520 who were not. A total of 736 women completed a second questionnaire 2 years later, 341 (97.4%) of whom had been continuously employed during this period, and 395 (76.0%) who had never been employed by the project. Changes in health and well-being over 2 years were compared between women who were and were not hired. Women who were hired were younger and better educated, but were similar in other regards. After adjusting for selection differences, employed women were more likely to save cash, buy jewellery, and buy certain discretionary household goods over 2 years than those who were not hired. Expenditures on children's clothing increased more for employed women, and their children were more likely to be in private schools at follow-up, but there was no impact on health and survival of children. Women with a small steady stream of income did improve their personal economic situation by savings and increased expenditures for children and the household. Longer follow-up may reveal impacts on health access and expenditures, although these were not evident in 2 years of employment.