Suspect Screening Analysis of Pooled Human Serum Samples Using GC × GC/TOF-MS

Humans interact with thousands of chemicals. This study aims to identify substances of emerging concern and in need of human health risk evaluations. Sixteen pooled human serum samples were constructed from 25 individual samples each from the National Institute of Environmental Health Sciences' Clinical Research Unit. Samples were analyzed using gas chromatography (GC) × GC/time-of-flight (TOF)-mass spectrometry (MS) in a suspect screening analysis, with follow-up confirmation analysis of 19 substances. A standard reference material blood sample was also analyzed through the confirmation process for comparison. The pools were stratified by sex (female and male) and by age (≤45 and >45). Publicly available information on potential exposure sources was aggregated to annotate presence in serum as either endogenous, food/nutrient, drug, commerce, or contaminant. Of the 544 unique substances tentatively identified by spectral matching, 472 were identified in females, while only 271 were identified in males. Surprisingly, 273 of the identified substances were found only in females. It is known that behavior and near-field environments can drive exposures, and this work demonstrates the existence of exposure sources uniquely relevant to females.

A Data-Driven Approach to Estimating Occupational Inhalation Exposure Using Workplace Compliance Data

A growing list of chemicals are approved for production and use in the United States and elsewhere, and new approaches are needed to rapidly assess the potential exposure and health hazard posed by these substances. Here, we present a high-throughput, data-driven approach that will aid in estimating occupational exposure using a database of over 1.5 million observations of chemical concentrations in U.S. workplace air samples. We fit a Bayesian hierarchical model that uses industry type and the physicochemical properties of a substance to predict the distribution of workplace air concentrations. This model substantially outperforms a null model when predicting whether a substance will be detected in an air sample, and if so at what concentration, with 75.9% classification accuracy and a root-mean-square error (RMSE) of 1.00 log10 mg m-3 when applied to a held-out test set of substances. This modeling framework can be used to predict air concentration distributions for new substances, which we demonstrate by making predictions for 5587 new substance-by-workplace-type pairs reported in the US EPA's Toxic Substances Control Act (TSCA) Chemical Data Reporting (CDR) industrial use database. It also allows for improved consideration of occupational exposure within the context of high-throughput, risk-based chemical prioritization efforts.

The chemical landscape of high-throughput new approach methodologies for exposure

The rapid characterization of risk to humans and ecosystems from exogenous chemicals requires information on both hazard and exposure. The U.S. Environmental Protection Agency's ToxCast program and the interagency Tox21 initiative have screened thousands of chemicals in various high-throughput (HT) assay systems for in vitro bioactivity. EPA's ExpoCast program is developing complementary HT methods for characterizing the human and ecological exposures necessary to interpret HT hazard data in a real-world risk context. These new approach methodologies (NAMs) for exposure include computational and analytical tools for characterizing multiple components of the complex pathways chemicals take from their source to human and ecological receptors. Here, we analyze the landscape of exposure NAMs developed in ExpoCast in the context of various chemical lists of scientific and regulatory interest, including the ToxCast and Tox21 libraries and the Toxic Substances Control Act (TSCA) inventory. We examine the landscape of traditional and exposure NAM data covering chemical use, emission, environmental fate, toxicokinetics, and ultimately external and internal exposure. We consider new chemical descriptors, machine learning models that draw inferences from existing data, high-throughput exposure models, statistical frameworks that integrate multiple model predictions, and non-targeted analytical screening methods that generate new HT monitoring information. We demonstrate that exposure NAMs drastically improve the coverage of the chemical landscape compared to traditional approaches and recommend a set of research activities to further expand the development of HT exposure data for application to risk characterization. Continuing to develop exposure NAMs to fill priority data gaps identified here will improve the availability and defensibility of risk-based metrics for use in chemical prioritization and screening. IMPACT: This analysis describes the current state of exposure assessment-based new approach methodologies across varied chemical landscapes and provides recommendations for filling key data gaps.

Development of a Flame Retardant and an Organohalogen Flame Retardant Chemical Inventory

There have been many attempts to compile comprehensive lists of flame retardants. However, this goal has proven challenging due to the heterogeneity of compounds that can be used as flame retardants coupled with changes in formulation chemistry over time. Flame retardants have been the focus of many recent existing hazard, exposure, and risk assessments. These assessments have been class-based or for individual chemical substances. Here, diverse sets of publicly available data sources from governmental organizations and the open literature were compiled to develop an inventory of chemicals used as flame retardants and organohalogen flame retardants. The chemical substances from these data sources were mapped to appropriate chemical identifiers via manual curation and deduplicated. Despite different data sources containing a large number of overlapping chemical substances, compiling information from multiple data sources was found to increase the breadth of potential flame retardant chemistries. The flame retardant and organohalogen flame retardant inventories were developed as a resource for scientists interested in better understanding properties of flame retardant and organohalogen flame retardant classes.

Measurement(s)	chemical use information
Technology Type(s)	manual and automated literature collection

Correction to Designing QSARs for Parameters of High Throughput Toxicokinetic Models Using Open-Source Descriptors

The intrinsic metabolic clearance rate (Cl_int) and fraction of chemical unbound in plasma (f_up) serve as important parameters for high throughput toxicokinetic models, but experimental data are limited for many chemicals. Open-source quantitative structure-activity relationship (QSAR) models for both parameters were developed to offer reliable in silico predictions for a diverse set of chemicals regulated under U.S. law, including pharmaceuticals, pesticides, and industrial chemicals. As a case study to demonstrate their utility, model predictions served as inputs to the TK component of a risk-based prioritization approach based on Bioactivity: Exposure Ratios (BER), in which a BER < 1 indicates exposures are predicted to exceed a biological activity threshold. When applied to a subset of the Tox21 screening library (6631 chemicals) we found that the proportion of chemicals with BER < 1 was similar using either in silico (1337/6631; 20.16%) or in vitro (151/850; 17.76%) parameters. Further, when considering only the chemicals in the Tox21 set with in vitro data, there was a high concordance of chemicals classified with either BER < 1 or >1 using either in silico or in vitro parameters (776/850, 91.30%). Thus, the presented QSARs may be suitable for prioritizing the risk posed by many chemicals for which measured in vitro TK data are lacking.

Chemical Characterization of Recycled Consumer Products Using Suspect Screening Analysis

Recycled materials are found in many consumer products as part of a circular economy; however, the chemical content of recycled products is generally uncharacterized. A suspect screening analysis using two-dimensional gas chromatography time-of-flight mass spectrometry (GC × GC-TOFMS) was applied to 210 products (154 recycled, 56 virgin) across seven categories. Chemicals in products were tentatively identified using a standard spectral library or confirmed using chemical standards. A total of 918 probable chemical structures identified (112 of which were confirmed) in recycled materials versus 587 (110 confirmed) in virgin materials. Identified chemicals were characterized in terms of their functional use and structural class. Recycled paper products and construction materials contained greater numbers of chemicals than virgin products; 733 identified chemicals had greater occurrence in recycled compared to virgin materials. Products made from recycled materials contained greater numbers of fragrances, flame retardants, solvents, biocides, and dyes. The results were clustered to identify groups of chemicals potentially associated with unique chemical sources, and identified chemicals were prioritized for further study using high-throughput hazard and exposure information. While occurrence is not necessarily indicative of risk, these results can be used to inform the expansion of existing models or identify exposure pathways currently neglected in exposure assessments.

Suspect-screening analysis of a coastal watershed before and after Hurricane Florence using high-resolution mass spectrometry

On September 14, 2018, Hurricane Florence delivered ~686 mm rainfall to a 106 km² watershed in coastal North Carolina, USA. A forested land treatment site comprises one third of the watershed wherein municipal wastewater effluent is spray-irrigated onto 8.9 km² of forest. This communication provides insight for land treatment function under excess water duress as well as changes in organic chemical composition in on- and off-site waters before (June 2018) and after (September & December 2018) Hurricane Florence's landfall. We compare the numbers and relative abundances of chemical features detected using suspect screening high resolution mass spectrometry in waste-, ground-, and surface water samples. Values for upstream and receiving waters in September were lower than for sampling events in June and December, indicating an expected dilution effect across the watershed. Chemical diversity was greatest for all surface water samples in December, but only upstream surface water showed a dramatic five-fold increase in relative chemical abundance. Chemical abundance in on-site water and downstream surface water was equal to or lower than the September storm dilution effect. These data suggest that the land treatment system is functionally and hydrologically robust to extreme storm events and contributed to dilution of upstream chemical reservoirs for downstream receiving waters for months after the storm. Similar systems may embody one water reuse strategy robust to the increasing occurrence of extreme precipitation events.

Mining of Consumer Product Ingredient and Purchasing Data to Identify Potential Chemical Coexposures

BACKGROUND

Chemicals in consumer products are a major contributor to human chemical coexposures. Consumers purchase and use a wide variety of products containing potentially thousands of chemicals. There is a need to identify potential real-world chemical coexposures to prioritize in vitro toxicity screening. However, due to the vast number of potential chemical combinations, this identification has been a major challenge.

OBJECTIVES

We aimed to develop and implement a data-driven procedure for identifying prevalent chemical combinations to which humans are exposed through purchase and use of consumer products.

METHODS

We applied frequent itemset mining to an integrated data set linking consumer product chemical ingredient data with product purchasing data from 60,000 households to identify chemical combinations resulting from co-use of consumer products.

RESULTS

We identified co-occurrence patterns of chemicals over all households as well as those specific to demographic groups based on race/ethnicity, income, education, and family composition. We also identified chemicals with the highest potential for aggregate exposure by identifying chemicals occurring in multiple products used by the same household. Last, a case study of chemicals active in estrogen and androgen receptor in silico models revealed priority chemical combinations co-targeting receptors involved in important biological signaling pathways.

DISCUSSION

Integration and comprehensive analysis of household purchasing data and product-chemical information provided a means to assess human near-field exposure and inform selection of chemical combinations for high-throughput screening in in vitro assays. https://doi.org/10.1289/EHP8610.

Designing QSARs for Parameters of High-Throughput Toxicokinetic Models Using Open-Source Descriptors

The intrinsic metabolic clearance rate (Cl_int) and the fraction of the chemical unbound in plasma (f_up) serve as important parameters for high-throughput toxicokinetic (TK) models, but experimental data are limited for many chemicals. Open-source quantitative structure-activity relationship (QSAR) models for both parameters were developed to offer reliable in silico predictions for a diverse set of chemicals regulated under the U.S. law, including pharmaceuticals, pesticides, and industrial chemicals. As a case study to demonstrate their utility, model predictions served as inputs to the TK component of a risk-based prioritization approach based on bioactivity/exposure ratios (BERs), in which a BER < 1 indicates that exposures are predicted to exceed a biological activity threshold. When applied to a subset of the Tox21 screening library (6484 chemicals), we found that the proportion of chemicals with BER <1 was similar using either in silico (1133/6484; 17.5%) or in vitro (148/848; 17.5%) parameters. Further, when considering only the chemicals in the Tox21 set with in vitro data, there was a high concordance of chemicals classified with either BER <1 or >1 using either in silico or in vitro parameters (767/848, 90.4%). Thus, the presented QSARs may be suitable for prioritizing the risk posed by many chemicals for which measured in vitro TK data are lacking.

Expanded coverage of non-targeted LC-HRMS using atmospheric pressure chemical ionization: a case study with ENTACT mixtures

Non-targeted analysis (NTA) is a rapidly evolving analytical technique with numerous opportunities to improve and expand instrumental and data analysis methods. In this work, NTA was performed on eight synthetic mixtures containing 1264 unique chemical substances from the U.S. Environmental Protection Agency's Non-Targeted Analysis Collaborative Trial (ENTACT). These mixtures were analyzed by atmospheric pressure chemical ionization (APCI) and electrospray ionization (ESI) using both positive and negative polarities for a total of four modes. Out of the 1264 ENTACT chemical substances, 1116 were detected in at least one ionization mode, 185 chemicals were detected using all four ionization modes, whereas 148 were not detected. Forty-four chemicals were detected only by APCI, and 181 were detected only by ESI. Molecular descriptors and physicochemical properties were used to assess which ionization type was preferred for a given compound. One ToxPrint substructure (naphthalene group) was found to be enriched in compounds only detected using APCI, and eight ToxPrints (e.g., several alcohol moieties) were enriched in compounds only detected using ESI. Examination of physicochemical parameters for ENTACT chemicals suggests that those with higher aqueous solubility preferentially ionized by ESI-. While ESI typically detects a larger number of compounds, APCI offers chromatograms with less background, fewer co-elutions, and additional chemical space coverage, suggesting both should be considered for broader coverage in future NTA research. Graphical abstract.

Estimation of the Emission Characteristics of SVOCs from Household Articles Using Group Contribution Methods

The risk to humans from chemicals in consumer products is a function of both hazard and exposure. There is an ongoing effort to quantify chemical exposure due to household articles such as furniture and building materials. Polymers and plastic materials make up a substantial portion of these articles, which may contain chemical additives such as plasticizers. When these additives are not bound to the polymer matrix, they are free to diffuse throughout it and leach or emit from the surface. We have implemented a methodology to predict plasticizer emission from polyvinyl chloride (PVC) products, based on group contribution methods that consider a free volume effect to estimate activity coefficients for chemicals in polymer-solvent solutions. Using the estimated activity coefficients, we calculate steady-state gas phase concentrations for plasticizers in equilibrium with the polymer surface (y₀). The method uses only the structure of the chemical and polymer, the weight fraction, and physical-chemical properties, allowing rapid estimation of y₀ at different weight fractions in PVC. Using the predicted y₀ values and weight fraction data gleaned from public databases, we estimate plasticizer exposures associated with 72 PVC-containing articles using a high-throughput model. We also investigate potential exposures associated with plasticizer substitutions in these products.

The Next Generation Blueprint of Computational Toxicology at the U.S. Environmental Protection Agency

The U.S. Environmental Protection Agency (EPA) is faced with the challenge of efficiently and credibly evaluating chemical safety often with limited or no available toxicity data. The expanding number of chemicals found in commerce and the environment, coupled with time and resource requirements for traditional toxicity testing and exposure characterization, continue to underscore the need for new approaches. In 2005, EPA charted a new course to address this challenge by embracing computational toxicology (CompTox) and investing in the technologies and capabilities to push the field forward. The return on this investment has been demonstrated through results and applications across a range of human and environmental health problems, as well as initial application to regulatory decision-making within programs such as the EPA's Endocrine Disruptor Screening Program. The CompTox initiative at EPA is more than a decade old. This manuscript presents a blueprint to guide the strategic and operational direction over the next 5 years. The primary goal is to obtain broader acceptance of the CompTox approaches for application to higher tier regulatory decisions, such as chemical assessments. To achieve this goal, the blueprint expands and refines the use of high-throughput and computational modeling approaches to transform the components in chemical risk assessment, while systematically addressing key challenges that have hindered progress. In addition, the blueprint outlines additional investments in cross-cutting efforts to characterize uncertainty and variability, develop software and information technology tools, provide outreach and training, and establish scientific confidence for application to different public health and environmental regulatory decisions.

Consensus Modeling of Median Chemical Intake for the U.S. Population Based on Predictions of Exposure Pathways

Prioritizing the potential risk posed to human health by chemicals requires tools that can estimate exposure from limited information. In this study, chemical structure and physicochemical properties were used to predict the probability that a chemical might be associated with any of four exposure pathways leading from sources-consumer (near-field), dietary, far-field industrial, and far-field pesticide-to the general population. The balanced accuracies of these source-based exposure pathway models range from 73 to 81%, with the error rate for identifying positive chemicals ranging from 17 to 36%. We then used exposure pathways to organize predictions from 13 different exposure models as well as other predictors of human intake rates. We created a consensus, meta-model using the Systematic Empirical Evaluation of Models framework in which the predictors of exposure were combined by pathway and weighted according to predictive ability for chemical intake rates inferred from human biomonitoring data for 114 chemicals. The consensus model yields an R² of ∼0.8. We extrapolate to predict relevant pathway(s), median intake rate, and credible interval for 479 926 chemicals, mostly with minimal exposure information. This approach identifies 1880 chemicals for which the median population intake rates may exceed 0.1 mg/kg bodyweight/day, while there is 95% confidence that the median intake rate is below 1 μg/kg BW/day for 474572 compounds.

Consumer and clinician perspectives on personalising breast cancer prevention information

BACKGROUND

Personalised prevention of breast cancer has focused on women at very high risk, yet most breast cancers occur in women at average, or moderately increased risk (≤moderate risk).

OBJECTIVES

To determine; 1) interest of women at ≤ moderate risk (consumers) in personalised information about breast cancer risk; 2) familial cancer clinicians' (FCCs) perspective on managing women at ≤ moderate risk, and; 3) both consumers' and FCCs reactions to iPrevent, a personalised breast cancer risk assessment and risk management decision support tool.

METHODS

Seven focus groups on breast cancer risk were conducted with 49 participants; 27 consumers and 22 FCCs. Data were analysed thematically.

RESULTS

Consumers reported some misconceptions, low trust in primary care practitioners for breast cancer prevention advice and frustration that they often lacked tailored advice about breast cancer risk. They expressed interest in receiving personalised risk information using iPrevent. FCCs reported an inadequate workforce to advise women at ≤ moderate risk and reacted positively to the potential of iPrevent to assist.

CONCLUSIONS

While highlighting a potential role for iPrevent, several outstanding issues remain. For personalised prevention of breast cancer to extend beyond women at high risk, we must harness women's interest in receiving tailored information about breast cancer prevention and identify a workforce willing to advise women.

Rapid experimental measurements of physicochemical properties to inform models and testing

The structures and physicochemical properties of chemicals are important for determining their potential toxicological effects, toxicokinetics, and route(s) of exposure. These data are needed to prioritize the risk for thousands of environmental chemicals, but experimental values are often lacking. In an attempt to efficiently fill data gaps in physicochemical property information, we generated new data for 200 structurally diverse compounds, which were rigorously selected from the USEPA ToxCast chemical library, and whose structures are available within the Distributed Structure-Searchable Toxicity Database (DSSTox). This pilot study evaluated rapid experimental methods to determine five physicochemical properties, including the log of the octanol:water partition coefficient (known as log(Kow) or logP), vapor pressure, water solubility, Henry's law constant, and the acid dissociation constant (pKa). For most compounds, experiments were successful for at least one property; log(Kow) yielded the largest return (176 values). It was determined that 77 ToxPrint structural features were enriched in chemicals with at least one measurement failure, indicating which features may have played a role in rapid method failures. To gauge consistency with traditional measurement methods, the new measurements were compared with previous measurements (where available). Since quantitative structure-activity/property relationship (QSAR/QSPR) models are used to fill gaps in physicochemical property information, 5 suites of QSPRs were evaluated for their predictive ability and chemical coverage or applicability domain of new experimental measurements. The ability to have accurate measurements of these properties will facilitate better exposure predictions in two ways: 1) direct input of these experimental measurements into exposure models; and 2) construction of QSPRs with a wider applicability domain, as their predicted physicochemical values can be used to parameterize exposure models in the absence of experimental data.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

OBJECTIVE

Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).

METHODS

The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data.

RESULTS

Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.

CONCLUSION

The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.

PRACTICE IMPLICATIONS

Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

Consumer product chemical weight fractions from ingredient lists

Assessing human exposures to chemicals in consumer products requires composition information. However, comprehensive composition data for products in commerce are not generally available. Many consumer products have reported ingredient lists that are constructed using specific guidelines. A probabilistic model was developed to estimate quantitative weight fraction (WF) values that are consistent with the rank of an ingredient in the list, the number of reported ingredients, and labeling rules. The model provides the mean, median, and 95% upper and lower confidence limit WFs for ingredients of any rank in lists of any length. WFs predicted by the model compared favorably with those reported on Material Safety Data Sheets. Predictions for chemicals known to provide specific functions in products were also found to reasonably agree with reported WFs. The model was applied to a selection of publicly available ingredient lists, thereby estimating WFs for 1293 unique ingredients in 1123 products in 81 product categories. Predicted WFs, although less precise than reported values, can be estimated for large numbers of product-chemical combinations and thus provide a useful source of data for high-throughput or screening-level exposure assessments.

Suspect Screening Analysis of Chemicals in Consumer Products

A two-dimensional gas chromatography-time-of-flight/mass spectrometry (GC×GC-TOF/MS) suspect screening analysis method was used to rapidly characterize chemicals in 100 consumer products-which included formulations (e.g., shampoos, paints), articles (e.g., upholsteries, shower curtains), and foods (cereals)-and therefore supports broader efforts to prioritize chemicals based on potential human health risks. Analyses yielded 4270 unique chemical signatures across the products, with 1602 signatures tentatively identified using the National Institute of Standards and Technology 2008 spectral database. Chemical standards confirmed the presence of 119 compounds. Of the 1602 tentatively identified chemicals, 1404 were not present in a public database of known consumer product chemicals. Reported data and model predictions of chemical functional use were applied to evaluate the tentative chemical identifications. Estimated chemical concentrations were compared to manufacturer-reported values and other measured data. Chemical presence and concentration data can now be used to improve estimates of chemical exposure, and refine estimates of risk posed to human health and the environment.

Abstract P6-09-04: Benign breast disease and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC)

Background: Benign breast disease (BBD) is one of the strongest risk factors for breast cancer but it is unclear whether the strength of the association with BBD and breast cancers varies by breast cancer family history. Few studies of BBD enrich specifically for putative genetic factors by over-sampling based on family history let alone evaluate potential interactions with measures of underlying familial risk. The aim of this study was to evaluate how risk associated with BBD is modified by underlying familial risk so as to guide clinical management and risk assessment of women with BBD.

Methods: Using a prospective family study cohort of 17,154 women unaffected with breast cancer at baseline and followed by questionnaire at regular intervals, we examined the association between BBD and breast cancer risk using Cox Proportional Hazards models. We classified women as having BBD if they reported at baseline having been told by a doctor that they had BBD, such as a non-cancerous cyst or breast lump. We did not have information on histologic sub-type. We confirmed self-reported diagnosis of BBD with pathology reports in a subset of the New York cohort and found high agreement between self-reported and pathologically confirmed BBD (93.5%). We assessed multiplicative and additive interactions with underlying familial risk profile (FRP) defined as either fixed-time horizon of 1-year, or total lifetime risk, estimated from the Breast Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) model.

Results: During 176,756 person-years of follow-up (mean 10.2, maximum 23.7 years), we observed 968 incident breast cancers cases with an average age at diagnosis of 55.8 years and average age at enrollment into the cohort of 46.8 years. At baseline, 4,704 (27%) women reported having a previous diagnosis of BBD. Compared to women with no history of BBD, breast cancer risk was increased in women of all ages (HR: 1.37, 95% CI: 1.19,1.56), and in women up to age 45 years (using attained age models) (HR: 1.40, 95% CI: 1.01,1.93). In terms of recency of BBD, we found that the increased risk associated with BBD remained 21 years or more after the initial BBD diagnosis (HR: 1.37, 95% CI: 1.11, 1.68). We found no evidence for multiplicative interactions with FRP, which implies that the increase in absolute risk associated with BBD depends on a woman's FRP (Table 1).

Conclusions: Women with a history of BBD have an increased risk of breast cancer that multiplies their underlying familial risk (FRP). These results could prove to be valuable for risk counseling and clinical management.

Table 1: Cumulative Incidence of Breast Cancer to age 45, 55, and 65 by BBD and underlying FRP as measured by 10-year BOADICEA score.AgeNo BBD, &lt;3.4 %BBD, &lt;3.4%No BBD, ≥3.4%BBD, ≥3.4%454.6 (3.8, 5.6)6.1(4.7, 8.0)12.1 (10.2, 14.5)16.1 (13.1, 19.7)557.4 (6.3, 8.7)9.8 (7.5, 12.8)19.1 (16.6, 22.0)25.0 (21.7, 28.9)659.7 (8.2, 11.5)12.8 (9.9, 16.5)24.5 (21.8, 27.6)31.8 (28.3, 35.7)

Citation Format: Zeinomar N, Phillips KA, Liao Y, MacInnis RJ, Dite GS, Daly MB, John EM, Andrulis IL, Buys SS, Hopper JL, Terry MB. Benign breast disease and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-04.

Abstract P6-09-01: Risk-reducing oophorectomy and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC)

Background: Whether risk-reducing salpingo oophorectomy (RRSO) reduces breast cancer risk in addition to reducing ovarian cancer risk is controversial with some arguing that the previous evidence of a reduction in breast cancer risk from RRSO was due to bias. Evidence from independent prospective cohorts of high-risk women is needed to resolve this controversy.

Methods: Using a prospective family study cohort of 17,810 women unaffected with breast cancer at baseline, we examined the association between RRSO and breast cancer risk using Cox Proportional Hazards models. We compared results estimating RRSO as a non-time-dependent variable to results treating RRSO as a time-dependent variable, because failing to account for the time-varying nature of a covariate person- time prior to RRSO, should it exist, will incorrectly attribute the cancer-free person-time to RRSO. We separately examined the association with RRSO in BRCA1 and BRCA2 mutation carriers and non-carriers, and further performed gene-stratified analyses in women with BRCA1 and BRCA2 only. We also assessed multiplicative interactions with underlying familial risk profile (FRP), defined as total lifetime risk estimated from the Breast Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) model.

Results: During a median 10.7 years of follow-up (maximum 23.7 years), we observed 1,040 incident cases of breast cancer with an average age at diagnosis of 55.8 years and average age at enrollment into the cohort of 46.8 years. A total of 2434 (14%) women reported at baseline having a RRSO. We observed decreased risk of breast cancer associated with RRSO for both BRCA1(N= 650) and BRCA2(N=557) mutation carriers when RRSO was treated as a fixed covariate (HR= 0.60, 95% CI=0.40-0.92 and HR= 0.40, 95%CI = 0.23-0.69, respectively). In contrast, when we treated RRSO as a time-varying covariate, for both BRCA1 and BRCA2 carriers, we no longer observed a decreased risk for BRCA1 and BRCA2 carriers (HR= 1.67, 95% CI=1.05-2.67 and HR= 0.97, 95%CI = 0.53-1.80, respectively). There was no association between RRSO and breast cancer risk for non-carriers (N=16,603), whether we treated RRSO as a fixed or time varying covariate (HR= 0.88, 95% CI=0.72-1.08 and HR= 1.06, 95%CI = 0.85-1.30, respectively).

Conclusions: Our findings provide an independent replication that the reduced risk of breast cancer previously observed in BRCA1 and BRCA2 mutation carrier women may be from bias in counting person-time. Clinical management of high-risk women should counsel based on the reduced risk of ovarian cancer from RRSO, but not breast cancer.

Citation Format: Terry MB, Phillips KA, Daly MB, Andrulis IL, Liao Y, Ma X, Zeinomar N, MacInnis RJ, Dite GS, John EM, Buys SS, Hopper JL. Risk-reducing oophorectomy and breast cancer risk across the spectrum of familial risk using a prospective family study cohort (ProF-SC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-01.

Using exposure prediction tools to link exposure and dosimetry for risk-based decisions: A case study with phthalates

A few different exposure prediction tools were evaluated for use in the new in vitro-based safety assessment paradigm using di-2-ethylhexyl phthalate (DEHP) and dibutyl phthalate (DnBP) as case compounds. Daily intake of each phthalate was estimated using both high-throughput (HT) prediction models such as the HT Stochastic Human Exposure and Dose Simulation model (SHEDS-HT) and the ExpoCast heuristic model and non-HT approaches based on chemical specific exposure estimations in the environment in conjunction with human exposure factors. Reverse dosimetry was performed using a published physiologically based pharmacokinetic (PBPK) model for phthalates and their metabolites to provide a comparison point. Daily intakes of DEHP and DnBP were estimated based on the urinary concentrations of their respective monoesters, mono-2-ethylhexyl phthalate (MEHP) and monobutyl phthalate (MnBP), reported in NHANES (2011-2012). The PBPK-reverse dosimetry estimated daily intakes at the 50th and 95th percentiles were 0.68 and 9.58 μg/kg/d and 0.089 and 0.68 μg/kg/d for DEHP and DnBP, respectively. For DEHP, the estimated median from PBPK-reverse dosimetry was about 3.6-fold higher than the ExpoCast estimate (0.68 and 0.18 μg/kg/d, respectively). For DnBP, the estimated median was similar to that predicted by ExpoCast (0.089 and 0.094 μg/kg/d, respectively). The SHEDS-HT prediction of DnBP intake from consumer product pathways alone was higher at 0.67 μg/kg/d. The PBPK-reverse dosimetry-estimated median intake of DEHP and DnBP was comparable to values previously reported for US populations. These comparisons provide insights into establishing criteria for selecting appropriate exposure prediction tools for use in an integrated modeling platform to link exposure to health effects.

High-throughput screening of chemicals as functional substitutes using structure-based classification models

Identifying chemicals that provide a specific function within a product, yet have minimal impact on the human body or environment, is the goal of most formulation chemists and engineers practicing green chemistry. We present a methodology to identify potential chemical functional substitutes from large libraries of chemicals using machine learning based models. We collect and analyze publicly available information on the function of chemicals in consumer products or industrial processes to identify a suite of harmonized function categories suitable for modeling. We use structural and physicochemical descriptors for these chemicals to build 41 quantitative structure-use relationship (QSUR) models for harmonized function categories using random forest classification. We apply these models to screen a library of nearly 6400 chemicals with available structure information for potential functional substitutes. Using our Functional Use database (FUse), we could identify uses for 3121 chemicals; 4412 predicted functional uses had a probability of 80% or greater. We demonstrate the potential application of the models to high-throughput (HT) screening for "candidate alternatives" by merging the valid functional substitute classifications with hazard metrics developed from HT screening assays for bioactivity. A descriptor set could be obtained for 6356 Tox21 chemicals that have undergone a battery of HT in vitro bioactivity screening assays. By applying QSURs, we were able to identify over 1600 candidate chemical alternatives. These QSURs can be rapidly applied to thousands of additional chemicals to generate HT functional use information for combination with complementary HT toxicity information for screening for greener chemical alternatives.

A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder

BACKGROUND

This report prospectively examines the 4-year course, and predictors of course, of body dysmorphic disorder (BDD), a common and often severe disorder. No prior studies have prospectively examined the course of BDD in individuals ascertained for BDD. Method The Longitudinal Interval Follow-Up Evaluation (LIFE) assessed weekly BDD symptoms and treatment received over 4 years for 166 broadly ascertained adults and adolescents with current BDD at intake. Kaplan-Meier life tables were constructed for time to remission and relapse. Full remission was defined as minimal or no BDD symptoms, and partial remission as less than full DSM-IV criteria, for at least 8 consecutive weeks. Full relapse and partial relapse were defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining full or partial remission respectively. Cox proportional hazards regression examined predictors of remission and relapse.

RESULTS

Over 4 years, the cumulative probability was 0.20 for full remission and 0.55 for full or partial remission from BDD. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. Eighty-eight percent of subjects received mental health treatment during the follow-up period.

CONCLUSIONS

In this observational study, BDD tended to be chronic. Several intake variables predicted greater chronicity of BDD.

Adequacy of risk-reducing gynaecologic surgery in BRCA1 or BRCA2 mutation carriers and other women at high risk of pelvic serous cancer

The aim of this study was to describe the type of risk-reducing gynaecologic surgery (RRGS) and the extent of pathological evaluation being undertaken for Australasian women at high familial risk of pelvic serous cancer. Surgical and pathology reports were reviewed for women with BRCA1/BRCA2 mutations, or a family history of breast and ovarian cancer, who underwent RRGS between 1998 and 2008. "Adequate" surgery was defined as complete removal of all ovarian and extra-uterine fallopian tube tissue. "Adequate" pathology was defined as paraffin embedding of all removed ovarian and tubal tissue. Predictors of adequacy were assessed using logistic regression. There were 201 women, including 173 mutation carriers, who underwent RRGS. Of these, 91% had adequate surgery and 23% had adequate pathology. Independent predictors of adequate surgery were surgeon type (OR = 20; 95% CI 2-167; P = 0.005 for gynaecologic oncologists versus general gynaecologists), more recent surgery (OR = 1.33/year; 95% CI 1.07-1.67; P = 0.012) and younger patient age (OR = 0.93/year of age; 95% CI 0.87-0.99; P = 0.028). Independent predictors of adequate pathology were more recent surgery (OR = 1.26/year; 95% CI 1.06-1.49; P = 0.008) and surgeon type (OR = 3.1; 95% CI 1.4-6.7; P = 0.004 for gynaecologic oncologists versus general gynaecologists). Four serous ovarian cancers and one endometrioid endometrial cancer were detected during surgery or pathological examination. In conclusion Australasian women attending a specialist gynaecologic oncologist for RRGS are most likely to have adequate surgery and pathological examination. Additional education of clinicians and consumers is needed to ensure optimal surgery and pathology in these women.

Age-related differences in corpus callosum area of capuchin monkeys

Capuchin monkeys (Cebus apella) are New World primates with relatively large brains for their body size. The developmental trajectories of several brain regions-including cortical white matter, frontal lobe white matter, and basal ganglia nuclei-are similar to humans. Additionally, capuchins have independently evolved several behavioral and anatomical characteristics in common with humans and chimpanzees-including complex manipulative abilities, use of tools, and the use of precision grips-making them interesting species for studies of comparative brain morphology and organization. Here, we report the first investigation into the development of the corpus callosum (CC) and its regional subdivisions in capuchins. CC development was quantified using high-resolution structural magnetic resonance imaging (MRI) images from 39 socially reared subjects (male n=22; female n=18) ranging in age from 4 days (infancy) to 20 years (middle adulthood). The total area of the CC and the subdivisions of the genu, rostral midbody, medial midbody, caudal midbody, and splenium were traced from the midsagittal section. Total CC area displayed significant differences across this time span and was best explained by quadratic growth. Sustained linear growth was observed in the subdivisions of the genu, rostral midbody, and splenium; sustained quadratic growth was seen in the subdivision of the medial midbody. Differences in growth were not detected in the subdivision of the caudal midbody. Females had a larger raw area of the total CC and of the medial midbody and caudal midbody throughout the lifespan. Our results indicate that capuchins show continued white matter development beyond adolescence in regions related to cognitive and motor development.

Prospective study of breast cancer risk for mutation negative women from BRCA1 or BRCA2 mutation positive families

Published studies have reached contradictory conclusions regarding breast cancer risk for women from families segregating a BRCA1 or BRCA2 mutation who do not carry the family-specific mutation. Accurate estimation of breast cancer risk is crucial for appropriate counselling regarding risk management. The aim of this study is to prospectively assess whether breast cancer risk for mutation negative women from families segregating BRCA1 or BRCA2 mutations is greater than for women in the general population. Eligible women were 722 first-, second- and third-degree relatives of a BRCA1 or BRCA2 mutation carrier from 224 mutation positive (128 BRCA1, 96 BRCA2) families, had no personal cancer history at baseline, and had been tested and found not to carry the family-specific mutation. Self-reported family history of cancer, preventive interventions and verified cancer diagnoses were collected at baseline, and every 3 years thereafter. Median follow-up was 6.1 years (range 0.1-12.4 years). Time at risk of breast cancer was censored at cancer diagnosis or risk-reducing surgery. Standardised incidence ratios (SIR) were estimated by comparing observed to population incidences of invasive breast cancer using Australian Cancer Incidence and Mortality Books. Six cases of invasive breast cancer were observed. The estimated SIRs were 1.14 (95% CI: 0.51-2.53) overall (n = 722), 1.29 (95% CI: 0.58-2.88) when restricted to first- and second-degree relatives of an affected mutation carrier (n = 442) and 0.48 (95% CI: 0.12-1.93) when restricted to those with no family history of breast cancer in the non-mutation carrying parental lineage (n = 424). There was no evidence that mutation negative women from families segregating BRCA1 or BRCA2 mutations are at increased risk of breast cancer. Despite this being the largest prospective cohort to assess this issue, moderately increased breast cancer risk (2-fold) cannot be ruled out.

What is a mental/psychiatric disorder? From DSM-IV to DSM-V

The distinction between normality and psychopathology has long been subject to debate. DSM-III and DSM-IV provided a definition of mental disorder to help clinicians address this distinction. As part of the process of developing DSM-V, researchers have reviewed the concept of mental disorder and emphasized the need for additional work in this area. Here we review the DSM-IV definition of mental disorder and propose some changes. The approach taken here arguably takes a middle course through some of the relevant conceptual debates. We agree with the view that no definition perfectly specifies precise boundaries for the concept of mental/psychiatric disorder, but in line with a view that the nomenclature can improve over time, we aim here for a more scientifically valid and more clinically useful definition.

Evolution of the cerebellar cortex: the selective expansion of prefrontal-projecting cerebellar lobules

It has been suggested that interconnected brain areas evolve in tandem because evolutionary pressures act on complete functional systems rather than on individual brain areas. The cerebellar cortex has reciprocal connections with both the prefrontal cortex and motor cortex, forming independent loops with each. Specifically, in capuchin monkeys cerebellar cortical lobules Crus I and Crus II connect with prefrontal cortex, whereas the primary motor cortex connects with cerebellar lobules V, VI, VIIb, and VIIIa. Comparisons of extant primate species suggest that the prefrontal cortex has expanded more than cortical motor areas in human evolution. Given the enlargement of the prefrontal cortex relative to motor cortex in humans, our hypothesis would predict corresponding volumetric increases in the parts of the cerebellum connected to the prefrontal cortex, relative to cerebellar lobules connected to the motor cortex. We tested the hypothesis by comparing the volumes of cerebellar lobules in structural MRI scans in capuchins, chimpanzees and humans. The fractions of cerebellar volume occupied by Crus I and Crus II were significantly larger in humans compared to chimpanzees and capuchins. Our results therefore support the hypothesis that in the cortico-cerebellar system, functionally related structures evolve in concert with each other. The evolutionary expansion of these prefrontal-projecting cerebellar territories might contribute to the evolution of the higher cognitive functions of humans.

Addressing the challenges of the clinical application of pharmacogenetic testing

Pharmacogenomics aims to use molecular genetic markers to predict treatment outcome. Indeed, within the past decade there has been a rapid emergence of pharmacogenetic tests to aid clinicians in predicting efficacy or toxicity for some drugs. Despite this major advance in therapeutic drug management, there remain challenges to the appropriate use of pharmacogenetic tests. We discuss UGT1A1 pharmacogenetic testing to illustrate the knowledge gaps impeding widespread use of pharmacogenetic tests in the clinical setting.

A comparative study of corpus callosum size and signal intensity in capuchin monkeys (Cebus apella) and chimpanzees (Pan troglodytes)

The evolution of corpus callosum (CC) was integral to the development of higher cognitive processes and hemispheric specialization. An examination of CC morphology and organization across different primate species will further our understanding of the evolution of these specified functions. Using magnetic resonance imaging (MRI) as a non-invasive technique to measure CC size and to approximate the degree of myelination in the corpus callosum, we report differences in CC morphology and organization in capuchin monkeys and chimpanzees, two divergent primate species that have independently evolved several behavioral and anatomical characteristics. Species differences in CC morphology were detected, with chimpanzees having a larger overall CC compared to capuchin monkeys. Additionally, chimpanzees had the genu as the largest subdivision; in capuchin monkeys, the genu and splenium were the largest subdivisions. Sex differences in signal intensity were detected; capuchin monkey males had higher signal intensity values whereas chimpanzee females had higher signal intensity values. Thus, while capuchin monkeys and chimpanzees show some similarity in patterns of CC morphology, these species differ significantly in the regional organization of the CC.

A comparison of quality of life and psychosocial functioning in obsessive-compulsive disorder and body dysmorphic disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) are possibly related disorders characterized by poor functioning and quality of life. However, few studies have compared these disorders in these important domains.

METHODS

We compared functioning and quality of life in 210 OCD subjects, 45 BDD subjects, and 40 subjects with comorbid BDD+OCD using reliable and valid measures.

RESULTS

OCD and BDD subjects had very poor scores across all measures, with no statistically significant differences between the groups. However, comorbid BDD+OCD subjects had greater impairment than OCD subjects on 11 scales/subscales, which remained significant after controlling for OCD severity. Comorbid BDD+OCD subjects had greater impairment than BDD subjects on 2 scales/subscales, which were no longer significant after controlling for BDD severity, suggesting that BDD severity may have accounted for greater morbidity in the comorbid BDD+OCD group.

CONCLUSIONS

Functioning and quality of life were poor across all three groups, although individuals with comorbid BDD+OCD had greater impairment on a number of measures. It is important for clinicians to be aware that patients with these disorders--and, in particular, those with comorbid BDD and OCD--tend to have very poor functioning and quality of life across a broad range of domains.

Delusional versus nondelusional body dysmorphic disorder: clinical features and course of illness

DSM-IV's classification of body dysmorphic disorder (BDD) is controversial. Whereas BDD is classified as a somatoform disorder, its delusional variant is classified as a psychotic disorder. However, the relationship between these BDD variants has received little investigation. In this study, we compared BDD's delusional and nondelusional variants in 191 subjects using reliable and valid measures that assessed a variety of domains. Subjects with delusional BDD were similar to those with nondelusional BDD in terms of most variables, including most demographic features, BDD characteristics, most measures of functional impairment and quality of life, comorbidity, and family history. Delusional and nondelusional subjects also had a similar probability of remitting from BDD over 1 year of prospective follow-up. However, delusional subjects had significantly lower educational attainment, were more likely to have attempted suicide, had poorer social functioning on several measures, were more likely to have drug abuse or dependence, were less likely to currently be receiving mental health treatment, and had more severe BDD symptoms. However, when controlling for BDD symptom severity, the two groups differed only in terms of educational attainment. These findings indicate that BDD's delusional and nondelusional forms have many more similarities than differences, although on several measures delusional subjects evidenced greater morbidity, which appeared accounted for by their more severe BDD symptoms. Thus, these findings offer some support for the hypothesis that these two BDD variants may constitute the same disorder. Additional studies are needed to examine this issue, which may have relevance for other disorders with both delusional and nondelusional variants in DSM.

Fertility- and menopause-related information needs of younger women with a diagnosis of early breast cancer

PURPOSE

The use of chemotherapy and endocrine therapies in the treatment of premenopausal women carries with it reproductive and gynecologic implications that young women may find distressing and discordant with plans for childbearing. This multicenter study aimed to investigate fertility- and menopause-related information needs among young women with a diagnosis of early-stage breast cancer.

PATIENTS AND METHODS

Two hundred twenty-eight women with a diagnosis of early-stage breast cancer who were aged 40 years or younger at diagnosis and who were 6 to 60 months after diagnosis were entered onto the trial. Participants completed a mailed self-report questionnaire that included a purposely designed fertility- and menopause-related information needs survey and standardized measures of distress, anxiety, quality of life, menopausal symptoms, and information-seeking style.

RESULTS

Seventy-one percent of participants discussed fertility-related issues with a health professional as part of their breast cancer treatment, and 86% discussed menopause-related issues. Consultation with a fertility or menopause specialist was the most preferred method of obtaining this information. Receiving fertility-related information was rated as being significantly more important than receiving menopause-related information at time of diagnosis (P < .001) and at treatment decision making (P = .058). Receiving menopause-related information was rated as being significantly more important than receiving fertility-related information during adjuvant treatment (P < .05), at completion of adjuvant treatment (P < .001), and during follow-up (P < .001). Common questions, sources of information, and correlates of perceived importance were identified.

CONCLUSION

The results of this study suggest that younger women have unmet needs for fertility- and menopause-related information and provide preliminary empirical data to guide the development of better fertility- and menopause-related patient education materials for younger women with a diagnosis of early breast cancer.

Exploring residency match violations in family practice

BACKGROUND AND OBJECTIVES

This study's objective was to learn what student applicants to family practice residency programs in 2002 understood about National Resident Matching Program guideline violations, whether they experienced violations, and how they were affected by perceived violations.

METHODS

We used qualitative analysis of in-depth interviews with 15 key informant students.

RESULTS

Only six of the 15 students believed that they had experienced a violation. Only two students had experienced an actual Match guideline violation, and two more experienced potential violations. There was substantial confusion about what constituted a violation. The sources of confusion involved failure to attend Match orientation, lack of clarity in published information, confusing messages from programs, rumors and word-of mouth, and students' own personal moral values. Equal Employment Opportunity Commission violations were interpreted by some as Match violations. Some students judged programs based on threats to the integrity of the Match, whether or not they experienced actual violations.

CONCLUSIONS

Real and potential Match violations did occur, but there is also considerable confusion about what constitutes a violation. There are opportunities to investigate violations, train students to recognize and deal with violations, and clarify actual violation definitions and for programs to avoid the real and perceived violations that affect their recruiting.

Clinical, pathological and genetic features of women at high familial risk of breast cancer undergoing prophylactic mastectomy

Prophylactic mastectomy (PM) is a risk-management option for women at high familial risk of breast cancer (BC). This study describes the PM experience of women enrolled in a large observational cohort study involving families with a history of hereditary breast cancer. Within 357 multiple-case BC families [119 (33%) BRCA1 or BRCA2 mutation positive], identified via family cancer clinics, 49 cases of PM [21 (43%) BRCA1 or BRCA2 mutation positive] were identified and their clinical, pathological and genetic features reviewed. Families with at least one incidence of PM displayed stronger breast/ovarian cancer histories than did families without PM. Median age at time of PM was 45 years (range 28-58). Ten cases (21%) were bilateral PMs in unaffected women and 39 cases were contralateral PMs in women with prior invasive BC (71%) or ductal carcinoma in situ (DCIS) (8%). Most (88%) underwent total mastectomy. Unnecessary axillary surgery occurred in eight subjects (16%). Malignant histology was found in three PM specimens (6%). Prior to genetic testing, PM was performed in two women who were subsequently shown not to carry the mutation specific to their family. Optimal utilization of genetic testing to guide surgical decision making, appropriate surgical technique and careful pathology examination of PM specimens, are important issues to consider prior to PM in women at high familial risk of BC.

A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study

Population-based women (n=1049) with breast cancer diagnosed mainly between 1996 and 1998, when aged 20-59 years, were mailed a questionnaire seeking information about self-reported shoulder stiffness and swelling, numbness and pain/ache in the arm following treatment (excluding 6 months from diagnosis). Of the 809 who completed the survey, approximately seven in eight experienced at least one symptom, one in six reported all four symptoms, and one in three considered that their arm morbidity interfered substantially with activities of daily living. Arm swelling occurred at some time in 39% of women, was present in 20% 1 year, and in 29% 4 years, after diagnosis. The prevalence of arm swelling was higher in women with axillary node dissection (OR=2.4; 95% Cl 1.0-5.6), and was increased in a women with a higher body mass index (P=0.02) and less education (P=0.01), but was not related to age, number of nodes excised or self-reports of radiation or type of surgery.

Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review

CONTEXT

Adverse drug reactions are a significant cause of morbidity and mortality. Although many adverse drug reactions are considered nonpreventable, recent developments suggest these reactions may be avoided through individualization of drug therapies based on genetic information, an application known as pharmacogenomics.

OBJECTIVE

To evaluate the potential role of pharmacogenomics in reducing the incidence of adverse drug reactions.

DATA SOURCES

MEDLINE English-language only searches for adverse drug reaction studies published between January 1995 and June 2000 and review articles of variant alleles of drug-metabolizing enzymes published between January 1997 and August 2000. We also used online resources, texts, and expert opinion.

STUDY SELECTION

Detailed inclusion criteria were used to select studies. We included 18 of 333 adverse drug reaction studies and 22 of 61 variant allele review articles.

DATA EXTRACTION

All the investigators reviewed and coded articles using standardized abstracting forms.

DATA SYNTHESIS

We identified 27 drugs frequently cited in adverse drug reaction studies. Among these drugs, 59% are metabolized by at least 1 enzyme with a variant allele known to cause poor metabolism. Conversely, only 7% to 22% of randomly selected drugs are known to be metabolized by enzymes with this genetic variability (range, P =.006-P<.001).

CONCLUSIONS

Our results suggest that drug therapy based on individuals' genetic makeups may result in a clinically important reduction in adverse outcomes. Our findings serve as a foundation for further research on how pharmacogenomics can reduce the incidence of adverse reactions and on the resulting clinical, societal, and economic implications.

Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder

It appears that many individuals with body dysmorphic disorder (BDD) receive nonpsychiatric medical treatment and surgery; however, this topic has had little systematic investigation. This study assessed the nonpsychiatric treatment sought and received by 289 individuals (250 adults and 39 children/adolescents) with DSM-IV BDD. Such treatment was sought by 76.4% and received by 66.0% of adults. Dermatologic treatment was most often received (by 45.2% of adults), followed by surgery (by 23.2%). These treatments rarely improved BDD symptoms. Results were similar in children/adolescents. These findings indicate that a majority of patients with BDD receive nonpsychiatric treatment but tend to respond poorly.

Insight and treatment outcome in obsessive-compulsive disorder

To determine whether (1) insight in obsessive-compulsive disorder (OCD) improves when OCD symptoms improve, and whether (2) degree of insight in OCD predicts response to sertraline, data were obtained from five sites participating in a larger multisite study of relapse in OCD. During the first 16 weeks of the study, 71 patients received open-label treatment with sertraline and were assessed using the Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) and a rating scale to evaluate insight, the Brown Assessment of Beliefs Scale (BABS), at study baseline and termination. Baseline total BABS score was not significantly correlated with change in Y-BOCS score. Change in BABS total score and change in Y-BOCS total score were significantly correlated. There was no significant difference in mean endpoint Y-BOCS scores for patients with poor insight (n = 14) compared to patients with good insight at baseline (n = 57). Thus, insight improved with decrease in OCD symptom severity. Degree of insight at baseline did not predict response to sertraline, i.e., patients with poor insight were just as likely to respond to sertraline as patients with good insight.

The effect of risk factor reductions between 1981 and 1990 on coronary heart disease incidence, prevalence, mortality and cost

OBJECTIVES

We sought to estimate the impact and cost-effectiveness of risk factor reductions between 1981 and 1990.

BACKGROUND

Coronary heart disease (CHD) mortality rates have declined dramatically, partly as a result of reductions in CHD risk factors.

METHODS

We used the CHD Policy Model, a validated computer-simulation model, to estimate the effects of actual investments made to change coronary risk factors between 1981 and 1990, as well as the impact of these changes on the incidence, prevalence, mortality and costs of CHD during this period and projected to 2015.

RESULTS

Observed changes in risk factors between 1981 and 1990 resulted in a reduction of CHD deaths by approximately 430,000 and overall deaths by approximately 740,000, with an estimated cost-effectiveness of about $44,000 per year of life saved during this period, based on the estimated actual costs of the interventions used. However, because much of the benefit of risk factor reductions is delayed, the estimated reductions for the 35-year period of 1981 to 2015 were 3.6 million CHD deaths and 1.2 million non-CHD deaths, at a cost of only about $5,400 per year of life saved.

CONCLUSIONS

Aggregate efforts to reduce risk factors between 1981 and 1990 have led to substantial reductions in CHD and should be well worth the cost, largely because of population-wide changes in life-style and habits. Some interventions are much better investments than others, and attention to such issues could lead to better use of resources and better outcomes in the future.