590 The Value of Peripheral Pulse Examination in the Diagnosis of Intermittent Claudication

Aim

The primary aim was to objectively evaluate the use of peripheral pulse examination as a screening tool for IC by calculating the sensitivity and specificity. Our secondary aim was to describe the cohort of patients referred to the clinic by their GP and identify areas for improvement and early initiation of best medical therapy.

Method

This study used a retrospective analysis of a prospectively maintained database. Records of all patients referred to the claudication clinic were collected from October 2018 to October 2019. The most distal palpable pulse of each leg was assigned a value and combined to create a ‘peripheral pulse score’. Risk factors, ABPI results, Peripheral Artery Disease (PAD) status and details of ongoing medical therapy were also recorded.

Results

211 patients referred by their GP were included in the study. The absence of bilateral foot pulses was found to have a sensitivity of 86%, specificity 92%, PPV 95% and NPV 79%. There is a strong correlation between peripheral pulse score and ABPI. Only 27% of patients suspected of having IC by their GP were on best medical therapy at their initial clinic visit.

Conclusions

Peripheral pulse examination is a valuable diagnostic tool for identifying patients with IC and can be used to guide referral to specialist services. We provide evidence for the use of foot pulses as a screening tool to be used by primary care providers. More patients being referred to the IC clinic can be started on best medical therapy for secondary prevention at the time of referral.

Knight Scholars Program: A Tiered Three-Year Mentored Training Program for Urban and Rural High School High School Students Increases Interest and Self-Efficacy in Interprofessional Cancer Research

Cancer research training programs build our future biomedical workforce. Training is often centered for students residing close to research institutions, making access more challenging for rural students. A cancer research training program was developed for high school students residing in five geographical regions across Oregon. Training was tiered in duration and intensity across the three years, including a one-week Introduction program and subsequent 10-week summer research training programs (Immersion and Intensive). A total of 60 students participated in in-person and/or virtual training, with Immersion students receiving mentored shadowing experiences in clinical care, public health, and outreach in their home communities. Laboratory rotations at a research-intensive institution enabled students to sample research environments before selecting an area of interest for Intensive training the following summer. Aligning with Self-Determination Theory, the Knight Scholars Program aims to build competence, relatedness, and autonomy of its trainees in biomedical sciences. The program exposed students to a wide range of interprofessional careers and collaborative teams, enabling scholars to envision themselves in various paths. Results show strong gains in interest and research self-efficacy for both Introduction and Immersion scholars, with findings highlighting the importance of representation within mentoring and training efforts.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Real-world comparison of the last generation balloon-expandable and self-expanding valves in patients undergoing TAVI

Background/Introduction

The balloon expandable (BE) Edwards Sapien-S3/Ultra, and the self-expanding (SE) Medtronic Evolut-Pro represent the main volume of transcatheter aortic valve implantation (TAVI) procedures conducted worldwide.

Purpose

The present study represents the largest real-world comparison of periprocedural and short-term outcome between the aforementioned last generation devices.

Methods

Consecutive patients who had undergone TAVI with either the BE (S3/Ultra) or SE (Evolut-Pro/R-34mm if 34mm valve was required) device, in five centers were retrospectively studied. Periprocedural and short-term outcomes were recorded and compared.

Results

In total, 1341 patients (58.5% male) were treated with contemporary BE and SE valves (574 and 767pts with BE and SE respectively) and followed up for a median of 18.7 (IQR 30) months. Baseline demographics were similar between the two groups apart from severe left ventricle (LV) systolic impairment and extensive aorta calcification, being more prevalent amongst BE and SE groups respectively. Patients treated with the Evolut-Pro/R34mm device had significantly lower peak (16±9mmHg for SE vs 23.9±6mmHg for the BE valves, p=0.001) and mean (8.6±6mmHg SE vs 11.2±5.2mmHg BE, p=0.001) gradients at discharge.

Conversely, the BE group demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.7% vs 5.2% for BE and SE valves respectively, p<0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in initially pacemaker-free patients, was higher for the S3/Ultra cohort compared to the self-expanding valve group (14.4% vs 12.3% respectively, p=0.001). No statistical difference was recorded between valve groups regarding cerebrovascular events (3.4% vs. 2.7% for SE and BE respectively, p=0.466), major vascular complications (4.2% vs. 3.0% for SE and BE respectively, p=0.251) and death to hospital discharge (1.6% vs. 2.9% for SE and BE respectively, p=0.117).

One-year Kaplan-Meier estimated survival was similar between the two groups (88.7% for BE vs. 91.4% for SE valves, plog-rank=0.093). When adjusting for age, extensive calcification of the aorta and baseline LV function all caused mortality hazard ratios were similar between patients treated with BE vs SE valves (HR 1.39; 95% CI 0.97 to 1.98, p=0.07).

Conclusions

Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates superiority of the former in terms of residual PVL, at the expense of higher transvalvular gradients and higher need of new PPM implantation. The latter however may represent differences in center practices with regards to thresholds for permanent pacing. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Verification and Validation of Digital Pathology (Whole Slide Imaging) for Primary Histopathological Diagnosis: All Wales Experience

Aims:

The study is aimed to verify Aperio AT2 scanner for reporting on the digital pathology platform (DP) and to validate the cohort of pathologists in the interpretation of DP for routine diagnostic histopathological services in Wales, United Kingdom.

Materials, Methods and Results:

This was a large multicenter study involving seven hospitals across Wales and unique with 22 (largest number) pathologists participating. 7491 slides from 3001 cases were scanned on Leica Aperio AT2 scanner and reported on digital workstations with Leica software of e-slide manager. A senior pathology fellow compared DP reports with authorized reports on glass slide (GS). A panel of expert pathologists reviewed the discrepant cases under multiheader microscope to establish ground truth. 2745 out of 3001 (91%) cases showed complete concordance between DP and GS reports. Two hundred and fifty-six cases showed discrepancies in diagnosis, of which 170 (5.6%) were deemed of no clinical significance by the review panel. There were 86 (2.9%) clinically significant discrepancies in the diagnosis between DP and GS. The concordance was raised to 97.1% after discounting clinically insignificant discrepancies. Ground truth lay with DP in 28 out of 86 clinically significant discrepancies and with GS in 58 cases. Sensitivity of DP was 98.07% (confidence interval [CI] 97.57–98.56%); for GS was 99.07% (CI 98.72–99.41%).

Conclusions:

We concluded that Leica Aperio AT2 scanner produces adequate quality of images for routine histopathologic diagnosis. Pathologists were able to diagnose in DP with good concordance as with GS.

Strengths and Limitations of this Study:

Strengths of this study – This was a prospective blind study. Different pathologists reported digital and glass arms at different times giving an ambience of real-time reporting. There was standardized use of software and hardware across Wales. A strong managerial support from efficiency through the technology group was a key factor for the implementation of the study.

Limitations:

This study did not include Cytopathology and in situ hybridization slides. Difficulty in achieving surgical pathology practise standardization across the whole country contributed to intra-observer variations.

Dietary patterns and longitudinal change in hip bone mineral density among older men

Studying dietary patterns is often more informative than individual nutrients or foods. We found that a Prudent dietary pattern (rich in vegetables and fish) was associated with reduced loss of total hip BMD in older men. A Prudent dietary pattern may be a potential lifestyle strategy for minimizing bone loss.

INTRODUCTION

This study aimed to identify baseline dietary patterns using factor analysis in a cohort of older men and to evaluate whether the dietary patterns were associated with bone mineral density change (%ΔBMD) at the total hip and femoral neck over time.

METHODS

Participants (n = 4379; mean age 72.9 ± 5.5 years) were from the Osteoporotic Fractures in Men (MrOS) prospective cohort study and had dietary data collected at baseline (March 2000-April 2002) and BMD measured at baseline and Visit 2 (March 2005-May 2006). Dietary intake was assessed with a brief Block food frequency questionnaire (FFQ); factor analysis was used to derive dietary patterns. BMD was measured by dual-energy x-ray absorptiometry (DXA); %ΔBMD was calculated from baseline to Visit 2. We used generalized linear regression to estimate least square (LS) means of %ΔBMD in quartiles of the dietary pattern scores adjusted for potential confounding factors.

RESULTS

Two major dietary patterns were derived: Prudent (abundant in vegetables, salad, and non-fried fish) and Western (rich in hamburger, fries, processed meats, cheese, and sweets/desserts). There was an inverse association between adherence to the Prudent pattern and total hip %ΔBMD (p-trend = 0.028 after adjusting for age and clinical site; p-trend = 0.033 after further adjustment for smoking, calcium supplement use, diabetes, hypertension, and total energy intake). No other consistent associations between dietary patterns and %ΔBMD were observed.

CONCLUSIONS

Greater adherence to a Prudent dietary pattern may attenuate total hip BMD loss (%ΔBMD) in older men.

Intratumoural expression of deoxycytidylate deaminase or ribonuceotide reductase subunit M1 expression are not related to survival in patients with resected pancreatic cancer given adjuvant chemotherapy

BACKGROUND

Deoxycytidylate deaminase (DCTD) and ribonucleotide reductase subunit M1 (RRM1) are potential prognostic and predictive biomarkers for pyrimidine-based chemotherapy in pancreatic adenocarcinoma.

METHODS

Immunohistochemical staining of DCTD and RRM1 was performed on tissue microarrays representing tumour samples from 303 patients in European Study Group for Pancreatic Cancer (ESPAC)-randomised adjuvant trials following pancreatic resection, 272 of whom had received gemcitabine or 5-fluorouracil with folinic acid in ESPAC-3(v2), and 31 patients from the combined ESPAC-3(v1) and ESPAC-1 post-operative pure observational groups.

RESULTS

Neither log-rank testing on dichotomised strata or Cox proportional hazard regression showed any relationship of DCTD or RRM1 expression levels to survival overall or by treatment group.

CONCLUSIONS

Expression of either DCTD or RRM1 was not prognostic or predictive in patients with pancreatic adenocarcinoma who had had post-operative chemotherapy with either gemcitabine or 5-fluorouracil with folinic acid.

Expression of dihydropyrimidine dehydrogenase (DPD) and hENT1 predicts survival in pancreatic cancer

BACKGROUND

Dihydropyrimidine dehydrogenase (DPD) tumour expression may provide added value to human equilibrative nucleoside transporter-1 (hENT1) tumour expression in predicting survival following pyrimidine-based adjuvant chemotherapy.

METHODS

DPD and hENT1 immunohistochemistry and scoring was completed on tumour cores from 238 patients with pancreatic cancer in the ESPAC-3(v2) trial, randomised to either postoperative gemcitabine or 5-fluorouracil/folinic acid (5FU/FA).

RESULTS

DPD tumour expression was associated with reduced overall survival (hazard ratio, HR = 1.73 [95% confidence interval, CI = 1.21-2.49], p = 0.003). This was significant in the 5FU/FA arm (HR = 2.07 [95% CI = 1.22-3.53], p = 0.007), but not in the gemcitabine arm (HR = 1.47 [0.91-3.37], p = 0.119). High hENT1 tumour expression was associated with increased survival in gemcitabine treated (HR = 0.56 [0.38-0.82], p = 0.003) but not in 5FU/FA treated patients (HR = 1.19 [0.80-1.78], p = 0.390). In patients with low hENT1 tumour expression, high DPD tumour expression was associated with a worse median [95% CI] survival in the 5FU/FA arm (9.7 [5.3-30.4] vs 29.2 [19.5-41.9] months, p = 0.002) but not in the gemcitabine arm (14.0 [9.1-15.7] vs. 18.0 [7.6-15.3] months, p = 1.000). The interaction of treatment arm and DPD expression was not significant (p = 0.303), but the interaction of treatment arm and hENT1 expression was (p = 0.009).

CONCLUSION

DPD tumour expression was a negative prognostic biomarker. Together with tumour expression of hENT1, DPD tumour expression defined patient subgroups that might benefit from either postoperative 5FU/FA or gemcitabine.

25-Hydroxyvitamin D assays: Potential interference from other circulating vitamin D metabolites

The vitamin D External Quality Assessment Scheme (DEQAS) for 25-hydroxyvitamin D (25-OHD) has approximately 1100 participants in 53 countries using 26 different methods or variants of methods (October 2014). In April 2015, the scheme was extended to cover 24,25-dihydroxyvitamin D (24,25(OH)₂D). Since 2013, the 25-OHD scheme has been accuracy-based with values assigned by the NIST reference measurement procedure (RMP). DEQAS is uniquely placed to assess the accuracy (bias) and specificity of 25-OHD methods in a routine laboratory setting. Other vitamin D metabolites are known to interfere in 25-OHD assays and DEQAS has distributed samples spiked with 3-epi-25-OHD₃ (52.4nmol/L), 24R,25(OH)₂D₃ (14.4nmol/L) and 24S,25(OH)₂D₃ (57.9nmol/L). The 3-epimer showed a cross reactivity of 56% in a competitive protein binding assay but was not detected in any antibody-based methods. Not all HPLC/UV or LC-MS/MS methods were able to resolve 3-epi-25-OHD₃ from 25-OHD₃ and thus overestimated total 25-OHD. The cross reactivity of 24R,25(OH)₂D₃ (24S,25(OH)₂D₃) ranged from <5% (<5%) to 548% (643%) in ligand binding assays. Both 24-hydroxylated metabolites were resolved by HPLC/UV and LC-MS/MS methods and thus caused no complications in the measurement of 25-OHD. Most antibodies to 25-OHD are known to cross-react with dihydroxylated metabolites but interference in some assays was far greater than expected. This may be related to the anomalous behaviour of exogenously added metabolites in these 25-OHD methods.

TACTIC: a multicentre, open-label, single-arm phase II trial of panitumumab, cisplatin, and gemcitabine in biliary tract cancer

PURPOSE

The phase II TACTIC trial prospectively selected patients with KRAS wild-type advanced biliary tract cancer for first-line treatment with panitumumab and combination chemotherapy.

METHODS

Of 78 patients screened, 85 % had KRAS wild-type tumours and 48 were enrolled. Participants received cisplatin 25 mg/m(2) and gemcitabine 1000 mg/m(2) on day 1 and day 8 of each 21-day cycle and panitumumab 9 mg/kg on day 1 of each cycle. Treatment was continued until disease progression, unacceptable toxicity, or request to discontinue. The primary endpoint was the clinical benefit rate (CBR) at 12 weeks (complete response, partial response, or stable disease). CBR of 70 % was considered to be of clinical interest. Secondary outcomes were progression-free survival, time to treatment failure, overall survival, CA19.9 response and safety.

RESULTS

Thirty-four patients had a clinical benefit at 12 weeks, an actuarial rate of 80 % (95 % CI 65-89 %). 46 % had a complete or partial response. Median progression-free survival was 8.0 months (95 % CI 5.1-9.9) and median overall survival 11.9 months (95 % CI 7.4-15.8). Infection accounted for 27 % of the grade 3 or 4 toxicity, with rash (13 %), fatigue (13 %), and hypomagnesemia (10 %) among the more common grade 3 or 4 non-haematological toxicities.

CONCLUSION

A marker-driven approach to patient selection was feasible in advanced biliary tract cancer in an Australian population. The combination of panitumumab, gemcitabine, and cisplatin in KRAS wild-type cancers was generally well tolerated and showed promising clinical efficacy. Further exploration of anti-EGFR therapy in a more selected population is warranted.

Automated immunoassays for 25-hydroxyvitamin D (25-OHD): do plasticisers interfere?

The international quality assessment scheme for vitamin D metabolites (DEQAS) was established in 1989. The scheme involves the quarterly distribution of 5 serum samples prepared from blood collected in plain plastic bags. Following transfer of the donors to a clinic using different bags, sera were found to contain a contaminant that interfered in both the local LC-MS/MS assay and the NIST reference measurement procedure for 25-OHD. It seemed likely that the contaminant was a substance, possibly a plasticiser, leached from the plastic bag. It was subsequently suggested that the unidentified contaminant might also cause interference in certain automated non-extraction assays for 25-OHD. This was investigated in 3 automated immunoassays by comparing serum 25-OHD results from blood collected simultaneously into plain glass tubes and plastic bags. There was no significant difference in results, indicating that the leached substance had no effect on any of the 3 immunoassays examined.

Nutrient biomarker patterns, cognitive function, and MRI measures of brain aging

OBJECTIVE

To examine the cross-sectional relationship between nutrient status and psychometric and imaging indices of brain health in dementia-free elders.

METHODS

Thirty plasma biomarkers of diet were assayed in the Oregon Brain Aging Study cohort (n = 104). Principal component analysis constructed nutrient biomarker patterns (NBPs) and regression models assessed the relationship of these with cognitive and MRI outcomes.

RESULTS

Mean age was 87 ± 10 years and 62% of subjects were female. Two NBPs associated with more favorable cognitive and MRI measures: one high in plasma vitamins B (B1, B2, B6, folate, and B12), C, D, and E, and another high in plasma marine ω-3 fatty acids. A third pattern characterized by high trans fat was associated with less favorable cognitive function and less total cerebral brain volume. Depression attenuated the relationship between the marine ω-3 pattern and white matter hyperintensity volume.

CONCLUSION

Distinct nutrient biomarker patterns detected in plasma are interpretable and account for a significant degree of variance in both cognitive function and brain volume. Objective and multivariate approaches to the study of nutrition in brain health warrant further study. These findings should be confirmed in a separate population.

Serum and dietary vitamin D and cardiovascular disease risk in elderly men: a prospective cohort study

BACKGROUND AND AIM

Recent research suggests that low vitamin D may be associated with cardiovascular disease (CVD).

METHODS AND RESULTS

We prospectively evaluated the association of dietary plus supplemental vitamin D intake and serum 25(OH) vitamin D with CVD incidence in the Osteoporotic Fractures in Men (MrOS) Study. Vitamin D intake was measured using a food frequency questionnaire and self-reported supplemental intake in 3094 men (mean age 76.4 years). From a subset of this population, we measured 25(OH) vitamin D in 813 men. Median 25(OH) vitamin D was 25.3 ng/mL. During a median follow-up of 4.4 years, there were 472 CVD cases, including 371 from coronary heart disease (CHD) and 101 from cerebrovascular attack (CVA). In the 25(OH) vitamin D sub-cohort, there were 140 cases of CVD including 115 from CHD and 25 from CVA. We used a Cox proportional hazards regression to calculate hazard ratios (HR) for CVD by vitamin D quartile. After adjusting for age, season, and standard CVD risk factors, the lowest quartile of 25(OH) vitamin D (HR, 1.18; 95% CI, 0.69-2.03) and vitamin D intake (HR, 0.76; 95% CI, 0.56-1.04) were not significantly associated with CVD incidence, compared to the highest vitamin D quartiles. When 25(OH) vitamin D was further analyzed by sufficiency (≥30 ng/mL), insufficiency (≥15-29.9 ng/mL), and deficiency (<15 ng/mL), vitamin D deficiency was not significantly associated with CVD incidence compared to sufficiency (HR 1.34; 95% CI 0.65-2.77).

CONCLUSION

Vitamin D intake and serum 25(OH) vitamin D were not associated with CVD risk.

Agent orange as a risk factor for positive prostate biopsy

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Background: Agent Orange (AO), a defoliate contaminated with the known carcinogen dioxin, has become a prominent concern as veterans of the Vietnam War who were exposed to AO are now reaching the age at which prostate cancer is most prevalent. While sufficient evidence has linked AO exposure to many diseases, only limited but suggestive evidence exists to support a positive association between AO and prostate cancer. Despite mixed findings, recent studies have found that the risk of prostate cancer in those exposed to AO was as high as twice the risk in those not exposed. The goal of this study was to examine this association between AO exposure and prostate cancer in a cohort of men referred for a prostate biopsy.

Methods: In this retrospective cohort-design, risk factors were identified using historical clinical data from a population of veterans referred to the Portland VA Hospital for a prostate biopsy between 1993 and 2010. In addition to AO exposure, covariates included prostate specific antigen density (PSAD), results of the digital rectal exam (DRE), age at biopsy, family history, body mass index (BMI), race, and medication use. Outcomes of the biopsies were defined as either positive or negative according to the pathology report and risk factors were compared between individuals found to have prostate cancer and those without cancer. Multiple logistic regression was used to evaluate the effect of AO on risk of prostate cancer after adjustment for confounders.

Results: Of the 2,720 veterans who underwent prostate biopsy, 896 (32.9%) were found to have prostate cancer. After adjustment for significant confounders including PSAD, DRE, age at biopsy, and family history of prostate cancer, veterans with prostate cancer were 49% more likely to have been exposed to AO as compared to those without prostate cancer (odds ratio = 1.49; 95% CI: 1.06-2.11, p=0.022).

Conclusions: Agent Orange exposure was associated with a significant increase in prostate cancer detection in men referred for a prostate biopsy. The limitations in identifying biologically significant levels of AO exposure in this study may suggest potential for underestimation of the true risk. This study supports the findings of recent studies suggesting that AO exposure increases the risk of prostate cancer.

No significant financial relationships to disclose.

Risk of arterial thromboembolic events in patients with advanced colorectal cancer receiving bevacizumab

BACKGROUND

Bevacizumab is an antiangiogenic mAb with efficacy against several cancers, but it is associated with risk of arterial thromboembolism (ATE). Further data are needed to determine the safety of bevacizumab.

PATIENTS AND METHODS

We recorded grade 3, 4, or 5 ATE events and other data (including age, baseline cardiovascular risk factors, history of ATE, and aspirin use) from 471 patients with metastatic colorectal cancer in the MAX (Mitomycin, Avastin, Xeloda) trial of capecitabine monotherapy versus capecitabine with bevacizumab with or without mitomycin C.

RESULTS

Bevacizumab-treated patients had 12 grade 3, 4, or 5 ATEs (3.8% incidence). ATEs occurred in 2.1% of patients >65 years, 5% of those with a history of ATE, and 5% of those with cardiac risk factors. Age, history of ATE, or vascular risk factors did not increase risk. Aspirin users had a higher incidence than nonusers (8.9% versus 2.7%) but had higher rates of vascular risk factors.

CONCLUSIONS

Bevacizumab was associated with a modestly higher risk of ATE, but safety was not significantly worse in older patients or patients with a history of ATE or vascular risk factors. The effect of aspirin in preventing ATE in patients receiving bevacizumab could not be determined from this study.

Erythrocyte fatty acids and prostate cancer risk: a comparison of methods

The role of fatty acids (FA) in prostate carcinogenesis is unclear. Interest in the inter-relationship among different types of FA has resulted in new analytic approaches to FA and their role in cancer development. We evaluated the association between erythrocyte FA and prostate cancer in 127 prostate cancer patients and 183 screen negative controls. We present three approaches to the analyses of the FA and prostate cancer association; (1) individual or common groups of FA, (2) biologically meaningful FA ratios and (3) principal components analysis. Monounsaturated FA and the alpha-linolenic:eicosapentaenoic ratio were associated with reduced risk of prostate cancer. However, Factor 1, which was strongly correlated with some long chain saturated FA, was associated with an increased risk of prostate cancer. We provide an example of modeling FA and their inter-relationships on the risk of prostate cancer. Comparing three approaches suggests the importance of considering the impact of the entire fatty acid profile in disease prevention.

ABC; An AGITG trial of fixed dose rate (FDR) gemcitabine (gem) and cisplatin for patients (pts) with advanced biliary tract cancer (ABC)

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Background: No standard regimen exists for pts with ABC. Previous studies suggest that FDR optimises gem activity. This study evaluated the activity of FDR gem with low dose cisplatin using a previously identified schedule. Methods: Single arm, multi- centre phase II trial, planned to enrol 45 pts > 18 years, ECOG PS = 2, with previously untreated histologically / cytologically confirmed, inoperable locally advanced or metastatic ABC. Treatment consisted of FDR gem 1000 mg/m2 (10 mg/m2/min) and cisplatin 20 mg/m2 days 1& 8 q21 days until progression or intolerable toxicity. The primary end point was response rate (RR) by RECIST. Secondary end points included tolerability and safety, progression free and overall survival (PFS, OS) and response duration (RD). Results: 50 pts were enrolled from Feb 05 to Oct 06. Mean age was 60y (39–78); 88% had ECOG PS 0–1; 54% were female. Primary sites were gall bladder 45%, biliary tree 51%, ampulla 4%. Distant metastases were present in 63%. Past treatments included biliary stent in 29%, bypass in 6%, and an external drain in 4%. With a minimum follow-up of 12 weeks, best response was a confirmed PR in 11 pts (RR 22%, 95% CI 11 - 36) and SD (after 4 cycles) in 11 pts (22%), 1 (2%) unevaluable. CA19–9 responses occurred in 6 of 33 pts (18%). Median OS was 7 mo (0.3–13), PFS 4.4 mo (0.3–13), and RD 8 mo (5–12). One year survival rate was 30%. The median number of cycles was 4 (1–16). Treatment was delayed at least once in 45% of pts; mean delay 9d. Grade 3/4 (NCI/CTC) toxicities included infection 9%, fatigue 9%, anorexia/nausea 11%, vomiting 9%, anaemia 9%, neutropenia 28%, thrombocytopenia 15%, abnormal ALP 25%, GGT 47%, AST 6%. There was 1 treatment related death (hematemesis with grade 4 thrombocytopenia). Exploratory analysis of CA 19–9 and its association with response assessment and overall survival will be presented in June. Conclusions: This combination was well tolerated. The observed response rate is consistent with the expected 35% rate and may be superior to that expected with gem monotherapy. Further testing of this dose and scheduling is warranted. The authors thank Lilly for an unrestricted grant to conduct this study.

[Table: see text]

Statin use and inflammation in prostate biopsy tissue

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Background: The statin class of drugs has been shown to affect tumors through a number of mechanisms including inhibiting tissue inflammation. Inflammation is a common finding in men undergoing a prostate biopsy and may play a role in prostatic tumorigenesis. We set out to determine whether the use of statin drugs was associated with altered tissue inflammation on prostate biopsy. Methods: Data were collected on all men with a PSA </= 10 ng/ml that underwent a prostate biopsy. A urinalysis to rule out the presence of infection was carried out in all men. The presence or absence of cancer and/or inflammation was determined by pathology report review. Statin data were recorded from the VA electronic pharmacy database. Statin duration and intensity variables were calculated for each subject based on total days used for each statin at each prescribed dose. Only men with a negative biopsy were considered in our analyses. Odds ratios (OR) as estimates of the relative risk for prostate inflammation associated with each level of statin use and 95 percent confidence intervals (CI) were obtained using pooled conditional logistic regression stratified on year of biopsy. Results: Out of 1,482 men with data available on inflammation, family history of prostate cancer, age and race; 436 were found to have prostatic inflammation. In final adjusted models stratified on year of biopsy (prior to 1997, 1997–2001, 2001 -2006) we found no association between any statin use (OR=0.88, 95% CI (0.70–1.11)), intensity of use (OR=0.93, 95% CI (0.86–1.01)), or duration of use (OR=0.932, 95% CI (0.86–1.01). These results did not change when individual statin types were analyzed. Conclusions: Statin use was not associated with a reduction in tissue inflammation in men undergoing a prostate biopsy. If statin use affects prostatic carcinogenesis, it is unlikely to do so by affecting tissue inflammatory networks.

No significant financial relationships to disclose.

Demographic factors associated with the diet quality of older US men: baseline data from the Osteoporotic Fractures in Men (MrOS) study

OBJECTIVE

Throughout the world, the proportion of the male population aged 65 years and older is increasing. Yet, we have limited information regarding diet quality and predictors of diet quality in this segment of the population. The objectives of the current analyses are to describe the diet quality of a cohort of men >65 years of age, and identify lifestyle factors associated with poor diet quality.

METHODS

We present a cross-sectional analysis of the diet quality of 5928 men, aged 65-100 years, who are participants in the Osteoporotic Fractures in Men (MrOS) cohort study. Dietary intake was determined using a modified Block 98 food-frequency questionnaire. Diet quality was calculated using the previously validated Diet Quality Index-Revised (DQI-R). Univariate and multivariate modelling was used to estimate the variance in diet quality predicted by a number of sociodemographic factors, including age, race/ethnicity, body mass index (BMI), marital status, education, smoking status, physical activity, self-perceived health and nutritional supplement use.

RESULTS

Overall, we found that in this geographically diverse group of older men, diet quality was low, with a mean modified DQI-R for the entire study population of 62.5 (standard deviation 13.1) out of an ideal of 100. Further, younger age, very low total calorie intake (< or = 1187 kcal day- 1), higher BMI, residence in a North or Southeast community, being of African-American or Hispanic race, being less educated, not using dietary supplements and smoking were each significant independent predictors of a poorer diet.

CONCLUSION

These data may prove useful in both understanding the dietary intake of older US men as it relates to published dietary guidelines, and for targeting future dietary intervention programmes.

The effect of dutasteride on intraprostatic dihydrotestosterone concentrations in men with benign prostatic hyperplasia

The dual 5alpha-reductase inhibitor, dutasteride has been shown to suppress serum dihydrotestosterone (DHT) by >90%. In the present study, the effect of dutasteride 0.5 mg/day on intraprostatic DHT levels was investigated. In this multicenter, double-blind trial, 43 men with benign prostatic hyperplasia (BPH) scheduled to undergo transurethral resection of the prostate (TURP) were randomized to receive dutasteride, 0.5 mg/day or placebo for 3 months before surgery. Intraprostatic DHT, testosterone and dutasteride levels were determined at the time of TURP. Changes in serum DHT and testosterone from baseline, and both serum and intraprostatic dutasteride levels at the time of TURP were also assessed. Dutasteride reduced intraprostatic DHT by 94% relative to placebo (P<0.001); the adjusted mean intraprostatic DHT concentration was 3.23 and 0.209 ng/g in the placebo and dutasteride groups, respectively. In the dutasteride group, serum DHT was reduced from baseline by 93% at month 3, a significantly greater reduction (P<0.001) than the 15% decrease observed in the placebo group. There was a reciprocal increase in intraprostatic testosterone but the level of intraprostatic testosterone in the dutasteride group tended to be lower than the intraprostatic DHT level in the placebo group (P=0.06). Significant intraprostatic DHT suppression was achieved in all subjects who received dutasteride, regardless of the level of intraprostatic dutasteride. There was a strong positive correlation between serum and intraprostatic dutasteride concentrations (R(2)=0.73). After 3 months of treatment, dutasteride 0.5 mg/day provided near-complete suppression of both intraprostatic and serum DHT in men with BPH.

Differences in proteoglycan deposition in the airways of moderate and severe asthmatics

Excess deposition of proteoglycans (PGs) has been described in the subepithelial layer of the asthmatic airway wall. However, less is known about deposition in the airway smooth muscle (ASM) layer, and whether the pattern of deposition is altered depending upon disease severity. Endobronchial biopsies were performed in patients with severe or moderate asthma (defined using American Thoracic Society criteria) and in control subjects. Biopsies were immunostained for the PGs biglycan, lumican, versican and decorin. PG deposition was measured in the subepithelial and ASM layers, the former by calculating the area of positive staining, and the latter by determining the percentage area stained using point counting. Immunostaining for PGs was prominent in biopsies from both moderate and severe asthmatics, compared with control subjects. While there was no difference in the amount of PG in the subepithelial layer between the two asthmatic groups, the percentage area of biglycan and lumican staining in the ASM layer was significantly greater in moderate versus severe asthmatics. Differences in the deposition of proteoglycans within the airway smooth muscle layer of moderate versus severe asthmatics potentially impact on the functional behaviour of the airway smooth muscle in these two groups of patients.

Effect of obesity on PSA density (PSAD): A new clinical predictor of prostate cancer

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Background: The escalating rate of obesity in the Western world presents a diagnostic challenge when screening for prostate cancer. Increased body-mass index (BMI) disrupts the ability to effectively screen this population due to an associated decrease in serum prostate-specific antigen (PSA) levels and an increase in prostate volume. We therefore sought to understand how BMI impacts the probability of harboring prostate cancer. Methods: Data were collected on 647 referred men with a serum PSA of ≤ 10 ng/ml who underwent an ultrasound-guided prostate biopsy. Variables analyzed included: age, BMI, digital rectal exam (DRE), PSA, PSAD (i.e. PSA ÷ prostate volume), prostate volume, hypoechoic lesions on ultrasound and cancer on biopsy. A one-way ANOVA was performed to determine differences in log2 (PSAD) among BMI groups (<25 kg/m2 vs. 25–30 kg/m2 vs. >30 kg/m2). Multivariate logistic regression analysis was performed to estimate the odds-ratio (OR) and 95% confidence intervals (CI). Results: Prostate cancer was detected in 19.2 % of patients. ANOVA showed the mean PSAD to be significantly different in the three BMI groups (F value = 7.1, p = .0009). The mean PSAD significantly decreased as the BMI level increased (p = .0002). Independent pre-biopsy predictors of prostate cancer were tabulated (see below). Conclusions: Obesity was associated with a decrease in PSA density. The multivariate logistic regression revealed that the effect of PSAD on cancer detection was significantly modified by BMI. Specifically, the OR associated with a doubling of PSAD was 1.7 when BMI was <25 kg/m2 vs. 2.1 when BMI was ≥25 kg/m2). This interaction was an independent predictor of prostate cancer risk, along with DRE and ultrasound findings. These data underscore the need to consider BMI as a potential effect modifier of traditional clinical risk factors for prostate cancer. The dramatic rise in obesity in the United States makes this effect modification particularly relevant.

[Table: see text]

No significant financial relationships to disclose.