117 THE ASSOCIATION BETWEEN SELF-REPORTED SENSORY FUNCTION (VISION AND HEARING) AND COGNITIVE FUNCTION FROM THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)

Background

With an aging population worldwide and in Ireland, comes more age-related health problems, including problems with hearing and vision. Ageing is also associated with a gradual decline in some cognitive functions. Sensory impairments (both hearing and vision) have been shown to have an association with cognitive impairment, with a greater cognitive decline seen in those with a combined hearing and vision loss. There is a well-established association between sensory and cognitive impairment, however, no study to date has looked at similar data collected in Ireland. The objective of this study is to analyse data from an Irish sample.

Methods

This study used data collected from Wave 4 of the Irish Longitudinal Study on Ageing (TILDA). Participants with missing data or information were excluded, leaving a complete dataset of 4,612, for analysis. Multiple linear regression analyses were carried out to compare Mini-Mental State Examination (MMSE) scores to self-reported sensory impairment (hearing impairment alone, vision impairment alone and Dual Sensory Impairment (DSI)) while adjusting for several covariates (age, gender, level of education, alcohol consumption, smoking history, depressive symptoms, mobility, loneliness, and physical activity).

Results

Self-reported fair/poor hearing and self-reported fair/poor vision had statistically significant lower MMSE scores than participants with self-reported excellent/very good/good hearing and self-reported excellent/very good/good vision respectively (hearing estimated standard error: –0.055, p value: 3.67e-11; vision estimated standard error: –0.080, p value: 5.14e-15). Self-reported DSI was associated with lower MMSE scores compared to participants without DSI (DSI estimated standard error: –0.13, p value: 5.55e-13).

Conclusion

This cross-sectional study and secondary data analysis demonstrated that in older Irish adults there is an association between hearing impairment, vision impairment and dual sensory impairment and lower cognitive function. These findings contribute to the growing body of research done internationally using other large scale health surveys.

Gender and immunosuppression impact on Merkel cell carcinoma diagnosis and prognosis. A population based cohort study

Background

Merkel cell carcinoma (MCC), a rare cutaneous neuroendocrine endocrine tumour is increasing in incidence, and continues to carry a poor prognosis.

Objectives

The objectives of this study were to examine all Irish cases of MCC from 1 January 1994 over 2 decades, focusing on gender and organ transplantation recipients (OTRs). Cases were identified from the National Cancer Registry of Ireland. Covariates of interest included age, body site, period of diagnosis, deprivation‐status and history of non‐melanoma skin cancer (NMSC).

Results

In total 314 MCC cases were identified. A female predominance was noted (53.8%). Comparison between age‐standardised rates between the earliest period (1994–1996) with the latest period (2012–2014) showed an increase of 105% in total. The trend in age‐standardised incidence rates were noted to be increasing significantly (p = 0.0004). Average age at diagnosis was 77.6 years (male 75.1 years, female 79.7 years). Overall, the majority of MCC cases presented on the head and neck (n = 170, 54.1%). Differences in anatomical location of MCCs were noted between genders. Males were found to be more likely to have a history of previous NMSCs (males n = 73 [57.9%], females n = 53 [42.1%]). Thirty‐one percentage of patients died from MCC, average survival was 3.5 years in those who died of this malignancy. Ten organ transplant recipients developed MCC. OTR who developed MCC were diagnosed at a younger average age of 65.1 years. Standardized incidence ratio for MCC in OTR was 59.96. A higher proportion of OTR died from MCC (70%), with a shorter median survival of 0.14 years. In competing risks regression, gender was not significantly associated with risk of dying, females having a non‐significantly higher hazard of dying. Organ transplant recipients and patients from less deprived areas were at greater risk of dying from MCC.

Conclusions

This population based study provides epidemiological, clinical and outcome data for MCC over a 20‐year period.

Association between end-of-life cancer care and immigrant status: a retrospective cohort study in Ontario, Canada

OBJECTIVE

To compare recent immigrants and long-term residents in Ontario, Canada, on established health service quality indicators of end-of-life cancer care.

DESIGN

Retrospective, population-based cohort study of cancer decedents between 2004 and 2015.

SETTING

Ontario, Canada.

PARTICIPANTS

We grouped 13 085 immigrants who arrived in Ontario in 1985 or later into eight major ethnic groups based on birth country, mother tongue and surname, and compared them to 229 471 long-term residents who were ≥18 years at the time of death.

PRIMARY AND SECONDARY OUTCOME MEASURES

Aggressive care, defined as a composite of ≥2 emergency department visits, ≥2 new hospitalisations or an intensive care unit admission within 30 days of death; and supportive care, defined as a physician house call within 2 weeks, or palliative nursing or personal support worker home visit within 6 months of death. Multivariable logistic regression was used to examine the association between immigration status and the odds of each main outcome.

RESULTS

Compared with long-term residents, immigrants overall and by ethnic group had higher rates of aggressive care (13.7% vs 17.5%, respectively; p<0.001). Among immigrants, Southeast Asians had the highest use while White-Eastern and Western Europeans had the lowest. Supportive care use was similar between long-term residents and immigrants (50.0% vs 50.5%, respectively; p=0.36), though lower among Southeast Asians (46.6%) and higher among White-Western Europeans (55.6%). After adjusting for sociodemographic characteristics and comorbidities, immigrants remained more likely than long-term residents to receive aggressive care (OR: 1.15, 95% CI 1.09 to 1.21), yet were less likely to receive supportive care (OR: 0.95, 95% CI 0.91 to 0.98).

CONCLUSIONS

Among cancer decedents in Ontario, immigrants are more likely to use aggressive healthcare services at the end of life than long-term residents, while supportive care varies by ethnicity. Contributors to variation in end-of-life care require further study.

Antimicrobial Use in US Hospitals: Comparison of Results From Emerging Infections Program Prevalence Surveys, 2015 and 2011

BACKGROUND

In the 2011 US hospital prevalence survey of healthcare-associated infections and antimicrobial use 50% of patients received antimicrobial medications on the survey date or day before. More hospitals have since established antimicrobial stewardship programs. We repeated the survey in 2015 to determine antimicrobial use prevalence and describe changes since 2011.

METHODS

The Centers for Disease Control and Prevention's Emerging Infections Program sites in 10 states each recruited ≤25 general and women's and children's hospitals. Hospitals selected a survey date from May-September 2015. Medical records for a random patient sample on the survey date were reviewed to collect data on antimicrobial medications administered on the survey date or day before. Percentages of patients on antimicrobial medications were compared; multivariable log-binomial regression modeling was used to evaluate factors associated with antimicrobial use.

RESULTS

Of 12 299 patients in 199 hospitals, 6084 (49.5%; 95% CI, 48.6-50.4%) received antimicrobials. Among 148 hospitals in both surveys, overall antimicrobial use prevalence was similar in 2011 and 2015, although the percentage of neonatal critical care patients on antimicrobials was lower in 2015 (22.8% vs 32.0% [2011]; P = .006). Fluoroquinolone use was lower in 2015 (10.1% of patients vs 11.9% [2011]; P < .001). Third- or fourth-generation cephalosporin use was higher (12.2% vs 10.7% [2011]; P = .002), as was carbapenem use (3.7% vs 2.7% [2011]; P < .001).

CONCLUSIONS

Overall hospital antimicrobial use prevalence was not different in 2011 and 2015; however, differences observed in selected patient or antimicrobial groups may provide evidence of stewardship impact.

The use of imaging in endometrial cancer prior to potential surgery: Are guidelines being followed?

OBJECTIVES

Clinical practice guidelines recommend against routine preoperative axial imaging studies (CT/MRI) for endometrial cancer, except for cases of locally advanced disease or aggressive histologies. This study utilized population-based data to evaluate the use of preoperative imaging and factors associated with its use.

METHODS

A population-based cohort of women diagnosed with endometrial cancer from 2006 to 2016 were identified from the Ontario Cancer Registry in Ontario, Canada. Patients were excluded if they had: hysterectomy prior to the date of diagnosis, non-epithelial histology or a prior cancer diagnosis within 5 years. Preoperative imaging (CT or MRI) rates were calculated over time. Predictive factors for preoperative imaging use were determined using multi-variable regression analysis.

RESULTS

17,718 cases were eligible for analysis. From 2006 to 2016, the proportion of patients receiving preoperative imaging increased from 22.2% to 39.3%. In a subgroup of patients with low-risk disease (stage 1, endometrioid adenocarcinoma), imaging increased from 16.3% to 29.5%. Multivariate analysis showed an association between preoperative imaging and advanced stage, advanced grade, non-endometrioid morphology, surgery with a gynecologic oncologist, surgery at a teaching hospital and a later year of diagnosis. From 2006 to 2016, the yearly incidence of endometrial cancer increased from 22.3/100,000 to 36.1/100,000, representing a mean annual increase of 3.6% per year.

CONCLUSIONS

Endometrial cancer incidence and the use of preoperative imaging are increasing. Factors most associated with preoperative imaging are high-risk features. However, preoperative imaging is still being performed in low-risk patients, indicating non-adherence to guidelines, which has implications for constrained healthcare resources.

The Standardized Antimicrobial Administration Ratio: A New Metric for Measuring and Comparing Antibiotic Use

Background

To provide a standardized, risk-adjusted method for summarizing antibiotic use (AU), enable hospitals to track their AU over time and compare their AU data to national benchmarks, the Centers for Disease Control and Prevention developed the Standardized Antimicrobial Administration Ratio (SAAR).

Methods

Hospitals reporting to the National Healthcare Safety Network (NHSN) AU Option collect and submit aggregated AU data electronically as antimicrobial days of therapy per patient days present. SAARs were developed for specific NHSN adult and pediatric patient care locations and cover five antimicrobial agent categories: (1) broad-spectrum agents predominantly used for hospital-onset/multi-drug resistant bacteria; (2) broad-spectrum agents predominantly used for community-acquired infections; (3) anti-methicillin-resistant Staphylococcus aureus agents; (4) agents predominantly used for surgical site infection prophylaxis; and (5) all antibiotic agents. The SAAR is an observed-to-predicted use ratio where predicted use is estimated from a statistical model; a SAAR of 1 indicates that observed use and predicted use are equal.

Results

Most location-level SAARs were statistically significantly different than 1: adult locations up to 52% lower than 1 and up to 41% higher than 1. Median SAARs in adult and pediatric ICUs had a range of 0.667-1.119. SAAR distributions serve as an external comparison to national SAARs.

Conclusions

This is the first aggregate AU metric that uses point-of-care, antimicrobial administration data electronically reported to a national surveillance system to enable risk-adjusted, AU comparisons across multiple hospitals. Endorsed by the National Quality Forum, SAARs provide AU benchmarks that stewardship programs can use to help drive improvements.

Germline genetic testing for inherited prostate cancer in practice: Implications for genetic testing, precision therapy, and cascade testing

BACKGROUND

Genetic testing capability and guidelines are rapidly expanding to assess inherited prostate cancer (PCA). Clinical genetic data from multigene testing can provide insights into the germline pathogenic variant (PV) spectrum and correlates in men with PCA unselected for metastatic disease to optimize identification of men for genetic evaluation and management.

METHODS

A retrospective cross-sectional analysis was conducted of de-identified clinical genetic testing data from a large commercial genetic testing laboratory in the US. ICD-10 claims codes were used to identify men with PCA, along with family history data. Gleason score was abstracted from test request forms. Overall PV rate among men with PCA was estimated, along with PVs in DNA repair genes. Family history and Gleason score association to germline DNA repair PVs was assessed using Fisher's exact test with correction for false-discovery.

RESULTS

As of August 2017, genetic results were available on 1328 men with PCA. Overall PV rate was 15.6%, with 10.9% of PV in DNA repair genes. PVs were most commonly identified in BRCA2 (4.5%), CHEK2 (2.2%), ATM (1.8%), and BRCA1 (1.1%). Breast cancer family history was significantly associated with germline DNA repair PVs (OR 1.89, [95%CI 1.33, 2.68], P = 0.003). Among men with Gleason score>= 6 (n = 706), Gleason> = 8 was significantly associated with DNA repair PVs (OR 1.85 [95%CI 1.22, 2.80], P = 0.004).

CONCLUSIONS

A substantial proportion of men with PCA unselected for metastatic disease carry germline DNA repair PVs. Breast cancer family history and high Gleason score are important predictors to identify men with PCA who may carry germline DNA repair PVs. Our findings support current NCCN guidelines and have implications for genetic assessment, therapeutic management, and cascade testing for men with PCA and their families.

Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals

BACKGROUND

A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care-associated infection. We repeated the survey in 2015 to assess changes in the prevalence of health care-associated infections during a period of national attention to the prevention of such infections.

METHODS

At Emerging Infections Program sites in 10 states, we recruited up to 25 hospitals in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected 1 day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of health care-associated infections. We compared the percentages of patients with health care-associated infections and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of health care-associated infections.

RESULTS

In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had health care-associated infections in 2015 (394 patients [3.2%; 95% confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0%; 95% CI, 3.7 to 4.4]) (P<0.001), largely owing to reductions in the prevalence of surgical-site and urinary tract infections. Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile [now Clostridioides difficile]), and surgical-site infections were the most common health care-associated infections. Patients' risk of having a health care-associated infection was 16% lower in 2015 than in 2011 (risk ratio, 0.84; 95% CI, 0.74 to 0.95; P=0.005), after adjustment for age, presence of devices, days from admission to survey, and status of being in a large hospital.

CONCLUSIONS

The prevalence of health care-associated infections was lower in 2015 than in 2011. To continue to make progress in the prevention of such infections, prevention strategies against C. difficile infection and pneumonia should be augmented. (Funded by the Centers for Disease Control and Prevention.).

Abstract P4-06-09: Addition of a remote genetic counselor to the breast specialist's team improves clinical decision-making

Background: There is a shortage of trained genetic counselors (GC) and often long wait times for appointments, resulting in other specialists frequently ordering genetic testing. However, non-genetic specialists, including breast surgeons, find it difficult to stay current in genetics due to rapid advances in gene discovery, expanded panel offerings, and frequent changes to professional guidelines. We tested a novel model for hereditary cancer risk assessment where breast surgeons had “on demand” access to a remote laboratory-based genetic counselor for peer to peer consultation. In this study we sought to determine the impact this model has on breast surgeons' routinely ordering genetic testing including test identification, ordering patterns, and medical management.

Methods: An IRB approved multi-center prospective study involved 14 community-based breast cancer surgeons experienced with hereditary cancer risk assessment without a genetic counselor as part of their practice. Cases were all discussed with a remote Invitae GC to determine testing eligibility and selection. Physicians had the option to utilize remote GCs to discuss results or to refer to traditional genetic counseling services. Pre and post-test surveys were completed for each patient by the testing physician. To protect patient privacy, a unique case ID was used to link patient test data with identifying data.

Results: A total of 192 patients were evaluated with median age of 52. Risk assessment via BRCAPRO and the Hughes Risk model were performed on 98% of patients by the physicians. 65% of patients met NCCN guidelines for testing. Pathogenic mutations were found in 14% of patients. Breast surgeons changed their test selection 21% of the time after discussion with a GC. They called to discuss results in 47% of cases and medical management changes were incorporated in 15% of these cases based on discussion with a remote GC.

Conclusions: Remote GC provider support assisted physicians in facilitating customized test selection, aided in navigating challenging counseling cases, and impacted clinical management. This service may serve as a viable, effective model for 'on demand' genetic counseling support and may be a novel opportunity to expand genetic testing in a breast surgery setting.

Citation Format: Rosen B, O'Leary E, Shan Y, Pat W, Peter B. Addition of a remote genetic counselor to the breast specialist's team improves clinical decision-making [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-06-09.

Expanded Gene Panel Use for Women With Breast Cancer: Identification and Intervention Beyond Breast Cancer Risk

Background

Clinicians ordering multi-gene next-generation sequencing panels for hereditary breast cancer risk have a variety of test panel options. Many panels include lesser known breast cancer genes or genes associated with other cancers. The authors hypothesized that using broader gene panels increases the identification of clinically significant findings, some relevant and others incidental to the testing indication. They examined clinician ordering patterns and compared the yield of pathogenic or likely pathogenic (P/LP) variants in non-BRCA genes of female breast cancer patients.

Methods

This study analyzed de-identified personal and family histories in 1085 breast cancer cases with P/LP multi-gene panel findings in non-BRCA cancer genes and sorted them into three groups by the panel used for testing: group A (breast cancer genes only), group B (commonly assessed cancers: breast, gynecologic, and gastrointestinal), and group C (a more expanded set of tumors). The frequency of P/LP variants in genes with established management guidelines was compared and evaluated for consistency with personal and family histories.

Results

This study identified 1131 P/LP variants and compared variants in clinically actionable genes for breast and non-breast cancers. Overall, 91.5% of these variants were in genes with management guidelines. Nearly 12% were unrelated to personal or family history.

Conclusion

Broader panels were used for 85.6% of our cohort (groups B and C). Although pathogenic variants in non-BRCA genes are reportedly rare, the study found that most were in clinically actionable genes. Expanded panel testing improved the identification of hereditary cancer risk. Small, breast-limited panels may miss clinically relevant findings in genes associated with other heritable cancers.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-017-5963-7) contains supplementary material, which is available to authorized users.

Unexpected germline mutations in a pan-cancer analysis including sarcoma, renal, and other cancers

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Background: Multi-gene testing for cancer predisposition is increasingly utilized in clinical care. Although the diagnostic yield and management implications of such testing in breast, ovarian and colorectal cancer are relatively well understood, data for other cancer types are still emerging. In this study we retrospectively examined 39,147 patients referred for hereditary cancer syndrome testing for pathogenic germline variants in 80 cancer risk genes, focusing on those patients with renal, sarcoma, paraganglioma, melanoma, and pancreatic cancers. Methods: Test results and personal/family history were extracted from a sequential series of de-identified clinical test reports. Data for genes not clinically ordered were analyzed under an IRB approved research protocol. Common low penetrance risk alleles were excluded. Results: Overall, 14.3% (5,589) of patients carried germline pathogenic mutations in 80 cancer risk genes. Of the 949 patients with renal cancer 20% (190) were positive, and 44% of these findings were “unexpected”, meaning they appeared in genes that are not commonly requisitioned in renal cancer patients. Of the 423 sarcoma patients, 16% (68) had positive findings, 45% of which were “unexpected”. For both cancer types, greater than 90% of these “unexpected” findings were in genes with published management recommendations. Similar results were observed in melanoma, paraganglioma and pancreatic cancer patients. A second or third pathogenic variant, many of which were also “unexpected”, were found in 3.6% of positive cases. Conclusions: In this series of patients we estimate almost 12% of pathogenic variants across cancer indications are “unexpected”. These data suggest many actionable pathogenic variants are being missed due to adherence to overly restrictive, narrowly constructed tumor-specific panels. Clinicians should expand the scope of their test panels in order to capture variants with the potential to impact patients and their family members by informing implementation of established management guidelines.

Need for re-evaluation of current guidelines based on results from germline genetic testing in prostate cancer

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Background: Inherited risk for prostate cancer (PCa) is potentially associated with more aggressive disease. Recent data indicate that DNA repair gene abnormalities may be much more common than previously appreciated, especially BRCA2, ATM, CHEK2, BRCA1, RAD51D, and PALB2. Herein, we investigate the efficacy of a targeted gene panel in men with PCa and evaluate clinical factors in relationship to current guidelines for genetic screening. Methods: DNA sequencing and exon-level copy number analysis were performed in 1158 PCa patients (pts) between 2013 and 2016 at a commercial diagnostic laboratory. The genes requisitioned varied but consistently included 14 genes on a hereditary PCa panel, most of which were DNA repair genes. Evaluation included Gleason scores and eligibility for genetic screening based on any NCCN testing criteria in pts with positive findings (pathogenic, likely pathogenic, and risk allele). Results: Pathogenic findings were identified in 199 of 1158 (17.2%) pts, 13 pts (1.0%) had two variants. Roughly 75% of detected variants were in genes on the hereditary PCa panel, of which 34.4% were BRCA1/2. Positive variants in HOXB13, a gene associated only with PCa risk, were identified in eight (3.8%) pts. DNA mismatch repair variants, alterations with substantial known therapeutic implications, were detected in 1.7% of samples. A total of 12.4% of pts with Gleason scores of ≤6, compared with 15.4% of those with scores of ≥7 had a pathogenic variant. Within this cohort, 126 (63%) patients with positive results were eligible for genetic testing based on currently available NCCN guidelines, whereas 73 (37%) would not have qualified. Conclusions: Current NCCN guidelines and Gleason scores cannot be used to reliably stratify PCa pts for the presence/absence of pathogenic germline variants. Most positive results identified in this study have important management implications for pts and their families. The percentage of pts with germline variants who did not meet current genetic screening criteria underscores the need for revisiting current guidelines which cannot, at this time, reliably be used to predict pathologic findings on genetic testing.

Transforming Growth Factor (TGF)-β Promotes de Novo Serine Synthesis for Collagen Production

TGF-β promotes excessive collagen deposition in fibrotic diseases such as idiopathic pulmonary fibrosis (IPF). The amino acid composition of collagen is unique due to its high (33%) glycine content. Here, we report that TGF-β induces expression of glycolytic genes and increases glycolytic flux. TGF-β also induces the expression of the enzymes of the de novo serine synthesis pathway (phosphoglycerate dehydrogenase (PHGDH), phosphoserine aminotransferase 1 (PSAT1), and phosphoserine phosphatase (PSPH)) and de novo glycine synthesis (serine hydroxymethyltransferase 2 (SHMT2)). Studies in fibroblasts with genetic attenuation of PHGDH or SHMT2 and pharmacologic inhibition of PHGDH showed that these enzymes are required for collagen synthesis. Furthermore, metabolic labeling experiments demonstrated carbon from glucose incorporated into collagen. Lungs from humans with IPF demonstrated increased expression of PHGDH and SHMT2. These results indicate that the de novo serine synthesis pathway is necessary for TGF-β-induced collagen production and suggest that this pathway may be a therapeutic target for treatment of fibrotic diseases including IPF.

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents

CONTEXT

Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life.

OBJECTIVES

To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life.

METHODS

We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent.

RESULTS

Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week.

CONCLUSION

Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.

Establishing a population-based patient-reported outcomes study (PROMs) using national cancer registries across two jurisdictions: the Prostate Cancer Treatment, your experience (PiCTure) study

OBJECTIVE

To establish an international patient-reported outcomes (PROMs) study among prostate cancer survivors, up to 18 years postdiagnosis, in two countries with different healthcare systems and ethical frameworks.

DESIGN

A cross-sectional, postal survey of prostate cancer survivors sampled and recruited via two population-based cancer registries. Healthcare professionals (HCPs) evaluated patients for eligibility to participate. Questionnaires contained validated instruments to assess health-related quality of life and psychological well-being, including QLQ-C30, QLQ-PR25, EQ-5D-5L, 21-question Depression, Anxiety and Stress Scale (DASS-21) and the Decisional Regret Scale.

SETTING

Republic of Ireland (RoI) and Northern Ireland (NI).

PRIMARY OUTCOME MEASURES

Registration completeness, predictors of eligibility and response, data missingness, unweighted and weighted PROMs.

RESULTS

Prostate cancer registration was 80% (95% CI 75% to 84%) and 91% (95% CI 89% to 93%) complete 2 years postdiagnosis in NI and RoI, respectively. Of 12,322 survivors sampled from registries, 53% (n=6559) were classified as eligible following HCP screening. In the multivariate analysis, significant predictors of eligibility were: being ≤59 years of age at diagnosis (p<0.001), short-term survivor (<5 years postdiagnosis; p<0.001) and from RoI (p<0.001). 3348 completed the questionnaire, yielding a 54% adjusted response rate. 13% of men or their families called the study freephone with queries for assistance with questionnaire completion or to talk about their experience. Significant predictors of response in multivariate analysis were: being ≤59 years at diagnosis (p<0.001) and from RoI (p=0.016). Mean number of missing questions in validated instruments ranged from 0.12 (SD 0.71; EQ-5D-5L) to 3.72 (SD 6.30; QLQ-PR25). Weighted and unweighted mean EQ-5D-5L, QLQ-C30 and QLQ-PR25 scores were similar, as were the weighted and unweighted prevalences of depression, anxiety and distress.

CONCLUSIONS

It was feasible to perform PROMs studies across jurisdictions, using cancer registries as sampling frames; we amassed one of the largest, international, population-based data set of prostate cancer survivors. We highlight improvements which could inform future PROMs studies, including utilising general practitioners to assess eligibility and providing a freephone service.

Abstract 08: Clinical exome sequencing in the diagnosis of pediatric cancer predisposition

Background: Currently, there are few guidelines on genetic testing of pediatric patients for cancer predisposition and on appropriate cancer surveillance recommendations once a genetic cancer predisposition is diagnosed. Previous research studies estimated that only about 5-10% of pediatric cancers are due to a heritable cause. However, this may be an underestimation of the true incidence in the pediatric population where most patients being diagnosed with cancer do not have a significant history of environmental risk exposures, such as smoking or ultra-violet sun exposure.

Methods: We have created a multi-disciplinary Pediatric Cancer Predisposition Clinic at the University of California, Los Angeles (UCLA) that serves dual research and clinical missions of taking care of pediatric patients at an increased risk of cancer due to a genetic condition and advancing our understanding of cancer predisposition. Each family meets with a pediatric geneticist, pediatric oncologist, and genetic counselor for pre- and post- test counseling. We also consider the medical and psychosocial effects of these analyses on not only the patient, but also the parents of our patients, as well as direct relatives, who are affected and may need cancer surveillance.

When indicated, we use Clinical Exome Sequencing (CES) through the UCLA Clinical Genomics Center, as our first-line diagnostic test due to the unusual presentation of the many inherited cancer susceptibility genes in childhood. This single test assays 95% of all protein-coding sequence of current clinically offered disease genes and is usually more efficient and cost-effective than single-gene or panel testing, and data are saved for re-interpretation. We then formulate individualized cancer surveillance recommendations and coordinate all tests with the family and general pediatrician.

Results: There were 32 patients evaluated in the first 14 months. The average age of the patients was 10 years. Thirty-one referrals were from within our institution. Two patients had a history of cancer and presented with known familial cancer predisposition syndromes (Rhabdoid tumor predisposition and Hereditary paraganglioma-pheochromocytoma syndromes). Six additional patients presented without a personal history of cancer but with a known genetic syndrome associated with an increased cancer risk (Gorlin, Bannayan-Riley-Ruvalcaba, Cowden, Li-Fraumeni, Beckwith-Wiedemann, and Von Hippel-Lindau syndromes). Four patients were referred with known familial mutations in the family and had positive confirmatory testing (Li-Fraumeni, Familial adenomatous polyposis, and two with Neurofibromatosis Type 1). One patient was referred with a known mutation in the family and had negative testing (Hyperparathyroidism-jaw tumor syndrome).

Nineteen patients had a family history indicative of familial early-onset cancer as well as a personal history of cancer and had CES was ordered. Of these, CES resulted in two reportable, likely pathogenic mutations in PTEN and NF-1. Four patients had no clinically significant genetic variants identified, 11 patients had variants of uncertain clinical significance, and two patients' results are pending.

Conclusion: More thorough and broad scale germline analyses are needed to accurately inform patients of inherited risk to cancer, as it is not always obvious based on clinical presentation or family history. Our findings demonstrate a significant number of genomic variants with uncertain but potentially relevant clinical significance that warrant further study. CES is already a routinely used tool for mendelian genetic syndromes, and its routine use in testing the germline genomes of children with cancer holds the promise to augment diagnosis, treatment, and screening, and to permit the exploration of early initiation of cancer prevention strategies of patients with high risk of cancer.

Citation Format: Vivian Chang, Hane Lee, Tom Davidson, Naghmeh Dorrani, Erin O'Leary, Patricia A. Ganz, Stanley F. Nelson, Julian A. Martinez-Agosto. Clinical exome sequencing in the diagnosis of pediatric cancer predisposition. [abstract]. In: Proceedings of the AACR Special Conference: Cancer Susceptibility and Cancer Susceptibility Syndromes; Jan 29-Feb 1, 2014; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(23 Suppl):Abstract nr 08. doi:10.1158/1538-7445.CANSUSC14-08

The wait time creep: changes in the surgical wait time for women with uterine cancer in Ontario, Canada, during 2000-2009

OBJECTIVE

Uterine cancer is a major cancer of women, with outcomes potentially worsening with delayed diagnosis or hysterectomy, the main treatment. Yet cancer surgery wait times are not reported by cancer site. This study sought to examine changes in wait times for uterine cancer surgery between 2000 and 2009 and to identify predictors of longer surgery wait times.

METHODS

Population-based retrospective analysis of a cohort of uterine cancer patients diagnosed between April 2000 and March 2009. Using linked administrative data, all cases in which a patient had hysterectomy following diagnosis were identified. Wait time was defined as days from diagnosis of uterine cancer (day 0) to hysterectomy. Regression analysis was used to examine the relationship between covariates and wait time.

RESULTS

Wait times increased steadily between 2000 and 2006 from a median of 34 to 54 days, followed by a plateau until 2009-during which patients waited a median of between 53 and 55 days for surgery after diagnosis. Overall, 55% of patients had a wait time longer than 6 weeks after diagnosis. Predictors of a wait time greater than 6 weeks included older age, region, lower income, later year of diagnosis, surgery by a gynaecologic oncologist, non-sarcoma histology group and having surgery in a teaching hospital.

CONCLUSION

Over half of uterine cancer patients waited longer than the recommended 6 weeks for surgery. Future reporting of cancer wait times by each disease site regularly would help to identify progress to reduce wait times and opportunities for improvement.

Impact of wait times on survival of women with uterine cancer

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Background: Reducing cancer wait times have been a priority investment for Cancer Care Ontario since 2005. Our objective was to determine whether wait time from histologic diagnosis of uterine cancer to time of definitive surgery by hysterectomy impacted on all cause survival. Methods: Cases were identified in the Ontario Cancer Registry using ICD-09 codes 179 and 182. Excluded were women without histologic/cytologic confirmation of cancer prior to surgery, with no definitive surgery, or with wait times of ≤14 days or >2 years. Survival was calculated using the Kaplan-Meier method from the day of hysterectomy. Factors were evaluated for their prognostic ability on survival using Cox proportional hazards regression. Wait time was evaluated as a continuous variable and dichotomized at selected cutpoints in the univariable analyses and in a multivariable model adjusting for significant patient factors identified using forward stepwise selection. Results: The final study population included 8,744 women. 51.9% had surgery by a gynaecologist and 69.9% had endometrioid adenocarcinoma. The optimal model is shown below. Multivariable analysis of factors prognostic for survival. Longer wait times remained a statistically significant negative prognostic factor for survival regardless of definition, univariably (p<0.002) and multivariably after adjusting for other significant factors (p<0.001). The final multivariable model is shown. 5-year (95%CI) survival for women with more than 12 week wait times was 61.4 (57.8-64.8)% versus 71.9 (69.9-73.8)% for women with less than 6 week wait time. Conclusions: The longer a woman waits from diagnosis of uterine cancer to definitive surgery negatively impacts her overall survival. [Table: see text]

A new method for automatic tracking of facial landmarks in 3D motion captured images (4D)

The aim of this study was to validate the automatic tracking of facial landmarks in 3D image sequences. 32 subjects (16 males and 16 females) aged 18-35 years were recruited. 23 anthropometric landmarks were marked on the face of each subject with non-permanent ink using a 0.5mm pen. The subjects were asked to perform three facial animations (maximal smile, lip purse and cheek puff) from rest position. Each animation was captured by the 3D imaging system. A single operator manually digitised the landmarks on the 3D facial models and their locations were compared with those of the automatically tracked ones. To investigate the accuracy of manual digitisation, the operator re-digitised the same set of 3D images of 10 subjects (5 male and 5 female) at 1 month interval. The discrepancies in x, y and z coordinates between the 3D position of the manual digitised landmarks and that of the automatic tracked facial landmarks were within 0.17mm. The mean distance between the manually digitised and the automatically tracked landmarks using the tracking software was within 0.55 mm. The automatic tracking of facial landmarks demonstrated satisfactory accuracy which would facilitate the analysis of the dynamic motion during facial animations.

Modelling the demographics of the Irish cattle population

In recent years, national authorities have committed very substantial resources to the creation and maintenance of databases capable of recording important animal event data, such as births, deaths and movements. This has primarily been driven by the need to ensure the quality and safety of animal products. However, it can also be used to assist policy makers in decision making. Despite the abundance of animal event data, as yet there is little published information about the use of these data to better understand the demography of cattle populations. This study reports the development of, and outputs from, a demographic model using data routinely collected from the Irish cattle population. The demographic model was based on a series of life tables detailing age-specific probabilities of survival up to a maximum of 17 years. These outputs were used to determine characteristics of the Irish cattle population, including estimated mortality rates, life expectancies and age profiles, and estimated cattle numbers by age and date. Separate life tables were developed for each of the 204 monthly birth cohorts born between January 1989 and December 2005. Within the Irish cattle population, the peak estimated mortality rate occurs at 29-33 months. The estimated life expectancy at birth of cattle in Ireland was 42 months. When the survival rates for all the cohorts within a population are calculated, then it is possible to use these rates as a model for determining future population size and answering cohort specific queries.

Two-stage liver resection and chemotherapy for bilobar colorectal liver metastases

BACKGROUND

A significant number of patients with colorectal metastatic disease confined to the liver are inoperable at assessment. For these patients, the outlook is poor. Chemotherapy can 'down-stage' some tumours and render them operable. The authors present a series of patients with inoperable disease despite down-staging with chemotherapy, who underwent a two-stage resection to clear their metastatic disease.

METHODS

The case-notes of 11 patients who were found to have inoperable hepatic metastatic disease were identified using computerised medical records and mean hospital stay, survival and long-term follow-up data was noted.

RESULTS

The mean follow-up from initial resection was 13.5 months (range of 5-20 months). Three deaths were recorded in the follow-up interval. Causes of death included recurrence of hepatic disease following completion of two-stage resection, progression of original hepatic disease leading to inoperability at second stage operation and recurrence of original primary colorectal tumour. The mean survival in the patients who died was 17 months (range of 15-19 months). The remaining patients are alive to date with six patients showing no evidence of hepatic recurrence, follow-up period of 13 months (range of 8-20 months). One patient developed de novo prostate cancer and is awaiting his second liver resection, and one patient has stable hepatic disease with no evidence of progression.

CONCLUSION

Two-stage liver resection can prolong survival when compared to chemotherapy alone, with a recurrence rate equivalent to ablation techniques. Longer-term studies are needed for further evaluation.

Effects of SP500263, a novel selective estrogen receptor modulator, on bone, uterus, and serum cholesterol in the ovariectomized rat

We describe here the activity of a novel selective estrogen receptor modulator, SP500263. When given to adult ovariectomized (OVX) rats for 28 days at doses of 0.3, 1, or 3 mg/kg/day, we found that SP500263 partially protected against OVX-induced loss of bone mineral content in the distal ends of femurs and in the whole bone. SP500263 also antagonized the OVX-induced increase in body weight. However, unlike 17beta-estradiol, SP500263 at efficacious doses did not prevent the OVX-induced loss in uterine wet weight. A small but significant effect on uterine wet weight was noted with raloxifene dosed at 1 mg/kg. As expected, SP500263 but not raloxifene acted as an estrogen antagonist on the uterus in adult rats when administered for 7 days at 30 mg/kg/day. Finally, SP500263 had no statistically significant effects on total serum cholesterol and serum triglycerides in OVX rats treated for 28 days. Raloxifene had no significant effects on body weight, bone mineral content, and serum cholesterol or triglycerides in the OVX-rat model. In summary, SP500263 is a new orally active SERM that acts in rats as an estrogen agonist on bone without causing uterine stimulatory effects.

Efficiency of Dispatch and Infiltrator cardiac infusion catheters in arterial localization of nanoparticles in a porcine coronary model of restenosis

Localized intramural delivery of sustained release biodegradable nanoparticles containing an antiproliferative agent could provide prolonged drug effect at the site of vascular injury that could inhibit the proliferation of smooth muscle cells and hence restenosis. The efficiency of arterial localization of nanoparticles is crucial in maximizing the drug effect in the target tissue. Therefore, the objective of the present study was to determine the comparative efficiency of the Dispatch and the Infiltrator cardiac infusion catheters to localize nanoparticles in the arterial wall. Following a standard balloon angioplasty procedure on the left anterior descending artery (LAD) in a porcine coronary model of restenosis, a suspension of nanoparticles containing a fluorescent marker was infused at the site of injury using either the Dispatch or the Infiltrator catheter. One hour following the infusion, animals were sacrificed and the nanoparticle levels in the LAD and other tissue were analyzed. The Dispatch catheter resulted in 3.3 folds greater efficiency of nanoparticle localization in the LAD than the Infiltrator catheter (309 +/- 124 vs. 93 +/- 43 microg/g of tissue, n = 6 for Dispatch and n = 5 for Infiltrator, p = 0.082, t-test). It is estimated that about 2% of the arterial volume can be displaced with the nanoparticle infusion. Fluorescence microscopy of the cross-sections of the LAD revealed greater fluorescence activity in the intimal layer with both the catheters, however the arteries infused using the Dispatch catheter demonstrated relatively higher degree of fluorescence activity in the medial and adventitial layers. The transmission electron microscopy of the arterial sections demonstrated infiltration of nanoparticles in the arterial wall and the histological analysis of the sections demonstrated no apparent damage to the endothelium due to the infusion of nanoparticles.

PLIP, a novel splice variant of Tip60, interacts with group IV cytosolic phospholipase A(2), induces apoptosis, and potentiates prostaglandin production

The group IV cytosolic phospholipase A(2) (cPLA(2)) has been localized to the nucleus (M. R. Sierra-Honigmann, J. R. Bradley, and J. S. Pober, Lab. Investig. 74:684-695, 1996) and is known to translocate from the cytosolic compartment to the nuclear membrane (S. Glover, M. S. de Carvalho, T. Bayburt, M. Jonas, E. Chi, C. C. Leslie, and M. H. Gelb, J. Biol. Chem. 270:15359-15367, 1995; A. R. Schievella, M. K. Regier, W. L. Smith, and L. L. Lin, J. Biol. Chem. 270:30749-30754, 1995). We hypothesized that nuclear proteins interact with cPLA(2) and participate in the functional effects of this translocation. We have identified a nuclear protein, cPLA(2)-interacting protein (PLIP), a splice variant of human Tip60, which interacts with the amino terminal region of cPLA(2). Like Tip60, PLIP cDNA includes the MYST domain containing a C2HC zinc finger and well-conserved similarities to acetyltransferases. Both PLIP and Tip60 coimmunoprecipitate and colocalize with cPLA(2) within the nuclei of transfected COS cells. A polyclonal antibody raised to PLIP recognizes both PLIP and Tip60. Endogenous Tip60 and/or PLIP in rat mesangial cells is localized to the nucleus in response to serum deprivation. Nuclear localization coincides temporally with apoptosis. PLIP expression, mediated by adenoviral gene transfer, potentiates serum deprivation-induced prostaglandin E(2) (PGE(2)) production and apoptosis in mouse mesangial cells from cPLA(2)(+/+) mice but not in mesangial cells derived from cPLA(2)(-/-) mice. Thus PLIP, a splice variant of Tip60, interacts with cPLA(2) and potentiates cPLA(2)-mediated PGE(2) production and apoptosis.

Renal concentrating defect in mice lacking group IV cytosolic phospholipase A(2)

Eicosanoids regulate various cellular functions that are important in physiological and pathophysiological processes. Arachidonic acid is released from membranes by phospholipase A(2) (PLA(2)) activity. Activated macrophages derived from mice lacking the 85-kDa group IV cytosolic PLA(2) (cPLA(2)) have a markedly reduced release of prostaglandin E(2) and leukotrienes B(4) and C(4). Under basal conditions and after furosemide, urinary prostaglandin E(2) excretion is reduced in cPLA(2)-knockout (cPLA(2)(-/-)) mice. Serum creatinine, Na(+), K(+), and Ca(2+) concentrations, glomerular filtration rate, and fractional excretion of Na(+) and K(+) are not different in cPLA(2)(-/-) and cPLA(2)(+/+) mice. Maximal urinary concentration is lower in 48-h water-deprived cPLA(2)(-/-) mice compared with cPLA(2)(+/+) animals (1,934 +/- 324 vs. 3,541 +/- 251 mmol/kgH(2)O). Plasma osmolality is higher (337 +/- 5 vs. 319 +/- 3 mmol/kgH(2)O) in cPLA(2)(-/-) mice that lose a greater percentage of their body weight (20 +/- 2 vs. 13 +/- 1%) compared with cPLA(2)(+/+) mice after water deprivation. Vasopressin does not correct the concentrating defect. There is progressive reduction in urinary osmolality with age in cPLA(2)(-/-) mice. Membrane-associated aquaporin-1 (AQP1) expression, identified by immunocytochemical techniques, is reduced markedly in proximal tubules of older cPLA(2)(-/-) animals but is normal in thin descending limbs. However, Western blot analysis of kidney cortical samples revealed an equivalent AQP1 signal intensity in cPLA(2)(+/+) and cPLA(2)(-/-) animals. Young cPLA(2)(-/-) mice have normal proximal tubule AQP1 staining. Collecting duct AQP2, -3, and -4 were normally expressed in the cPLA(2)(-/-) mice. Thus mice lacking cPLA(2) develop an age-related defect in renal concentration that may be related to abnormal trafficking and/or folding of AQP1 in the proximal tubule, implicating cPLA(2) in these processes.

Deletion of cytosolic phospholipase A(2) suppresses Apc(Min)-induced tumorigenesis

Although nonsteroidal antiinflammatory drugs (NSAIDs) show great promise as therapies for colon cancer, a dispute remains regarding their mechanism of action. NSAIDs are known to inhibit cyclooxygenase (COX) enzymes, which convert arachidonic acid (AA) to prostaglandins (PGs). Therefore, NSAIDs may suppress tumorigenesis by inhibiting PG synthesis. However, various experimental studies have suggested the possibility of PG-independent mechanisms. Notably, disruption of the mouse group IIA secretory phospholipase A(2) locus (Pla2g2a), a potential source of AA for COX-2, increases tumor number despite the fact that the mutation has been predicted to decrease PG production. Some authors have attempted to reconcile the results by suggesting that the level of the precursor (AA), not the products (PGs), is the critical factor. To clarify the role of AA in tumorigenesis, we have examined the effect of deleting the group IV cytosolic phospholipase A(2) (cPLA(2)) locus (Pla2g4). We report that Apc(Min/+), cPLA(2)(-/-) mice show an 83% reduction in tumor number in the small intestine compared with littermates with genotypes Apc(Min/+), cPLA(2)(+/-) and Apc(Min/+), cPLA(2)(+/+). This tumor phenotype parallels that of COX-2 knockout mice, suggesting that cPLA(2) is the predominant source of AA for COX-2 in the intestine. The protective effect of cPLA(2) deletion is thus most likely attributed to a decrease in the AA supply to COX-2 and a resultant decrease in PG synthesis. The tumorigenic effect of sPLA(2) mutations is likely to be through a completely different pathway.

Recruiting participants for community-based research: the Diabetic Retinopathy Awareness Program

PURPOSE

Recruiting participants is a major challenge for population studies. We present the recruitment methods followed by the Diabetic Retinopathy Awareness Program (DRAP), a community-based, randomized, masked, controlled trial to meet and exceed its sample size goals.

METHODS

A county-wide multi-media promotional campaign to recruit and enroll participants in the trial was planned and executed from October 1993 through April 1994, with the assistance of the local news media and community and professional groups. A toll-free 800 number recruitment line was established, and postage-paid recruitment postcards distributed. The trial was designed to examine whether a mailed educational intervention could increase compliance with vision care guidelines among persons with diabetes in the community.

RESULTS

A total of 2308 persons with diabetes were interviewed for eligibility and 813 enrolled in the intervention trial, exceeding the original recruitment goals of 1800 and 600, respectively. Those who completed the enrollment interview reflected county demographics. During recruitment, newspaper, television and radio stories featured the study; pharmacies and physician offices displayed study materials; public service announcements appeared in local print and broadcast media. The largest single recruitment response was a local television news report, followed by a newspaper story.

CONCLUSIONS

These experiences substantiate the need for a comprehensive coordinated approach, using planned multiple sources, to achieve recruitment success. By engaging the lay and professional communities along with the media, recruitment costs can be kept to a minimum. Participant costs can be minimized by employing a toll-free number and eliminating study participant travel, thus allowing for inclusion of traditionally underserved populations. This approach is applicable to other studies, where community-based participation is desired.

Detection of angiographically significant coronary artery disease with accelerated intermittent imaging after intravenous administration of ultrasound contrast material

BACKGROUND

Accelerated intermittent harmonic imaging (AII) is used to detect myocardial perfusion abnormalities after intravenous injection of ultrasound contrast medium. A low mechanical index and frame rates of 10 to 20 Hz are used to allow simultaneous wall motion analysis. The purpose of this study was to determine whether the myocardial contrast enhancement achieved with AII can be used to detect angiographically significant coronary artery disease during stress echocardiography.

METHODS

We gave intravenous perfluorocarbon containing microbubbles to 45 patients (total of 270 regions) during dobutamine (n = 27) or exercise (n = 18) stress testing with AII. Quantitative angiography was performed on all patients after the stress echocardiograms were interpreted.

RESULTS

Quantitative angiography showed >50% diameter stenosis of at least 1 vessel in 32 patients (total of 118 regions). There were visually evident contrast defects in 100 (85%) of these regions, and wall motion was abnormal in 64 (54%). Overall, there was agreement between regional perfusion and quantitative angiographic findings in 217 of the 270 regions (kappa = 0.61; 80% agreement). Agreement with findings at quantitative angiography was good for both dobutamine stress (kappa = 0.66; 83% agreement) and exercise (kappa = 0.53; 77% agreement). The greatest incremental benefit of AII versus wall motion was gained during dobutamine stress. The contrast studies depicted 90% of the regions supplied by a vessel with >50% stenosis, whereas wall motion depicted only 32% (P =.001).

CONCLUSIONS

The results of this study indicated that accelerated intermittent perfusion imaging during stress echocardiography can improve the sensitivity of the study in detecting angiographically significant coronary artery disease, especially during dobutamine stress.

Magnetic field exposure assessment: a comparison of various methods

The accurate and valid measurement of personal exposure to magnetic fields poses a major challenge for epidemiologic studies. When considering the various methods to assess exposure, it is unclear which measures are most relevant for studies of human disease, if any. Given these uncertainties, the Electromagnetic Fields and Breast Cancer on Long Island Study (EBCLIS) undertook a pilot study to develop the data collection protocol for a case-control study of breast cancer and magnetic fields. The pilot study used and compared various methods to assess residential exposures to magnetic fields, and related these measures to personal exposures. It included 31 women without breast cancer (mean age, 63+/-7 yr) who lived in their present homes for at least 15 yr. The pilot study consisted of an in-home interview, spot and 24-h magnetic field waveforms and broadband recordings, ground currents, wire coding, and personal 24-h broadband measurements. From the regression analyses, the model that best predicted personal magnetic field exposures included 24-h measurements in the bedroom and in the most lived-in room; as well as ground current test loads taken at the center of this most lived in room (r(2)=86%). The addition of other variables in this regression model yielded only small and nonsignificant increases in r(2). As a direct result of this pilot, EBCLIS will include ground current measurements in its protocol, which have not previously been collected as part of an epidemiologic study. Ground currents may be important because they may be richer in 180 Hz components than are the other currents in a power system. EBCLIS will have the opportunity to examine the ground-current hypothesis in the context of female breast cancer.

Etomidate and the osteocalcin response to gynaecological surgery

Circulating osteocalcin is a good marker of osteoblastic activity and decreases significantly after stressful physiological states such as major surgery. Glucocorticoids are known to inhibit osteoblastic activity and result in a decline in circulating osteocalcin. We used etomidate to inhibit the cortisol response to routine gynaecological surgery to determine if this would prevent the postoperative decline in osteocalcin. Twenty-four patients were allocated randomly to receive either thiopental or etomidate for induction of anaesthesia; all other aspects of anaesthesia and perioperative management were standardized. In the thiopental group, circulating cortisol increased significantly at 2 and 6 h after the start of surgery and plasma osteocalcin concentrations decreased significantly to almost 50% of baseline values at 48 h. Etomidate abolished the cortisol response to surgery, and circulating osteocalcin concentrations did not change after operation. There was a significant difference in osteocalcin concentration between the groups at 48 h. We conclude that the cortisol response to surgery is associated with a postoperative decrease in circulating osteocalcin.

Expression of the transcriptional repressor protein Kid-1 leads to the disintegration of the nucleolus

The rat Kid-1 gene codes for a 66-kDa protein with KRAB domains at the NH2 terminus and two Cys2His2-zinc finger clusters of four and nine zinc fingers at the COOH terminus. It was the first KRAB-zinc finger protein for which a transcriptional repressor activity was demonstrated. Subsequently, the KRAB-A domain was identified as a widespread transcriptional repressor motif. We now present a biochemical and functional analysis of the Kid-1 protein in transfected cells. The full-length Kid-1 protein is targeted to the nucleolus and adheres tightly to as yet undefined nucleolar structures, leading eventually to the disintegration of the nucleolus. The tight adherence and nucleolar distribution can be attributed to the larger zinc finger cluster, whereas the KRAB-A domain is responsible for the nucleolar fragmentation. Upon disintegration of the nucleolus, the nucleolar transcription factor upstream binding factor disappears from the nucleolar fragments. In the absence of Kid-1, the KRIP-1 protein, which represents the natural interacting partner of zinc finger proteins with a KRAB-A domain, is homogeneously distributed in the nucleus, whereas coexpression of Kid-1 leads to a shift of KRIP-1 into the nucleolus. Nucleolar run-ons demonstrate that rDNA transcription is shut off in the nucleolar fragments. Our data demonstrate the functional diversity of the KRAB and zinc finger domains of Kid-1 and provide new functional insights into the regulation of the nucleolar structure.

Canadian Bardet-Biedl syndrome family reduces the critical region of BBS3 (3p) and presents with a variable phenotype

There are at least five distinct Bardet-Biedl syndrome (BBS) loci, four of which have been mapped: 11q (BBS1), 16q (BBS2), 3p (BBS3), and 15q (BBS4). A comparative study of the three Arab-Bedouin kindreds used to map the BBS2, BBS3, and BBS4 loci suggests that the variability in the number and severity of clinical manifestations, particularly the pattern of polydactyly, reflects chromosome-specific subtypes of BBS [Carmi et al., 1995a; Am J Med Genet 59:199-203]. We describe a Newfoundland kindred of northern European descent and confirm the initial finding of a BBS locus on chromosome 3. However, the "BBS3 phenotype," which includes polydactyly of all four limbs and a progression to morbid obesity, was not observed. Rather, four of the five BBS patients in this family had polydactyly restricted to their feet. The obesity in these patients was reversible with caloric restriction and/or exercise. Mental retardation has been considered a major symptom of BBS. However, formal IQ testing shows that these patients are of average intelligence. Haplotype analysis reduces the BBS3 critical region to a 6-cM interval between D3S1595-D3S1753.

Adrenocortical disorders

Preoperative preparation for the patient with adrenal disorders is directed toward restoring the intravascular volume and the electrolyte concentrations to normal. Hypertension and hypokalemia may be controlled by restricting sodium intake and administration of the aldosterone antagonist spironolactone. Patients taking steroids preoperatively must be adequately replaced throughout the perioperative phase at times of maximum stress.

Reduced fertility and postischaemic brain injury in mice deficient in cytosolic phospholipase A2

Phospholipase A2 (PLA2) enzymes are critical regulators of prostaglandin and leukotriene synthesis and can directly modify the composition of cellular membranes. PLA2 enzymes release fatty acids and lysophospholipids, including the precursor of platelet-activating factor, PAF, from phospholipids. Free fatty acids, eicosanoids, lysophospholipids and PAF are potent regulators of inflammation, reproduction and neurotoxicity. The physiological roles of the various forms of PLA2 are not well defined. The cytosolic form, cPLA2, preferentially releases arachidonic acid from phospholipids and is regulated by changes in intracellular calcium concentration. We have now created 'knockout' (cPLA2-/-) mice that lack this enzyme, in order to evaluate its physiological importance. We find that cPLA2-/- mice develop normally, but that the females produce only small litters in which the pups are usually dead. Stimulated peritoneal macrophages from cPLA2-/- animals did not produce prostaglandin E2 or leukotriene B4 or C4. After transient middle cerebral artery occlusion, cPLA2-/- mice had smaller infarcts and developed less brain oedema and fewer neurological deficits. Thus cPLA2 is important for macrophage production of inflammatory mediators, fertility, and in the pathophysiology of neuronal death after transient focal cerebral ischaemia.