The MARECA (national study of management of breast cancer locoregional recurrence and oncological outcomes) study: protocol for a prospective, multicentre cohort study

Background

Despite a UK 5-year breast cancer survival rate of 86.6%, patients may develop breast cancer recurrence within the same breast after breast conserving surgery, as well as in the remaining skin or chest wall after mastectomy or in the ipsilateral lymph glands. These recurrences, collectively termed locoregional recurrence (LRR), occur in around 8% of patients within 10 years of their original diagnosis. Currently, there is a lack of robust information on the presentation and prevalence of LRR with no UK-specific clinical guidelines available for the optimal management of this patient group. Additionally, there is a need to identify patterns of LRR presentation and their progression, which will enable prognostic factors to be determined. This will subsequently enable the tailoring of treatment and improve patient outcome.

Methods

The MARECA study is a prospective, multicentre cohort study recruiting patients diagnosed with breast cancer LRR +/- associated distant metastases. Over 50 UK breast units are participating in the study with the aim of recruiting at least 500 patients over a recruitment period of 24 months. The data collected will detail the tumour pathology, imaging results, surgical treatment, radiotherapy and systemic therapy of the primary and recurrent breast cancer. Study follow-up will be for up to 5 years following LRR diagnosis to determine subsequent oncological outcomes and evaluate potential prognostic factors.

Discussion

This study will address the current knowledge gap and identify subgroups of patients who have less successful treatment outcomes. The results will determine the current management of LRR and the prognosis of patients diagnosed with breast cancer LRR +/- distant metastases in the UK, with the aim of establishing best practice and informing future national guidelines. The results will direct future research and inform the design of additional interventional trials and translational studies.

Examining the variation in consent in general surgery

INTRODUCTION

Consent is a fundamental aspect of surgery and expectations around the consent process have changed following the Montgomery vs Lanarkshire Health Board (2015) court ruling. This study aimed to identify trends in litigation pertaining to consent, explore variation in how consent is practised among general surgeons and identify potential causes of this variation.

METHODS

This mixed-methods study examined temporal variation in litigation rates relating to consent (between 2011 and 2020), using data obtained from National Health Service (NHS) Resolutions. Semi-structured clinician interviews were then conducted to gain qualitative data regarding how general surgeons take consent, their ideologies and their outlook on the recent legal changes. The quantitative component included a questionnaire survey aiming to explore these issues with a larger population to improve the generalisability of the findings.

RESULTS

NHS Resolutions litigation data showed a significant increase in litigation pertaining to consent following the 2015 health board ruling. The interviews demonstrated considerable variation in how surgeons approach consent. This was corroborated by the survey, which illustrated considerable variation in how consent is documented when different surgeons are presented with the same case vignette.

CONCLUSION

A clear increase in litigation relating to consent was seen in the post-Montgomery era, which may be due to legal precedent being established and increased awareness of these issues. Findings from this study demonstrate variability in the information patients receive. In some cases, consent practices did not adequately meet current regulations and therefore are susceptible to potential litigation. This study identifies areas for improvement in the practice of consent.

Outcomes of complex oncoplastic breast surgery in older women. Analysis of data from the Age Gap cohort study

KEY WORDS

Breast cancer, mastectomy, breast conserving surgery, post-mastectomy reconstruction, older women, quality of life.

Intervention to reduce age bias in medical students' decision making for the treatment of older women with breast cancer: A novel approach to bias training

Objectives: Despite NICE guidelines to 'treat people with invasive breast cancer, irrespective of age, with surgery and appropriate systemic therapy, rather than endocrine therapy alone', older patients receive differential treatment and experience worse outcomes. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and potentially perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients nor, consequentially, has removing age bias been considered as an approach to improving outcomes. Many organizations carry out bias training with the aim of reducing negative impacts from biased decision making, yet the few evaluations of these interventions have mostly seen small or negative effects. This study explores whether a novel intervention to address age bias leads to better quality decision making for the treatment of older women with breast cancer.Methods: An online study compared medical students' treatment recommendations for older breast cancer patients and the reasoning for their decision making before and after a novel bias training intervention. Thirty-one medical students participated in the study.Results: The results show that the bias training intervention led medical students to make better quality decisions for older breast cancer patients. The quality of decision making was measured by decreases in age-based decision making and increased efforts to include patients in decision making. These results suggest there is value in exploring whether if anti-bias training interventions could usefully be applied in other areas of practice where older patients experience poorer outcomes.Conclusions: This study evidences that bias training improves the quality of decision making by medical students in respect of older breast cancer patients. The study findings show promise that this novel approach to bias training might usefully be applied to all medical practitioners making treatment recommendations for older patients.

Is early bowel resection better than medical therapy for ileocolonic Crohn's disease? A systematic review and meta-analysis

AIM

There is emerging evidence supporting early bowel resection (EBR) for ileocaecal Crohn's disease (CD) as an alternative to conventional escalation of medical therapy (MT). Here, we present a systematic review and meta-analysis of studies comparing the outcomes of EBR with those of MT in ileocolonic CD, with a focus on ileocaecal disease.

METHODOLOGY

The MEDLINE, Embase, CINAHL and Cochrane Central Register of Controlled Trials databases were searched for studies reporting the outcomes of EBR versus MT for ileocolonic CD. The Cochrane tools for assessment of risk of bias were used to assess the methodological quality of studies.

RESULTS

Nine records (from 8 studies, with a total of 1867 patients) were included in the analysis. Six studies were observational and two were randomised controlled trials. There was a reduced need for drug therapy in the EBR arm. The rate of intestinal resection at 5 years was 7.8% in the EBR arm and 25.4% in the MT group with a pooled OR of 0.32 (95% CI 0.19, 0.54; p < 0.0001). The EBR group had a longer resection-free survival (HR 0.56, 95% CI 0.38, 0.83; p = 0.004). These outcomes were consistent in a subgroup analysis of patients with ileocaecal disease. Morbidity and quality of life scores were similar across the two groups.

CONCLUSION

EBR is associated with a more stable remission compared to initial MT for ileocolonic Crohn's disease. There is enough evidence to support EBR as an alternative to escalation of MT in selected patients with limited ileocaecal disease.

Results of shared learning of a new magnetic seed localisation device - A UK iBRA-NET breast cancer localisation study

INTRODUCTION

Shared learning is imperative in the assessment and safe implementation of new healthcare interventions. Magnetic seeds (Magseed®) potentially offer logistical benefit over wire localisation for non-palpable breast lesions but few data exist on outcomes comparing these techniques. A national registration study (iBRA-NET) was conducted to collate device outcomes. In order to share learning, thematic analysis was conducted to ascertain early clinical experiences of Magseed® and wire guided localisation and explore how learning events may be applied to improve clinical outcomes.

METHODS

A qualitative study of 27 oncoplastic surgeons, radiologists and physicians was conducted in January 2020 to ascertain the feasibility and challenges associated with Magseed® versus wire breast localisation surgery. Four focus groups were asked to discuss experiences, concerns and shared learning outcomes which were tabulated and analysed thematically.

RESULTS

Three key themes were identified comparing Magseed® and wire localisation of breast lesions relating to preoperative, intraoperative and postoperative learning outcomes. Percutaneous Magseed® detection, instrument interference and potential seed or wire dislodgement were the most common issues identified. Clinician experience suggested Magseed® index lesion identification was non-inferior to wire placement and improved the patient pathway in terms of scheduling and multi-site insertion.

CONCLUSIONS

Prospective shared learning suggested Magseed® offered additional non-clinical benefits over wire localisation, improving the efficiency of the patient pathway. Recommendations for improving breast localisation technique, appropriate patient selection and clinical practice through shared learning are discussed that may aid other surgeons in the adoption of this relatively new technique.

Is there evidence of age bias in breast cancer health care professionals' treatment of older patients?

OBJECTIVES

Despite NICE (2009; 2018) guidelines to treat breast cancer patients 'irrespective of age', older women experience differential treatment and worse outcomes beyond that which can be explained by patient health or patient choice. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and perhaps perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients.

METHODS

This mixed methods study explored age bias amongst breast cancer HCPs through four components: 1) An implicit associations test (31 HCPs) 2) A treatment recommendations questionnaire (46 HCPs). 3) An attitudes about older patients questionnaire (31 HCPs). 4) A treatment recommendations interview (20 HCPs).

RESULTS

This study showed that breast cancer HCPs held negative implicit associations towards older women; HCPs were less likely to recommend surgery for older patients; some HCPs held assumptions that older patients are more afraid, less willing and able to be involved in decision-making, and are less willing and able to cope with being informed of a poor treatment prognosis; and conditions which disproportionately affect older patients, such as dementia, are not always well understood by breast cancer HCPs.

CONCLUSIONS

These results indicate that there are elements of age bias present amongst breast cancer HCPs. The study's findings of age-based assumptions and a poorer understanding of conditions which disproportionately affect older patients align with patterns of differential treatment towards older breast cancer patients suggesting that age bias may be, at least in part, driving differential treatment.

The MARECA (national study of management of breast cancer locoregional recurrence and oncological outcomes) study: National practice questionnaire of United Kingdom multi-disciplinary decision making

INTRODUCTION

Evidence based guidelines for the optimal management of breast cancer locoregional recurrence (LRR) are limited, with potential for variation in clinical practice. This national practice questionnaire (NPQ) was designed to establish the current practice of UK breast multidisciplinary teams (MDTs) regarding LRR management.

METHODS

UK breast units were invited to take part in the MARECA study MDT NPQ. Scenario-based questions were used to elicit preference in pre-operative staging investigations, surgical management, and adjuvant therapy.

RESULTS

822 MDT members across 42 breast units (out of 144; 29%) participated in the NPQ (February-August 2021). Most units (95%) routinely performed staging CT scan, but bone scan was selectively performed (31%). For patients previously treated with breast conserving surgery (BCS) and radiotherapy, few units (7%) always/usually offered repeat BCS. However, in the absence of radiotherapy, most units (90%) always/usually offered repeat BCS. For patients presenting with isolated local recurrence following previous BCS and SLNB (sentinel lymph node biopsy), most units (95%) advocated repeat SLNB. Where SLNs could not be identified, 86% proceeded to a four-node axillary sampling procedure. For ER positive, HER2 negative, node negative local recurrence, 10% of units always/usually offered chemotherapy. For ER positive, HER2 negative, node positive local recurrence, this recommendation increased to 64%. For triple negative breast cancer local recurrence, 90% of units always/usually offered chemotherapy.

CONCLUSION

This survey has highlighted where consistencies and variations exist in the multidisciplinary management of breast cancer LRR. However, further research is required to determine how these management patterns influence patient outcomes, which will further refine optimal treatment pathways.

Examining the barriers faced by female surgical trainees: a qualitative study

INTRODUCTION

Today, women make up 56% of medical students, yet just 13% of surgical consultants - a number that has remained static since 2013. This qualitative study explored some of the barriers to female success in modern surgery.

METHODS

Semistructured qualitative interviews were undertaken primarily with female surgical trainees to determine the barriers they face. Male trainees and training programme directors (TPDs) were also interviewed for triangulation.

RESULTS

20 interviews were performed (16 female trainees, 3 male trainees, and 1 TPD) between October 2019 and March 2020. Family pressures and becoming a mother were significant barriers for women training in surgery - a barrier that did not apply to male trainees who were fathers, often resulting in women choosing to train less than full time (LTFT). Unfortunately LTFT training presents further obstacles for female trainees. The set-up of the national training programme in surgery provides many non-gender-specific barriers, chiefly moving hospital every 6 months causing disrupted training and long commutes, disproportionately affecting females with child care responsibilities. Sexism and discrimination are still common, both from colleagues and patients. Many participants perceived inherent differences between genders in communication and methods for coping with stress.

CONCLUSION

Greater gender equality in surgery may be achieved by changes in the structure and organisation of training to reduce the tension between the professional role and the predominantly female-led role of raising children. Better equality and diversity training and awareness at all levels in surgery may help to mitigate some of the conscious and unconscious bias that still exists.

Differences in treatment and survival of older patients with operable breast cancer between the United Kingdom and the Netherlands – A comparison of two national prospective longitudinal multi-centre cohort studies

Background

Previous studies have shown that survival outcomes for older patients with breast cancer vary substantially across Europe, with worse survival reported in the United Kingdom. It has been hypothesised that these differences in survival outcomes could be related to treatment variation.

Objectives

We aimed to compare patient and tumour characteristics, treatment selection and survival outcomes between two large prospective cohorts of older patients with operable breast cancer from the United Kingdom (UK) and The Netherlands.

Methods

Women diagnosed with operable breast cancer aged ≥70 years were included. A baseline comprehensive geriatric assessment was performed in both cohorts, with data collected on age, comorbidities, cognition, nutritional and functional status. Baseline tumour characteristics and treatment type were collected. Univariable and multivariable Cox regression models were used to compare overall survival between the cohorts.

Results

3262 patients from the UK Age Gap cohort and 618 patients from the Dutch Climb cohort were included, with median ages of 77.0 (IQR: 72.0–81.0) and 75.0 (IQR: 72.0–81.0) years, respectively. The cohorts were generally comparable, with slight differences in rates of comorbidity and frailty. Median follow-up for overall survival was 4.1 years (IQR 2.9–5.4) in Age Gap and 4.3 years (IQR 2.9–5.5) in Climb. In Age Gap, both the rates of primary endocrine therapy and adjuvant hormonal therapy after surgery were approximately twice those in Climb (16.6% versus 7.3%, p < 0.001 for primary endocrine therapy, and 62.2% versus 38.8%, p < 0.001 for adjuvant hormonal therapy). There was no evidence of a difference in overall survival between the cohorts (adjusted HR 0.94, 95% CI 0.74–1.17, p = 0.568).

Conclusions

In contrast to previous studies, this comparison of two large national prospective longitudinal multi-centre cohort studies demonstrated comparable survival outcomes between older patients with breast cancer treated in the UK and The Netherlands, despite differences in treatment allocation.

•

No survival difference between UK and Netherlands for older breast cancer patients.

•

Similar patient and tumour characteristics seen in both cohorts.

•

Higher rates of mastectomy for older breast cancer patients in Netherlands.

•

Higher rates of adjuvant therapies for older breast cancer patients in UK.

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Observational cohort study in older women with early breast cancer: Use of radiation therapy and impact on health-related quality of life and mortality

BACKGROUND

Radiotherapy reduces in-breast recurrence risk in early breast cancer (EBC) in older women. This benefit may be small and should be balanced against treatment effect and holistic patient assessment. This study described treatment patterns according to fitness and impact on health-related quality-of-life (HRQoL).

METHODS

A multicentre, observational study of EBC patients aged ≥ 70 years, undergoing breast-conserving surgery (BCS) or mastectomy, was undertaken. Associations between radiotherapy use, surgery, clinico-pathological parameters, fitness based on geriatric parameters and treatment centre were determined. HRQoL was measured using the European Organisation for the Research and Treatment of Cancer (EORTC) questionnaires.

RESULTS

In 2013-2018 2811 women in 56 UK study centres underwent surgery with a median follow-up of 52 months. On multivariable analysis, age and tumour risk predicted radiotherapy use. Among healthier patients (based on geriatric assessments) with high-risk tumours, 534/613 (87.1%) having BCS and 185/341 (54.2%) having mastectomy received radiotherapy. In less fit individuals with low-risk tumours undergoing BCS, 149/207 (72.0%) received radiotherapy. Radiotherapy effects on HRQoL domains, including breast symptoms and fatigue were seen, resolving by 18 months.

CONCLUSION

Radiotherapy use in EBC patients ≥ 70 years is affected by age and recurrence risk, whereas geriatric parameters have limited impact regardless of type of surgery. There was geographical variation in treatment, with some fit older women with high-risk tumours not receiving radiotherapy, and some older, low-risk, EBC patients receiving radiotherapy after BCS despite evidence of limited benefit. The impact on HRQoL is transient.

Cost-Effectiveness Modeling of Surgery Plus Adjuvant Endocrine Therapy Versus Primary Endocrine Therapy Alone in UK Women Aged 70 and Over With Early Breast Cancer

OBJECTIVES

Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective.

METHODS

Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}.

RESULTS

For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3).

CONCLUSION

From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.

Bridging The Age Gap: observational cohort study of effects of chemotherapy and trastuzumab on recurrence, survival and quality of life in older women with early breast cancer

BACKGROUND

Chemotherapy improves outcomes for high risk early breast cancer (EBC) patients but is infrequently offered to older individuals. This study determined if there are fit older patients with high-risk disease who may benefit from chemotherapy.

METHODS

A multicentre, prospective, observational study was performed to determine chemotherapy (±trastuzumab) usage and survival and quality-of-life outcomes in EBC patients aged ≥70 years. Propensity score-matching adjusted for variation in baseline age, fitness and tumour stage.

RESULTS

Three thousands four hundred sixteen women were recruited from 56 UK centres between 2013 and 2018. Two thousands eight hundred eleven (82%) had surgery. 1520/2811 (54%) had high-risk EBC and 2059/2811 (73%) were fit. Chemotherapy was given to 306/1100 (27.8%) fit patients with high-risk EBC. Unmatched comparison of chemotherapy versus no chemotherapy demonstrated reduced metastatic recurrence risk in high-risk patients(hazard ratio [HR] 0.36 [95% CI 0.19-0.68]) and in 541 age, stage and fitness-matched patients(adjusted HR 0.43 [95% CI 0.20-0.92]) but no benefit to overall survival (OS) or breast cancer-specific survival (BCSS) in either group. Chemotherapy improved survival in women with oestrogen receptor (ER)-negative cancer (OS: HR 0.20 [95% CI 0.08-0.49];BCSS: HR 0.12 [95% CI 0.03-0.44]).Transient negative quality-of-life impacts were observed.

CONCLUSIONS

Chemotherapy was associated with reduced risk of metastatic recurrence, but survival benefits were only seen in patients with ER-negative cancer. Quality-of-life impacts were significant but transient.

TRIAL REGISTRATION

ISRCTN 46099296.

Bridging the Age Gap in breast cancer: Impact of chemotherapy on quality of life in older women with early breast cancer

INTRODUCTION

Older patients with early breast cancer (EBC) derive modest survival benefit from chemotherapy but have increased toxicity risk. Data on the impact of chemotherapy for EBC on quality of life in older patients are limited, but this is a key determinant of treatment acceptance. We aimed to investigate its effect on quality of life in older patients enrolled in the Bridging the Age Gap study.

MATERIALS AND METHODS

A prospective, multicentre, observational study of EBC patients ≥70 years old was conducted in 2013-2018 at 56 UK hospitals. Demographics, patient, tumour characteristics, treatments and adverse events were recorded. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaires (EORTC-QLQ) C30, BR23 and ELD 15 plus the Euroqol-5D (eq-5d) over 24 months and analysed at each time point using baseline adjusted linear regression analysis and propensity score-matching.

RESULTS

Three thousand and four hundred sixteen patients were enrolled in the study; 1520 patients undergoing surgery and who had high-risk EBC were included in this analysis. 376/1520 (24.7%) received chemotherapy. At 6 months, chemotherapy had a significant negative impact in several EORTC-QLQ-C30 domains, including global health score, physical, role, social functioning, cognition, fatigue, nausea/vomiting, dyspnoea, appetite loss, diarrhoea and constipation. Similar trends were documented on other scales (EORTC-QLQ-BR23, EORTC-QLQ-ELD15 and EQ-5D-5L). Its impact was no longer significant at 18-24 months in unmatched and matched cohorts.

CONCLUSIONS

The negative impact of chemotherapy on quality-of-life is clinically and statistically significant at 6 months but resolves by 18 months, which is crucial to inform decision-making for older patients contemplating chemotherapy.

TRIAL REGISTRATION NUMBER ISRCTN

46099296.

Observational cohort study to determine the degree and causes of variation in the rate of surgery or primary endocrine therapy in older women with operable breast cancer

BACKGROUND

In the UK there is variation in the treatment of older women with breast cancer, with up to 40% receiving primary endocrine therapy (PET), which is associated with inferior survival. Case mix and patient choice may explain some variation in practice but clinician preference may also be important.

METHODS

A multicentre prospective cohort study of women aged >70 with operable breast cancer. Patient characteristics (health status, age, tumour characteristics, treatment allocation and decision-making preference) were analysed to identify whether treatment variation persisted following case-mix adjustment. Expected case-mix adjusted surgery rates were derived by logistic regression using the variables age, co-morbidity, tumour stage and grade. Concordance between patients' preferred and actual decision-making style was assessed and associations between age, treatment and decision-making style calculated.

RESULTS

Women (median age 77, range 70-102) were recruited from 56 UK breast units between 2013 and 2018. Of 2854/3369 eligible women with oestrogen receptor positive breast cancer, 2354 were treated with surgery and 500 with PET. Unadjusted surgery rates varied between hospitals, with 23/56 units falling outside the 95% confidence intervals on funnel plots. Adjusting for case mix reduced, but did not eliminate, this variation between hospitals (10/56 units had practice outside the 95% confidence intervals). Patients treated with PET had more patient-centred decisions compared to surgical patients (42.2% vs 28.4%, p < 0.001).

CONCLUSIONS

This study demonstrates variation in treatment selection thresholds for older women with breast cancer. Health stratified guidelines on thresholds for PET would help reduce variation, although patient preference should still be respected.

Bridging the Age Gap: a prognostic model that predicts survival and aids in primary treatment decisions for older women with oestrogen receptor-positive early breast cancer

BACKGROUND

A prognostic model was developed and validated using cancer registry data. This underpins an online decision support tool, informing primary treatment choice for women aged 70 years or older with hormone receptor-positive early breast cancer.

METHODS

Data from women diagnosed between 2002 and 2010 in the English Northern and Yorkshire and West Midlands regions were used to develop the model. Primary treatment options of surgery with adjuvant endocrine therapy or primary endocrine therapy were compared. Models predicting the hazard of breast cancer-specific mortality and hazard of other-cause mortality were combined to derive survival probabilities. The model was validated externally using data from the Eastern Cancer Registration and Information Centre.

RESULTS

The model was developed using data from 23 842 women, and validated externally on a data set from 14 526 patients. The overall model calibration was good. At 2 and 5 years, predicted mortality from breast cancer and other causes differed from the observed rate by less than 1 per cent. At 5 years, there were slight overpredictions in breast cancer mortality (2629 predicted versus 2556 observed deaths; P = 0·142) and mortality from all causes (6399 versus 6320 respectively; P = 0·583). The discrepancy varied between subgroups. Model discrimination was 0·75 or above for all mortality measures.

CONCLUSION

A prognostic model for older women with oestrogen receptor-positive early breast cancer was developed and validated in the present study. This forms a basis for an online decision support tool (https://agegap.shef.ac.uk/).

Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study

Background

Breast cancer surgery in older women is variable and sometimes non-standard owing to concerns about morbidity. Bridging the Age Gap in Breast Cancer is a prospective multicentre cohort study aiming to determine factors influencing treatment selection and outcomes from surgery for older patients with breast cancer.

Methods

Women aged at least 70 years with operable breast cancer were recruited from 57 UK breast units between 2013 and 2018. Associations between patient and tumour characteristics and type of surgery in the breast and axilla were evaluated using univariable and multivariable analyses. Oncological outcomes, adverse events and quality-of-life (QoL) outcomes were monitored for 2 years.

Results

Among 3375 women recruited, surgery was performed in 2816 patients, of whom 24 with inadequate data were excluded. Sixty-two women had bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70–95) years. Breast surgery comprised mastectomy in 1138 and breast-conserving surgery in 1716 procedures. Axillary surgery comprised axillary lymph node dissection in 575 and sentinel node biopsy in 2203; 76 had no axillary surgery. Age, frailty, dementia and co-morbidities were predictors of mastectomy (multivariable odds ratio (OR) for age 1·06, 95 per cent c.i. 1·05 to 1·08). Age, frailty and co-morbidity were significant predictors of no axillary surgery (OR for age 0·91, 0·87 to 0·96). The rate of adverse events was moderate (551 of 2854, 19·3 per cent), with no 30-day mortality. Long-term QoL and functional independence were adversely affected by surgery.

Conclusion

Breast cancer surgery is safe in women aged 70 years or more, with serious adverse events being rare and no mortality. Age, ill health and frailty all influence surgical decision-making. Surgery has a negative impact on QoL and independence, which must be considered when counselling patients about choices.

Adjuvant Chemotherapy for Breast Cancer in Older Women: An Analysis of Retrospective English Cancer Registration Data

AIMS

Adjuvant chemotherapy is recommended as a treatment for women with high recurrence risk early breast cancer. Older women are less likely to receive chemotherapy than younger women. This study investigated the impact of chemotherapy on breast cancer-specific survival in women aged 70 + years using English registry data.

MATERIALS AND METHODS

Cancer registration data were obtained from two English regions from 2002 to 2012 (n = 29 728). The impact of patient-level characteristics on the probability of receiving adjuvant chemotherapy was explored using logistic regression. Survival modelling was undertaken to show the effect of chemotherapy and age/health status on breast cancer-specific survival. Missing data were handled using multiple imputation.

RESULTS

In total, 11 735 surgically treated early breast cancer patients were identified. Use of adjuvant chemotherapy has increased over time. Younger age at diagnosis, increased nodal involvement, tumour size and grade, oestrogen receptor-negative or human epidermal growth factor receptor 2-positive disease were all associated with increased probability of receiving chemotherapy. Chemotherapy was associated with a significant reduction in the hazard of breast cancer-specific mortality in women with high risk cancer, after adjusting for patient-level characteristics (hazard ratio 0.74, 95% confidence interval 0.67-0.81).

DISCUSSION

Chemotherapy is associated with an improved breast cancer-specific survival in older women with early breast cancer at high risk of recurrence . Lower rates of chemotherapy use in older women may, therefore, contribute to inferior cancer outcomes. Decisions on potential benefits for individual patients should be made on the basis of life expectancy, treatment tolerance and patient preference.

Efficient development and usability testing of decision support interventions for older women with breast cancer

BACKGROUND

Around one-third of breast cancers diagnosed every year in the UK are in women aged ≥70 years. However, there are currently no decision support interventions (DESIs) for older women who have a choice between primary endocrine therapy and surgery followed by adjuvant endocrine therapy (surgery+endocrine therapy), or who can choose whether or not to have chemotherapy following surgery. There is also little evidence-based guidance specifically on the management of these older patients. A large UK cohort study is currently underway to address this lack of evidence and to develop two DESIs to facilitate shared decision-making with older women about breast cancer treatments. Here, we present the development and initial testing of these two DESIs.

METHODS

An initial prototype DESI was developed for the choice of primary endocrine therapy or surgery+endocrine therapy. Semi-structured interviews with healthy volunteers and patients explored DESI acceptability, usability, and utility. A framework approach was used for analysis. A second DESI for the choice of having chemotherapy or not was subsequently developed based on more focused development and testing.

RESULTS

Participants (n=22, aged 75-94 years, 64% healthy volunteers, 36% patients) found the primary endocrine therapy /surgery+endocrine therapy DESI acceptable, and contributed to improved wording and illustrations to address misunderstandings. The chemotherapy DESI (tested with 14 participants, aged 70-87 years, 57% healthy volunteers, 43% patients) was mostly understandable, however, suggestions for rewording sections were made. Most participants considered the DESIs helpful, but highlighted the importance of complementary discussions with clinicians.

CONCLUSION

It was possible to use a template DESI to efficiently create a second prototype for a different treatment option (chemotherapy). Both DESIs were acceptable and considered helpful to support/augment consultations. Development of acceptable additional DESIs for similar target populations using simplified methods may be an efficient way to develop future DESIs. Further research is needed to test the effectiveness of the DESIs.

What influences healthcare professionals' treatment preferences for older women with operable breast cancer? An application of the discrete choice experiment

INTRODUCTION

Primary endocrine therapy (PET) is used variably in the UK as an alternative to surgery for older women with operable breast cancer. Guidelines state that only patients with "significant comorbidity" or "reduced life expectancy" should be treated this way and age should not be a factor.

METHODS

A Discrete Choice Experiment (DCE) was used to determine the impact of key variables (patient age, comorbidity, cognition, functional status, cancer stage, cancer biology) on healthcare professionals' (HCP) treatment preferences for operable breast cancer among older women. Multinomial logistic regression was used to identify associations.

RESULTS

40% (258/641) of questionnaires were returned. Five variables (age, co-morbidity, cognition, functional status and cancer size) independently demonstrated a significant association with treatment preference (p < 0.05). Functional status was omitted from the multivariable model due to collinearity, with all other variables correlating with a preference for operative treatment over no preference (p < 0.05). Only co-morbidity, cognition and cancer size correlated with a preference for PET over no preference (p < 0.05).

CONCLUSION

The majority of respondents selected treatment in accordance with current guidelines, however in some scenarios, opinion was divided, and age did appear to be an independent factor that HCPs considered when making a treatment decision in this population.

The decision-making process for senior cancer patients: treatment allocation of older women with operable breast cancer in the UK

Objective

Up to 40% of women over 70 years with primary operable breast cancer in the UK are treated with primary endocrine therapy (PET) as an alternative to surgery. A variety of factors are important in determining treatment for older breast cancer patients. This study aimed to identify the patient and tumor factors associated with treatment allocation in this population.

Methods

Prospectively collected data on treatment received (surgery vs. PET) were analysed with multivariable logistic regression using the variables age, modified Charlson Comorbidity Index (CCI), activities of daily living (ADL) score, Mini-Mental State Examination (MMSE) score, HER2 status, tumour size, grade and nodal status.

Results

Data were available for 1,122 cancers in 1,098 patients recruited between February 2013 and June 2015 from 51 UK hospitals. About 78% of the population were treated surgically, with the remainder being treated with PET. Increasing patient age at diagnosis, increasing CCI score, large tumor size (5 cm or more) and dependence in one or more ADL categories were all strongly associated with non-surgical treatment (P<0.05).

Conclusion

Increasing comorbidity, large tumor size and reduced functional ability are associated with reduced likelihood of surgical treatment of breast cancer in older patients. However, age itself remains a significant factor for non-surgical treatment; reinforcing the need for evidence-based guidelines.

The balance of clinician and patient input into treatment decision-making in older women with operable breast cancer

OBJECTIVE

Primary endocrine therapy (PET) is an alternative to surgery for oestrogen receptor positive operable breast cancer in some older women. However the decision to offer PET involves complex trade-offs and is influenced by both patient choice and healthcare professional (HCP) preference. This study aimed to compare the views of patients and HCPs about this decision and explore decision-making (DM) preferences and whether these are taken into account during consultations.

METHODS

This multicentre, UK, mixed methods study had three components: (a) questionnaires to older women undergoing counseling about breast cancer treatment options which assessed their DM preferences and realities; (b) qualitative interviews with older women with operable breast cancer offered a choice of either surgery or PET and (c) qualitative interviews with HCPs (both of which focused on DM preferences in this setting).

RESULTS

Thirty-three patients and 34 HCPs were interviewed. A range of opinions about patient involvement in DM were identified. Patients indicated varying preferences for DM involvement which were variably taken into account by HCPs. These qualitative findings were broadly supported by the questionnaire results. Most patients (536/729; 73.5%) achieved their preferred DM style; however, the remainder felt that their DM preferences had not been taken into consideration.

CONCLUSIONS

These results suggest that whilst many older women achieve their desired level of DM engagement, some do not, raising the possibility that they may be making choices which are not concordant with their treatment preferences.

Primary endocrine therapy as a treatment for older women with operable breast cancer - a comparison of randomised controlled trial and cohort study findings

INTRODUCTION

One third of all breast cancers occur in women over the age of 70. Primary endocrine therapy (PET) is used in some women to minimise morbidity in a population with higher rates of comorbidity and frailty. In the UK up to 40% of women over 70 are treated with PET although there is a high rate of variability of practice between centres reflecting a lack of guidance about case selection.

METHODS

A systematic review of the literature was performed to try and establish if this form of treatment is still valid in modern breast practice.

RESULTS

Six randomised controlled trials (RCTs) and 31 non-randomised studies were deemed eligible. Available data demonstrate an advantage for surgery over PET in terms of disease control and a likely survival benefit in patients with a predicted life expectancy of five years or more. Patients treated only with aromatase inhibitors (AIs) had superior rates of disease control when compared to Tamoxifen.

CONCLUSIONS

Guidelines to aid selection are needed but PET should be reserved for patients with reduced predicted life expectancy (e.g. less than five years), with AIs being preferable over Tamoxifen.

Transparent cap colonoscopy versus standard colonoscopy: a systematic review and meta-analysis

Due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought after. Several studies have examined the use of a transparent cap attached to the tip of the colonoscope, but the data are inconsistent. The aim of our study was to establish whether transparent cap colonoscopy is beneficial in the improvement of caecal intubation rate, time and polyp detection. We undertook a systematic review and meta-analysis in the form of a Cochrane review to evaluate these outcomes. We included fourteen randomised controlled trials that have been published to date. Transparent cap colonoscopy demonstrates a significant reduction in caecal intubation time, by an average of 48 s, when compared to standard colonoscopy. There was no significant difference in caecal intubation rate or polyp detection between the two groups. Despite a significant difference in caecal intubation time, the clinical significance of the transparent cap remains to be seen. We believe further research is needed to investigate this adjunct.

Abdominal trauma in primary blast injury

BACKGROUND

Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure.

METHODS

MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations.

RESULTS

Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes.

CONCLUSION

Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.

Metagenomic sequencing of an in vitro-simulated microbial community

Background

Microbial life dominates the earth, but many species are difficult or even impossible to study under laboratory conditions. Sequencing DNA directly from the environment, a technique commonly referred to as metagenomics, is an important tool for cataloging microbial life. This culture-independent approach involves collecting samples that include microbes in them, extracting DNA from the samples, and sequencing the DNA. A sample may contain many different microorganisms, macroorganisms, and even free-floating environmental DNA. A fundamental challenge in metagenomics has been estimating the abundance of organisms in a sample based on the frequency with which the organism's DNA was observed in reads generated via DNA sequencing.

Methodology/Principal Findings

We created mixtures of ten microbial species for which genome sequences are known. Each mixture contained an equal number of cells of each species. We then extracted DNA from the mixtures, sequenced the DNA, and measured the frequency with which genomic regions from each organism was observed in the sequenced DNA. We found that the observed frequency of reads mapping to each organism did not reflect the equal numbers of cells that were known to be included in each mixture. The relative organism abundances varied significantly depending on the DNA extraction and sequencing protocol utilized.

Conclusions/Significance

We describe a new data resource for measuring the accuracy of metagenomic binning methods, created by in vitro-simulation of a metagenomic community. Our in vitro simulation can be used to complement previous in silico benchmark studies. In constructing a synthetic community and sequencing its metagenome, we encountered several sources of observation bias that likely affect most metagenomic experiments to date and present challenges for comparative metagenomic studies. DNA preparation methods have a particularly profound effect in our study, implying that samples prepared with different protocols are not suitable for comparative metagenomics.

Comparative metagenomics and population dynamics of the gut microbiota in mother and infant

Colonization of the gastrointestinal tract (GIT) of human infants with a suitable microbial community is essential for numerous aspects of health, but the progression of events by which this microbiota becomes established is poorly understood. Here, we investigate two previously unexplored areas of microbiota development in infants: the deployment of functional capabilities at the community level and the population genetics of its most abundant genera. To assess the progression of the infant microbiota toward an adult-like state and to evaluate the contribution of maternal GIT bacteria to the infant gut, we compare the infant’s microbiota with that of the mother at 1 and 11 months after delivery. These comparisons reveal that the infant’s microbiota rapidly acquires and maintains the range of gene functions present in the mother, without replicating the phylogenetic composition of her microbiota. Microdiversity analyses for Bacteroides and Bifidobacterium, two of the main microbiota constituents, reveal that by 11 months, the phylotypes detected in the infant are distinct from those in the mother, although the maternal Bacteroides phylotypes were transiently present at 1 month of age. The configuration of genetic variants within these genera reveals populations far from equilibrium and likely to be undergoing rapid growth, consistent with recent population turnovers. Such compositional turnovers and the associated loss of maternal phylotypes should limit the potential for long-term coadaptation between specific bacterial and host genotypes.

Is intrinsic sphincter deficiency a complication of simple hysterectomy?

PURPOSE

Intrinsic sphincter deficiency may cause disabling stress urinary incontinence. While some pelvic operations are implicated as a cause of this condition, simple hysterectomy for benign disease is not recognized as one of them. We evaluated the association of simple hysterectomy with intrinsic sphincter deficiency.

MATERIALS AND METHODS

We performed a case control study to assess the association of simple hysterectomy with intrinsic sphincter deficiency in a consecutive group of 387 incontinent women. From 1995 to 1997 we identified 67 patients with and 67 controls without a history of hysterectomy. Further comparison was done after forming a subgroup at low risk for intrinsic sphincter deficiency. All patients were evaluated by a fluoroscopic urodynamic technique and abdominal leak point pressure was determined.

RESULTS

Intrinsic sphincter deficiency was present in 48% of the 67 patients and 24% of the 67 controls. In the lower risk subgroup we noted this condition in 29 patients (52%) and 53 controls (21%).

CONCLUSIONS

In this population of incontinent women intrinsic sphincter deficiency, as diagnosed by low abdominal leak point pressure, appears to be a complication of simple hysterectomy.

Circadian rhythm of the preovulatory surge of luteinizing hormone and its relationships to rhythms of body temperature and locomotor activity in turkey hens

Simultaneous measurements of plasma LH, body temperature, and locomotor activity were made in laying turkey hens and are reported. Blood samples were remotely collected using a jugular cannula system, and body temperature and locomotor activity were remotely monitored using a radiotelemetry system in freely moving laying turkeys. Under a photoschedule of 14L:10D, the period for preovulatory surges of LH was 25.7 +/- 0.4 h while the periods for peak body temperature and onset of sustained locomotor activity were 24.9 +/- 0.4 and 25.7 +/- 0.5 h, respectively. During exposure to constant light, the periods for preovulatory surges of LH, peak body temperature, and onset of sustained locomotor activity increased to 27.9 +/- 0.9, 26.7 +/- 0.7, and 27.4 +/- 0.7 h, respectively. With the 14L:10D photoschedule, initiation of LH surges was restricted to the scotophase, but after 8 days of constant light, initiation of LH surges had dispersed throughout the 24-h subjective day and night. With constant light, the amplitude of the peak body temperature rhythm decreased, while the duration of the locomotor activity rhythm became broadened and, in some birds, disorganized. Peak body temperature and onset of locomotor activity rhythms and LH surges did not coincide, even though peak body temperature, onset of locomotor activity, and LH surges had similar periods. It is concluded that 1) the photoschedule influences the periods of the LH surge, peak body temperature, and onset of locomotor activity; and 2) a specific or direct relationship between the rhythms of LH surge, body temperature, and locomotor activity remains to be determined in laying turkey hens.

Effects of 60 Hz magnetic field exposure on polymorphonuclear leukocyte activation

We have investigated the effects of a sinusoidal 60 Hz magnetic field on free radical (superoxide anion) production, degranulation (beta-glucuronidase and lysozyme release) and viability in human neutrophils (PMNs). Experiments were performed blindly in very controlled conditions to examine the effects of a magnetic field in resting PMNs and in PMNs stimulated with a tumor promoter: phorbol 12-myristate 13-acetate (PMA). Exposure of unstimulated human PMNs to a 60 Hz magnetic field did not affect the functions examined. In contrast, exposure of PMNs to a 22 milliTesla (mT), 60 Hz magnetic field induced significant increases in superoxide anion (O2-) production (26.5%) and in beta-glucuronidase release (53%) when the cells were incubated with a suboptimal stimulating dose of PMA. Release of lysozyme and lactate dehydrogenase was unchanged by the magnetic field, whether the cells were stimulated or not. A 60 Hz magnetic field did not have any effect on O2- generation by a cell-free system xanthine/xanthine oxidase, suggesting that a magnetic field could upregulate common cellular events (signal transduction) leading to O2- generation and beta-glucuronidase release. In conclusion, exposure of PMNs to a 22 mT, 60 Hz magnetic field potentiates the effect of PMA on O2- generation and beta-glucuronidase release. This effect could be the result of an alteration in the intracellular signaling.

Newborn infants' sensitivity to perceptual cues to lexical and grammatical words

In our study newborn infants were presented with lists of lexical and grammatical words prepared from natural maternal speech. The results show that newborns are able to categorically discriminate these sets of words based on a constellation of perceptual cues that distinguish them. This general ability to detect and categorically discriminate sets of words on the basis of multiple acoustic and phonological cues may provide a perceptual base that can help older infants bootstrap into the acquisition of grammatical categories and syntactic structure.

Hepatitis B virus transgenic mouse model of chronic liver disease

A model for hepatitis B virus-associated chronic liver disease has been made using cloned hepatitis B virus DNA as a transgene in a severe combined immunodeficient host. These mice consistently support virus gene expression and replication. After adoptive transfer of unprimed, syngeneic splenocytes, these mice cleared virus from liver and serum, and developed chronic liver disease. This model will permit identification of the host and virus contributions to chronic liver disease in the absence of tolerance.

Phonotactic and prosodic effects on word segmentation in infants

This research examines the issue of speech segmentation in 9-month-old infants. Two cues known to carry probabilistic information about word boundaries were investigated: Phonotactic regularity and prosodic pattern. The stimuli used in four head turn preference experiments were bisyllabic CVC.CVC nonwords bearing primary stress in either the first or the second syllable (strong/weak vs. weak/strong). Stimuli also differed with respect to the phonotactic nature of their cross-syllabic C.C cluster. Clusters had either a low probability of occurring at a word juncture in fluent speech and a high probability of occurring inside of words ("within-word" clusters) or a high probability of occurring at a word juncture and a low probability of occurring inside of words ("between-word" clusters). Our results show that (1) 9-month-olds are sensitive to how phonotactic sequences typically align with word boundaries, (2) altering the stress pattern of the stimuli reverses infants' preference for phonotactic cluster types, (3) the prosodic cue to segmentation is more strongly relied upon than the phonotactic cue, and (4) a preference for high-probability between-word phonotactic sequences can be obtained either by placing stress on the second syllable of the stimuli or by inserting a pause between syllables. The implications of these results are discussed in light of an integrated multiple-cue approach to speech segmentation in infancy.

Phonological and acoustic bases for earliest grammatical category assignment: a cross-linguistic perspective

Maternal infant-directed speech in Mandarin Chinese and Turkish (two mother-child dyads each; ages of children between 0;11 and 1;8) was examined to see if cues exist in input that might assist infants' assignment of words to lexical and functional item categories. Distributional, phonological, and acoustic measures were analysed. In each language, lexical and functional items (i.e. syllabic morphemes) differed significantly on numerous measures. Despite differences in mean values between categories, distributions of values typically displayed substantial overlap. However, simulations with self-organizing neural networks supported the conclusion that although individual dimensions had low cue validity, in each language multidimensional constellations of presyntactic cues are sufficient to guide assignment of words to rudimentary grammatical categories.

Determination of testis temperature rhythms and effects of constant light on testicular function in the domestic fowl (Gallus domesticus)

There is a wide range of opinions regarding the operating temperature of the testis in the domestic fowl. We used physiological monitoring techniques to investigate testis and body temperature over daily periods and under various light regimes to elucidate body temperature gradients in the fowl. We confirm that the operating temperature of the adult fowl's testes is equivalent to core body temperature (40-41 degrees C). Long-term continuous temperature monitoring showed that there was no difference between the temperature of the testis, liver, and peritoneum during a 24-h period either in a normal light:dark cycle or under constant light conditions. However, there was a slight decrease in all temperatures at subjective night in each case, a decrease that does not appear to be sufficient to influence spermatogenesis. Birds maintained under constant light throughout two cycles of the seminiferous epithelium (28 days) still exhibited normal testis function and structure, even when "nightly" testis temperature decrease was the lowest. Thus, by undergoing spermatogenesis at an elevated temperature, the domestic fowl system is unique among the homeothermic animal systems studied to date.

Osteoid osteoma and osteoblastoma: MRI appearances and the significance of ring enhancement

We assessed the value of contrast-enhanced fat-suppressed MRI on nine patients with osteoid osteomas and osteoblastomas. The results were compared with plain films, bone scintigraphy, computed tomography (CT) and pathological specimens. On contrast-enhanced fat-suppressed T1-weighted images the non-calcified nidi showed homogeneous enhancement, whereas the calcified lesions showed a ring enhancement sign that was proportional in intensity to the extent of the remaining part of the vascularized nidus. The degree of bone marrow and soft tissue enhancement was relative to the size and reactive inflammatory changes of the lesions. Although CT was diagnostic in most of the cases and more specific to show the calcified lesions, MRI was confirmatory in one case. We concluded that, although CT is the primary diagnostic investigation in osteoid osteomas, MRI can be reserved for equivocal cases.

Expression pattern and mapping of the murine versican gene (Cspg2) to chromosome 13

Versican is a modular proteoglycan harboring a hyaluronan-binding domain at its amino-terminal end and a selectin-like domain at its carboxyl-terminal end, separated by a large intervening region containing the attachment sites for the glycosaminoglycan side chains. By virtue of its modular nature, versican may play a role in cellular attachment, migration, and proliferation by interacting with cell surfaces and extracellular matrix molecules. To discern the function of versican through the analysis of spontaneous and targeted genetic mutations, we have isolated a mouse versican cDNA encoding part of the hyaluronan-binding region, analyzed its mRNA expression in various adult mouse tissues and embryos, and determined the chromosomal location of the gene. Murine versican was 89% identical to human versican at the amino acid level and was highly expressed in mouse embryos at Days 13, 14, and 18. Expression was also detected in adult mouse brain, heart, lung, spleen, skeletal muscle, skin, tail, kidney, and testis. Using interspecific backcross analysis, we assigned the versican gene (Cspg2) to mouse chromosome 13, in a region that is syntenic with the long arm of human chromosome 5 where the human CSPG2 gene is located.

Emerging integration of sequential and suprasegmental information in preverbal speech segmentation

5 studies examined contributions of syllable-ordering and rhythmic properties of syllable strings to 6- and 9-month-old infants' speech segmentation. A pair of methods measuring complementary properties of representational units was used: a noise detection task sensitive to perceived cohesiveness of pairs of syllables, and a discrimination maintenance task sensitive to compactness of representations of syllable pairs. For 9-month-olds, results show that a key pair of syllables was represented as a unit when the grouping of these syllables was supported by correlated regularities of ordering and rhythm in the set of stimulus strings, but not when such grouping was supported by only rhythmic or only syllable-ordering regularity. For 6-month-olds, results show that a key pair of syllables was represented as a unit whenever grouping was supported by rhythmic regularity in the stimulus strings, regardless of whether syllable-ordering regularity was also present. Thus, whereas 9-month-olds appear to be capable of integrating sequential and suprasegmental information in forming worldlike (multisyllabic) phonological percepts, 6-month-olds are not. The emergence of integrative abilities portends increased efficiency in speech processing and may contribute to the formation and use of an initial lexicon.

Role of CT and MR imaging in the management of tuberculous spondylitis

Tuberculous spondylitis is an infection involving one or more of the components of the spine, namely the vertebral body, intervertebral disc and ligaments, paravertebral soft tissues, and the epidural space. The causative organism belongs to one of the different strains of Mycobacterium tuberculosis. The role of CT and MR imaging in the diagnosis and management of tuberculous spondylitis is reviewed, and the differential diagnosis of these appearances is discussed. The possible impact of HIV infection on the number of reported cases and their mode of presentation also is considered. The need for prompt diagnosis is emphasized.

Insulin signaling in chick embryos exposed to alcohol

Although insulin is known to be an important generator of regulatory signals during fetal growth and development, neither the immediate nor long-term effects of alcohol (ethanol) on insulin action are well understood. In the rat, fetal exposure to alcohol has been shown to be correlated with a subsequent abnormal response to a glucose load in the neonate and adult. Further, fetal hypoplasia secondary to maternal alcohol consumption is correlated with decreased placental glucose transport and with a lowering of the glucose levels in fetal tissues. However, the fetal effects of alcohol cannot be completely overcome by glucose/caloric supplementation, suggesting that factors other than glucose transport are involved. Using an embryonic chick model that negates the factors of maternal/placental metabolism and transport, the current study found that fetal alcohol exposure markedly increased insulin binding in developing tissue, but had little effect on the binding of the insulin-like growth factors. Competitive binding experiments revealed a marked increase in insulin receptor numbers, but no change in binding affinity as a result of the alcohol exposure. Basal uptake of 2-deoxyglucose by fetal tissue was lowered by alcohol exposure, but incubation with exogenous porcine insulin (1 x 10(-7) M) resulted in a significant increase in glucose uptake by the alcohol-exposed embryos. The increases in insulin binding and in insulin-dependent glucose uptake notwithstanding, exogenous insulin could not induce normal levels of ornithine decarboxylase activity in embryonic cells previously exposed to alcohol.(ABSTRACT TRUNCATED AT 250 WORDS)

The murine decorin. Complete cDNA cloning, genomic organization, chromosomal assignment, and expression during organogenesis and tissue differentiation

Decorin, a proteoglycan known to interact with collagen and growth factors, may play key roles during ontogenesis, tissue remodeling, and cancer. We have deciphered the complete protein sequence of the murine decorin by cDNA cloning, elucidated its gene structure and chromosomal location, and investigated its expression in the developing embryo. The decorin protein and the gene were highly conserved vis à vis the human counterpart; however, the murine gene lacked a leader exon, exon Ib, which was found only in the human. Using interspecific backcrossing, we assigned the gene to chromosome 10 just proximally to the Steel gene locus. In situ hybridization studies of developing mouse embryos showed a distinct pattern of expression with a progressive increase of decorin mRNA during ontogenesis. At early stages (day 11 postconception), decorin was detectable only in the floor plate region. Subsequently (days 13-16 postconception), decorin expression was especially prominent in the meninges and mesothelial linings of pericardium, pleura, and coelomic cavity, as well as in the dermis and subepithelial layers of the intestine and urinary bladder. In contrast, the major parenchymal organs were only weakly positive for decorin mRNA. These findings suggest that decorin may play a role in epithelial/mesenchymal interactions during organ development and shaping.

Quantitation of cytokine levels in skin graft donor site wound fluid

We quantified endogenous levels of multiple cytokines in skin graft donor site wounds in patients with small to moderate-sized burn injuries. Thirteen patients aged 11 months to 61 years with mean TBSA burn of 4 +/- 1 per cent underwent placement of occlusive wound dressings on partial skin thickness donor site wounds. Fluid was aspirated from beneath the dressing on postoperative day 1 and every subsequent 24 h until no further fluid could be obtained. Interleukin-1 alpha (IL-1) and tumour necrosis factor-alpha (TNF-alpha) levels were determined by enzyme-linked immunosorbent assay (ELISA). Epidermal growth factor (EGF), basic-fibroblast growth factor (bFGF), and platelet-derived growth factor (PDGF) were measured by an enzyme immunoassay (EIA). We found substantial levels of EGF and TNF-alpha in the donor site wound fluid in all 13 patients; detectable levels of bFGF in five patients; and elevated levels of IL-1 in three patients. There were no detectable levels of these cytokines in normal human serum. In contrast, there were no measurable levels of PDGF in any patient's wound fluid; the mean level in serum was 1.5 ng/ml +/- 0.2 s.e.m. Studies of cytokines in the normal wound healing environment may help in the design of future therapies to augment wound healing.

Composite grafts of human keratinocytes grown on a polyglactin mesh-cultured fibroblast dermal substitute function as a bilayer skin replacement in full-thickness wounds on athymic mice

We have developed and tested in athymic mice a new, cultured, dermal-epidermal graft composed of two human cell types coupled with a biodegradable dermal scaffold. Cultured, proliferating human keratinocytes (HK) were applied to the surface of a living dermal tissue replacement that is composed of human fibroblasts cultured on a polyglactin mesh. After 4 to 6 days of coculture, proliferating HKs achieved confluency on the surface of the living dermal tissue replacement. Grafts were then transferred to full-thickness wounds on the dorsum of athymic mice. Sixteen animals were grafted, and the mean percentage of graft take (original wound area covered) on day 20 after grafting was 51.25%. Staining with antibody specific for human involucrin confirmed the presence of HKs on closed wounds, and staining with antibody specific for human laminin revealed a continuous layer of laminin at the dermal-epidermal junction on day 20. Animals closed with living dermal tissue replacement alone markedly contracted, whereas application of living dermal tissue replacement-HK grafts appeared to retard contraction. Because polyglactin mesh fibers are absorbed by hydrolysis rather than by enzymatic degradation, this living composite graft may be more resistant to destruction when placed on excised human wounds than are composite grafts, which are composed of a collagen matrix. The inclusion of the living dermal substitute may ultimately provide better skin quality than is achieved from the use of cultured keratinocytes alone. Fragility of the epidermal layer is probably due to the short-term culture of HKs on the living dermal tissue replacement, and further efforts to develop a thicker epithelial layer may improve graft durability.

Perceptual strategies in prelingual speech segmentation

Previous work has suggested that infants may segment continuous speech by a BRACKETING STRATEGY that segregates portions of the speech stream based on prosodic cues to their endpoints. The two present studies were designed to assess whether infants also can deploy a CLUSTERING STRATEGY that exploits asymmetries in transitional probabilities between successive elements, aggregating elements with high transitional probabilities and identifying points of low transitional probabilities as boundaries between units. These studies examined effects of the structure and redundancy of speech context on infants' discrimination of two target syllables using an operant head-turning procedure. After discrimination training on the target syllables in isolation, discrimination maintenance was tested when the target syllables were embedded in one of three contexts. Invariant Order contexts were structured to promote clustering, whereas the Redundant and Variable Order contexts were not. Thirty-six seven-month-olds were tested in Experiment I, in which stimuli were produced with varying intonation contours; 36 eight-month-olds were tested in Experiment 2, in which stimuli were produced with comparable flat pitch contours. In both experiments, performance of the three groups was equivalent in an initial 20-trial test. However, in a second 20-trial test, significant improvements in performance were shown by infants in the Invariant Order condition. No such gains were shown by infants in the other two conditions. These studies suggest that clustering may complement bracketing in infants' discovery of units of language.

Input, innateness, and induction in language acquisition

Input and innateness compliment one another in language acquisition. Children exposed to different languages acquire different languages. Children's language experience, however, underdetermines the grammars that they acquire; the constraints that are not supplied by input must be available endogenously, and the ultimate origin of these endogenous contributions to acquisition may be traced to the biology of the mind. To the extent that assumptions of innateness encourage greater explicitness in the formulation of theories of acquisition, they should be welcomed. Excessively powerful assumptions of innateness may not be subject to empirical disconfirmation, however. Therefore, attention should be devoted to the development of a theory of language input, particularly with regard to identifying invariants of input. In combination with a linguistic theory providing an account of the endstate of acquisition, a theory of input would permit the deduction of properties of the mind that underlie the acquisition of language.