Universal DNA methylation age across mammalian tissues

Aging, often considered a result of random cellular damage, can be accurately estimated using DNA methylation profiles, the foundation of pan-tissue epigenetic clocks. Here, we demonstrate the development of universal pan-mammalian clocks, using 11,754 methylation arrays from our Mammalian Methylation Consortium, which encompass 59 tissue types across 185 mammalian species. These predictive models estimate mammalian tissue age with high accuracy (r > 0.96). Age deviations correlate with human mortality risk, mouse somatotropic axis mutations and caloric restriction. We identified specific cytosines with methylation levels that change with age across numerous species. These sites, highly enriched in polycomb repressive complex 2-binding locations, are near genes implicated in mammalian development, cancer, obesity and longevity. Our findings offer new evidence suggesting that aging is evolutionarily conserved and intertwined with developmental processes across all mammals.

Tool use and social homophily among male bottlenose dolphins

Homophilous behaviour plays a central role in the formation of human friendships. Individuals form social ties with others that show similar phenotypic traits, independently of relatedness. Evidence of such homophily can be found in bottlenose dolphins ( Tursiops aduncus) in Shark Bay, Western Australia, where females that use marine sponges as foraging tools often associate with other females that use sponges. 'Sponging' is a socially learned, time-consuming behaviour, transmitted from mother to calf. Previous research illustrated a strong female bias in adopting this technique. The lower propensity for males to engage in sponging may be due to its incompatibility with adult male-specific behaviours, particularly the formation of multi-level alliances. However, the link between sponging and male behaviour has never been formally tested. Here, we show that male spongers associated significantly more often with other male spongers irrespective of their level of relatedness. Male spongers spent significantly more time foraging, and less time resting and travelling, than did male non-spongers. Interestingly, we found no difference in time spent socializing. Our study provides novel insights into the relationship between tool use and activity budgets of male dolphins, and indicates social homophily in the second-order alliance composition of tool-using bottlenose dolphins.

The macrophage activation marker CD163 is associated with IL28B genotype and hepatic inflammation in chronic hepatitis C virus infected patients

Recent data highlighted the association of the macrophage activation marker CD163 with histological inflammation and fibrosis in chronic hepatitis C virus (HCV) infection. The aim of this study was to investigate the influence of successful antiviral treatment and IL28B genotypes on macrophage activation reflected by CD163 levels in HCV infected patients. In a retrospective cohort study, serum sCD163 levels were correlated with results of liver histopathology, IL28B genotyping and clinical parameters in 329 patients with HCV infection, 15 healthy controls and in 161 patients who achieved a sustained virologic response after antiviral treatment. sCD163 levels were significantly higher in patients with chronic HCV infection in comparison to healthy controls (5202 vs 896 ng/mL, P < 0.001). In the multivariate logistic regression analyses, sCD163 was independently associated with histologically determined inflammation (P = 0.043) but not with fibrosis (P = 0.091). sCD163 dropped significantly after successful antiviral treatment in comparison to baseline values (5202 vs 3093 ng/mL, P < 0.001). In the univariate analyses, sCD163 was significantly associated with IL28B genotype (C/C vs C/T+T/T) with higher values in the C/C group (6098 vs 4812 ng/mL, P = 0.003). In the multivariate logistic regression model, sCD163 levels were significantly associated with IL28B genotype (P = 0.003) and sustained virologic response (SVR) (P < 0.001). Our data support the association of activated liver macrophages with hepatic necroinflammation in chronic HCV infection as sCD163 levels drop rapidly after SVR. The irresponsiveness of IL28B minor genotypes to interferon might be related to a lower level of macrophage activation in these patients.

Ledipasvir/sofosbuvir treatment of hepatitis C virus is associated with reduction in serum apolipoprotein levels

The interaction of lipoproteins with hepatitis C virus (HCV) has pathogenic and therapeutic implications. Our aim was to evaluate changes in the apolipoprotein profile of patients with chronic hepatitis C during and after successful cure with ledipasvir and sofosbuvir (LDV/SOF) with and without ribavirin (RBV). One hundred HCV genotype 1 patients who had achieved SVR-12 after treatment with 12 weeks of LDV/SOF ± RBV were selected from the ION-1 clinical trial. Frozen serum samples from baseline, end of treatment and week 4 of follow-up were used to assay apolipoproteins (apoAI, apoAII, apoB, apoCII, apoCIII, apoE) using the Multiplex platform to assess for changes in the apolipoprotein levels. At the end of treatment compared to baseline, a significant reduction in apoAII levels (-14.97 ± 63.44 μg/mL, P = 0.0067) and apoE levels (-4.38 ± 12.19 μg/mL, P < 0.001) was noted. These declines from baseline in apoAII (-16.59 ±66.15 μg/mL, P = 0.0075) and apoE (-2.66 ± 12.64 μg/mL, P = 0.015) persisted at 4 weeks of post-treatment follow-up. In multivariate analysis, treatment with LDV/SOF + RBV was independently associated with reduction in apoE (beta = 5.31 μg/mL, P = 0.002) (compared to RBV-free LDV/SOF) (P < 0.05). In contrast, apoCII levels overall increased from baseline to end of treatment (+2.74 ±11.76 μg/mL, P = 0.03) and persisted at 4 weeks of follow-up (+4.46 ± 12.81 μg/mL from baseline, P = 0.0005). Subgroup analysis revealed an increase in apoCII during treatment only in patients receiving LDV/SOF without RBV (+5.52 ± 11.92 μg/mL, P = 0.0007) but not in patients receiving LDV/SOF + RBV (P = 0.638). Treatment with LDV/SOF ± RBV is associated with a persistent reduction in the apolipoprotein AII and E after achieving cure. These data suggest that treatment with LDV/SOF ± RBV may be associated with alterations in serum apolipoproteins which could potentially impact viral eradication.

Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days.

CONCLUSIONS

Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.

Soluble CD163 is an indicator of liver inflammation and fibrosis in patients chronically infected with the hepatitis B virus

Soluble CD163 (sCD163), a marker for macrophage activation, was found to be associated with the severity of liver cirrhosis. The aim of the current study was to investigate whether serum sCD163 levels correlate with liver inflammation and fibrosis in patients with chronic hepatitis B virus (HBV) infection. In a retrospective cohort study, serum sCD163 levels were assessed by ELISA together with clinical and laboratory data in 186 patients with chronic HBV infection and 15 healthy controls. The relation between parameters for liver fibrosis and necroinflammation and sCD163 levels was analysed. Additionally, sCD163 was quantified in a subset of follow-up serum samples after initiation of antiviral treatment. sCD163 levels differed among phases of chronic HBV infection (P < 0.0001), and sCD163 concentrations were associated with inflammatory activity and fibrosis in the liver. sCD163 levels ≥ 1961 ng/l had a high specificity in the identification of subjects with substantial fibrosis (F ≥ 2). sCD163 concentrations decreased significantly after initiation of antiviral treatment. The correlation of sCD163 levels with necroinflammation and fibrosis and the sCD163 decline under treatment indicates that macrophage activation plays a role in HBV-related liver pathogenesis.

Metformin does not affect risk of biochemical recurrence following radical prostatectomy: results from the SEARCH database

Background

While epidemiologic studies suggest that metformin use among diabetics may decrease prostate cancer (PC) incidence, the effect of metformin use on PC outcome is unclear. We investigated the association between pre-operative metformin use, dose and duration of use and biochemical recurrence (BCR) in PC patients with diabetes who underwent radical prostatectomy (RP).

Methods

We conducted a retrospective cohort analysis within the Shared Equal Access Regional Cancer Hospital (SEARCH) database of 371 PC patients with diabetes who underwent RP. Time to BCR between metformin users and non-users, and by metformin dose and duration of use was assessed using multivariable Cox proportional analysis adjusted for demographic, clinical and/or pathologic features. Time to castrate-resistant PC (CPRC), metastases and PC-specific mortality were explored as secondary outcomes using unadjusted analyses.

Results

Of 371 diabetic men, 156 (42%) were using metformin prior to RP. Metformin use was associated with more recent year of surgery (p<0.0001) but no clinical or pathologic characteristics. After adjustment for year of surgery, clinical and pathologic features, there were no associations between metformin use (HR 0.93; 95%CI 0.61–1.41), high metformin dose (HR 0.96; 95%CI 0.57–1.61) or duration of use (HR 1.00; 95%CI 0.99–1.02) and time to BCR. A total of 14 patients (3.8%) developed CRPC, 10 (2.7%) distant metastases and 8 (2.2%) died from PC. Unadjusted analysis suggested high metformin dose versus non-use was associated with increased risk of CRPC (HR 5.1; 95%CI 1.6–16.5), metastases (HR 4.8; 95%CI 1.2–18.5) and PC-specific mortality (HR 5.0; 95%CI 1.1–22.5).

Conclusions

Metformin use, dose or duration of use was not associated with BCR in this cohort of diabetic PC patients treated with RP. The suggestion that higher metformin dose was associated with increased risk of CPRC, metastases and PC-specific mortality merits testing in large prospective studies with longer follow-up.

Sexual bother and function after radical prostatectomy: predictors of sexual bother recovery in men despite persistent post-operative sexual dysfunction

Changes in sexual bother (SB) following radical prostatectomy (RP) negatively affect health-related quality of life (HRQoL) of prostate cancer survivors. However, post-operative SB tends to be neglected whereas sexual function (SF) is thoroughly assessed in clinical practice and few studies have focused on and evaluated patients' SB. We retrospectively reviewed 2 345 consecutive patients who underwent RP between 2001 and 2009 at a single institution. SF and SB were assessed using Expanded Prostate Cancer Index Composite (EPIC) questionnaires. We stratified our cohort by SB recovery and post-operative SF status, including a subset of men who recovered SB despite persistent post-RP sexual dysfunction. Multivariable logistic regression analyses were conducted to identify factors for men who have SB recovery. Of 319 eligible patients, 133 (41.7%) recovered their SB at a mean of 20 months after RP. Among the 133 men who demonstrated SB recovery, 109 had post-operative sexual dysfunction. Patients with SB recovery despite post-RP sexual dysfunction were more likely to be old (p = 0.004), to have higher clinical T stage (p < 0.001), to have more non-nerve-sparing RP (p < 0.001), to have lower pre-operative EPIC-SF/SB scores (p < 0.001), to have more extracapsular extension (p = 0.031) and to be PDE5i non-users after surgery (p < 0.001). In multivariable analysis, predictors for this subset were lower comorbidity (OR 0.62, p = 0.043), higher clinical cancer stage (OR 2.35, p = 0.026), worse pre-operative SF (OR 0.98, p = 0.010), SB (OR 0.98, p < 0.010) and no PDE5i use (OR 0.37, p = 0.002); age was not related (OR 0.99, p = 0.555). As SB can influence patients' overall HRQoL, expectations of SB recovery should be provided to patients in the same way that SF recovery is presented. This study may help clinicians to discuss SB with patients and assess their potential for SB recovery following RP.

Non-alcoholic fatty liver disease (NAFLD) is associated with low level of physical activity: a population-based study

BACKGROUND

High intensity exercise improves metabolic status and may potentially mobilise hepatic fat.

AIM

To assess the level of physical activity (PA) of subjects with non-alcoholic fatty liver disease (NAFLD).

METHODS

Data were obtained from NHANES (2003-2006). Activity counts obtained from accelerometer readings (ActiGraph, Fort Walton Beach, FL), from 7 consecutive days quantified total PA and time spent engaged in different levels of activity. All measures were counts/minutes/day: (sedentary <100; light 100-0027; moderate, 2020-5999 and vigorous, 6000+). NAFLD was defined as a fatty liver index >60 (FLI) in the absence of other chronic liver disease. Subjects with NAFLD were compared to controls using stratum-specific Chi-squared and t-tests. Simple linear regression analyses (with Taylor series linearised variance estimation and weighting) were used to determine the association between PA levels and NAFLD. P-values <0.05 were considered significant. Statistical analyses were conducted using sudaan version 10.1 and sas version 9.1.

RESULTS

We included 3056 participants. NAFLD patients were older, had higher BMI, larger waist circumference, higher sum of skinfolds, more likely to have insulin resistance (HOMA > 3.0) and type-2 diabetes (all P-values <0.01). Average PA for NAFLD subjects was about 28.7 counts/minute/day less than controls (P < 0.01). Furthermore, NAFLD subjects spent less time participating in activity at any level (P < 0.01). Subjects with NAFLD and DM were in the lowest quartile of average PA as well as moderate-vigorous PA (P < 0.01).

CONCLUSIONS

Data from this study show that non-alcoholic fatty liver disease patients have low level of physical activity and, when they have diabetes mellitus, they perform at the lowest quartile of physical activity and moderate-vigorous physical activity.

Prostate cancer risk in men with prostate and breast cancer family history: results from the REDUCE study (R1)

BACKGROUND

To what degree the associations between PCa risk and family history of prostate cancer (PCa) and/or breast cancer (BCa) are attributable to screening biases is unclear. We examined these questions within the REDUCE study, where biopsies were largely independent of prostate specific antigen (PSA) minimizing screening biases.

METHODS

Data were from REDUCE, which tested dutasteride 0.5 mg daily for PCa risk reduction in men with PSA 2.5-10.0 ng mL(-1) and a negative prestudy biopsy. Among men undergoing at least one on-study biopsy with complete data (n = 6415; 78.1%), the association between family history and PCa risk was tested using multivariate logistic regression adjusting for clinicodemographic characteristics.

RESULTS

A family history of PCa alone was associated with increased PCa diagnosis (OR: 1.47, 95%CI: 1.22-1.77). In North America, PCa family history was not related to PCa diagnosis (OR: 1.02, 95%CI: 0.73-1.44), whereas outside North America, PCa family history was significantly related to diagnosis (OR: 1.72, 95%CI: 1.38-2.15) (P-interaction = 0.01). A family history of both PCa and BCa (OR: 2.54, 95%CI: 1.72-3.75) but not BCa alone (OR: 1.04, 95%CI: 0.84-1.29) was associated with increased PCa risk versus no family history and irrespective of geographical region.

CONCLUSIONS

In REDUCE, PCa family history was significantly related to PCa diagnosis, although only for men outside North America. The presence of both PCa and BCa family history significantly increased risk versus PCa family history alone, irrespective of geographical region. Ultimately, our observations may support the need for changes in how we address family history in terms of both risk of PCa diagnosis and general risk stratification.

[Calcified]

A 73-year-old woman was referred due to an acute and progressive worsening of a previously mildly impaired kidney function of unknown origin. The kidney biopsy showed a phosphate nephropathy. We identified Colophos®, a phosphate-containing purgative as the causing agent, which the patient had received for bowel cleansing for a colonoscopy one day before the detection of the acute kidney failure. During the following months the kidney function initially declined further and then improved. Most cases of phosphate nephropathy are associated with the ingestion of phosphate-containing purgatives. Persons at risk are women, elderly persons, patients with impaired kidney function, hypertension, and dehydration. The consequence is sometimes an irreversible tubulointerstitial injury that can lead to end-stage renal disease in a minority of the cases.

[Migraine-induced kidney stones?]

A 42-year old woman was referred for a metabolic evaluation after two episodes of kidney stones. Her laboratory results revealed a normal anion-gap metabolic acidosis, a marked hypocitraturia (0,6 mmol/24h; norm 1,6-4,5) and a urinary pH of 7,0 confirming renal tubular acidosis (RTA). We identified topiramate, our patient's medication for migraine, as the cause of the RTA. Topiramate, a carboanhydrase inhibitor leads to RTA of a mixed (proximal and distal) type and thus significantly increases the risk for kidney stones.

P4-12-08: Five Year Preliminary Outcomes of a Prospective Surveillance Model To Reduce Upper Extremity Morbidity Related to Breast Cancer Treatment

Background

Early detection and management of physical impairments after breast cancer treatment contribute to successful functional outcomes and improved quality of life throughout disease treatment and survivorship. Assessment of upper extremity (UE) morbidity including; shoulder dysfunction, scarring, pain, fatigue and lymphedema should be conducted through a prospective surveillance model of care to promote early identification of impairments and provide intervention while functional limitations are minimal, thereby preventing long term loss of function. This report highlights 5-year findings related to physical function in patients participating in a prospective surveillance model of care.

Methods: A prospective, observational study enrolled women with breast cancer at the point of disease diagnosis (n=196) and measured UE morbidity, impairments and functional disability over a 5 year period. Patient demographics, cancer characteristics, measures of UE strength, range of motion (ROM) and limb volume were taken pre-operatively and repeated at 1, 3, 6, 9, 12 and 60 months post-operatively. Subjective assessment of physical activity, health status and quality of life were assessed by questionnaire at 12 and 60 months. 166 subjects completed visits at 1 year and 95 completed visits at 5 years. All subjects received education regarding exercise, risk reduction and advice on return to activity. If physical impairments were detected during the study, immediate physical therapy intervention was initiated to alleviate the impairment.

Results: The incidence of objective UE impairments at five years after treatment was 9% with loss of shoulder ROM, 25% with subclinical lymphedema (defined as a ≥ 3% change in limb volume from baseline), 5.6% with advanced lymphedema (Stage I or II) and 27.8% with clinically significant fatigue (defined as ≥ 3 on a visual analog scale). Subjectively 8.4% reported feeling moderately or severely disabled with their affected arm, 11.1% reported moderate to severe difficulty carrying heavy objects, 4.2% reported moderate to severe limitations with heavy household chores.

Discussion: This is the first prospective cohort study in the United States to specifically monitor physical and functional outcomes to 5-years post breast cancer treatment. The prospective surveillance model of care, conducted by the physical therapist, enabled early detection and treatment of breast cancer treatment-related impairments resulting in improved long-term function. Long-term incidence of UE morbidity after breast cancer treatment has been documented in the literature as high as 40–60% with lymphedema and up to 60% with fatigue. This study clearly demonstrates the potential for substantial reduction in UE dysfunction related to breast cancer treatment when using an early identification and intervention model. Morbidity such as pain, reduced range of motion, decreased strength and sub-clinical lymphedema were detected early and managed through the prospective model. These results strongly suggest that prospective surveillance monitoring for functional impairments is an optimal construct to assure long-term function in women after breast cancer treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-08.

Diabetes and cancer risk in the REDUCE trial

194

Background: Men with diabetes mellitus (DM) are less likely to be diagnosed with prostate cancer (PC). As diabetic men have lower PSA values, it is unclear if this is due to reduced PC incidence or lower biopsy rates from the lower PSA. To account for differential biopsy rates, we explored the link between DM and risk of PC and high-grade PC in the REDUCE trial. We also explored if these associations differed by body mass index (BMI) as a prior study suggested BMI may modify the effect of DM on PC aggressiveness.

Methods: The 4-year REDUCE study tested the effect of dutasteride 0.5 mg daily on PC risk reduction in men with PSA of 2.5-10.0 ng/mL and a negative prostate biopsy. Men underwent study-mandated biopsies at 2 and 4 years regardless of PSA. DM was determined by self report at baseline. BMI (kg/m2) was calculated from height and weight measured at baseline. The risk of PC and high-grade PC (Gleason 7-10) was determined using multivariate logistic regression adjusting for age, race, BMI, PSA, and treatment arm. Effect modification by BMI (<25, 25-29.9, and >30 kg/m2) was tested via interactions.

Results: Of 8,122 men in the REDUCE trial, 499 (6.1%) had DM. Diabetic men were older (63.8 vs. 62.7 yrs, p=0.001) with a higher BMI (median BMI 27.8 vs. 26.8, p<0.0001). After adjusting for age and BMI, diabetic men had lower PSA values (p=0.04). On multivariate analysis, DM was not associated with PC risk (OR 0.96, 95% CI 0.75-1.22, p=0.74). When stratified by BMI, DM was not associated with PC risk in any group (all p>0.23) and the results did not vary by BMI category (p-interaction=0.13). DM was not associated with high-grade PC on multivariate analysis (OR 0.88, 95% CI 0.58-1.33, p=0.55). When stratified by BMI, though DM was not associated with high-grade PC risk in any single group (all p>0.14), there was a suggestion of effect modification by BMI (p-interaction=0.056) with a positive association between DM and high-grade PC in obese men (OR 1.32) and an inverse association in normal weight men (OR 0.35).

Conclusions: In the REDUCE trial, when all men undergo biopsy regardless of PSA, DM is not associated with lower PC risk, but rather equal PC risk and equal risk of high-grade PC. These results suggest the lower rate of PC among diabetic men in prior studies may be driven by lower biopsy rates from lower PSA.

[Table: see text]

Abstract P1-10-06: Racial Disparities in Physical and Functional Domains in Women with Early Breast Cancer

Background. There is limited research on the racial/ethnic disparities in breast cancer survivors’ (BCS) physical functioning and quality of life (QOL). Previous studies note that African American (AA) women are typically diagnosed with larger, more aggressive tumors and require more intensitve surgical and adjuvant treatment potentiating higher levels of functional morbidity. Reasons given for these disparities include; genetic predisposition, poor access to screening and cultural norms that may impact a patients willingness to seek screening and early treatment. This analysis compared the QOL and prevalence of physical impairments (including lymphedema, seroma, cording) of white and African-American BCS from a US Military hospital where all patients have coverage and access to health care services. Methods. Data was analyzed from 166 women (130 white and 28 African-American). Participants were assessed preoperatively and examined at 1, 3, 6, 9, 12-24 months post surgery for impairments by a physical therapist. QOL was assessed at 12-24 months post-operation through the Short Form Health Survey (SF36v2). Analysis of variance estimated differences in QOL and occurrences of impairments between white and African-American BCS. Results. African-American BCS: were premenopausal(P&lt;.05), had ER/PR negative tumors(P&lt;.001, P&lt;.05), and received radiation(P&lt;.05). No significant differences were found in type, stage, grade, or size of BC tumor, surgery type, lymph node dissection, or number of lymph nodes sampled. More AA BCS were employed(P&lt;.05) and socially active(P&lt;.05), but less recreationally active(P&lt;.05); there were no significant differences in marital status. More AA BCS had axillary web syndrome(P &lt;.05) and lymphedema(P &lt;.05). No significant differences were found in seroma, fatigue, chestwall pain, shoulder pain, numbness, and self-reported QOL. Conclusions. Results suggest a difference in physical effects of BC treatment on white and AA women; however, contrary to other studies, no differences in QOL were noted. Our cohort demonstrates an interesting trend, in that only ER/PR status differed and other characteristics of the tumor were not different between racial groups. This differs from past reports and may suggest that access to care plays a role in promoting earlier stage diagnosis. However, despite the homogeneity of our cohorts tumor status we found that AA BCS may be at a higher risk for common impairments associated with BC treatment and should be monitored prospectively to mitigate the potential for impairments. Further research should examine effects of BC treatments on women of various ethnicities.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-06.

Functional recovery after surgery in patients with breast cancer

e20539

Background: Upper extremity dysfunction and decreased quality of life are frequently reported sequelae of the treatment for early stage breast cancer (BC). Surgical trauma and/or radiation therapy may lead to upper extremity (UE) impairments, functional limitations and disabilities including pain, stiffness, lymphedema, decreased strength and range of motion (ROM) and decreased activity tolerance. In this study we examined specific functional characteristics of shoulder impairments and associated limitations. Methods: Women (n=88, mean age = 53y [SD=11.81]) newly diagnosed with unilateral, Stage I to III BC were screened pre-operatively for this prospective trial. Patient data and physical therapy based assessments were recorded at the pre-operative visit (baseline) and at 1, 3, and 12+ months (BA, M1, M3, M12) after surgical treatment including pain (VAS on 10 point scale), bilateral shoulder ROM and strength (MMT). Volumes for upper extremities were taken using an optoelectric device (Perometer®). During post BC treatment visits, appropriate physical therapy was provided, and if there was a diagnosis of lymphedema, a light-grade compression garment was fitted. ROMs (shoulder Abd, ER, Flex, IR), a composite MMT value, and volume were analyzed with one-way repeated ANOVA including Greenhouse-Geisser correction for non-normal data where necessary. Post hoc testing was done using Within-Subjects Contrasts. Limited range of values for pain resulted in a highly skewed distribution, inappropriate for statistical testing. Results: For the variables Abd, ER, Flex, and sumMMT there was a decrease in function from BA to M1, improvement from M1 to M3, and further improvement from M3 to M12 (all p < 0.0001). For IR there was a decrease from BA to M1, no difference between M1 and M3, and an improvement from M1 and M3 to M12 (p < 0.3). Pain remained relatively low with 60–80% of the women reporting ≤2/10. Conclusions: After surgery for breast cancer, a decrement in shoulder function may be expected around 1 month after the procedure. Most subjects demonstrated significant improvement in function by 3 months after the procedure, and by 12 months, subjects achieved near complete recovery of shoulder impairment.

No significant financial relationships to disclose.

Health-related quality of life in patients with non-alcoholic fatty liver disease

BACKGROUND

The relative impact of non-alcoholic fatty liver disease (NAFLD) on health-related quality of life (HRQL) compared to other chronic liver diseases has not been fully explored.

AIM

To compare the domain scores of the 29-item Chronic Liver Disease Questionnaire (CLDQ) for patients with NAFLD to those with chronic hepatitis B and chronic hepatitis C.

METHODS

A HRQL questionnaire, CLDQ, was routinely administered to patients attending a liver clinic. Additional clinical and laboratory data were obtained on patients with NAFLD, chronic hepatitis B, and chronic hepatitis C from our quality of life database. Scores for each of the six CLDQ domains were compared using one-way anova and multiple regression.

RESULTS

Complete data were available for 237 patients. NAFLD patients scored lowest on multiple CLDQ domains. Based on the bivariate data, NAFLD patients have the poorest HRQL, followed by chronic hepatitis C and chronic hepatitis B patients. Multivariate analysis showed that some specific domain score correlations remained significant for NAFLD diagnosis, cirrhosis, gender, and body mass index.

CONCLUSION

NAFLD patients had significantly lower quality of life scores compared with patients with hepatitis B or hepatitis C on multiple CLDQ domains, suggesting that HRQL was severely impaired in patients with NAFLD.

Correlations among vitality, physical competence, lipid profile and measures of inflammation in transplant survivors with chronic graft versus host disease

7108

Background: Chronic graft vs. host disease (cGVHD) is a multi-system disorder and a late complication of cancer therapy experienced by more than 50% of survivors after allogeneic hematopoietic stem cell transplantation. An improved understanding of the underlying biology and its relation to clinical symptoms may guide the development of better treatments for cGVHD. Methods: In a prospective, cross-sectional natural history protocol we examined the associations among organ/system dysfunction, measures of physical performance and health status with clinical measures of inflammation and fat metabolism. Variables included: 1. a composite severity score (CAS) rated by clinician-specialists (skin, eyes, mouth, gastrointestinal/liver, hematological, gynecological, pulmonary function evaluations); 2.functional measures [2 minute walk time (WT), grip strength (GS), SF-36 physical component summary score (PCS), vitality (VT) subscale, maximal activity score (MAS) of the Human Activity Profile]; 3.Laboratory tests (glucose, LDH, hemoglobin, ferritin, platelets, lymphocytes, pre-albumin, cholesterol, lipoproteins (HDL, LDL), triglycerides (TG), beta-2microglobulin (B2), and CRP. Results: 43 pts (mean age 47 yrs) with prior hematologic malignancy participated (mean 3 yrs post transplant). An average of 3.5 organ systems were affected, 77% were on systemic treatment for cGVHD, and 67% had prior acute GVHD. The mean body mass index (BMI) was 25, TG 255, cholesterol 222, LDL 132. They were moderately disabled by self-report (MAS), had slower than normal WT (540 ft/min), lower than normal GS (63 pounds), PCS (36) and VT (46) than a healthy population. Using a backward selection model with a significance of 0.1, low lung diffusing capacity (p<.001) and low PCS (p=0.01) correlated with high CAS. VT correlated negatively with LDH, platelets, B2 and LDL (all p<0.01). Low GS correlated with high LDH and B2 (p=0.01). Conclusions: Reported physical function and vitality in cGVHD patients are associated with abnormal lipid profiles and markers of inflammation. Establishment of such profiles is a critical step in the development of testable and validated outcome measures and for evaluation of new therapies in cGVHD.

No significant financial relationships to disclose.

Metabolic syndrome traits in long-term survivors of pediatric sarcoma at a single institution

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Multi-modality therapy (MMT) for pediatric sarcoma (SARC) may result in late endocrine abnormalities and increased cardiovascular morbidity. Metabolic syndrome (MS; NCEP ATPIII definition), a cluster of obesity, dyslipidemia, hyperglycemia and hypertension, conveys an increased risk of type 2 diabetes and cardiovascular disease. This cross-sectional study investigated the prevalence of the MS traits (MST) in long-term survivors of MMT for SARC. 32 survivors of SARC (predominantly Ewing’s; median age 36.5 years, range 17–54; f:m = 15:17; median age at MMT of 15 years, range 7–34; median time since completion of MMT 18 years, range 3–33) completed CT evaluation of abdominal obesity, DEXA scan for body mass composition, fasting serum lipid profile (FLP), the Human Activity Profile (HAP) and PAI and beta 2 microglobulin (B2M) analysis. Results, compared to appropriate controls were considered statistically significant if the p-value < 0.01. SARC survivors were more likely to have one or more MST (common OR 4.04, CI:[1.52, 13.55], p=0.0045). Subjects aged 20–39 had a higher pooled prevalence of the MS (common OR 4.29 [1.50, 11.21], p=0.0077), defined as 3 or more traits, compared to controls stratified by gender. Analysis of individual MST demonstrated higher prevalence of hypertension (common OR 2.61,[1.20, 5.59], p=0.015), hypertriglyceridemia (common OR 3.63, [1.75, 7.60], p=0.0006), and male abdominal obesity (common OR 4.52, [1.57, 13.39], p=0.0046). SARC survivors had a higher prevalence of hypercholesterolemia than healthy adults (p=0.012). PAI antigen (p=0.043), PAI activity (p=0.018) and B2M levels (p=0.043) increased with an increasing number of MST. In male subjects, total testosterone declined (p=0.008) as the number of MST increased. Average (p=0.028) and maximum (p=0.041) activity levels decreased as the number of MST increased. After a median follow up of 18 years, adult SARC survivors of MMT have an increased prevalence of MST, especially between ages 20–39 years. The development of MST may be associated with decreased testosterone and decreased activity level. Younger male adult SARC survivors may be at particular risk for type 2 diabetes and cardiovascular disease and should be monitored.

No significant financial relationships to disclose.

A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy

BACKGROUND

The rheolytic thrombectomy catheter has been specially designed to remove intravascular thrombus from coronary and peripheral arteries. It demonstrates a practical application of Bernoulli's principle relating to a low-pressure zone in the region of a high-velocity jet. In this device, this effect is created by direct high-pressure saline jets located at the tip. Thrombus is drawn into this region and, because of the large pressure difference, undergoes mechanical thrombolysis due to the powerful mixing forces. The resulting microparticles are aspirated through the same catheter and removed from the body.

METHODS AND RESULTS

We report the use of this device in two patients presenting with severe pulmonary embolism and contraindications to thrombolytic therapy. The two procedures were successfully performed with an excellent immediate angiographic result at the site of the rheolytic thrombectomy. In both cases, the clinical improvement was maintained at follow-up with the same good angiographic result and a decrease to a normal level of the systolic pulmonary pressure.

CONCLUSIONS

This preliminary results suggest that this easy technical method may be useful in the treatment of life-threatening pulmonary embolism in patients with absolute contraindications to thrombolytic therapy. A larger cohort of patients is necessary to determine whether this treatment should be proposed as an alternative to the use of fibrinolytics in selected patients.

Ethics and caring: cornerstones of nursing geriatric case management

1. Paternalism, the most frequent ethical concern voiced by both elders and their caregivers, is unilateral decision-making not in accord with the client's stated wishes or value system. 2. It is common that older people are intimidated by professionals and lack the sophistication and vocabulary to express their desires in a rational and assertive manner. 3. Often the family's decisions regarding client care do not correlate with the patient's choices in the sense that clients want to avoid needless pain and suffering and are more accepting than the families of the potential outcome of death. 4. Detailing the nursing care plan in writing and allowing several days for client/family review and approval lessen misunderstanding and dissatisfaction.

Compartmentalization of inflammatory cell phenotypes in normal gingiva and peri-implant keratinized mucosa

The interpretation of studies aimed at understanding the pathophysiology of periodontal breakdown has been hampered by an insufficient understanding of the physiology of host responses in clinically healthy gingiva. This investigation was aimed at the evaluation of the in situ phenotype and topographic distribution of the inflammatory cells in clinically normal gingiva and peri-implant keratinized mucosa (PIKM). Soft tissue biopsies were obtained from clinically healthy gingiva or PIKM in 14 patients. Acetone fixed, cryostat sections were stained with a panel of monoclonal antibodies with a three stage avidin-biotin immunoperoxidase technique. Numbers of positive cells/mm2 were determined with a calibrated image analysis system. The major findings of the study were: (i) the presence of significantly higher densities of phenotypically characterized mononuclear cells in the ICT than in the JE in both gingiva and PIKM; (ii) the absence of a significant difference in PMN densities between JE and ICT in both gingiva and PIKM; (iii) the absence of statistically significant differences in densities of phenotypically characterized leukocytes associated with gingiva and PIKM; (iv) the presence of regional differences in the relative proportions of immunocompetent cells in both the gingiva and PIKM. It is concluded that inflammatory cells are selectively distributed in gingiva and PIKM. Unique functional compartments could be identified. The observed compartmentalization requires selective regulatory mechanisms.

Vascular adhesion molecules and initial development of inflammation in clinically healthy human keratinized mucosa around teeth and osseointegrated implants

Expression of vascular cell adhesion molecules (HEV-CAMs) by capillary loops represents an early step necessary for leukocyte extravasation and subsequent migration to sites of inflammation. The purpose of this investigation was to compare, the presence and distribution of ICAM-1, ELAM-1, VCAM-1 and PECAM-1 expression in the microvasculature of healthy gingiva and peri-implant keratinized mucosa. The selected HEV-CAMs were detected by a three stage immunoperoxidase technique in serial sections from clinically characterized sites. Biopsies were qualitatively and quantitatively analyzed. All biopsies displayed a small inflammatory infiltrate subjacent to the most coronal extension of the junctional epithelium. HEV-CAMs were expressed both in the sulcular and oral aspects of biopsies. Intensity of ICAM-1, ELAM-1 and VCAM-1 staining, however, was consistently higher in the region of the infiltrated connective tissue subjacent to the most coronal extension of the junctional epithelium. Only a fraction of microvascular loops were positive for ICAM-1, ELAM-1 or VCAM-1 when compared to the constitutively expressed PECAM-1. No significant differences were observed between gingiva and keratinized peri-implant mucosa. It was concluded that in healthy gingiva or peri-implant mucosa 1. HEV-CAM expressing capillary loops were in close topographic association with the inflammatory infiltrate; 2. only a fraction of capillary loops are activated to express ICAM-1, ELAM-1 and VCAM-1 at any given time; and 3. HEV-CAM expression in the periodontium may be influenced by local factors.

Localized expression of mRNA for phagocyte-specific chemotactic cytokines in human periodontal infections

In bacterial infections, mononuclear and polymorphonuclear phagocytes are key components of host defenses. Recent investigations have indicated that chemokines are able to recruit and activate phagocytes. In particular, interleukin-8 (IL-8) attracts polymorphonuclear leukocytes (PMNs), while monocyte chemoattractant protein-1 (MCP-1) is selective for cells of the monocyte/macrophage lineage. In this investigation, we analyzed the in situ expression of IL-8 and MCP-1 mRNAs in human periodontal infections. Specific mRNA was detected by in situ hybridization using 35S-labeled riboprobes in frozen tissue sections. Phagocytes (PMNs and macrophages) were specifically detected as elastase-positive or CD68+ cells by a three-stage immunoperoxidase technique. Results indicated that expression of phagocyte-specific cytokines was confined to selected tissue locations and, in general, paralleled phagocyte infiltration. In particular, IL-8 expression was maximal in the junctional epithelium adjacent to the infecting microorganisms; PMN infiltration was more prominent in the same area. MCP-1 was expressed in the chronic inflammatory infiltrate and along the basal layer of the oral epithelium. Cells of the monocyte/macrophage lineage were demonstrated to be present in the same areas. The observed expression pattern may be the most economic way to establish a cell-type-selective chemotactic gradient within the tissue that is able to effectively direct polymorphonuclear phagocyte migration toward the infecting microorganisms and modulate mononuclear phagocyte infiltration in the surrounding tissues. This process may optimize host defenses and contribute to containing leukocyte infiltration to the infected and inflamed area, thus limiting tissue damage.

Psychotherapy with Southeast Asian refugees: implications for treatment of Western patients

Working with Southeast Asian refugees in psychotherapy can teach Western psychotherapists how our culture-impacted notions of health, psychopathology, and psychotherapy influence the way we hear, understand, and respond to our patients. Western conceptions of individual boundaries, family ties, the relationship of mind and body, and ways of knowing are among the issues that arise for the Western psychotherapist who works with Southeast Asian refugees. While we in the West have seen rapid technological advances, we also have suffered dislocations, change, and the loss of traditional bases of meaning. Yet despite the differences, there are also elements within Western culture that resonate with what are usually considered "Asian" ways. These include the self-in-relation concepts described by feminist writers and the attitude of therapist as learner described by some contemporary psychoanalysts as well as by a contemporary Western philosopher. Refugees and Western patients alike want their unique faces "seen" and hope to birth new and expanded meanings in their psychotherapeutic dialogues.

Autologous blood transfusion: why and how

Although first reported more than 100 years ago, autologous blood transfusion was grossly underused until the 1980s, when the safety of blood came into question. With the discovery of transfusion-transmitted human immunodeficiency virus (HIV), physicians and patients began to request this form of transfusion. In this article, four modalities of autologous transfusion are described: preoperative blood donation, acute normovolemic hemodilution, intraoperative blood recovery, and postoperative blood salvage. The indications and contraindications for the use of these modalities, patient eligibility, and the blood center's involvement in these services also are explained.

Isometric exercise increases strength and does not produce sustained creatinine phosphokinase increases in a patient with polymyositis

A patient with active stable idiopathic polymyositis received a 4-week supervised right quadriceps and biceps isometric strengthening program. He demonstrated a significant increase in isometric peak torque without a sustained rise in creatinine phosphokinase (CPK). A significant decrease in postexercise CPK occurred at the end of the exercise program. We conclude a randomized clinical trial using a nonexercised patient group vs an exercised patient group may be useful.

Evidence that the putative COOH-terminal signal transamidase involved in glycosylphosphatidylinositol protein synthesis is present in the endoplasmic reticulum

Nascent proteins destined to be processed to a glycosylphosphatidylinositol (GPI)-anchored membrane form contain NH2-terminal and COOH-terminal signal peptides. The first directs a nascent protein into the endoplasmic reticulum; the second peptide targets the protein to a putative COOH-terminal signal transamidase where cleavage of the peptide and addition of the GPI anchor occur. We recently showed that ATP hydrolysis is required for maturation of GPI proteins at a stage prior to transamidation. Here we show that one of the ATP-requiring proteins involved in processing of GPI-anchored proteins in the endoplasmic reticulum is the immunoglobulin heavy chain binding protein (BiP; GRP 78). This and related findings indicate that GPI transamidase is localized in the endoplasmic reticulum.

Occupational infectious disease exposures in EMS personnel

Reports of occupationally transmitted hepatitis B virus (HBV) and human immunodeficiency virus (HIV) prompted the Portland Bureau of Fire Rescue and Emergency Services (PFB) to institute a comprehensive program for handling and tracking on-the-job infectious disease exposures. Data were collected for a 2-year period beginning January 1, 1988, and ending December 31, 1989, utilizing verbal and written exposure reports, prehospital care reports, and PFB statistical information. Two hundred and fifty-six (256) exposures were categorized. The overall incidence of reported exposure was 4.4/1,000 emergency medical service (EMS) calls. Of these exposures, 14 (5.5%) were needle sticks, 15 (5.9%) were eye splashes, 8 (3.1%) were mucous membrane exposures, 38 (14.8%) were exposure to nonintact skin, 120 (46.9%) were exposures to intact skin, and 61 (23.8%) involved respiratory exposure only. The incidence of exposure of nonintact skin or mucous membranes to blood or body fluids and needle sticks was 1.3/1,000 EMS calls. Forty-eight individuals (64% of those incurring needle sticks, or exposure of non-intact skin or mucous membranes to blood or body fluids) were treated and followed for signs of infection. Of this group, 11 individuals (26%) previously vaccinated against hepatitis B demonstrated inadequate HBsAb titers at the time of exposure. Requests for HIV and HBV information on source patients were made for needle sticks or exposure of nonintact skin or mucous membranes to blood or high-risk body fluids. Information on the source patient's HIV status was obtained for 57% of these requests.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of pain, motion, and edema after modified radical mastectomy vs. local excision with axillary dissection and radiation

Recent data suggest that prognosis is similar for women with primary breast cancer whether they receive modified radical mastectomy (MRM) or local excision and axillary dissection with radiation (XRT). The effects of either of these treatments on arm mobility, pain, or edema have not been compared. To assess the impact of MRM or XRT on mobility, pain, or edema, we evaluated patients treated in a prospective randomized trial designed to assess prognosis following MRM or XRT. All were provided a standardized physical therapy program including arm mobilization, shoulder strengthening, prevention and treatment of upper extremity edema, and education about arm function. Patients were evaluated for chest wall pain, arm motion, muscle strength, and edema as determined by circumferential measurements at the wrist, forearm, and arm. Evaluations were performed preoperatively and at yearly anniversaries of their surgery. Women receiving XRT had more chest wall tenderness at 1 and 2 years after surgery than those receiving MRM (p2 less than 0.0001 and p2 = 0.0007 respectively). Those receiving MRM were slower to reach their preoperative range of motion (ROM) (p2 = 0.043). Incidence of muscle weakness was similar in both groups. The few patients with local recurrence of tumor had more upper extremity edema than those who did not recur (p2 = 0.085) at 1 year and (p2 = 0.02) at 2 years. In patients who did not develop local recurrence, those who had received XRT had greater but nonsignificant increases in upper extremity circumferential measures compared with those receiving MRM at any anniversary evaluation. Patients receiving MRM and XRT are likely to have some differences in functional outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Biosynthesis of phosphatidylinositol-glycan (PI-G)-anchored membrane proteins in cell-free systems: cleavage of the nascent protein and addition of the PI-G moiety depend on the size of the COOH-terminal signal peptide

Nascent translation products of PI-G-anchored membrane proteins contain both NH2- and COOH-terminal signal sequences of approximately 15-30 residues that are removed during processing. Removal of the latter occurs concomitant with the addition of the PI-G moiety to the newly formed COOH terminus. In human placental alkaline phosphatase (PLAP) the COOH-terminal signal peptide contains 29 residues. An engineered form of PLAP, miniPLAP 208, containing the same NH2- and COOH-terminal signal peptides as PLAP, was used as a substrate for cell-free processing. A comparison was made with mutants (delta 202, delta 197, delta 184, and delta 179) truncated at the COOH terminus. Intact preprominiPLAP 208 and truncated delta 202 were processed to yield the same mature product which, by size and distribution between Triton X-114 and water before and after treatment with inositol-specific phospholipases, indicates that it contained the PI-G moiety. Mutants that were further truncated at the COOH terminus, miniPLAPs delta 197, delta 184, and delta 179, were processed only at their NH2 termini. Those portions of the COOH-terminal sequence in miniPLAPs delta 197 and delta 1984 that extended beyond residue 179 were not removed during processing.

Level of axillary involvement by lymph node metastases from breast cancer is not an independent predictor of survival

We examined the relationship of axillary level of lymph node metastases from clinical stage I and II breast cancer to overall survival and disease-free survival rates in 135 patients who underwent complete axillary lymph node dissection to determine if anatomic level of axillary involvement (I vs II vs III) is an independent prognostic factor. All patients underwent either modified radical mastectomy or lumpectomy with axillary dissection and whole breast radiotherapy for breast cancer. Median follow-up was 6.9 years. We found no difference in overall survival or disease-free survival between patients whose highest or only level of axillary involvement was level I compared with patients whose highest or only level was II. Although patients whose highest level of nodal involvement was III had significantly worse overall survival and disease-free survival rates than patients whose highest nodal involvement was I or II, when patients were stratified by the total number of positive nodes (one to three vs four or more), there was no difference in overall survival or disease-free survival rates between levels I, II, and III. These findings indicate that the level of axillary involvement for stage II breast cancer is not of independent prognostic significance.

Biosynthesis of phosphatidylinositol glycan-anchored membrane proteins. Design of a simple protein substrate to characterize the enzyme that cleaves the COOH-terminal signal peptide

Many nascent proteins that are destined to be anchored to plasma membranes by a phosphatidylinositol glycan (PI-G) are in the range of 50-70 kDa so that changes of 2-3 kDa between precursors and products during processing are not easily detected. Furthermore, PI-G-anchored proteins are generally glycosylated so that changes between the nascent (prepro) proteins and the mature products are not due simply to the loss of signal peptides. These problems have made it difficult to monitor the processing of the prepro form of wild type human placental alkaline phosphatase (PLAP) in a cell-free system. We have designed a smaller and simpler substrate of PI-G "transamidase" derived by deletion of approximately 60% of the internal sequence of preproPLAP 513. This engineered protein, preprominiPLAP 208, retains the NH2- and COOH-terminal signal peptides of PLAP as well as all the epitopes for site-directed antibodies of the latter, but is devoid of glycosylation sites, the active site, and most of the cysteine residues. With preprominiPLAP, it has been possible to demonstrate, in a cell-free system, step by step conversion to the pro form and then to the mature form, with the concomitant loss of the appropriate signal peptides. These changes were shown to be time- and enzyme concentration-dependent. Studies with Asp-179 site-directed mutants of preprominiPLAP showed the same specificity for amino acids with a monosubstituted beta carbon at the cleavage/attachment site that were found previously with wild type PLAP.