Epidemiology and risk assessment for ovarian cancer

The incidence of ovarian cancer varies internationally with higher rates among women of North America and northern Europe. In the United States, there has been relatively little change in the incidence of ovarian cancer in recent decades. The incidence rate of ovarian cancer is highest among white and Hawaiian women, intermediate among African-American, Hispanic and Asian-American women, and lowest among Native American women. The most intensively studied risk factors have been family history, pregnancy history, and oral contraceptive use. Multiparity, lactation, oral contraceptive use, and tubal ligation/hysterectomy all decrease a woman's risk of ovarian cancer. One exposure that has been consistently associated with increased ovarian cancer risk is cosmetic talc applied to the perineum.

Motif-dependent DNA analysis of a methicillin-resistant Staphylococcus aureus collection

Methicillin-resistant Staphylococcus aureus (MRSA) has become a major nosocomial pathogen in recent years. Once introduced into the hospital environment, MRSA can spread rapidly, and its subsequent treatment is often difficult as it may be simultaneously resistant to several antibiotics. A useful strategy both to identify the source of infection and to monitor specific infecting strains would be beneficial, facilitating the implementation of control and preventive measures. In this study, a typing strategy, based on the amplification of a conserved repeat-motif in the bacterial genome, was applied in a hospital setting to analyse an MRSA collection. Using a fluorescent-labelled oligonucleotide primer RW3A, which annealed to several dispersed short-repeat sequences occurring throughout the bacterial genome, DNA amplification fingerprint patterns were produced by polymerase chain reaction (PCR). Thirty-nine MRSA isolates were successfully analysed using conventional agarose gel electrophoresis and GeneScan technology. The latter method provides a finer resolution, making use of capillary electrophoresis in an ABI Prism 310 genetic analyser. The fluorescent detection approach can facilitate the construction of a fingerprint database which can be accessed for comparison of any isolate. Quantitative analysis of all patterns divided the MRSA isolates into four different groups, based on their RW3A fingerprints. Most of the isolates (88%) were assigned to one of three main groups, while the remaining isolates (12%) comprised a fourth, miscellaneous group.

Effect of smoking on breast cancer in carriers of mutant BRCA1 or BRCA2 genes

BACKGROUND

Smoking has carcinogenic effects, and possibly antiestrogenic effects as well, but it has not been found to be a risk factor for breast cancer in women in the general population. However, hereditary breast cancer is primarily a disease of premenopausal women, and interactions between genes and hormonal and environmental risk factors may be particularly important in this subgroup.

METHODS

We conducted a matched case-control study of breast cancer among women who have been identified to be carriers of a deleterious mutation in either the BRCA1 or the BRCA2 gene. These women were assessed for genetic risk at one of several genetic counseling programs for cancer in North America. Information about lifetime smoking history was derived from a questionnaire routinely administered to women who were found to carry a mutation in either gene. Smoking histories of case subjects with breast cancer and age-matched healthy control subjects were compared. Odds ratios for developing breast cancer were determined for smokers versus nonsmokers by use of conditional logistic regression for matched sets after adjustment for other known risk factors.

RESULTS

Subjects with BRCA1 or BRCA2 gene mutations and breast cancer were significantly more likely to have been nonsmokers than were subjects with mutations and without breast cancer (two-sided P = .007). In a multivariate analysis, subjects with BRCA1 or BRCA2 mutations who had smoked cigarettes for more than 4 pack-years (i.e., number of packs per day multiplied by the number of years of smoking) were found to have a lower breast cancer risk (odds ratio = 0.46, 95% confidence interval = 0.27-0.80; two-sided P = .006) than subjects with mutations who never smoked.

CONCLUSIONS

This study raises the possibility that smoking reduces the risk of breast cancer in carriers of BRCA1 or BRCA2 gene mutations.

Prostate-specific antigen production in the female breast: association with progesterone

Prostate-specific antigen (PSA) is produced by the female breast. Prior in vitro evidence suggests that PSA expression in breast epithelial cells is regulated by androgens and progestins but not estrogens. The purpose of this study was to determine whether (a) PSA expression in breast nipple aspirate fluid (NAF) and in serum is influenced by progesterone (PG); (b) the ability to obtain NAF decreases with repeated breast aspirations; and (c) PSA in NAF correlates with abnormal NAF cytology. Eight pre- and three postmenopausal women with no breast cancer risk factors were enrolled in a pilot study and had NAF and serum collected every 3-4 days for a month to evaluate the influence of serum PG, luteinizing hormone, estradiol, and follicle-stimulating hormone on PSA in serum and in NAF. NAF was obtained in 99% (112 of 113) of aspiration visits. Median, mean, and peak NAF but not serum PSA levels were higher in pre- than in postmenopausal subjects. NAF PSA levels were associated with the rise or peak in serum PG in seven of eight premenopausal women (seven of seven with a PG surge) and in zero of three postmenopausal women. Considering all 11 women, there was an association between NAF PSA and PG (P = 0.005) but not luteinizing hormone, estradiol, or follicle-stimulating hormone. NAF volume did not significantly change over time. Atypical hyperplasia (9%) and hyperplasia without atypia (36%) were identified in the NAF of a subset of the subjects. Median, mean, and peak levels of NAF PSA (P = 0.05, 0.05, and 0.10, respectively) were higher in subjects with normal versus hyperplastic cytology. PSA production in the breast increases in association with PG. With aspiration every 3-4 days, NAF volume does not significantly decrease over time. NAF cytology and PSA levels in NAF may help identify women at increased breast cancer risk. Changes in biomarkers of breast cancer risk in NAF (including PSA and cytology) may predate mammographic abnormalities. NAF may, therefore, be useful as a breast cancer screening tool for young women who are not recommended to undergo mammography and as an adjunct to screen women who have mammograms performed.

The I1307K APC mutation does not predispose to colorectal cancer in Jewish Ashkenazi breast and breast-ovarian cancer kindreds

An increased incidence of colorectal cancer has been observed in breast and breast-ovarian cancer syndrome families, including those of Ashkenazi origin. Recently, a germ-line missense mutation in the APC gene, I1307K, was identified that may indirectly cause colorectal cancer in Ashkenazi Jews. To determine whether the excess of colon cancer in some breast-ovarian cancer families is related to the I1307K mutation, we evaluated 264 Ashkenazi Jews from 158 families. Most of these individuals had either a personal or a family history of breast and/or ovarian cancer, and 19.3% (51 of 264) carried one of the recurrent BRCA1 (185delAG or 5382 insC) or BRCA2 (6174delT) mutations. We detected the APC I1307K mutation in 7% (11 of 158) of the Ashkenazi Jewish families and in 4.5% (12 of 264) of the individuals participating in these studies. Of the families studied, 26.6% (42 of 158) had at least one case of colorectal cancer in a first-, second-, or third-degree relative of the proband. Significantly, of the 12 individuals who possessed the I1307K mutation, none was diagnosed with colorectal cancer and none had a known first-, second-, or third-degree relative diagnosed with colon cancer. The results suggest that factors other than the I1307K mutation contribute to the increased incidence of colon cancer in Ashkenazi breast-ovarian cancer families. Our results emphasize that only a subset of Ashkenazi Jewish individuals with a family history of colorectal cancer should be viewed as candidates for genetic susceptibility testing for the I1307K APC mutation.

Relationship-specific social psychological adaptations

Mainstream social psychology has sought parsimonious explanations of broad general applicability, and has in practice focused on stranger interactions. An evolutionary perspective; however, justifies predicting a rich diversity of relationship-specific social psychological adaptations. The demands of motherhood, fatherhood, mateship, sibship and other relationships are qualitatively distinct, and so, it appears, are the psychophysiological mechanisms that have evolved to deal with them. One window on what distinguishes social relationships is provided by the substance and epidemiology of interpersonal conflicts. Homicides exhibit victim-killer relationship-specific patterns in context, motive and demography, which we discovered only because we adopted an evolutionary psychological perspective. We offer a number of specific hypotheses about possible human psychological adaptations that have yet to be assessed, but are readily derived from consideration of the particular qualities of specific relationship types.

Evolutionary theory and the human family

Emlen's (1995) paper "An evolutionary theory of the family" reviewed existing ideas about the nature of family systems and the reasons why they have evolved in certain animal species. His theorizing led him to propose 15 predictions about how family systems function, based on favorable evidence from various species, mostly birds. While he suggested that these predictions can be applied to the human case, he himself did not attempt to do so. We consider the applicability of Emlen's 15 predictions to the study of human family systems, and find that several aspects of the life history and ecology of Homo sapiens require that they be modified. These considerations include: (1) the importance of intragroup solidarity in the context of intergroup competition: unlike in many other species where dispersal constraints arise from food or breeding site shortages, the primary pressure driving human sociality seems to be competition from other human groups; (2) the complex nature of exchange and reciprocity in human society: reciprocal altruism in particular is integral to human social interaction and leads to a particularly high degree of non-nepotistic helping behavior; and (3) the implications of menopause and the existence of potentially dominant, postreproductive helpers: helpers of this sort have little incentive to disperse or to encourage offspring to disperse, thus greatly increasing family stability.

Induction of the E-selectin promoter by interleukin 1 and tumour necrosis factor alpha, and inhibition by glucocorticoids

Cytokine-induced expression of the endothelial cell surface adhesion molecule E-selectin is inhibited by glucocorticoids (GCs). To investigate possible mechanisms for steroid inhibition, a reporter gene (ESAP) was constructed, comprising the cytokine responsive region of the E-selectin gene (nt -383 to +81) coupled to alkaline phosphatase (AP). In A549 cells stably transfected with the ESAP gene, AP production was highly responsive to the cytokines interleukin 1beta (IL-1beta) and tumour necrosis factor alpha, with ED50 values of 3 pM and 1000 pM respectively. Furthermore the cytokine-induced AP responses were inhibited by GCs, indicating that both transcriptional activation and GC suppression of the E-selectin gene were mediated via regulatory elements within the same region of the promoter. The relative potencies of GC drugs as inhibitors of IL-1beta (10 pM)-stimulated ESAP-gene activation were fluticasone> beclomethasone>dexamethasone, with IC50 values of 0.13, 1.1 and 2.7 nM respectively. Inhibition by fluticasone was blocked by the GC receptor (GR) antagonist drug mifepristone (Ru486), which is consistent with the suppressive effects of GCs being mediated via the GR. However, because the E-selectin promoter lacks a consensus glucocorticoid responsive element, mechanisms for inhibition independent of GR-DNA binding were investigated. Evidence that GCs also inhibited cytokine activation of a synthetic nuclear factor kappaB (NFkappaB)-driven reporter gene transiently transfected into A549 cells suggested that interference with the activation and/or function of this transcription factor was important for GC inhibition of ESAP. However, in A549-ESAP cells, fluticasone (100 nM) did not affect IL-1beta (10 pM)-induced IkBalpha degradation, NFkappaB-p65 nuclear translocation or the DNA-binding capacity of nuclear NFkappaB complexes, over a period during which cytokine-induced ESAP-gene activation was inhibited. Finally, there was no evidence to suggest that GC enhancement of IkBalpha gene expression contributed to the suppression of the cytokine response. We conclude that interference by GR with the transcriptional activation potential of DNA-bound NFkappaB complexes might contribute to mechanisms underlying the anti-inflammatory effects of GCs.

Factor V Leiden in Greek thrombophilic patients: relationship with activated protein C resistance test and levels of thrombin-antithrombin complex and prothrombin fragment 1 + 2

We studied 172 Greek patients (72 men aged 44.0 +/- 16.7 years and 100 women aged 46.5 +/- 14.1 years) with an unexplained thrombophilic tendency. One hundred and four apparently healthy persons (63 men aged 34.2 +/- 10.0 years and 41 women aged 37.1 +/- 13.3 years) were included as a control group. We performed the activated protein C resistance (APC-r) test using a clotting test (Chromogenix kit), detection of factor V Leiden using polymerase chain reaction (PCR)-restriction fragment length polymorphisms and measurement of thrombin-antithrombin complexes (TAT) and prothrombin fragment 1 + 2 (F1 + 2) levels with an immunoenzymatic assay. The normal range for the APC-r test (> 2.12) was determined from the controls. The factor V Leiden mutation was found in 31.9% of all the patients tested, in 28.1% of the unrelated patients with documented thrombophilic tendency of unknown origin and in 4.8% of the healthy controls. The APC-r test had a sensitivity of 0.42 and a specificity of 0.91 for the detection of factor V Leiden. Furthermore, we found no significant difference in levels of TAT and F1 + 2 between patients with and without the mutation and there was no correlation between aPC-r values and levels of TAT and F1 + 2.

[Microbial behavior and hurdles in Venezuelan intermediate moisture food]

Sixteen Venezuelan IMF, dairy products, dry-salted fish products, meat products and vegetable products (specially fruit products) were characterized; water activity, pH, moisture, acidity and humectants were determined, allowing us to identify the main hurdles. Parallelly the microbial profile and her evolution for each IMF were established in function of time and storage conditions. This information permits us to explain the different stability compartments for our IMF; simple modifications that will increase their stability are suggested. Water activity is not enough as a hurdle if it is not accompanied by an appropriate packaging, specially in tropical countries, that would limit water migrations.

Assessment of postoperative pain management: patient satisfaction and perceived helpfulness

OBJECTIVE

Increasing attention has been given to the assessment of patient satisfaction as a way to monitor quality of care in hospital settings. Postoperative patient satisfaction has been thought to be related to level of pain intensity, expectations of outcome, perceived concern by the staff, and helpfulness of treatments. The aim of this study is to develop a simple, reliable measure to assess pain and satisfaction in postsurgical patients and to examine factors related to patient satisfaction.

DESIGN

A satisfaction questionnaire was developed for this study and administered to 119 patients who had undergone a major orthopedic surgical procedure. The majority of the patients were diagnosed with osteoarthritis and reported moderate to severe preoperative pain. The 13-item measure was found to be reliable (test-retest r = .86; interexaminer r = .98), valid (exploratory factor analyses; intercorrelations), and easy to administer.

RESULTS

Results showed that the majority of the patients were satisfied with their care (91%), postoperative pain intensity (94%), and the way they were treated by the physicians and nurses (98%). Patients with low postoperative pain ratings who perceived that the physicians and nurses showed concern with how much pain they were feeling reported greatest satisfaction with their care (p < .001). In general, lower postoperative pain ratings were the best predictors of satisfaction and helpfulness of treatment. Preoperative pain status, expected level of postoperative pain, and time waiting for pain medication after a request was made were not significantly correlated with ratings of postoperative pain or satisfaction.

CONCLUSIONS

These results highlight the important influence of adequate treatment of postoperative pain and perceived concern by the hospital staff on patient satisfaction.

Life expectancy, economic inequality, homicide, and reproductive timing in Chicago neighbourhoods

In comparisons among Chicago neighbourhoods, homicide rates in 1988-93 varied more than 100-fold, while male life expectancy at birth ranged from 54 to 77 years, even with effects of homicide mortality removed. This "cause deleted" life expectancy was highly correlated with homicide rates; a measure of economic inequality added significant additional prediction, whereas median household income did not. Deaths from internal causes (diseases) show similar age patterns, despite different absolute levels, in the best and worst neighbourhoods, whereas deaths from external causes (homicide, accident, suicide) do not. As life expectancy declines across neighbourhoods, women reproduce earlier; by age 30, however, neighbourhood no longer affects age specific fertility. These results support the hypothesis that life expectancy itself may be a psychologically salient determinant of risk taking and the timing of life transitions.

Recommendations for follow-up care of individuals with an inherited predisposition to cancer. II. BRCA1 and BRCA2. Cancer Genetics Studies Consortium

OBJECTIVE

To provide recommendations for cancer surveillance and risk reduction for individuals carrying mutations in the BRCA1 or BRCA2 genes.

PARTICIPANTS

A task force with expertise in medical genetics, oncology, primary care, gastroenterology, and epidemiology convened by the Cancer Genetics Studies Consortium (CGSC), organized by National Human Genome Research Institute (previously the National Center for Human Genome Research).

EVIDENCE

Studies evaluating cancer risk, surveillance, and risk reduction in individuals genetically susceptible to breast and ovarian cancer were identified using MEDLINE (National Library of Medicine) and from bibliographies of articles thus identified. Indexing terms used were "genetics" in combination with "breast cancer," "ovarian cancer," and "screening," or "surveillance" in combination with "cancer family" and "BRCA1" and "BRCA2." For studies evaluating specific interventions, quality of evidence was assessed using criteria of the US Preventive Services Task Force.

CONSENSUS PROCESS

The task force developed recommendations through discussions over a 14-month period.

CONCLUSIONS

Efficacy of cancer surveillance or other measures to reduce risk in individuals who carry cancer-predisposing mutations is unknown. Based on expert opinion concerning presumptive benefit, early breast cancer and ovarian cancer screening are recommended for individuals with BRCA1 mutations and early breast cancer screening for those with BRCA2 mutations. No recommendation is made for or against prophylactic surgery (eg, mastectomy, oophorectomy); these surgeries are an option for mutation carriers, but evidence of benefit is lacking, and case reports have documented the occurrence of cancer following prophylactic surgery. It is recommended that individuals considering genetic testing be counseled regarding the unknown efficacy of measures to reduce risk and that care for individuals with cancer-predisposing mutations be provided whenever possible within the context of research protocols designed to evaluate clinical outcomes.

Recommendations for follow-up care of individuals with an inherited predisposition to cancer. I. Hereditary nonpolyposis colon cancer. Cancer Genetics Studies Consortium

OBJECTIVE

To provide recommendations for cancer surveillance and risk reduction for individuals carrying mutations associated with hereditary nonpolyposis colon cancer (HNPCC).

PARTICIPANTS

A task force with expertise in medical genetics, oncology, primary care, gastroenterology, and epidemiology convened by the Cancer Genetics Studies Consortium (CGSC), organized by the National Human Genome Research Institute (previously the National Center for Human Genome Research).

EVIDENCE

Studies evaluating cancer risk, surveillance, and risk reduction in individuals genetically susceptible to colon cancer were identified using MEDLINE and bibliographies of articles thus identified. Indexing terms used were "genetics" in combination with "colon cancer," and "screening" in combination with "cancer family" and "HNPCC." For studies evaluating specific interventions, quality of evidence was assessed using criteria of the US Preventive Services Task Force.

CONSENSUS PROCESS

The task force developed recommendations through discussions over a 14-month period.

CONCLUSIONS

Efficacy of cancer surveillance or other measures to reduce risk in individuals who carry cancer-predisposing mutations is unknown. Based on observational studies, colonoscopy every 1 to 3 years starting at age 25 years is recommended for individuals known to have HNPCC-associated mutations. Endometrial cancer screening is also recommended, based on expert opinion concerning presumptive benefit. No recommendation is made for or against prophylactic surgery (ie, colectomy, hysterectomy); these surgeries are an option for mutation carriers, but evidence of benefit is lacking. It is recommended that individuals considering genetic testing be counseled regarding the unknown efficacy of measures to reduce risk and that care for individuals with cancer-predisposing mutations be provided whenever possible within the context of research protocols designed to evaluate clinical outcomes.

Nipple aspirate fluid: a promising non-invasive method to identify cellular markers of breast cancer risk

To evaluate the feasibility of nipple aspiration and to identify intermediate markers of breast cancer risk, nipple aspirate fluid (NAF) was collected from 177 subjects using a modified breast pump. The first 33 subjects demonstrated that we could obtain NAF quickly, reliably and repeatedly. Specimens from the remaining 144 subjects were collected to evaluate promising cellular biomarkers. NAF was obtained in 167 out of 177 (94%) subjects overall and in 99% of the 144 most recent subjects. Sufficient NAF was obtained to evaluate cytology in 160 out of 167 (96%) cases and specimens were sufficiently cellular to analyse DNA markers in 53% of cases. Among the last 144 subjects, menopausal status did not influence the ability to obtain NAF. NAF cytology correlated with increased breast cancer risk (P = 0.002). Using computerized image analysis of NAF epithelial cells, DNA index (P = 0.0002), percentage of cells in G2M (P = 0.05) and percentage of cells with hypertetraploidy (P = 0.002) increased as cytology became more abnormal. Our data indicate that NAF can be obtained in essentially all eligible subjects; that breast epithelial cells are evaluable in > 95% of NAF samples for cytology and in over half of NAF samples for DNA index (ploidy) and cell cycle analysis; and that abnormal NAF cytology correlates with increased breast cancer risk. This suggests that biomarkers identified in nipple aspirate fluid may prove useful either as an adjunct to currently accepted breast cancer screening methods, or to evaluate response to a chemopreventive agent.

Prostate-specific antigen levels in nipple aspirate fluid correlate with breast cancer risk

Despite the fact that breast cancer is the most common non-cutaneous cancer and a leading cause of cancer deaths in women, accepted markers of breast cancer risk miss up to 40% of these tumors. Moreover, screening methods involving the analysis of tissue or cells are limited by the need for a surgical biopsy. Nipple aspiration is a quick, efficient, noninvasive method to obtain breast epithelial cells, the cells at risk for transformation to carcinoma. Prostate-specific antigen (PSA), a protein thought to be specific to the prostate but recently found in a subset of breast tumors, has been correlated with improved survival. The purpose of this study was to measure PSA in a group of women with increasing breast cancer risk (no risk or family history of breast cancer, precancerous mastopathy, and invasive cancer) and determine if PSA correlates with risk. Nipple aspirate fluid was obtained from the intact breast and from surgical specimens using a modified breast pump. PSA was then measured in the fluid using a highly sensitive and specific immunofluorometric procedure. PSA was found at levels ranging from 0-13,423 ng/g of total protein, and there was a significant relationship between PSA level and breast cancer risk (P = 0.001). That is, all women with no risk factors and 90% of those with a family history had high PSA levels, whereas 68% of subjects with precancerous mastopathy or invasive cancer had low PSA levels. PSA was higher in premenopausal subjects (P = 0.002). After adjusting for the effect of menopausal status, there remained a significant association between PSA and breast cancer risk. These findings suggest that PSA in nipple aspirate fluid may be a useful marker of breast cancer risk.

Behavior of late potentials on the body surface during programmed ventricular stimulation

OBJECTIVES

This study sought to evaluate the behavior of late potentials on the body surface by signal averaging during programmed stimulation and to correlate the findings with the cycle length of induced ventricular tachycardia.

BACKGROUND

Clinically relevant late potentials may be concealed within the QRS complex and may be missed by the conventional signal-averaged electrocardiogram (SAECG). In contrast, some late potentials may arise from dead-end pathways or pathways not capable of supporting sustained ventricular tachycardia (VT). It has been shown that durations of late potentials in sinus rhythm correlate poorly with VT cycle length.

METHODS

Signal-averaged electrocardiography during sinus rhythm, right ventricular pacing (S1) and introduction of a right ventricular extrastimulus (S2) was performed in 95 patients: 11 patients with a structurally normal heart and no inducible VT (Group I); 44 with a previous myocardial infarction (MI) and no inducible monomorphic VT (Group II); and 40 with a previous MI and inducible monomorphic VT (Group III).

RESULTS

The best subset of SAECG variables and the best cut points for each variable to differentiate between patients with and without VT were first established for each rhythm studied. Total duration of the filtered QRS complex (QRSD) was found to be the only independent predictor of inducibility of VT. When late potentials were defined for these criteria (QRSD > OR = 113, > or = 178 and > or = 168 ms for the SAECG during sinus rhythm, S1 and S2, respectively), there was no difference in the incidence of false positive (16% vs. 18%) or false negative (30% vs. 26%) late potentials between sinus rhythm and S1. During S2, there were significantly fewer false positive late potentials (11% vs. 16%) and fewer false negative late potentials (17% vs. 30%) than with sinus rhythm. Compared with sinus rhythm, 31% of the false positive late potentials detected during sinus rhythm were lost, whereas 43% of the false negative late potentials became detectable after S2, resulting in improved sensitivity (83% vs. 70%), specificity (89% vs. 84%) and predictive accuracy (86% vs. 77%, p < 0.05). Among the patients with VT, QRSD during S2 achieved the best correlation with VT cycle length (r = 0.74) and was the only independent predictor of VT cycle length when all SAECG variables were considered.

CONCLUSIONS

Late potentials revealed by ventricular extrastimuli but concealed during sinus rhythm may be clinically relevant and may explain some of the false negative late potentials and reduced sensitivity of the conventional SAECG in predicting VT. In contrast, those late potentials that are detected during sinus rhythm but lost after ventricular extrastimuli are often clinically irrelevant and may account for the false positive late potentials and reduced specificity of the conventional SAECG.

Methotrexate removal during haemodialysis in a patient with advanced laryngeal carcinoma

A 62-year-old patient on long-term haemodialysis who developed an inoperable T2N3Mo squamous-cell carcinoma of the larynx was treated with weekly low-dose methotrexate (MTX) after failing to respond to radiotherapy. The patient was initially given one dose of 10 mg MTX (6 mg/m2) as a 1-h infusion, then he received three further i.v. doses of 20 mg (12 mg/m2). Haemodialysis was performed 15-18 h after each dose and the patient received folinic acid (30 mg i.v.q 6 h) until the MTX concentration was < 0.1 mumol/l. The MTX concentration was measured regularly until it reached < 0.1 mumol/l, and additional samples were withdrawn pre- and post-dialysis. The MTX elimination rate constant and half-life were estimated with the patient on and off dialysis. The patient failed to respond to treatment but did not experience MTX-related toxicity. The elimination half-life ranged from 22 to 42 h when he was off dialysis but fell to a median of 5.5 h during dialysis. Low-dose MTX was given to a patient on regular haemodialysis without evidence of toxicity. The rate of MTX elimination was increased during haemodialysis, although high MTX concentrations persisted for several days and prolonged rescue with folinic acid was required.

Mapping of a gene for type 2 diabetes associated with an insulin secretion defect by a genome scan in Finnish families

Non-insulin dependent diabetes mellitus (NIDDM) affects more than 100 million people worldwide and is associated with severe metabolic defects, including peripheral insulin resistance, elevated hepatic glucose production, and inappropriate insulin secretion. Family studies point to a major genetic component, but specific susceptibility genes have not yet been identified-except for rare early-onset forms with monogenic or mitochondrial inheritance. We have screened over 4,000 individuals from a population isolate in western Finland, identified 26 families (comprising 217 individuals) enriched for NIDDM and performed a genome-wide scan using non-parametric linkage analysis. We found no significant evidence for linkage when the families were analysed together, but strong evidence for linkage when families were classified according to mean insulin levels in affecteds (in oral glucose tolerance tests). Specifically, families with the lowest insulin levels showed linkage (P = 2 x 10(-6)) to chromosome 12 near D12S1349. Interestingly, this region contains the gene causing the rare, dominant, early-onset form of diabetes MODY3. Unlike MODY3 families, the Finnish families with low insulin have an age-of-onset typical for NIDDM (mean = 58 years). We infer the existence of a gene NIDDM2 causing NIDDM associated with low insulin secretion, and suggest that NIDDM2 and MODY3 may represent different alleles of the same gene.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

A common mutation in BRCA2 that predisposes to a variety of cancers is found in both Jewish Ashkenazi and non-Jewish individuals

Recent studies have identified mutations in the breast and (ovarian cancer susceptibility gene 2 (BRCA2), one which has been found in the germline of several males and one female affected with breast cancer. To establish the carrier frequency of this mutation in a large population of individuals affected with cancer, we evaluated constitutional DNA isolated from 83 individuals diagnosed with breast cancer and 93 diagnosed with ovarian cancer at any age, 42 of whom reported a family history of cancer. Using a simple allele-specific PCR-based nonradioactive method, we detected a total of eight individuals (4.5%) carrying a 1-bp deletion at nucleotide 6174 of the BRCA2 gene (6174delT). The age of disease onset in the mutant allele carriers was highly variable and typically late onset (41-72 years for breast cancer and 48-73 years for ovarian cancer). Evaluation of family histories for the eight mutant allele carriers revealed that several individuals had significant cancer histories that included, in addition to breast and/or ovarian cancer, an increased incidence of colon, esophageal, pancreatic, stomach, and hematopoietic cancers. Interestingly, seven of the eight individuals were of Ashkenazi Jewish descent. Haplotype data for the mutant allele carriers using markers spanning the region of the BRCA2 gene on chromosome 13ql2-ql3 suggest that only two of the confirmed Jewish Ashkenazi individuals share a single common ancestry, indicating several independent origins for this mutation. These data provide evidence for the presence of a specific BRCA2 mutation which has its origins in both Jewish Ashkenazi and non-Jewish populations. The observed overrepresentation of specific mutations within a subgroup of the general population may eventually help contribute to the development of inexpensive and routine tests such as the one described in our study.

Two distinct origins of a common BRCA1 mutation in breast-ovarian cancer families: a genetic study of 15 185delAG-mutation kindreds

We screened 163 women from breast-ovarian cancer-prone families, as well as 178 individuals affected with breast and/or ovarian cancer but unselected for family history, for germ-line mutations in exon 2 of BRCA1, by SSCP analysis and direct sequencing. A total of 25 mutations were detected. Thirteen of 64 Jewish Ashkenazi women and 2 non-Jewish individuals were found to possess the 185delAG mutation. Haplotype data for all 15 individuals, with markers intragenic to BRCA1, suggest that the Jewish Ashkenazi individuals share a common ancestry that is distinct from the lineage shared by the other two women. These data provide the first evidence of two distinct lines of transmission for the 185delAG mutation, only one of which has its origins in the Jewish Ashkenazi population. Our screening also uncovered 10 affected individuals with an 11-bp deletion at nucleotide 188 of BRCA1 (188del11), 4 of whom are Ashkenazi Jews. This is only the third reported mutation detected within the Jewish Ashkenazi population and may represent the second most common alteration in BRCA1 found in Ashkenazi Jews in the United States. The observed overrepresentation of specific mutations within a subgroup of the general population may eventually contribute to the development of inexpensive and routine tests for BRCA1 mutations, as well as to the elucidation of other contributory factors (e.g., diet, environment, and chemical exposures) that may play a key role in cancer initiation and development. The implications of the mutational data, as well as the role that founder effect, demographic history, and penetrance play in the resulting observed phenomena, are discussed.

BRCA2 germline mutations in male breast cancer cases and breast cancer families

The breast cancer susceptibility gene, BRCA2 on chromosome 13q12-13, was recently isolated. Mutations in BRCA2 are thought to account for as much as 35% of all inherited breast cancer as wall as a proportion of inherited ovarian cancer. Many BRCA2-linked families also contain cases of male breast cancer. We have analysed germline DNA from 50 males with breast cancer (unselected for family history) and 26 individuals from site-specific female breast and breast-ovarian cancer families for mutations in BRCA2. All 17 breast-ovarian cancer families have been screened for BRCA1 coding region mutations and none were detected. Conformation-sensitive gel electrophoresis (CSGE) analysis of PCR-amplified DNA followed by direct sequencing was used to detect sequence variants. Three of eleven individuals carry the same mutation, all are of Ashkenazi Jewish descent, supporting the observation by Neuhausen et al. in this issue that there is a common mutation in this population. Eleven truncating mutations and nine polymorphisms were identified -- all were coding region variants. No loss-of-transcript mutations were identified in the sixteen samples for which this analysis was possible. Seven of the nine disease-associated mutations were detected in the 50 men with breast cancers; for thus in our series, BRCA2 mutations account for 14% of male breast cancer, all but one of which had a family history of male and/or female breast cancer.