Demonstrating the reliability of in vivo metabolomics based chemical grouping: towards best practice

While grouping/read-across is widely used to fill data gaps, chemical registration dossiers are often rejected due to weak category justifications based on structural similarity only. Metabolomics provides a route to robust chemical categories via evidence of shared molecular effects across source and target substances. To gain international acceptance, this approach must demonstrate high reliability, and best-practice guidance is required. The MetAbolomics ring Trial for CHemical groupING (MATCHING), comprising six industrial, government and academic ring-trial partners, evaluated inter-laboratory reproducibility and worked towards best-practice. An independent team selected eight substances (WY-14643, 4-chloro-3-nitroaniline, 17α-methyl-testosterone, trenbolone, aniline, dichlorprop-p, 2-chloroaniline, fenofibrate); ring-trial partners were blinded to their identities and modes-of-action. Plasma samples were derived from 28-day rat tests (two doses per substance), aliquoted, and distributed to partners. Each partner applied their preferred liquid chromatography-mass spectrometry (LC-MS) metabolomics workflows to acquire, process, quality assess, statistically analyze and report their grouping results to the European Chemicals Agency, to ensure the blinding conditions of the ring trial. Five of six partners, whose metabolomics datasets passed quality control, correctly identified the grouping of eight test substances into three categories, for both male and female rats. Strikingly, this was achieved even though a range of metabolomics approaches were used. Through assessing intrastudy quality-control samples, the sixth partner observed high technical variation and was unable to group the substances. By comparing workflows, we conclude that some heterogeneity in metabolomics methods is not detrimental to consistent grouping, and that assessing data quality prior to grouping is essential. We recommend development of international guidance for quality-control acceptance criteria. This study demonstrates the reliability of metabolomics for chemical grouping and works towards best-practice.

In vitro and in vivo efficacy of a cosmetic product formulated with new lipid particles for the treatment of aged skin

BACKGROUND

The cumulative oxidative damage causes an acceleration in the skin aging.

OBJECTIVES

To evaluate the ability of a new patented matrix of lipid particles (SIREN CAPSULE TECHNOLOGY™) to have superior anti-aging properties due to its high sensitivity to reactive oxygen species (ROS), testing its efficacy versus free or encapsulated vitamins.

METHODS

An in vitro study was conducted to evaluate the protective effects of lipid particles using menadione as an enhancer of oxidative stress. Subsequently, in vivo studies evaluated skin hydration, skin barrier function, and smoothness and wrinkle depth. For this purpose, gels containing free or encapsulated vitamins were used as controls.

RESULTS

In vitro, the SIREN CAPSULE TECHNOLOGY™ gel shows inhibitory activity against ROS production through menadione induction. In fact, at both tested concentrations, ROS production is lower than in the control samples (placebo, free vitamins, encapsulated vitamins). In vivo, the net effect of SIREN CAPSULE TECHNOLOGY™ gel versus the others permitted to conclude that lipid particles exert a higher skin moisturizing effect (20.17%) and a stronger effect in reducing transepidermal water loss (-16.29%) after 4 weeks of treatment. As for surface analysis, a gel based on SIREN CAPSULE TECHNOLOGY™ improves the skin texture in a similar way than gel containing encapsulated vitamins (Ra and Rz variations in 4 weeks).

CONCLUSIONS

SIREN CAPSULE TECHNOLOGY™ represents an advance and a successful strategy to develop cosmetic products for the treatment of skin conditions associated with an accumulation of ROS. SIREN CAPSULE TECHNOLOGY™ represents a result-oriented breakthrough in the effective delivery of active ingredients to the skin.

B7-H3 Associates with IMPDH2 and Regulates Cancer Cell Survival

Lung cancer is one of the most common cancers worldwide, and despite improvements in treatment regimens, patient prognosis remains poor. Lung adenocarcinomas develop from the lung epithelia and understanding how specific genetic and environmental factors lead to oncogenic transformation in these cells is of great importance to define the pathways that contribute to tumorigenesis. The recent rise in the use of immunotherapy to treat different cancers has prompted the exploration of immune modulators in tumour cells that may provide new targets to manipulate this process. Of these, the B7 family of cell surface receptors, which includes PD-1, is of particular interest due to its role in modulating immune cell responses within the tumour microenvironment. B7-H3 (CD276) is one family member that is upregulated in many cancer types and suggested to contribute to tumour-immune interactions. However, the function and ligand(s) for this receptor in normal lung epithelia and the mechanisms through which the overexpression of B7-H3 regulate cancer progression in the absence of immune cell interactions remain unclear. Here, we present evidence that B7-H3 is associated with one of the key rate-limiting metabolic enzymes IMPDH2, and the localisation of this complex is altered in human lung cancer cells that express high levels of B7-H3. Mechanistically, the IMPDH2:B7-H3 complex provides a protective role in cancer cells to escape oxidative stress triggered by chemotherapy, thus leading to cell survival. We further demonstrate that the loss of B7-H3 in cancer cells has no effect on growth or migration in 2D but promotes the expansion of 3D spheroids in an IMPDH2-dependent manner. These findings provide new insights into the B7-H3 function in the metabolic homeostasis of normal and transformed lung cancer cells, and whilst this molecule remains an interesting target for immunotherapy, these findings caution against the use of anti-B7-H3 therapies in certain clinical settings.

Discriminatory Changes in Circulating Metabolites as a Predictor of Hepatocellular Cancer in Patients with Metabolic (Dysfunction) Associated Fatty Liver Disease

Introduction

The burden of metabolic (dysfunction) associated fatty liver disease (MAFLD) is rising mirrored by an increase in hepatocellular cancer (HCC). MAFLD and its sequelae are characterized by perturbations in lipid handling, inflammation, and mitochondrial damage. The profile of circulating lipid and small molecule metabolites with the development of HCC is poorly characterized in MAFLD and could be used in future studies as a biomarker for HCC.

Methods

We assessed the profile of 273 lipid and small molecule metabolites by ultra-performance liquid chromatography coupled to high-resolution mass spectrometry in serum from patients with MAFLD (n = 113) and MAFLD-associated HCC (n = 144) from six different centers. Regression models were used to identify a predictive model of HCC.

Results

Twenty lipid species and one metabolite, reflecting changes in mitochondrial function and sphingolipid metabolism, were associated with the presence of cancer on a background of MAFLD with high accuracy (AUC 0.789, 95% CI: 0.721-0.858), which was enhanced with the addition of cirrhosis to the model (AUC 0.855, 95% CI: 0.793-0.917). In particular, the presence of these metabolites was associated with cirrhosis in the MAFLD subgroup (p < 0.001). When considering the HCC cohort alone, the metabolic signature was an independent predictor of overall survival (HR 1.42, 95% CI: 1.09-1.83, p < 0.01).

Conclusion

These exploratory findings reveal a metabolic signature in serum which is capable of accurately detecting the presence of HCC on a background of MAFLD. This unique serum signature will be taken forward for further investigation of diagnostic performance as biomarker of early stage HCC in patients with MAFLD in the future.

The gut microbiota and metabolome are associated with diminished COVID-19 vaccine-induced antibody responses in immunosuppressed inflammatory bowel disease patients

BACKGROUND

Patients with inflammatory bowel disease (IBD) treated with anti-TNF therapy exhibit attenuated humoral immune responses to vaccination against SARS-CoV-2. The gut microbiota and its functional metabolic output, which are perturbed in IBD, play an important role in shaping host immune responses. We explored whether the gut microbiota and metabolome could explain variation in anti-SARS-CoV-2 vaccination responses in immunosuppressed IBD patients.

METHODS

Faecal and serum samples were prospectively collected from infliximab-treated patients with IBD in the CLARITY-IBD study undergoing vaccination against SARS-CoV-2. Antibody responses were measured following two doses of either ChAdOx1 nCoV-19 or BNT162b2 vaccine. Patients were classified as having responses above or below the geometric mean of the wider CLARITY-IBD cohort. 16S rRNA gene amplicon sequencing, nuclear magnetic resonance (NMR) spectroscopy and bile acid profiling with ultra-high-performance liquid chromatography mass spectrometry (UHPLC-MS) were performed on faecal samples. Univariate, multivariable and correlation analyses were performed to determine gut microbial and metabolomic predictors of response to vaccination.

FINDINGS

Forty-three infliximab-treated patients with IBD were recruited (30 Crohn's disease, 12 ulcerative colitis, 1 IBD-unclassified; 26 with concomitant thiopurine therapy). Eight patients had evidence of prior SARS-CoV-2 infection. Seventeen patients (39.5%) had a serological response below the geometric mean. Gut microbiota diversity was lower in below average responders (p = 0.037). Bilophila abundance was associated with better serological response, while Streptococcus was associated with poorer response. The faecal metabolome was distinct between above and below average responders (OPLS-DA R²X 0.25, R²Y 0.26, Q² 0.15; CV-ANOVA p = 0.038). Trimethylamine, isobutyrate and omega-muricholic acid were associated with better response, while succinate, phenylalanine, taurolithocholate and taurodeoxycholate were associated with poorer response.

INTERPRETATION

Our data suggest that there is an association between the gut microbiota and variable serological response to vaccination against SARS-CoV-2 in immunocompromised patients. Microbial metabolites including trimethylamine may be important in mitigating anti-TNF-induced attenuation of the immune response.

FUNDING

JLA is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-502), funded by Imperial College London and The Joyce and Norman Freed Charitable Trust. BHM is the recipient of an NIHR Academic Clinical Lectureship (CL-2019-21-002). The Division of Digestive Diseases at Imperial College London receives financial and infrastructure support from the NIHR Imperial Biomedical Research Centre (BRC) based at Imperial College Healthcare NHS Trust and Imperial College London. Metabolomics studies were performed at the MRC-NIHR National Phenome Centre at Imperial College London; this work was supported by the Medical Research Council (MRC), the National Institute of Health Research (NIHR) (grant number MC_PC_12025) and infrastructure support was provided by the NIHR Imperial Biomedical Research Centre (BRC). The NIHR Exeter Clinical Research Facility is a partnership between the University of Exeter Medical School College of Medicine and Health, and Royal Devon and Exeter NHS Foundation Trust. This project is supported by the National Institute for Health Research (NIHR) Exeter Clinical Research Facility. The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care.

Diet Patterns Are Associated with Circulating Metabolites and Lipid Profiles of South Asians in the United States

BACKGROUND

South Asians are at higher risk for cardiometabolic disease than many other racial/ethnic minority groups. Diet patterns in US South Asians have unique components associated with cardiometabolic disease.

OBJECTIVES

We aimed to characterize the metabolites associated with 3 representative diet patterns.

METHODS

We included 722 participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort study aged 40-84 y without known cardiovascular disease. Fasting serum specimens and diet and demographic questionnaires were collected at baseline and diet patterns previously generated through principal components analysis. LC-MS-based untargeted metabolomic and lipidomic analysis was conducted with targeted integration of known metabolite and lipid signals. Linear regression models of diet pattern factor score and log-transformed metabolites adjusted for age, sex, caloric intake, and BMI and adjusted for multiple comparisons were performed, followed by elastic net linear regression of significant metabolites.

RESULTS

There were 443 metabolites of known identity extracted from the profiling data. The "animal protein" diet pattern was associated with 61 metabolites and lipids, including glycerophospholipids phosphatidylethanolamine PE(O-16:1/20:4) and/or PE(P-16:0/20:4) (β: 0.13; 95% CI: 0.11, 0.14) and N-acyl phosphatidylethanolamines (NAPEs) NAPE(O-18:1/20:4/18:0) and/or NAPE(P-18:0/20:4/18:0) (β: 0.13; 95% CI: 0.11, 0.14), lysophosphatidylinositol (LPI) (22:6/0:0) (β: 0.14; 95% CI: 0.12, 0.17), and fatty acid (FA) (22:6) (β: 0.15; 95% CI: 0.13, 0.17). The "fried snacks, sweets, high-fat dairy" pattern was associated with 12 lipids, including PC(16:0/22:6) (β: -0.08; 95% CI: -0.09, -0.06) and FA (22:6) (β: 0.14; 95% CI: -0.17, -0.10). The "fruits, vegetables, nuts, and legumes" pattern was associated with 5 metabolites including proline betaine (β: 0.17; 95% CI: 0.09, 0.25) (P < 0.0002).

CONCLUSIONS

Three predominant dietary patterns in US South Asians are associated with circulating metabolites differentiated by lipids including glycerophospholipids and PUFAs and the amino acid proline betaine.

Associations of NAFLD with circulating ceramides and impaired glycemia

AIM

Determine the association of circulating ceramides with NAFLD and glycemic impairment.

METHODS

Sample: 669 participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort aged 40-84 years without cardiovascular disease, cirrhosis, or significant alcohol intake.

CLINICAL MEASURES

Computed tomography scans at baseline for hepatic attenuation. Fasting serum specimens at baseline and after 5 years. Lipidomics: LC-MS-based analysis of 19 known ceramide signals.

STATISTICAL ANALYSIS

Linear and logistic regression models of log-transformed ceramides, hepatic attenuation and glucose adjusted for age, sex, calories, study site, BMI, exercise, diet quality, alcohol, saturated fat, lipid-lowering medications and fasting glucose.

RESULTS

Average age was 55 years, 44% were women, mean BMI was 25.9 kg/m2, and 8% had NAFLD. In adjusted models, Cer(d16:1/20:0) and Cer(d18:1/18:0) were associated with lower mean hepatic attenuation (increased liver fat) (β -4.29; 95% CI [-5.98, -2.59]) and (β -3.40; 95% CI [-5.11, -1.70]), and LacCer(d18:1/16:0) with higher attenuation (β 4.44; 95% CI [2.15, 6.73]). All three ceramides partially mediated the relationship between hepatic attenuation and fasting glucose by 16%, 11% and 5%, respectively, after 5-years.

CONCLUSIONS

Three circulating ceramides were strongly associated with NAFLD and fasting glucose after 5 years, and partially mediated this association.

Antiviral metabolite 3'-deoxy-3',4'-didehydro-cytidine is detectable in serum and identifies acute viral infections including COVID-19

BACKGROUND

There is a critical need for rapid viral infection diagnostics to enable prompt case identification in pandemic settings and support targeted antimicrobial prescribing.

METHODS

Using untargeted high-resolution liquid chromatography coupled with mass spectrometry, we compared the admission serum metabolome of emergency department patients with viral infections (including COVID-19), bacterial infections, inflammatory conditions, and healthy controls. Sera from an independent cohort of emergency department patients admitted with viral or bacterial infections underwent profiling to validate findings. Associations between whole-blood gene expression and the identified metabolite of interest were examined.

FINDINGS

3'-Deoxy-3',4'-didehydro-cytidine (ddhC), a free base of the only known human antiviral small molecule ddhC-triphosphate (ddhCTP), was detected for the first time in serum. When comparing 60 viral with 101 non-viral cases in the discovery cohort, ddhC was the most significantly differentially abundant metabolite, generating an area under the receiver operating characteristic curve (AUC) of 0.954 (95% CI: 0.923-0.986). In the validation cohort, ddhC was again the most significantly differentially abundant metabolite when comparing 40 viral with 40 bacterial cases, generating an AUC of 0.81 (95% CI 0.708-0.915). Transcripts of viperin and CMPK2, enzymes responsible for ddhCTP synthesis, were among the five genes most highly correlated with ddhC abundance.

CONCLUSIONS

The antiviral precursor molecule ddhC is detectable in serum and an accurate marker for acute viral infection. Interferon-inducible genes viperin and CMPK2 are implicated in ddhC production in vivo. These findings highlight a future diagnostic role for ddhC in viral diagnosis, pandemic preparedness, and acute infection management.

FUNDING

NIHR Imperial BRC; UKRI.

The Metabolomic Effects of Tripeptide Gut Hormone Infusion Compared to Roux-en-Y Gastric Bypass and Caloric Restriction

CONTEXT

The gut-derived peptide hormones glucagon-like peptide-1 (GLP-1), oxyntomodulin (OXM), and peptide YY (PYY) are regulators of energy intake and glucose homeostasis and are thought to contribute to the glucose-lowering effects of bariatric surgery.

OBJECTIVE

To establish the metabolomic effects of a combined infusion of GLP-1, OXM, and PYY (tripeptide GOP) in comparison to a placebo infusion, Roux-en-Y gastric bypass (RYGB) surgery, and a very low-calorie diet (VLCD).

DESIGN AND SETTING

Subanalysis of a single-blind, randomized, placebo-controlled study of GOP infusion (ClinicalTrials.gov NCT01945840), including VLCD and RYGB comparator groups.

PATIENTS AND INTERVENTIONS

Twenty-five obese patients with type 2 diabetes or prediabetes were randomly allocated to receive a 4-week subcutaneous infusion of GOP (n = 14) or 0.9% saline control (n = 11). An additional 22 patients followed a VLCD, and 21 underwent RYGB surgery.

MAIN OUTCOME MEASURES

Plasma and urine samples collected at baseline and 4 weeks into each intervention were subjected to cross-platform metabolomic analysis, followed by unsupervised and supervised modeling approaches to identify similarities and differences between the effects of each intervention.

RESULTS

Aside from glucose, very few metabolites were affected by GOP, contrasting with major metabolomic changes seen with VLCD and RYGB.

CONCLUSIONS

Treatment with GOP provides a powerful glucose-lowering effect but does not replicate the broader metabolomic changes seen with VLCD and RYGB. The contribution of these metabolomic changes to the clinical benefits of RYGB remains to be elucidated.

Circulating metabolites and lipids are associated with glycaemic measures in South Asians

BACKGROUND

South Asians are at higher risk for diabetes (DM) than many other racial/ethnic groups. Circulating metabolites are measurable products of metabolic processes that may explain the aetiology of elevated risk. We characterized metabolites associated with prevalent DM and glycaemic measures in South Asians.

METHODS

We included 717 participants from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, aged 40-84 years. We used baseline fasting serum for metabolomics and demographic, behavioural, glycaemic data from baseline and at 5 years. We performed LC-MS untargeted metabolomic and lipidomic analysis with targeted integration of known signals. Individual linear and ordinal logistic regression models were adjusted for age, sex, BMI, diet, exercise, alcohol, smoking and family history of DM followed by elastic net regression to identify metabolites most associated with the outcome.

RESULTS

There were 258 metabolites with detectable signal in >98% of samples. Thirty-four metabolites were associated with prevalent DM in an elastic net model. Predominant metabolites associated with DM were sphingomyelins, proline (OR 15.86; 95% CI 4.72, 53.31) and betaine (OR 0.03; 0.004, 0.14). Baseline tri- and di-acylglycerols [DG (18:0/16:0) (18.36; 11.79, 24.92)] were positively associated with fasting glucose and long-chain acylcarnitines [CAR 26:1 (-0.40; -0.54, -0.27)] were inversely associated with prevalent DM and HbA_1c at follow-up.

DISCUSSION

A metabolomic signature in South Asians may help determine the unique aetiology of diabetes in this high-risk ethnic group. Future work will externally validate our findings and determine the effects of modifiable risk factors for DM.

A rational mouse model to detect on-target, off-tumor CAR T cell toxicity

Off-tumor targeting of human antigens is difficult to predict in preclinical animal studies and can lead to serious adverse effects in patients. To address this, we developed a mouse model with stable and tunable human Her2 (hHer2) expression on normal hepatic tissue and compared toxicity between affinity-tuned Her2 chimeric antigen receptor T cells (CARTs). In mice with hHer2-high livers, both the high-affinity (HA) and low-affinity (LA) CARTs caused lethal liver damage due to immunotoxicity. In mice with hHer2-low livers, LA-CARTs exhibited less liver damage and lower systemic levels of IFN-γ than HA-CARTs. We then compared affinity-tuned CARTs for their ability to control a hHer2-positive tumor xenograft in our model. Surprisingly, the LA-CARTs outperformed the HA-CARTs with superior antitumor efficacy in vivo. We hypothesized that this was due, in part, to T cell trafficking differences between LA and HA-CARTs and found that the LA-CARTs migrated out of the liver and infiltrated the tumor sooner than the HA-CARTs. These findings highlight the importance of T cell targeting in reducing toxicity of normal tissue and also in preventing off-tumor sequestration of CARTs, which reduces their therapeutic potency. Our model may be useful to evaluate various CARTs that have conditional expression of more than 1 single-chain variable fragment (scFv).

P17 Prediction of response of methotrexate in patients with rheumatoid arthritis using serum lipidomics

Background

For patients with rheumatoid arthritis (RA), introduction of early, effective therapy has consistently been shown to improve long-term outcomes. Low-dose methotrexate (MTX) is commonly prescribed as first-line treatment for RA. However, MTX is not effective for a large minority of patients and there is currently no way to determine ahead of therapy which patients are most likely to benefit. Metabolomics and lipidomics are emerging approaches for studying patient stratification in RA and have the potential to identify disease processes that underpin treatment outcomes. Here we apply state-of-the-art machine learning algorithms to predict MTX treatment response, by testing serum lipid levels measured at two time-points (pre-treatment and following 4 weeks on drug) to predict MTX response by 6 months.

Methods

This study included patients from the Rheumatoid Arthritis Medication Study (RAMS), a UK multi-centre one-year prospective observational study investigating predictors of response to MTX in patients with RA. Since 2008, patients who are about to start MTX for the first time are asked to provide demographic and clinical data, as well as blood samples to permit DNA, RNA and serum-based biomarker studies. Patients about to commence MTX treatment were followed longitudinally and those categorised as good or non-responders following 6 months on-drug using EULAR response criteria were analysed. Serum lipid levels were measured at pre-treatment and following 4 weeks on drug using ultra-performance liquid chromatography tailored for complex lipid analysis, coupled to mass spectrometry. State-of-the-art supervised machine learning methods were then applied to predict EULAR response at 6 months. Models including lipid levels were compared to models including clinical covariates (including: MTX start dose, steroid use at inclusion, BMI, number of swollen joints, number of tender joints, CRP levels, patients’ assessment of their overall wellbeing, gender, age-at-inclusion, age-at-onset, disease duration, HAQ score and pre-treatment smoking habits).

Results

Following quality control, 3,366 features (1,060 in negatively-charged mode and 2,306 in positive mode) were available for analysis at pre-treatment and 4 weeks from 100 RA patients categorised as good (GR, n = 50) or poor (NR, n = 50) responders to MTX following 6 months on drug. The best model performance for the classifier including clinical covariates was observed using L1/L2-regularised logistic regression (ROC AUC 0.68 ± 0.02). However, the clinical covariate model outperformed the classifier including lipid levels when either pre- or on-treatment time-points were investigated (ROC AUC 0.61 ± 0.02).

Conclusion

These data do not support the utility of early treatment lipidomic monitoring in routine clinical practice in patients started on MTX for their RA.

Disclosures

M. Maciejewski: Shareholder/stock ownership; owns stock or stock options in Pfizer. C. Sands None. N. Nair None. S. Ling None. S. Verstappen None. K. Hyrich None. A. Barton None. D. Ziemek Shareholder/stock ownership; owns stock or stock options in Pfizer. M. Lewis None. D. Plant None.

Plasma lipid profiles discriminate bacterial from viral infection in febrile children

Fever is the most common reason that children present to Emergency Departments. Clinical signs and symptoms suggestive of bacterial infection are often non-specific, and there is no definitive test for the accurate diagnosis of infection. The 'omics' approaches to identifying biomarkers from the host-response to bacterial infection are promising. In this study, lipidomic analysis was carried out with plasma samples obtained from febrile children with confirmed bacterial infection (n = 20) and confirmed viral infection (n = 20). We show for the first time that bacterial and viral infection produces distinct profile in the host lipidome. Some species of glycerophosphoinositol, sphingomyelin, lysophosphatidylcholine and cholesterol sulfate were higher in the confirmed virus infected group, while some species of fatty acids, glycerophosphocholine, glycerophosphoserine, lactosylceramide and bilirubin were lower in the confirmed virus infected group when compared with confirmed bacterial infected group. A combination of three lipids achieved an area under the receiver operating characteristic (ROC) curve of 0.911 (95% CI 0.81 to 0.98). This pilot study demonstrates the potential of metabolic biomarkers to assist clinicians in distinguishing bacterial from viral infection in febrile children, to facilitate effective clinical management and to the limit inappropriate use of antibiotics.

The effects of kisspeptin on β-cell function, serum metabolites and appetite in humans

AIMS

To investigate the effect of kisspeptin on glucose-stimulated insulin secretion and appetite in humans.

MATERIALS AND METHODS

In 15 healthy men (age: 25.2 ± 1.1 years; BMI: 22.3 ± 0.5 kg m-2 ), we compared the effects of 1 nmol kg-1 h-1 kisspeptin versus vehicle administration on glucose-stimulated insulin secretion, metabolites, gut hormones, appetite and food intake. In addition, we assessed the effect of kisspeptin on glucose-stimulated insulin secretion in vitro in human pancreatic islets and a human β-cell line (EndoC-βH1 cells).

RESULTS

Kisspeptin administration to healthy men enhanced insulin secretion following an intravenous glucose load, and modulated serum metabolites. In keeping with this, kisspeptin increased glucose-stimulated insulin secretion from human islets and a human pancreatic cell line in vitro. In addition, kisspeptin administration did not alter gut hormones, appetite or food intake in healthy men.

CONCLUSIONS

Collectively, these data demonstrate for the first time a beneficial role for kisspeptin in insulin secretion in humans in vivo. This has important implications for our understanding of the links between reproduction and metabolism in humans, as well as for the ongoing translational development of kisspeptin-based therapies for reproductive and potentially metabolic conditions.

Global metabolic changes induced by plant-derived pyrrolizidine alkaloids following a human poisoning outbreak and in a mouse model

Several hundred cases of Hirmi Valley Liver Disease (HVLD), an often fatal liver injury, occurred from 2001 to 2011 in a cluster of rural villages in Tigray, Ethiopia. HVLD is principally caused by contamination of the food supply with plant derived pyrrolizidine alkaloids (PAs), with high exposure to the pesticide DDT among villagers increasing their susceptibility. In an untargeted global approach we aimed to identify metabolic changes induced by PA exposure through 1H NMR spectroscopic based metabolic profiling. We analysed spectra acquired from urine collected from HVLD cases and controls and a murine model of PA exposure and PA/DDT co-exposure, using multivariate partial least squares discriminant analysis. In the human models we identified changes in urinary concentrations of tyrosine, pyruvate, bile acids, N-acetylglycoproteins, N-methylnicotinamide and formate, hippurate, p-cresol sulphate, p-hydroxybenzoate and 3-(3-hydroxyphenyl) propionic acid. Tyrosine and p-cresol sulphate were associated with both exposure and disease. Similar changes to tyrosine, one-carbon intermediates and microbial associated metabolites were observed in the mouse model, with tyrosine correlated with the extent of liver damage. These results provide mechanistic insight and implicate the gut microflora in the human response to challenge with toxins. Pathways identified here may be useful in translational research and as "exposome" signals.

Abstract P6-08-01: Perceptions of breast cancer risk, psychological adjustment and behaviors in adolescent girls at high-risk and population-risk for breast cancer

BACKGROUND: Preliminary evidence suggests that many girls from breast cancer (BC) families are aware of their increased risk for BC. How this awareness impacts their psychosocial adjustment and health behaviors remains unknown.

METHODS: 11–19 YO girls at high-risk (HR) or population-risk (PR) for BC completed self-administered quantitative surveys informed by the Self-Regulation Theory of Health Behavior. Girls with a first or second-degree relative with BC were classified as HR. For hypothesis testing, we used simple linear and logistic regressions. To account for correlation of responses within families, we used robust (cluster-corrected) standard errors or Generalized Estimating Equations.

RESULTS: 47 PR and 89 HR girls have completed surveys. Age did not differ between groups (Mage = 15.6; SD=2.4). 30% of HR girls have a mother with BC. 67% of HR girls vs. 30% of PR girls reported self-perceived risk for adult BC to be “higher than other girls my age,” (p = &lt;0.01, Table 1).

Metabolic surgery profoundly influences gut microbial-host metabolic cross-talk

BACKGROUND AND AIMS

Bariatric surgery is increasingly performed worldwide to treat morbid obesity and is also known as metabolic surgery to reflect its beneficial metabolic effects especially with respect to improvement in type 2 diabetes. Understanding surgical weight loss mechanisms and metabolic modulation is required to enhance patient benefits and operative outcomes.

METHODS

The authors applied a parallel and statistically integrated bacterial profiling and metabonomic approach to characterise Roux-en-Y gastric bypass (RYGB) effects in a non-obese rat model.

RESULTS

Substantial shifts of the main gut phyla towards higher concentrations of Proteobacteria (52-fold), specifically Enterobacter hormaechei, are shown. Low concentrations of Firmicutes (4.5-fold) and Bacteroidetes (twofold) in comparison with sham-operated rats were also found. Faecal extraction studies revealed a decrease in faecal bile acids and a shift from protein degradation to putrefaction through decreased faecal tyrosine with concomitant increases in faecal putrescine and diaminoethane. Decreased urinary amines and cresols were found and indices of modulated energy metabolism were demonstrated after RYGB, including decreased urinary succinate, 2-oxoglutarate, citrate and fumarate. These changes could also indicate renal tubular acidosis, which is associated with increased flux of mitochondrial tricarboxylic acid cycle intermediates. A surgically induced effect on the gut-brain-liver metabolic axis is inferred from modulated faecal γ-aminobutyric acid and glutamate.

CONCLUSION

This profound co-dependence of mammalian and microbial metabolism, which is systematically altered after RYGB surgery, suggests that RYGB exerts local and global metabolic effects. The effect of RYGB surgery on the host metabolic-microbial cross-talk augments our understanding of the metabolic phenotype of bariatric procedures and can facilitate enhanced treatments for obesity-related diseases.

Should Minors Be Offered BRCA1/2 Testing for Hereditary Breast Cancer? Opinions of Parents Who Have Undergone BRCA1/2 Testing

Background: Professional societies recommend against the genetic testing of minors for hereditary cancer syndromes that present in adulthood. Yet, many adolescent specialists indicate that they would consider BRCA1/2 testing of minor children. We conducted interviews with parents who have had BRCA1/2 testing, to evaluate their opinions regarding the genetic testing of minors for BRCA1/2. Methods: 244 parents, including 67 BRCA1/2 mutation carriers (MCs), 140 parents with uninformative negative results (UN), 14 with true negative results (TN) & 23 with a variant of uncertain significance (VUS), from two cancer risk assessment programs completed semi-structured interviews. We used multiple logistic regressions to evaluate the associations among biomedical factors, demographic factors and support of testing minors. Wald tests and likelihood ratio tests were used to assess statistical significance for binary covariates and nominal covariates. Results: 38% of parents supported testing minors for BRCA1/2 in response to a dichotomous (Y/N) question. Support was greatest among parents with TN (64%) and UN (40%) results and lower among MCs (31%) and parents with a VUS (26%). In a multivariable analysis, support was greatest among parents who tested negative (p=0.02), were of minority race (p=0.06) and among fathers (&lt;0.01). Responses to open-ended questions suggest that 27% of parents unconditionally support testing of minors, and 25% support testing only in certain situations. Psychological risks, a lack of medical necessity and the insufficient maturity of minors, were frequent concerns of those opposed. The potential to positively impact minors' health behaviors was the most reported reason for supporting testing. Conclusions: Up to 52% of parents who have undergone BRCA1/2 testing support pediatric testing for BRCA1/2. Given willingness among general and pediatric practitioners and interest among parents, further research is necessary to formally evaluate the risks and benefits of providing genetic testing to minors for adult-onset hereditary cancer syndromes in order to inform clinical practice and public policy that will ensure optimal psychosocial and medical outcomes for all members of families at risk for hereditary cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4071.

Parent perceptions of offspring responses to parental communication of BRCA1/2 test results

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Background: Many BRCA1/2 mutation carriers report sharing their genetic test results with their minor children. The impact of this communication on offspring remains unknown. Methods: 163 parents who had BRCA1/2 testing completed qualitative interviews regarding their experiences with communication of their genetic test results to offspring. Descriptive responses were coded and response proportions utilized to summarize results. We used multiple regressions fit by GEE to test associations with disclosure. We controlled for parent mutation status in each regression. Results: 163 parents (52 BRCA1/2 mutation carriers) reported on 323 offspring 5 to 25 years old at the time of parent genetic testing. 107 (66%) parents reported disclosing to at least one offspring. Child age (p < 0.001) and parent cancer history (p = 0.004) were positively associated with disclosure. Parents without a BRCA1/2 mutation were more likely to communicate test results than parents with a mutation (p = 0.007). Among parents who disclosed, few (14%) reported they perceived their offspring to have had an initial negative affective or behavioral response. Others (13%) reported offspring concern for self and family. Reports of initial negative responses and concern were more frequent among parents with a mutation or a variant of uncertain significance. Many parents reported that the communication had no significant impact (39%) or a positive impact (36%) on their offspring. Conclusions: Many parents report sharing BRCA1/2 test results with their offspring. Parent self-reports suggest that they do not perceive most offspring to experience adverse reactions to this communication. Self-reports suggest that offspring learning of a BRCA1/2 mutation or a variant of uncertain significance may be more susceptible to initial negative reactions. Further research is necessary to explore psychosocial and behavioral responses to learning of hereditary risk during childhood and adolescence, and to inform the development of interventions to optimize adaptive response.

No significant financial relationships to disclose.

Translocation of enteropathogenic Escherichia coli across an in vitro M cell model is regulated by its type III secretion system

Enteropathogenic Escherichia coli (EPEC) is an extracellular pathogen that utilizes a type III secretion system (TTSS) to modulate diverse host cell processes including cytoskeletal dynamics, tight junction permeability and macrophage phagocytosis. Some EPEC strains exhibit selective tropism for the specialized follicle-associated epithelium (FAE) overlying lymphoid follicles in the gut, which is a major site of uptake of inert particulates and pathogens, but do not translocate from the intestinal lumen in significant numbers. We have investigated the interaction of EPEC with FAE using an established in vitro model of the specialized FAE in which polarized enterocyte-like Caco-2 cells cocultured with the Raji B cell line undergo a phenotypic switch to a form that morphologically and functionally resembles the specialized antigen-transporting M cells found within FAE. Having confirmed that coculture with Raji B cells induces brush border reorganization and enhances particle transport across Caco-2 cells, we investigated translocation of bacteria across the M cell model. While Salmonella translocation was markedly upregulated by Raji coculture, transport of wild-type EPEC occurred at similarly low levels across both native Caco-2 and Caco-2/Raji-cocultured layers. Translocation rates were markedly higher for EPEC strains lacking either functional TTSS or the effector protein EspF. These observations resemble previously reported data on the inhibition of macrophage phagocytosis by EPEC, which has also been reported to be dependent on TTSS and EspF. Furthermore, as with macrophage phagocytosis, enhanced translocation of a TTSS mutant was blocked by wortmannin, implicating inhibition of phosphatidyl inositol 3-kinase-mediated signalling in the regulation of M cell translocation by EPEC.

Going through the motions: the ATPase cycle of p97

p97 (VCP, Cdc48), a type II AAA+ ATPase family member, is ubiquitous, essential, highly abundant, and involved in a diverse range of biological functions with roles in membrane fusion, endoplasmic-reticulum associated degradation, transcriptional activation, and cell cycle control. As such, dysfunction of this protein has serious pathological consequences and has been implicated in a variety of cancers and neurodegenerative diseases. p97 has a large number of adaptor proteins through which it transmits energy from ATPase activity to conformational changes which are then exerted onto target proteins. p97 has been studied by a variety of biochemical and structural techniques at various resolutions and stages throughout its ATPase cycle. From these studies, many models have been proposed and consequently a single model for p97's action cannot be suggested. Many questions about the mechanism of p97 still remain, including whether the protomers act in a concerted manner and crucially how the induced changes in p97 are transmitted to its adaptor proteins and target substrates. The elucidation of p97's mechanism is not only important in furthering our knowledge of this intriguing protein and its many functions, but subsequently in the development of potential therapies for diseases associated with p97 dysfunction.

Quality assurance of neuroradiology in a District General Hospital

BACKGROUND

An increasing number of neurologists in District General Hospitals (DGHs) rely on local neuroimaging reports from general radiologists.

AIM

To determine the level of disagreement between general radiologists and neuroradiologists in reporting neuroimaging from patients referred to a neurologist.

DESIGN

Prospective observational study.

METHODS

We studied 232 patients referred for a neuroradiologist's report on neuroimaging over a 17-month period. Pre-planned comparisons included primary and secondary report findings, length of report and suggestions for additional investigations.

RESULTS

Of the 593 patients assessed during the study period, a neuroradiologist's report was sought for 232 (39%): 119 men, 113 women, mean age 46.1 (SD 17.6) years. Primary findings differed in 37 patients (15.9%) (95%CI 11.5-21.3). Reports from neuroradiologists changed subsequent management in 31 (13.4%) (95%CI 9.3-18.4). Differences in secondary findings occurred in 52 (22.4%) (95%CI 17.2-28.3), and differences in either primary or secondary outcomes in 77 (33.2%) (95%CI 27.2-39.6). The level of disagreement in primary findings was as frequent among patients investigated with magnetic resonance imaging as among computerized tomogram-only patients (p = 0.13). Neuroradiologists recommended additional investigations for 24 patients (10.3%) (95%CI 6.7-15.0) and provided longer reports than general radiologists (p < 0.001).

DISCUSSION

Neuroimaging reports of some patients differ substantially between general radiologists and neuroradiologists. Optimal management of neurological patients in DGHs may require timely access to neuroradiologists.

Use of fluorescence imaging to investigate the structure and function of intestinal M cells

Fluorescence imaging technology can be applied to many aspects of cell biology ranging from the analysis of specific markers in cells and tissues to the biological actions and distribution of fluorescent proteins or particles in living cells. In this review, we examine the role of fluorescence imaging, in conjunction with other microscopical techniques, to study sites of uptake of material across the gastrointestinal epithelium. We will focus primarily on intestinal M cells, specialised antigen-sampling cells in the epithelium of the gut-associated lymphoid tissue (GALT), including Peyer's patches. In addition to their importance as sites for uptake of inert material, and hence their potential as a route of delivery of vaccines, etc., M cells are also a major site of infection by a range of microbial pathogens. The application of new fluorescence imaging technologies has expanded our knowledge on the structure, development and function of these fascinating cells.

A randomized trial of breast cancer risk counseling: the impact on self-reported mammography use

OBJECTIVES

We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer.

METHODS

Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up.

RESULTS

In multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants.

CONCLUSIONS

These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.

Epidermal Langerhans cell apoptosis is induced in vivo by nonanoic acid but not by sodium lauryl sulphate

Exposure to irritants may cause chronic irritant contact dermatitis (ICD), characterized by irregular epidermal thickening and a predominantly dermal mononuclear cell infiltrate. The mechanisms involved, and why only certain individuals are affected, are not clearly understood. Different irritants may trigger different cellular and molecular interactions between resident skin cells and recruited inflammatory cells. In some individuals these interactions may become self-perpetuating resulting in persistent inflammation in the absence of continued exposure. This study examined Langerhans cell (LC) density in clinically normal skin of 46 patients with chronic ICD and 10 healthy individuals, and compared the action of the two irritants nonanoic acid (NA) and sodium lauryl sulphate (SLS) on the LCs and keratinocytes of clinically normal skin in patients with chronic ICD. There was a higher number of LCs/mm basement membrane in patients compared with controls, although there was no difference in the number of dendrites/LC nor in dendrite length. SLS induced keratinocyte proliferation after 48 h exposure, had no effect on LC number or distribution, and induced keratinocyte apoptosis after 24 and 48 h exposure. In contrast, NA decreased keratinocyte proliferation after 24 h exposure but this returned to basal levels after 48 h, and induced epidermal cell apoptosis after only 6 h exposure. NA dramatically decreased LC number after 24 and 48 h exposure, which was accompanied by basal redistribution and decreased dendrite length. Most significantly, NA induced apoptosis in over half of the LCs present after 24 and 48 h exposure.

Improving the management of children's pain in A&E

This paper describes a project that sought to improve the management of children's pain in an A&E department. Pain management is not always seen as a priority in A&E departments. The problems are highlighted through two case studies, and guidelines to improve practice were developed in collaboration with a specialist multidisciplinary team.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

Epidermal keratinocyte production of interferon-gamma immunoreactive protein and mRNA is an early event in allergic contact dermatitis

Previous work has indicated the importance of cytokine cascades in the induction of contact dermatitis, but there is little information on the cellular localization of cytokines in human skin, particularly during the early phases of the inflammatory response to contact allergens. Using in situ hybridization for mRNA and immunocytochemistry on biopsies from a series of 16 patients with known allergic contact dermatitis, we examined the kinetics of early cytokine production after challenge with relevant or irrelevant antigen. We show that epidermal keratinocytes from patients challenged in vivo with allergen, but not irrelevant antigen, rapidly synthesize (within 4 h) mRNA for interferon-gamma and produce immunoreactive interferon-gamma. Interleukin-1alpha and interleukin-8 mRNA were also detected but showed no correlation with relevant antigen challenge. This study demonstrates that keratinocytes can produce interferon-gamma and that this production is linked to challenge with relevant antigen in allergic contact dermatitis. These findings indicate that keratinocytes may amplify allergen-specific T-lymphocyte-triggered interferon-gamma dependent responses and might partially explain the speed of reaction in this common disease and other delayed hypersensitivity reactions involving the skin.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

Effects of individualized breast cancer risk counseling: a randomized trial

BACKGROUND

Studies have shown that a majority of women with a family history of breast cancer have exaggerated perceptions of their own risk of this disease and experience excessive anxiety. In response to the need to communicate more accurate risk information to these women, specialized programs for breast cancer risk counseling have been initiated in medical centers across the United States.

PURPOSE

Our purpose was 1) to evaluate the impact of a standardized protocol for individualized breast cancer risk counseling on comprehension of personal risk among first-degree relatives of index breast cancer patients and 2) to identify women most and least likely to benefit from such counseling.

METHODS

This study is a prospective randomized trial comparing individualized breast cancer risk counseling to general health counseling (control). We studied 200 women aged 35 years and older who had a family history of breast cancer in a first-degree relative. Women with a personal history of cancer were excluded. Risk comprehension was assessed as the concordance between perceived "subjective" lifetime breast cancer risk and estimated "objective" lifetime risk.

RESULTS

The results of logistic regression analysis showed that women who received risk counseling were significantly more likely to improve their risk comprehension, compared with women in the control condition (odds ratio [OR] = 3.5; 95% confidence interval [CI] = 1.3-9.5; P = .01). However, in both groups, about two thirds of women continued to overestimate their lifetime risks substantially following counseling. Examination of subjects by treatment interaction effects indicated that risk counseling did not produce improved comprehension among the large proportion of women who had high levels of anxious preoccupation with breast cancer at base line (P = .02). In addition, white women were less likely to benefit than African-American women (OR = 0.34; 95% CI = 0.11-0.99; P = .05).

CONCLUSION

Efforts to counsel women about their breast cancer risks are not likely to be effective unless their breast cancer anxieties are also addressed.

IMPLICATIONS

Attention to the psychological aspects of breast cancer risk will be critical in the development of risk-counseling programs that incorporate testing for the recently cloned breast cancer susceptibility gene, BRCA1 (and BRCA2 when that gene has also been cloned).

Recruiting high risk women into a breast cancer health promotion trial

This study sought to identify factors that facilitate or hinder participation in a breast cancer health promotion trial among high-risk women. The subjects were 271 women ages 35 years and older who had a family history of breast cancer in at least one first-degree relative. All subjects were eligible for participation in a randomized trial which compares breast cancer risk counseling with general health counseling. Structured telephone interviews evaluated demographic characteristics, risk factors, risk perceptions, breast cancer concerns, and past screening practices. The results showed that education level was a key determinant of the importance of these factors in participation. Logistic regression modeling indicated that women with a high school education or less were most likely to participate if: (a) their relatives' diagnoses had greatly increased their perceptions of their personal risks [OR (OR) = 4.1], particularly if they perceived that risk to be very high (OR for interaction = 6.4); and (b) if they were ages 40-49 years versus 35-39 or 50 + years (OR = 2.6). By contrast, among women with education beyond high school, participation was predicted by (a) marital status (OR = 2.6), (b) employment (OR = 0.03 for employed), (c) number of affected relatives (OR = 0.07 for 1 versus 2 first-degree relatives), and (d) previous biopsy (OR = 0.42). These findings suggest that recruitment strategies that tailor messages to women's educational levels might be most effective.

Mammography adherence and psychological distress among women at risk for breast cancer

BACKGROUND

Previous studies estimate that first-degree relatives of women with breast cancer have a twofold to 10-fold increased risk of developing breast cancer. Recently, attention has focused on the mammography screening practices of women who are at high risk for breast cancer.

PURPOSE

Our purpose was to characterize mammography screening practices in a sample of first-degree relatives of breast cancer patients and to identify variables that may serve as barriers to or facilitators of adherence to mammography.

METHODS

Cross-sectional (rather than prospective) data were collected by telephone interviews with 140 women aged 35-79 years who had a family history of breast cancer in at least one first-degree relative (mother, sister, or daughter). Data were recorded on mammography screening patterns, depression, stress impact, and breast cancer worries.

RESULTS

Women whose mammography history adhered to age-specific recommendations varied by age: 76% of first-degree relatives aged 35-39 years, 86% aged 40-49 years, and 63% aged 50 years or more. In bivariate analyses, level of education (P = .001), employment (P = .046), and time since diagnosis of the index patient (P = .044) were significantly and positively associated with mammography adherence. Variables associated negatively with adherence included age (P = .019), intrusive thoughts about breast cancer (P = .042), and breast cancer worries that interfered with daily functioning (P = .004). Multivariate analysis by logistic regression indicated that only breast cancer worries (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.09-5.9) and education (OR = 4.8; CI = 1.6-14.3) were significant independent predictors of mammography adherence.

CONCLUSIONS

This study suggests that most women at high risk for breast cancer adhere to the recommended mammography screening guidelines of the National Cancer Institute. However, rates of adherence among high-risk women aged 50 years and older are suboptimal; only 63% of these women received annual screening mammograms, and 13% had never been screened. Breast cancer worries may pose a barrier to mammography adherence among high-risk women, particularly those with less formal education.

IMPLICATIONS

Prospective longitudinal studies are needed to validate the present findings and to evaluate the impact of psychoeducational interventions for women with affected first-degree relatives.

Academic detailing: a model for in-office CME

The National Cancer Institute (NCI), in its goal to reduce cancer mortality by 50% by the year 2000, has placed a special emphasis on prevention and early detection, especially in underserved populations. Check-Up On Health is a community based health education program being carried out by Fox Chase Cancer Center in three inner city Philadelphia neighborhoods, to improve the provision of appropriate cancer screening and prevention services to older, blue-collar adults by their primary care physicians. Primary care physicians in the chosen neighborhoods were targeted to receive a brief cancer prevention educational message delivered by project staff and patterned on the model of drug detailing developed by the pharmaceutical industry. This study represents an attempt to evaluate the feasibility and acceptability of such an approach aimed at improving cancer prevention promotion in the health care system. Primary care physicians were identified by community residents who attended one of 67 Check-Up On Health education presentations about cancer prevention at churches, social clubs, and senior-citizen centers within the targeted neighborhoods. An attempt was then made by project staff to visit each identified physician in his/her office or clinic, during office hours, both to conduct a brief survey and to deliver an educational message about either cancer screening guidelines or counseling for smoking cessation. The physicians were also provided with educational materials for themselves as well as their patients. Twelve months after the visit, a follow-up phone call to the physicians assessed the impact of the visit and solicited suggestions for future outreach efforts.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of two methods of predicting outcome in perinatal asphyxia

In a follow-up study of 122 full-term infants in whom postasphyxial encephalopathy occurred the incidence of death or severe handicap was 1 in 1000 deliveries. The abilities of two methods of diagnosing intrapartum asphyxia to predict outcome at a median age of 2.5 years were compared. A decision matrix calculation was undertaken to assess the sensitivity and specificity of low Apgar score and postasphyxial encephalopathy. A 10 min Apgar score less than or equal to 5 was the most sensitive of six different Apgar ratings in predicting adverse outcome (sensitivity 43%, specificity 95%) but even this was much less sensitive than the presence of moderate or severe encephalopathy in predicting death or severe handicap (sensitivity 96%).