The tumor biological significance of RNF43 and LRP1B in gastric cancer is complex and context-dependent

Gastric cancer (GC) is the fifth most common cancer in the world with a poor prognosis. Both RNF43 and LRP1B function as tumor suppressors in the Wnt signaling pathway and have been described to be frequently mutated in GC. In this study of a large and well characterized cohort of 446 GCs we explored the significance of expression of RNF43 and LRP1B and their correlations with clinicopathological patient characteristics. Immunostaining of whole mount tissue sections was documented with the histoscore. Dichotomized at the median, we separated the cohort into a low/negative and a high/positive group of RNF43 and LRP1B expression, respectively. Apart from the entire cohort, we also examined the intestinal and diffuse type GCs separately. Regarding the entire cohort, the expression of RNF43 and LRP1B correlated significantly with the Lauren phenotype and with each other. Interestingly, differences were noted regarding RNF43 between the intestinal and diffuse type GCs. Survival analysis of the intestinal type GCs showed that RNF43 low/negative GCs tended to have a better outcome compared with RNF43 high/positive GCs [24.5 months overall survival (OS) and 25.0 months tumor-specific survival (TSS) vs. 14.1 months OS and 17.9 months TSS, respectively]. To the contrary, diffuse type GCs with RNF43 low/negative had a worse outcome compared with RNF43 high/positive GCs (12.9 months OS and 18.2 months TSS vs. 17.1 months OS and 21.5 months TSS, respectively). On multivariate analysis, RNF43 low/negative versus high/positive was an independent prognosticator of survival in diffuse type GC (hazard ratio 2.393 for OS and 2.398 for TSS). These data support the contention that the expression and biological effect of RNF43 and LRP1B in GC is context-dependent.

Abstract P1-16-10: Treatment patterns and outcomes of different subtypes of metastatic breast cancer patients in a Swedish real world setting with a focus on HER2-/HR+ subtype

Introduction: The most frequent molecular subtype of metastatic breast cancer (MBC) is the HER2-/HR+ subtype. While there are several treatments available for HER2-/HR+ MBC patients, there is limited knowledge about how patients are treated in a real world setting. In this retrospective study, the aim was to describe the duration of four initial treatment lines, treatment patterns and outcomes in MBC subtypes, with a focus on the HER2-/HR+ subtype.

Methods: The population is a cohort of 370 MBC patients diagnosed during '09-´16 in Uppsala County, Sweden. Data were collected from a regional breast cancer registry which included medical records. The subtypes were HER2-/HR+(59%); HER2+/HR+(12%); HER2+/HR-(7%) and HER2-/HR-(12%) based on immunohistochemistry (IHC) and in situ hybridization (ISH) tests, 11% of records had missing data on subtypes. Kaplan-Meier estimates were used to model duration of treatment line, progression-free survival (PFS) and overall survival (OS). Cox proportional hazard models were used to test the association, expressed in hazard ratios (HR), between the subtypes and PFS and OS.

Results: The median PFS and OS of HER2-/HR+ subtype were 10.6 and 36.7 months, respectively. Compared to the HER2-/HR+ patients, a statistically significant difference was found for HER2-/HR- patients in terms of PFS (HR: 2.1; p-value<0.001) and OS (HR: 3.6; p-value<0.01), indicating a worse prognosis. HER2+/HR+ and HER2+/HR-patients had similar PFS and OS results to HER2-/HR+ patients.

A statistically significant association was found between HR+ expression and OS (HR: 0.5; p-value<0.001) and not between HER2+ expression and OS (HR: 1.0; p-value 0.79 ).

The median duration of treatment decreased with increasing treatment lines; HER2-/HR+ patients' first-line treatment lasted 7.2, second-line 5.5, third-line 4.7 and fourth-line 4.4 months. The proportion of chemotherapy increased with the number of treatment lines: 32%, 38%, 46% and 59% for first to fourth line, respectively.

The ten most used drugs of HER2-/HR+ cohort are summarized in Table 1. In total, endocrine therapy was given during 66% of the total treatment duration.

Table 1:Ten most used drugs of HER2-/HR+N=197Patient-years (sum of treatment durations)Relative frequency of patient-years (%). Total=511 yearsLetrozole19037Tamoxifen5611Capecitabine5511Exemestane438Fulvestrant316FEC245Paclitaxel235Docetaxel143Vinorelbine112Everolimus92

Conclusion: In this retrospective study of MBC patients, the expression of HR showed an individual positive impact of OS with a 50% reduction in hazards. In our cohort only the prognosis of HER2-/HR- patients were significantly worsened both in terms of PFS and OS compared to HER2-/HR+ subtype. In the analysis of HER2-/HR+ subtype, letrozole was the most durable therapy, used 37% of total treatment time. The most used chemotherapy was capecitabine, used in 11% of the treatment time.

Citation Format: Lindman H, Szilcz M, Freilich J, Carlqvist P, Vertuani S, Anell B, Holm B. Treatment patterns and outcomes of different subtypes of metastatic breast cancer patients in a Swedish real world setting with a focus on HER2-/HR+ subtype [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-16-10.

Acute esophagitis for patients with local-regional advanced non small cell lung cancer treated with concurrent chemoradiotherapy

PURPOSE

Esophagitis is common in patients treated with definitive radiotherapy for local-regional advanced non small cell lung cancer (NSCLC). The purpose of this study was to estimate the dose-effect relationship using clinical and dosimetric parameters in patients receiving intensity modulated radiotherapy (IMRT) and concomitant chemotherapy (CCT).

METHODS

Between 2009 and 2013, 117 patients with stages IIB-IIIB NSCLC were treated in a multicenter randomized phase II trial with 2 cycles of induction chemotherapy followed by IMRT and CCT. The esophagitis was prospectively scored using the Common Toxicity Criteria 3.0. Clinical and dosimetric variables were analyzed for the correlation with grade ⩾2 esophagitis through logistic regression.

RESULTS

Grade 2 esophagitis was experienced by 31 (27%). All models including gender, institution, a dosimetric parameter and a position parameter were significantly associated with esophagitis. The two models using the relative esophagus volume irradiated above 40 Gy (V40, OR=2.18/10% volume) or the length of esophagus irradiated above 40 Gy (L40, OR=4.03/5 cm) were optimal. The upper part of esophagus was more sensitive and females experienced more toxicity than men.

CONCLUSION

V40 and L40 were most effective dosimetric predictors of grade ⩾2 esophagitis. The upper part of esophagus was more sensitive.

Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study

BACKGROUND

The incidence of non-intercepted prescription errors and the risk factors involved, including the impact of computerised order entry (CPOE) systems on such errors, are unknown. Our objective was to determine the incidence, type, severity, and related risk factors of non-intercepted prescription dose errors.

PATIENTS AND METHODS

A prospective, comparative cohort study in two clinical oncology units. One institution used a CPOE system with no connection to the electronic patient record system, while the other used paper-based prescription forms. All standard prescriptions were included and reviewed. Doses were recalculated according to the guidelines of each institution, using the patient data as documented in the patient record, the paper-based prescription form, or the CPOE system. A non-intercepted prescription dose error was defined as ≥10% difference between the administered and the recalculated dose.

RESULTS

Data were collected from 1 November 2012 to 15 January 2013. A total of 5767 prescriptions were evaluated, 2677 from the institution using CPOE and 3090 from the institution with paper-based prescription. Crude analysis showed an overall risk of a prescription dose error of 1.73 per 100 prescriptions. CPOE resulted in 1.60 and paper-based prescription forms in 1.84 errors per 100 prescriptions, i.e. odds ratio (OR) = 0.87 [95% confidence interval (CI) 0.59-1.29, P = 0.49]. Fifteen different types of errors and four potential risk factors were identified. None of the dose errors resulted in the death of the patient.

CONCLUSIONS

Non-intercepted prescribing dose errors occurred in <2% of the prescriptions. The parallel CPOE system did not significantly reduce the overall risk of dose errors, and although it reduced the risk of calculation errors, it introduced other errors. Strategies to prevent future prescription errors could usefully focus on integrated computerised systems that can aid dose calculations and reduce transcription errors between databases.

Role of preoperative pain, muscle function, and activity level in discharge readiness after fast-track hip and knee arthroplasty

BACKGROUND AND PURPOSE

The concept of fast-track surgery has led to a decline in length of stay after total hip arthroplasty (THA) and total knee arthroplasty (TKA) to about 2-4 days. However, it has been questioned whether this is only achievable in selected patients-or in all patients. We therefore investigated the role of preoperative pain and functional characteristics in discharge readiness and actual LOS in fast-track THA and TKA.

METHODS

Before surgery, hip pain (THA) or knee pain (TKA), lower-extremity muscle power, functional performance, and physical activity were assessed in a sample of 153 [corrected] patients and used as independent variables to predict the outcome (dependent variable) – readiness for hospital discharge – for each type of surgery. Discharge readiness was assessed twice daily by blinded assessors

RESULTS

Median discharge readiness and actual length of stay until discharge were both 2 days. Univariate linear regression followed by multiple linear regression revealed that age was the only independent predictor of discharge readiness in THA and TKA, but the standardized coefficients were small (≤ 0.03).

INTERPRETATION

These results support the idea that fast-track THA and TKA with a length of stay of about 2-4 days can be achieved for most patients independently of preoperative functional characteristics.

Long-lasting disease stabilization in the absence of toxicity in metastatic lung cancer patients vaccinated with an epitope derived from indoleamine 2,3 dioxygenase

PURPOSE

To investigate targeting of indoleamine 2,3 dioxygenase (IDO) enzyme using a synthetic peptide vaccine administered to patients with metastatic non-small cell lung cancer (NSCLC).

EXPERIMENTAL DESIGN

In a clinical phase I study, we treated 15 HLA-A2-positive patients with stage III-IV NSCLC in disease stabilization after standard chemotherapy. Patients were treated with imiquimod ointment and subcutaneous vaccinations (100 μg IDO5 peptide, sequence ALLEIASCL, formulated in 900 μL Montanide). Primary endpoint was toxicity. Clinical benefit and immunity were assessed as secondary endpoints.

RESULTS

No severe toxicity was observed. One patient developed a partial response (PR) after one year of vaccine treatment, whereas long-lasting stable disease (SD) ≥ 8.5 months was demonstrated in another six patients. The median overall survival (OS) was 25.9 months. Patients demonstrated significant improved OS (P = 0.03) when compared with the group of patients excluded because of HLA-A2 negativity. IDO-specific CD8(+) T-cell immunity was demonstrated by IFN-γ Elispot and Tetramer staining. Fluorescence-activated cell sorting analyses demonstrated a significant reduction of the Treg population (P = 0.03) after the sixth vaccine (2.5 months) compared with pretreatment levels. Furthermore, expression of IDO was detected in nine of ten tumor biopsies by immunohistochemistry. High-performance liquid chromatography analyses of kynurenine/tryptophan (Kyn/Trp) ratio in sera were performed. In long-term analyses of two clinical responding patients, the ratio of Kyn/Trp remained stable.

CONCLUSIONS

The vaccine was well tolerated with no severe toxicity occurring. A median OS of 25.9 months was demonstrated and long-lasting PR+SD was seen in 47% of the patients.

Prognostic value of ECOG performance status in lung cancer assessed by patients and physicians

8103

Background: Physician-reported Eastern Cooperative Oncology Group (ECOG) performance status (MD-PS) is a reliable prognostic factor of overall survival (OS) and has a major influence on treatment decisions. MD-PS is also used to quantify cancer patients' general well-being and activities of daily life. The extent and prognostic importance of disagreements between MD-PS and cancer patients' self-reported ECOG PS (Pt-PS) have not been adequately evaluated. Methods: Four hundred and sixty consecutive patients with lung cancer (LC) were referred to the Dept. of Oncology at Herlev University Hospital, Denmark, from February 1 2012 to January 31 2013. Three hundred and forty-seven (75%) of these patients were enrolled in a prospective, longitudinal, LC biomarker study, “LUCAS”. Patients assessed their own Pt-PS in a questionnaire at first visit. Treating physicians scored the MD-PS at first visit. Results: Fifty-four (16%) LUCAS patients had missing PS data (39 no Pt-PS; 14 no MD-PS; 1 neither). LUCAS patients were significantly younger than the total LC population (mean age, 68.1 vs. 71.1; t-test: p < 0.01). The MD-PS and Pt-PS were distributed differently in the LUCAS cohort: PS=0 (121 vs. 76), PS=1 (147 vs. 145), PS=2 (39 vs. 54), PS=3 (25 vs. 30), PS=4 (0 vs. 2) (X2 test: p < 0.01). In 170 (58%) cases the physician and patient were in concordance. In 24 (8%) cases the MD-PS scored the patient in poorer PS compared to the Pt-PS. In 99 (34%) cases the MD-PS scored the patient in better PS than the Pt-PS. In 11 (4%) cases the physician scored a PS value more than 1 different from the patient; all were towards a better PS. The median OS in the total cohort (460 patients) was 9.7 months. MD-PS and Pt-PS were both effective in predicting OS. For patients with MD-PS = 0, a poorer Pt-PS did not significantly predict worse outcome. However, for patients with MD-PS = 1, there was a trend (HR 1.98, p = 0.08; log rank test) towards worse outcome if Pt-PS was > 1. Conclusions: Oncologists and patients frequently disagree regarding PS. The physicians tend to note a better PS score than the patients. The differences between MD-PS and Pt-PS could influence the prognostic value. It may be beneficial in clinical practice to involve patients in PS assessments.

Phase I study of peptide vaccine targeting indeolamine 2,3 dioxygenase in metastatic lung cancer patients

8084

Background: To investigate the targeting of indeolamine 2,3 dioxygenase (IDO) enzyme by a synthetic peptide vaccine for patients with metastatic non small-cell lung cancer (NSCLC). Methods: We treated15 HLA-A2 positive patients with stage III-IV NSCLC and disease stabilization (SD) after standard chemotherapy. Patients were treated every second week (induction) for three months, and thereafter monthly until progression (maintenance) with imiquimod ointment and vaccine (100 µg IDO5 peptide sequence ALLEIASCL mixed with 900 µL montanide) administered subcutaneously. Primary end point was toxicity. Clinical benefit and immune monitoring were assessed. Results: Patient characteristics: mean age (63, range 51-71), sex (F=8,M=7), PS(0=9,1=6), histology (adenocarcinoma=93%), previously anti-neoplastic treatments (1st line=100%, 2nd =40% and 3rd=27% of patients). No grade 3-4 CTCAE toxicity was observed. Median PFS was 5.2 months and median OS 2.1 years. Long-lasting disease stabilization (SD≥8.5 months) was demonstrated in 7 patients (47%). Patients demonstrated significant improved OS (P=0.02) when compared to the untreated group of excluded HLA-A2 negative NSCLC patients. IDO expression was frequently detected in tumour biopsies by immune-histochemistry staining. Immune induction of IDO specific CD8 T-cells were demonstrated by IFN-y Elispot and Tetramer staining. Immune correlates of T-lymphocyte subsets were performed by flow cytometry. HPLC analyses of Trp/Kyn ratio suggested stabilization or decrease of IDO activity in 11/15 (73%) of the patients. Conclusions: The vaccine was safe and well-tolerated with no grade 3/4 toxicity occurring. Long-lasting SD was seen in 47% of the patients demonstrating a median OS of 2.1 year. IHC demonstrated frequent IDO activity in NSCLC tumour biopsies, and blocking of IDO activity was indicated by Kyn/Trp ratio measurements. Clinical trial information: NCT01219348.

Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study

BACKGROUND

By measuring very early changes in muscle strength and functional performance after fast-track total hip arthroplasty (THA), post-operative rehabilitation, introduced soon after surgery, can be designed to specifically target identified deficits.

OBJECTIVES

Firstly, to quantify changes (compared to pre-operative values) in hip muscle strength, leg-press power, and functional performance in the first week after THA, and secondly, to explore relationships between the muscle strength changes, and changes in hip pain, systemic inflammation, and thigh swelling.

DESIGN

Prospective, cohort study.

SETTING

Convenience sample of patients receiving a THA at Copenhagen University Hospital, Hvidovre, Denmark, between March and December 2011.

PARTICIPANTS

Thirty-five patients (65.9 ± 7.2 years) undergoing THA.

MAIN OUTCOME MEASURES

Hip muscle strength, leg-press power, performance-based function, and self-reported disability were determined prior to, and 2 and 8 days after, THA (Day 2 and 8, respectively). Hip pain, thigh swelling, and C-Reactive Protein were also determined.

RESULTS

Five patients were lost to follow-up. Hip muscle strength and leg press power were substantially reduced at Day 2 (range of reductions: 41-58%, P<0.001), but less pronounced at Day 8 (range of reductions: 23-31%, P<0.017). Self-reported symptoms and function (HOOS: Pain, Symptoms, and ADL) improved at Day 8 (P<0.014). Changes in hip pain, C-Reactive Protein, and thigh swelling were not related to the muscle strength and power losses.

CONCLUSIONS

Hip muscle strength and leg-press power decreased substantially in the first week after THA - especially at Day 2 - with some recovery at Day 8. The muscle strength loss and power loss were not related to changes in hip pain, systemic inflammation, or thigh swelling. In contrast, self-reported symptoms and function improved. These data on surgery-induced changes in muscle strength may help design impairment-directed, post-operative rehabilitation to be introduced soon after surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246674.

No effect of fibrin sealant on drain output or functional recovery following simultaneous bilateral total knee arthroplasty: a randomized, double-blind, placebo-controlled study

BACKGROUND AND PURPOSE

Blood loss after total knee arthroplasty (TKA) may lead to anemia, blood transfusions, and increased total costs. Also, bleeding into the periarticular tissue may cause swelling and a reduction in quadriceps strength, thus impairing early functional recovery. In this randomized, double-blind, placebo-controlled study, we analyzed the possible effect of fibrin sealant on blood loss and early functional recovery in a fast-track setting.

METHODS

24 consecutive patients undergoing bilateral simultaneous TKA were included. 10 mL of fibrin sealant (Evicel) was sprayed onto one knee whereas the contralateral knee had saline. Drain output, the primary outcome, was measured from knee drains removed exactly 24 h after surgery. Secondary outcomes (knee swelling, pain, strength of knee extension, and range of movement (ROM)) were evaluated up to 21 days after surgery.

RESULTS

The drain output in knees treated with fibrin sealant and placebo was similar (582 mL and 576 mL, respectively). Likewise, no statistically significant differences were found between groups regarding swelling, pain, strength of knee extension, and ROM.

INTERPRETATION

Fibrin sealant as a local hemostatic in TKA showed no benefit in reducing drain output or in facilitating early functional recovery when used with a tourniquet, tranexamic acid, and a femoral bone plug.

Effect of knee joint icing on knee extension strength and knee pain early after total knee arthroplasty: a randomized cross-over study

OBJECTIVE

To investigate the acute effect of knee joint icing on knee extension strength and knee pain in patients shortly after total knee arthroplasty.

DESIGN

A prospective, single-blinded, randomized, cross-over study.

SETTING

A fast-track orthopaedic arthroplasty unit at a university hospital.

PARTICIPANTS

Twenty patients (mean age 66 years; 10 women) scheduled for primary unilateral total knee arthroplasty.

INTERVENTIONS

The patients were treated on two days (day 7 and day 10) postoperatively. On one day they received 30 minutes of knee icing (active treatment) and on the other day they received 30 minutes of elbow icing (control treatment). The order of treatments was randomized.

MAIN OUTCOME MEASURES

Maximal knee extension strength (primary outcome), knee pain at rest and knee pain during the maximal knee extensions were measured 2-5 minutes before and 2-5 minutes after both treatments by an assessor blinded for active or control treatment.

RESULTS

The change in knee extension strength associated with knee icing was not significantly different from that of elbow icing (knee icing change (mean (1 SD)) -0.01 (0.07) Nm/kg, elbow icing change -0.02 (0.07) Nm/kg, P = 0.493). Likewise, the changes in knee pain at rest (P = 0.475), or knee pain during the knee extension strength measurements (P = 0.422) were not different between treatments.

CONCLUSIONS

In contrast to observations in experimental knee effusion models and inflamed knee joints, knee joint icing for 30 minutes shortly after total knee arthroplasty had no acute effect on knee extension strength or knee pain.

Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty

OBJECTIVE

To (1) quantify changes in knee-extension strength and functional-performance at discharge after fast-track total hip arthroplasty (THA) and (2) investigate whether these changes correlate to changes in thigh and knee circumference (ie, swelling) or pain.

DESIGN

A prospective, descriptive, hypothesis-generating study.

SETTING

A special unit for fast-track hip and knee arthroplasty operations at a university hospital.

PARTICIPANTS

Twenty-four patients (20 women and 4 men; ages 69 ± 6.1 years) scheduled for primary unilateral THA.

METHODS

All patients were evaluated before surgery and on the day of hospital discharge.

MAIN OUTCOME MEASURES

Knee-extension strength, thigh and knee joint circumference, hip pain, and functional performance (Timed Up & Go, 30-Second Chair Stand, and 10-Meter Walk tests).

RESULTS

All investigated variables changed significantly from before to after surgery, except for hip pain. The average loss in knee-extension strength after surgery (32%, P = .01) did not correlate with increased thigh circumference (6%, P < .01) or knee circumference (3%, P < .01) or with reductions in functional performance: Timed Up & Go test (114%, P = .01), 30-Second Chair Stand test (36%, P = .01), and 10-Meter Walk test (50%, P < .01). Only the increase in knee circumference correlated significantly with reduced performance in the 10-Meter Walk test time (R = -0.59, P < .01), explaining 34% of the variance in the 10-Meter Walk test. No correlations between changes in hip pain and functional performance or knee-extension strength were found. Mean postoperative hospital stay was 2.1 days.

CONCLUSIONS

Knee-extension strength is considerably reduced at discharge after THA, but the early strength reduction does not correlate with changes in thigh or knee circumferences. Because functional performance is also considerably reduced at discharge (unrelated to reduced knee-extension strength), other mechanisms such as fear, avoidance of movement, or decreased hip-muscle strength also may be involved.

Loss of knee-extension strength is related to knee swelling after total knee arthroplasty

OBJECTIVE

To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA).

DESIGN

Prospective, descriptive, hypothesis-generating study.

SETTING

A fast-track orthopedic arthroplasty unit at a university hospital.

PARTICIPANTS

Patients (N=24; mean age, 66y; 13 women) scheduled for primary unilateral TKA were investigated 1 week before surgery and on the day of hospital discharge 2.4 days postsurgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We assessed all patients for knee-joint circumference, knee-extension strength, and functional performance using the Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking tests, together with knee pain during all active test procedures.

RESULTS

All investigated variables changed significantly from pre- to postsurgery independent of knee pain. Importantly, knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength (r=-.51; P=.01). Reduced fast-speed walking correlated significantly with decreased knee-extension strength (r=.59; P=.003) and decreased knee flexion (r=.52; P=.011). Multiple linear regression showed that knee swelling (P=.023), adjusted for age and sex, could explain 27% of the decrease in knee-extension strength. Another model showed that changes in knee-extension strength (P=.009) and knee flexion (P=.018) were associated independently with decreased performance in fast-speed walking, explaining 57% of the variation in fast-speed walking.

CONCLUSIONS

Our results indicate that the well-known finding of decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Future studies may look at specific interventions aimed at decreasing knee swelling postsurgery to preserve knee-extension strength and facilitate physical rehabilitation after TKA.

Timed up & go test score in patients with hip fracture is related to the type of walking aid

Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed Up & Go test score in patients with hip fracture is related to the type of walking aid.

OBJECTIVE

To determine the relationship between Timed Up & Go (TUG) test scores and type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG in patients with hip fracture who were allowed full weight-bearing (FWB).

DESIGN

Prospective methodological study.

SETTING

An acute orthopedic hip fracture unit at a university hospital.

PARTICIPANTS

Patients (N=126; 90 women, 36 men) with hip fracture with a mean age +/- SD of 74.8+/-12.7 years performed the TUG the day before discharge from the orthopedic ward.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The TUG was performed with the walking aid the patient was to be discharged with: a walker (n=88) or elbow crutches (n=38). In addition, all patients also performed the TUG using a rollator.

RESULTS

Patients who performed the TUG with a walker were on average 13.6 (95% confidence interval [CI], 11.2-16.1) seconds faster using a rollator compared with the walker (P<.001). Correspondingly, patients who performed the TUG with crutches were on average 3.5 (95% CI, 1.5-5.4) seconds faster using a rollator compared with elbow crutches (P=.001). In both patient groups, the between walking-aid scores were strongly correlated (r>.833, P<.001).

CONCLUSIONS

TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who are allowed FWB when discharged from the hospital, but all patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid when evaluating changes or comparing TUG scores in patients with hip fracture.

Different impact of excision repair cross-complementation group 1 on survival in male and female patients with inoperable non-small-cell lung cancer treated with carboplatin and gemcitabine

PURPOSE

The excision repair cross-complementation group 1 (ERCC1) status was assessed in patients receiving carboplatin and gemcitabine for inoperable non-small-cell lung cancer (NSCLC). We analyzed the association between the ERCC1 status and the overall survival after the chemotherapy.

PATIENTS AND METHODS

We retrospectively identified 163 patients with inoperable NSCLC and sufficient tumor tissue for ERCC1 analysis, who had received carboplatin and gemcitabine as first-line treatment. Immunohistochemistry was used to assess the expression of ERCC1.

RESULTS

One hundred sixty-three patients were included. Seventy (42%) were ERCC1 positive. Patients treated with carboplatin and gemcitabine and having ERCC1-negative tumors had a significantly increased survival when compared to patients with ERCC1-positive tumors (median survival, 12.0 months v 8.2 months; P = .02). This difference was mainly seen in men, where those with ERCC1-negative tumors had a significantly increased survival compared to men with ERCC1-positive tumors (median survival, 11.8 months v 7.9 months; P = .005). Conversely, women who were ERCC1 negative did not have a survival advantage over ERCC1-positive women.

CONCLUSION

We confirmed previous reports that ERCC1 expression is predictive for outcome in patients treated with carboplatin and gemcitabine. Patients with ERCC1-negative tumors had an increased survival compared to patients with ERCC1-positive tumors and this difference was mainly attributable to a survival difference among men.

Electroencephalographic prediction of anoxic brain damage after resuscitation from cardiac arrest in patients with acute myocardial infarction

The short-term prognostic value of routine electroencephalography (EEG), carried out on the days after cardiac arrest, was evaluated in a consecutive study of 185 patients with acute myocardial infarction together with an episode of clinical cardiac arrest. The individual EEGs were classified on a 5-grade scale. Of the 89 patients who survived, 18 had signs of anoxic brain damage; 96 patients died, 76 as a result of cerebral anoxia. Only 2 patients survived out of the total of 72 for whom the first EEG was classified as grades III--V. The EEGs of both these patients were recorded within a few hours after the cardiac arrest. None of the patients with an EEG of grade I died of cerebral anoxia, while all degrees of brain damage were otherwise observed in connection with EEGs of both grades I and II. It is concluded that an EEG of grades III--V indicates a fatal outcome, provided it has been recorded more than 24 hours after the cardiac arrest. A grade III--V EEG that is recorded within 24 hours after a cardiac arrest should be repeated some days later. It is not possible, on the basis of a single EEG, to predict the extent of the anoxic brain damage.

[Rehabilitation after total knee arthroplasty]

The short- and long-term benefits of post-discharge physiotherapy regimens after total knee arthroplasty are debatable. A national survey including hospitals in Denmark that perform total knee arthroplasty showed a large variability in indication and regimen for post-knee arthroplasty rehabilitation. Since hospital stay duration has decreased considerably, the need for post-discharge physiotherapy may also have changed. Thus, the indication for and types of rehabilitation programmes need to be studied within the context of fast-track knee arthroplasty.

Treatment of severe hypodontia–oligodontia—an interdisciplinary concept

The authors' experience with oral rehabilitation of patients suffering from oligodontia (i.e. six or more congenitally missing permanent teeth, third molars excluded) is reported. The concept is based on an interdisciplinary team approach involving pedodontists, orthodontists, maxillofacial surgeons and prosthodontists. A series of 112 consecutive patients suffering from oligodontia were referred from 1997 to 2001. Ten of the patients (8.9%) suffered from ectodermal dysplasia. The total number of missing teeth was 1126, with an average of 10 per patient. Ninety-two patients had either finished treatment or were on an active treatment schedule. Of these, 97% underwent some kind of orthodontic treatment. Of the 112 patients, 51 had finished treatment at the end of the follow-up period (mean 28 months, range 1-68). Of these, fixed implant-supported prosthetic restoration was used in 90% to replace missing teeth, often combined with alveolar ridge augmentations (73%), sinus floor augmentation (43%), inferior alveolar nerve transposition (18%) and orthognathic surgery (27%). Early diagnosis, and comprehensive treatment planning with good coordination and timing of the individual treatment phases are decisive for a successful treatment outcome. The therapeutic concept is presented with special emphasis on surgical aspects.

Epidermal growth factor receptor gene copy number and protein level are not associated with outcome of non-small-cell lung cancer patients treated with chemotherapy

BACKGROUND

Survival benefit of non-small-cell lung cancer (NSCLC) patients treated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors is predicted by high EGFR gene copy number and by strong EGFR protein expression. Clinical relevance of these features in patients treated with chemotherapy has not been reported.

PATIENTS AND METHODS

This study included 82 NSCLC patients treated with chemotherapy. There were 45% of females, 6% of never smokers and 45% of patients diagnosed with adenocarcinoma. EGFR gene copy number was evaluated by fluorescence in situ hybridization and EGFR protein level by immunohistochemistry.

RESULTS

High EGFR gene copy number and protein level were found in 33% and 71% of patients, respectively. Both markers were significantly associated (P = 0.01). For objective response and disease control, there was no difference between patients defined as negative or positive for both EGFR gene copy number (P = 0.39 and P = 1.00, respectively) and for EGFR protein (P = 1.00 and P = 0.80, respectively). There were no differences in progression-free and overall survival according to EGFR gene copy number (P = 0.76 and P = 0.82, respectively) and protein level (P = 0.67 and P = 0.62, respectively).

CONCLUSION

In chemotherapy-treated NSCLC patients, EGFR gene copy number was positively associated with protein level but none of the features were predictive for either treatment response or survival.

Genetic correlations between reproduction and production traits in swine

Genetic correlations between reproduction and production traits were estimated in swine. Reproduction traits investigated were age at first service (AFS), number of live-born piglets in the first litter (NBA1), interval from weaning to first service after first litter (WTS1), number of live-born piglets in the second litter (NBA2), and interval from weaning to first service after the second litter (WTS2). Females generating the data were Norwegian Landrace born in nucleus herds between 1990 and 2000, and the number of records ranged from 13,792 to 56,932. Genetic correlations were estimated among the main production traits in the breeding goal: adjusted age at 100 kg live weight (A100), percentage of lean meat content (LMC), individual feed consumption from 25 to 100 kg (FC), and bacon side quality (BSQ). Average adjusted backfat thickness (BF) was included as a production trait. The A100 and BF traits were recorded on gilts on-farm with 190,454 records, whereas LMC, BSQ, and FC were recorded on-station with the number of records ranging from 12,487 to 12,992. Analyses were carried out with a multivariate animal model using average information restricted maximum likelihood procedures by first running each reproduction trait with A100 and BF, followed by each reproduction trait with LMC, BSQ, and FC. Average heritabilities for reproduction traits were as follows: AFS (0.38), NBA1 (0.11), WTS1 (0.06), NBA2 (0.12), and WTS2 (0.03); and for production traits: A100 (0.30), BF (0.44), FC (0.22), LMC (0.58), and BSQ (0.23). The highest genetic correlation was estimated between A100 and AFS (r(g)= 0.68), also resulting in a positive genetic correlation between FC and AFS. Growth (A100) was negatively (i.e., unfavorably) genetically correlated to NBA1 and NBA2 (r(g) = 0.60 and rg = 0.42 respectively), and so the genetic correlation to FC also became unfavorable (r(g)= 0.23 and r(g) = 0.20). Single-trait selection for enhanced LMC would also affect NBA1 and NBA2 unfavorably (r(g)= -0.12 and r(g)= -0.24). Correlations between BF at 100 kg live weight and reproduction traits were close to zero; however, a low genetic correlation between BF and WTS1 was obtained (r(g)= -0.12), indicating that selection toward reduced BF at 100 kg live weight may have an unfavorable impact on WTS1.

Prognostic significance of EGFR FISH and IHC in non small-cell lung cancer patients treated with chemotherapy alone

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Background: High EGFR gene copy number by fluorescence in situ hybridization (FISH) predicts response and survival benefit in non small-cell lung cancer (NSCLC) patients (pts) treated with EGFR tyrosine-kinase inhibitors, but its prognostic value remains debated. We aimed to evaluate the association of EGFR FISH, EGFR immunohistochemistry (IHC) and prognosis in NSCLC pts treated with chemotherapy alone. Methods: 85 pts treated with platinum-containing chemotherapy (median follow up of 15 months [range: 2–29 months]) were included in the study. There were 47% females, 35% of pts with performance status (PS) 0, 53% PS = 1 and 12% PS = 2, 6% of never-smokers. Median age was 62 years (range: 41–80 years). Stage I-IIIA was diagnosed in 7%, stage IIIB - 44% and stage IV - 48% pts. Adenocarcinoma was the most common histology (51% pts). EGFR FISH was performed using LSI EGFR SpectrumOrange/CEP 7 SpectrumGreen probe and IHC using DAKO PharmDx kit. Results: FISH results were available in 79 pts (93%), and EGFR FISH-positive tumors (high polysomy or gene amplification) were found in 28 pts (35%). IHC results were available in 81 pts (95%) and 25 pts (31%) were scored as positive (staining index ≥200). Distribution of clinical characteristics did not differ according to either FISH or IHC result. FISH-positive pts had higher EGFR IHC staining indices as compared with FISH-negative pts (median 160 vs. 60, p = 0.005, Mann-Whitney U test). Median survival of FISH-positive pts was 12.6 months vs. 8.1 months in FISH-negative pts (log-rank p = 0.68; HR = 0.88 [95% CI: 0.49–1.59]) and the respective figures for progression-free survival (PFS) were 7.5 vs. 4.9 months, log-rank p = 0.72; HR = 0.91 [95% CI: 0.55–1.51]. Median survival in IHC-positive vs. IHC-negative pts was 6.6 months vs. 9.2 months (log-rank p = 0.44; HR = 1.27 [95% CI: 0.69–2.36]). There was no significant difference in PFS (median of 4.8 vs. 5.3 months, respectively; log-rank p = 0.71; HR = 1.11 [95% CI: 0.64–1.92]). FISH and IHC remained insignificant in a Cox regression survival analysis. Conclusion: In this cohort of NSCLC patients treated with chemotherapy alone, EGFR FISH was associated with EGFR IHC and both features had no statistically significant influence on prognosis.

[Table: see text]

Genetic analysis of litter size, parturition length, and birth assistance requirements in primiparous sows using a joint linear-threshold animal model

The aim of this study was to investigate whether selection for number of live born piglets has led to prolonged parturition and increased requirement for birth assistance, resulting in increased numbers of stillborn piglets. Data were collected from 6,718 primiparous Norwegian Landrace sows farrowing between 2001 and 2003. The need for birth assistance was recorded as a binary response. Physical intervention in the birth of piglets and/or hormonal treatment by the farmer was recorded as birth assistance. The duration of the parturition was analyzed as a binary trait (<4 h and >4 h). The statistical model used for analysis included contemporary groups of herd-year, litter breed, season of farrowing, parity in which the sow was born, a regression on the age of sow at farrowing, an additive genetic effect, and a service sire effect. A full Bayesian approach via Gibbs sampling was adopted to estimate the genetic relationships between these four traits. A total chain length of 100,000 iterations was run. The first 10,000 samples were discarded as burn-in, and the remaining 90,000 iterations were retained without thinning for post-Gibbs analysis. The highest direct heritability was estimated for the number of live-born piglets (h2 = 0.07), followed by the duration of farrowing (h2 = 0.05), the need for birth assistance (h2 = 0.05), and the number of stillborn piglets (h2 = 0.04). The genetic correlations revealed that the number of live and stillborn piglets was uncorrelated; however, the number of live piglets born had a moderate genetic correlation to the need for birth assistance (rg = 0.24 +/- 0.01) and duration of farrowing (rg = -0.20 +/- 0.01), whereas the number of stillborn piglets was highly correlated to the need for birth assistance (rg = 0.74 +/- 0.01) and the duration of parturition (rg = 0.66 +/- 0.01). The duration of farrowing and the need for birth assistance were genetically highly correlated (rg = 0.89 +/- 0.00). For all traits, the service sire variance was approximately one quarter in magnitude compared with its respective genetic variance. The results showed that selection for the number of live born piglets is not expected to influence the number of stillborn piglets. Increasing the number of live piglets born through selection should have a slight negative effect on farrowing duration and a minor increase in the need for birth assistance. Sows with a high genetic potential for birth assistance and prolonged parturition were more likely to give birth to greater numbers of stillborn piglets.

Factors associated with nutritional status in a group of people in an early stage of dementia

BACKGROUND & AIM

Beside cognitive and behavioural problems, nutritional difficulties and weight loss are often observed at the beginning of dementia disease. This weight loss has been hard to explain. But previous research has shown that it is not related to increased energy expenditure but rather to deficiency in intake at the beginning of the disease. The aim of this study was to investigate possible factors that may be associated with nutritional status among people in an early stage of dementia.

METHODS

Fifty-nine individuals with perceived impaired memory were interviewed with three assessment instruments and a number of other structured questions.

RESULTS

The results showed that predictors for nutritional status were: eating smaller portions, partly lost learned practices, and having a dry mouth.

CONCLUSIONS

Caring actions for this patient group should focus on support at meals and maintaining oral health.

Chemoenzymatic synthesis of sialylated glycopeptides derived from mucins and T-cell stimulating peptides

The Tn, T, sialyl-Tn, and 2,3-sialyl-T antigens are tumor-associated carbohydrate antigens expressed on mucins in epithelial cancers, such as those affecting the breast, ovary, stomach, and colon. Glycopeptides carrying these antigens are of interest for development of cancer vaccines and a short, chemoenzymatic strategy for their synthesis is reported. Building blocks corresponding to the Tn (GalNAc alpha-Ser/Thr) and T [Gal beta(1-->3)GalNAc alpha-Ser/Thr] antigens, which are relatively easy to obtain by chemical synthesis, were prepared and then used in the synthesis of glycopeptides on the solid phase. Introduction of sialic acid to give the sialyl-Tn [Neu5Ac alpha(2-->6)GalNAc alpha-Ser/Thr] and 2,3-sialyl-T [Neu5Ac alpha(2-->3)Gal beta(1-->3)GalNAc alpha-Ser/Thr] antigens is difficult when performed chemically at the building block level. Sialylation was therefore carried out with recombinant sialyltransferases in solution after cleavage of the Tn and T glycopeptides from the solid phase. In the same manner, the core 2 trisaccharide [Gal beta 1-->3(GlcNAc beta 1-->6)GalNAc] was incorporated in glycopeptides containing the T antigen by using a recombinant N-acetylglucosaminyltransferase. The outlined chemoenzymatic approach was applied to glycopeptides from the tandem repeat domain of the mucin MUC1, as well as to neoglycosylated derivatives of a T cell stimulating viral peptide.

Materials science. The hardest known oxide

A material as hard as diamond or cubic boron nitride has yet to be identified, but here we report the discovery of a cotunnite-structured titanium oxide which represents the hardest oxide known. This is a new polymorph of titanium dioxide, where titanium is nine-coordinated to oxygen in the cotunnite (PbCl2) structure. The phase is synthesized at pressures above 60 gigapascals (GPa) and temperatures above 1,000 K and is one of the least compressible and hardest polycrystalline materials to be described.

[Thalassemia and sickle-cell disease in Norway]

BACKGROUND

Thalassemia is common in the Mediterranean countries, the Middle East, parts of India and South East Asia, with the prevalence of mutations reported to be 2.5-15%. Sickle-cell anaemia is endemic primarily in central parts of Africa, but it also appears in the thalassaemia areas. The purpose of this study was to establish the prevalence of beta-thalassaemia, alfa-thalassaemia and sickle-cell anaemia in Norway.

MATERIAL AND METHODS

A questionnaire was sent to 149 departments of paediatrics, gynaecology and medicine in Norway. We asked for numbers registered in 1996 and 1997 of beta-thalassaemia and alfa-thalassaemia with subgroups, and sickle-cell anaemia.

RESULTS

The number of patients with thalassaemia was 44 (0.001%) in 1996 and 48 in 1997. In 1996 there were 28 patients with beta-thalassaemia minor, three with intermediary and five major, and six patients with alfa-thalassaemia minor and one with major. In 1996, ten patients were registered with sickle-cell anaemia; in 1997, fifteen patients.

INTERPRETATION

The numbers of patients with thalassaemia major or sickle-cell anaemia probably reflect the true prevalence of these diseases. However, for thalassaemia minor and sickle-cell anaemia trait the numbers appear to be too low, as most of these patients do not contact a hospital. The appearance of these diseases in Norway is closely related to immigration from endemic areas.

Cardiovascular responses to cold-water immersions of the forearm and face, and their relationship to apnoea

Apnoea as well as cold stimulation of the face or the extremities elicits marked cardiovascular reflexes in humans. The purpose of this study was to investigate whether forearm immersion in cold water has any effect on the cardiovascular responses to face immersion and apnoea. We recorded cardiovascular responses to coldwater immersions of the forearm and face in 19 (part I) and 23 subjects (part II). The experimental protocol was divided in two parts, each part containing four tests: I1, forearm immersion during eupnoea; I2, face immersion during eupnoea; I3, forearm and face immersion during eupnoea; I4, face immersion during apnoea; II1, apnoea without immersion; II2, forearm immersion during apnoea; II3, face immersion during apnoea; and II4, forearm and face immersion during apnoea. The water temperature was 9-11 degrees C. Cold-water immersion of either the forearm or face was enough to elicit the most pronounced thermoregulatory vasoconstriction during both eupnoea and apnoea. During eupnoea, heart rate responses to forearm immersion (3% increase) and face immersion (9% decrease) were additive during concurrent stimulation (3% decrease). During apnoea, the heart rate responses were not affected by the forearm immersion. The oxygen-conserving diving response seems to dominate over thermoregulatory responses in the threat of asphyxia. During breathing, however, the diving response serves no purpose and does not set thermoregulatory adjustments aside.

Depressed immunity and impaired proliferation of hematopoietic progenitor cells in patients with complete spinal cord injury

The bone marrow is supplied with both sensory and autonomic neurons, but their roles in regulating hematopoietic and immunocompetent cells are unknown. Leukocyte growth and activity in patients with stable and complete spinal cord injuries were studied. The innervation of the bone marrow below the injury level lacked normal supraspinal activity, that is, a decentralized bone marrow. Lymphocyte functions were markedly decreased in injured patients. Long-term colony formation of all hematopoietic cell lineages, including dendritic cells, by decentralized bone marrow cells was substantially reduced. It was concluded that nonspecific and adaptive lymphocyte-mediated immunity and growth of early hematopoietic progenitor cells are impaired in patients with spinal cord injuries. Possibly, this reflects cellular defects caused by the malfunctioning neuronal regulation of immune and bone marrow function.

Theoretical investigation of high pressure phases of carbon dioxide

The recent discovery of a new solid phase of carbon dioxide ( CO2-V) has made it apparent that the properties of this vital chemical species are drastically altered under high pressure conditions. The reported transition at around 40 GPa from the Cmca phase ( CO2-III), which is a molecular solid, into the novel phase, which was observed to be quartzlike, clearly suggests a dramatic change of the chemical, electronic, and structural properties. We here present a theoretical analysis of the implications of this metamorphosis. At even higher pressures, we predict the existence of a very hard phase of the stishovite type.

Effects of physical and apnea training on apneic time and the diving response in humans

The aim of this investigation was to study separately the effects of physical training and apnea training on the diving response and apneic time in humans. Both types of training have been suggested to lead to prolonged apneic time and an increased "diving response" (i.e., regional vasoconstriction and bradycardia). The study was also designed to examine the effects of these two types of training on the characteristics of the increase in apneic time with repeated apneas. Simulated diving tests were performed before and after the different training programs. The test format was one apnea and five apneas with facial immersion in cold water at 2-min intervals. An increase in apneic time was observed after physical training (n = 24), and this was attributable to an increased time beyond the physiological breaking point. The other parameters that were measured remained unaffected. After apnea training (n = 9), however, apneic time was increased by a delay in the physiological breaking point, which is mainly determined by the arterial tension of CO2. The diving response had increased, and the effect of repeated apneas on apneic time tended to be larger after apnea training. These results may explain the pronounced diving responses and long apneas observed in trained apneic divers.

Implant-supported mandibular overdentures retained with ball or bar attachments: a randomized prospective 5-year study

PURPOSE

The aim of the present study was to evaluate the periimplant conditions and the maintenance requirements for implant-supported overdentures in the mandible retained with ball or bar attachments during a 5-year period.

MATERIALS AND METHODS

Twenty-six completely edentulous patients had two Astra Tech dental implants placed in the anterior part of the mandible. The denture attachment system for the patients was chosen randomly by drawing lots. Eleven patients drew the bar attachment system and fifteen patients drew the ball attachment system. Plaque Index, Gingival Index, and probing pocket depth were assessed around each implant. Periotest values were recorded, and periodically identical intraoral radiographs were obtained with a specially designed film-holding device.

RESULTS

No implants were lost from baseline to the 5-year registration. The periimplant conditions were very healthy after 5 years. No significant differences of the periimplant variables were recorded between the bar and the ball groups. During the first year of function, significantly more complications/repairs were registered in the bar group than in the ball group. In the following years, no significant differences were registered. The mean frequency of complications/repairs per patient per year was 1.0 in the bar group and 0.6 in the ball group during the 5-year observation period.

CONCLUSION

Two implants with ball or bar attachment supported an overdenture in the mandible for 5 years with a 100% survival rate. No differences in marginal bone loss or health of the periimplant mucosa were observed between bar and ball attachment, but the frequency of technical complications/repairs per patient was higher around bar than ball attachments.

IL-13 can substitute for IL-4 in the generation of dendritic cells for the induction of cytotoxic T lymphocytes and gene therapy

Immunization with tumor-associated antigen pulsed dendritic cells (DC) has been shown to elicit both protective and therapeutic antitumor immunity in a variety of animal models and is currently being investigated for the treatment of cancer patients in clinical trials. In this study we show that DC can be generated from peripheral blood mononuclear cells of healthy donors as well as breast and melanoma cancer patients using granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-13 (IL-13) and that these DC have many of the same characteristics as DC differentiated using GM-CSF and IL-4. The DC generated in GM-CSF and IL-13 are CD14- and express high levels of the cell surface markers CD86, HLA-DR, and CD58, as do DC generated in GM-CSF and IL-4. The purity and yield of both DC populations are not significantly different. Furthermore, both populations of DC are effective at presentation of alloantigen as determined in a mixed lymphocyte response, and both are able to process and present soluble tetanus toxoid antigen to CD4+ T cells. Because we are interested in the generation of DC for antigen-specific cytotoxic T lymphocyte (CTL) generation, we compared the ability of peptide-pulsed DC differentiated in GM-CSF and IL-4 versus GM-CSF and IL-13 for the generation of influenza and MART-1 specific CTL. Both populations of DC induced CD3+ CD8+ CD4- and CD56- CTL, which could lyse the appropriate targets in an antigen-specific manner. Finally, both GM-CSF and IL-4 DC and GM-CSF and IL-13 DC yielded similar beta galactosidase expression levels after transduction with recombinant adenovirus containing the LacZ gene. These results suggest that DC generated in GM-CSF and IL-13 may be useful for immunotherapy and gene therapy protocols.

Cardiovascular change in elderly male breath-hold divers (Ama) and their socio-economical background at Chikura in Japan

The Ama have existed for more than 2000 years in Japan and Korea. They have been diving for seaweed and molluscs. Their traditional way of fishing, with goggles or a mask, but without a wetsuit, is still practised as a result of laws against overfishing. We investigated cardiovascular diving responses, expressed as heart rate (HR) reduction, peripheral vasoconstriction indicated by skin blood flow (SkBF) and mean arterial blood pressure (MAP) during breath-hold face immersion in a group of eight elderly male Ama at Chikura, Japan. Their data were compared to those from three other groups: a) elderly non-divers; b) young divers and c) young non-divers. Our previous studies have shown that young divers show a more pronounced bradycardia than young non-divers. The present study of elderly Ama and elderly non-divers was performed to investigate if this difference persists in old age. We found that, in spite of many years of diving experience, HR reduction of the elderly professional divers observed during face immersion did not differ from that of elderly non-divers, but it was much less pronounced than in the two younger groups. We conclude that even if a well-developed diving response at young age has been reduced to the level of non-divers, the Ama are still able to continue their work of diving in old age. Ama that has been a traditionally female occupation, is mostly practised by men at Chikura today. No young have been recruited for this profession. Therefore, the present Ama are senior and the traditional breath-hold diving will probably cease to exist in the near future. The probable reasons for these changes are discussed.