A risk of malignancy index incorporating CA 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer

Age, ultrasound score, menopausal status, a clinical impression score and serum CA 125 level were assessed to see how they could best distinguish between patients with benign (n = 101) and malignant (n = 42) pelvic masses. Each criteria used alone provided statistically significant discrimination. The most useful individual criteria were a serum CA 125 level of 30 U/ml (sensitivity 81%, specificity 75%) and an ultrasound score of 2 (sensitivity 71%, specificity 83%). Three criteria could be combined in a risk of malignancy index (RMI) which is simply calculated using the product of the serum CA 125 level (U/ml), the ultrasound scan result (expressed as a score of 0, 1 or 3) and the menopausal status (1 if premenopausal and 3 if postmenopausal). This index was statistically virtually as effective a discriminant between cancer and benign lesions as more formal methods. Using an RMI cut-off level of 200, the sensitivity was 85% and the specificity was 97%. Patients with an RMI score of greater than 200 had, on average, 42 times the background risk of cancer and those with a lower value 0.15 times the background risk.

The CA 125 tumour-associated antigen: a review of the literature

CA 125 is an antigenic determinant on a high-molecular-weight glycoprotein recognized by a monoclonal antibody which was raised using an ovarian cancer cell line as an immunogen. During the last 5 years the studies reviewed in this paper have provided information concerning the nature, distribution and clinical significance of CA 125. The CA 125 determinant is expressed by epithelial ovarian tumours and various other pathological and normal tissues of Müllerian origin. The function of the glycoprotein expressing CA 125 remains unclear but the distribution of the antigen suggests that it may have a physiological role. The highest serum levels of CA 125 are found in ovarian cancer patients, but elevation of serum CA 125 may also be associated with other malignancies and benign and physiological states, including pregnancy, endometriosis and menstruation. Despite limitations of sensitivity and specificity serum CA 125 estimation is of clinical value in the pre-operative diagnosis and monitoring of ovarian malignancy and may be a prognostic indicator for this disease. The role of CA 125 in screening for early-stage ovarian cancer is currently under investigation. Recent reports suggest that serum CA 125 measurement may also be of value as a prognostic indicator in endometrial cancer and as a reflection of disease status in advanced endometriosis.

Management of women who test positive for high-risk types of human papillomavirus: the HART study

BACKGROUND

Certain types of human papillomavirus (HPV) are the primary cause of almost all cervical cancers. HPV testing of cervical smears is more sensitive but less specific than cytology for detecting high-grade cervical intraepithelial neoplasia (CIN2+). HPV testing as a primary screening approach requires efficient management of HPV-positive women with negative or borderline cytology. We aimed to compare the detection rate and positive predictive values of HPV assay with cytology and to determine the best management strategy for HPV-positive women.

METHODS

We did a multicentre screening study of 11085 women aged 30-60 years. Women with borderline cytology and women positive for high-risk HPV with negative cytology were randomised to immediate colposcopy or to surveillance by repeat HPV testing, cytology, and colposcopy at 12 months.

FINDINGS

HPV testing was more sensitive than borderline or worse cytology (97.1% vs 76.6%, p=0.002) but less specific (93.3% vs 95.8%, p<0.0001) for detecting CIN2+. Of 825 randomised women, surveillance at 12 months was as effective as immediate colposcopy. In women positive for HPV at baseline, who had surveillance, 73 (45%) of 164 women with negative cytology and eight (35%) of 23 women with borderline cytology were HPV negative at 6-12 months. No CIN2+ was found in these women, nor in women with an initial negative HPV test with borderline (n=211) or mild (32) cytology.

INTERPRETATION

HPV testing could be used for primary screening in women older than 30 years, with cytology used to triage HPV-positive women. HPV-positive women with normal or borderline cytology (about 6% of screened women) could be managed by repeat testing after 12 months. This approach could potentially improve detection rates of CIN2+ without increasing the colposcopy referral rate.

New tumor markers: CA125 and beyond

A variety of biomarkers have been developed to monitor growth of ovarian cancer and to detect disease at an early interval. CA125 (MUC16) has provided a useful serum tumor marker for monitoring response to chemotherapy, detecting disease recurrence, distinguishing malignant from benign pelvic masses, and potentially improving clinical trial design. A rapid fall in CA125 during chemotherapy predicts a favorable prognosis and could be used to redistribute patients on multiarmed randomized clinical trials. Several studies now document that CA125 can serve as a surrogate marker for response in phase II trials. Serial measurement of CA125 might also provide a useful marker for monitoring stabilization of disease with cytostatic targeted therapeutic agents. The greatest potential for serum markers may be in detecting ovarian cancer at an early stage. A rising CA125 can be used to trigger transvaginal sonography (TVS) in a small fraction of patients. An algorithm has been developed that calculates risk of ovarian cancer based on serial CA125 values and refers patients at highest risk for TVS. Use of the algorithm is currently being evaluated in a trial with 200,000 women in the UK that will test critically the ability of a two-stage screening strategy to improve survival in ovarian cancer. Whatever the outcome, as 20% of ovarian cancers have little or no expression of CA125, additional serum markers will be required to detect all patients in an initial phase of screening. More than 30 serum markers have been evaluated alone and in combination with CA125 by different investigators. Some of the most promising include: HE4, mesothelin, M-CSF, osteopontin, kallikrein(s), and soluble EGF receptor. Two proteomic approaches have been used: one examines the pattern of peaks on mass spectroscopy and the other uses proteomic analysis to identify a limited number of critical markers that can be assayed by more conventional methods. Both approaches are promising and require further development. Several groups are placing markers on multiplex platforms to permit simultaneous assay of multiple markers with very small volumes of serum. Mathematical techniques are being developed to analyze combinations of marker levels to improve sensitivity and specificity. In the future, serum markers should improve the sensitivity of detecting recurrent disease as well as facilitate earlier detection of ovarian cancer.

Onset of blood lactate accumulation and marathon running performance

This study was designed to examine the interrelationships among endurance running performance (marathon), the exercise intensity at which the "onset of blood lactate accumulation" (OBLA) occurs training volume, and muscle fiber characteristics. In conjunction with Stockholm's Marathon (1979), 18 male subjects underwent a test to determine the relationship between treadmill running velocity and blood lactate accumulation. The velocity at which a blood lactate accumulation of 4 mmol x l-1 occurred was referred to as the VOBLA. The m. vastus lateralis was biopsied and muscle fiber type distribution (% slow twitch, ST) and capillary density determined. With marathon running velocity (VM) as the dependent variable, multiple regression analysis showed that VOBLA accounted for 92% of the variation in VM, and VOBLA plus training volume prior to the marathon accounted for 96% of this variation. All performance variables were positively correlated to % ST muscle fiber distribution (r = 0.55-0.69) and capillary density (r = 052-0.63). Thus, marathon running performance was closely related to VOBLA and to the ability to run at a pace close to that velocity during the race. These properties were in turn related to % ST, capillary density, and training volume.

Prevalence screening for ovarian cancer in postmenopausal women by CA 125 measurement and ultrasonography

OBJECTIVE

To assess the performance of the sequential combination of serum CA 125 measurement and ultrasonography in screening for ovarian cancer.

DESIGN

The serum CA 125 concentration of each subject was determined and those with a concentration > or = 30 U/ml were recalled for abdominal ultrasonography. If ultrasonography gave abnormal results surgical investigation was arranged. Volunteers were followed up by annual postal questionnaire.

SETTING

General practice, occupational health departments, ovarian cancer screening clinic.

SUBJECTS

22,000 women volunteers who were postmenopausal and aged over 45 years.

MAIN OUTCOME MEASURES

Apparent sensitivity, specificity, positive predictive value, years of cancer detected.

RESULTS

41 women had a positive screening result and were investigated surgically. 11 had ovarian cancer (true positive result) and 30 had other disorders or no abnormality (false positive result). Of the 21,959 volunteers with a negative screening result, eight subsequently presented clinically with ovarian cancer (false negative result) and 21,951 had not developed ovarian cancer during follow up (apparent true negative result). The screening protocol achieved a specificity of 99.9%, a positive predictive value of 26.8%, and an apparent sensitivity of 78.6% and 57.9% at one year and two year follow up respectively. The estimated number of years of cancer detected by the prevalence screen was 1.4 years.

CONCLUSIONS

This screening protocol is highly specific for ovarian cancer and can detect a substantial proportion of cases at a preclinical stage. Further investigation is required to determine the effect of the screening protocol on the ratio of early to late stage disease detected and on mortality from ovarian cancer.

Multimodal approach to screening for ovarian cancer

1010 postmenopausal women were recruited for an ovarian cancer screening programme incorporating serum CA-125 measurement and vaginal examination as initial tests and real-time ultrasonography as a secondary procedure in selected cases. The normal range for serum CA-125 in postmenopausal women was established. The specificity for ovarian cancer of serum CA-125 measurement and vaginal examination were 97.0% and 97.3%, respectively. The combinations of serum CA-125 measurement with ultrasound and vaginal examination with ultrasound achieved specificities of 99.8% and 99.0%, respectively. 100% specificity was achieved by serum CA-125 measurement with vaginal examination and by the combination of all three tests. The findings indicate that no individual screening test has acceptable specificity for ovarian cancer in postmenopausal women. However, the combination of CA-125 measurement with ultrasound did achieve acceptable specificity and offers the most hope of a specific and sensitive method for early detection.

Blood lactate. Implications for training and sports performance

The blood lactate response to exercise has interested physiologists for over fifty years, but has more recently become as routine a variable to measure in many exercise laboratories as is heart rate. This rising popularity is probably due to: the ease of sampling and improved accuracy afforded by recently developed micro-assay methods and/or automated lactate analysers; and the predictive and evaluative power associated with the lactate response to exercise. Several studies suggest that the strong relationship between exercise performance and lactate-related variables can be attributed to a reflection by lactate during exercise of not only the functional capacity of the central circulatory apparati to transport oxygen to exercising muscles, but also the peripheral capacity of the musculature to utilise this oxygen. For example, several studies contrast the relationship between VO2max and endurance running performance with that between a lactate variable and the same running performance. In every study, the lactate variable is more highly correlated with performance. Similarly, prescribing training intensity as a function of the lactate concentration elicited by the training may prove to be a means of obtaining a more homogeneous adaptation to training in a group of athletes or subjects than is obtained by setting intensity as a function of maximal heart rate or % VO2max. A review of the recent literature shows that the lactate response to supramaximal exercise is a sensitive indicator of adaptation to 'sprint training' and is correlated with supramaximal exercise performance. This review also describes the possible applications of lactate measurements to enhance the rate of recovery from high intensity exercise. Although the lactate response to exercise is reproducible under standardised conditions it can be influenced by the site of blood sampling, ambient temperature, changes in the body's acid-base balance prior to exercise, prior exercise, dietary manipulations, or pharmacological interpretation.

Changes in onset of blood lactate accumulation (OBLA) and muscle enzymes after training at OBLA

Eight well-trained middle and long distance male runners added to their regular training program a weekly 20-min treadmill run at a velocity calculated to elicit a blood lactate concentration of 4 mmol X 1-1. VO2 max, the running velocity eliciting 4 mmol X 1-1 blood lactate (VOBLA), and the activities of citrate synthase (CS), phosphofructokinase (PFK), lactate dehydrogenase (LDH) and LDH isozymes in the M. vastus lateralis were determined before and after 14 weeks of this training. Significant increases were observed in VOBLA and the relative fraction of heart-specific LDH, while the activity of PFK and the ratio of PFK/CS decreased after training. The change in VOBLA was negatively correlated to the mean rate of blood lactate accumulation during the last 15 min of the treadmill training runs, and positively correlated to the percentage of slow twitch fibers in the M. vastus lateralis. The data support the hypothesis that a steady state training intensity which approximates VOBLA will increase VOBLA, and will result in measureable local metabolic adaptations in the active skeletal muscles of well-trained runners without a significant change in maximal aerobic power. Muscle fiber type composition may be an indicator of the "trainability" of the musculature.

Lactate in human skeletal muscle after 10 and 30 s of supramaximal exercise

The purpose of this study was to evaluate the extent of anaerobic glycogenolysis, as indicated by intramuscular lactate concentration, after 10 and 30 s of supramaximal exercise and to compare male and female subjects in this regard. Fifteen males and seven females performed two cycle exercise bouts against a resistance which was standardized so that one pedal revolution resulted in 4.90 J work X kg body wt-1. A muscle biopsy was obtained after 10- and 30-s exercise bouts and analyzed for lactate concentration. The lactate concentrations averaged 36 and 61 mmol X kg dry wt-1 after the 10- and 30-s exercise bouts, respectively. The male subjects had higher (P less than 0.005) lactate concentrations and generated higher (P less than 0.001) power outputs for both exercise bouts. When the mean lactate concentrations were statistically adjusted after controlling for between-group variation in power output, no difference was evident between groups for the 10- or the 30-s lactate value. The results are evidence that pronounced lactate accumulation occurs during supramaximal exercise of a 10-s duration, suggesting that glycolysis can occur within this time frame. This is in contrast to the theory that glycolysis does not occur until endogenous phosphagen levels reach some critically low value, not thought to be obtainable within the first 10 s of supramaximal exercise.

Evaluation of endometrial carcinoma on magnetic resonance imaging

Our aims were to assess diagnostic performance of T2-weighted (T2W) and dynamic gadolinium-enhanced T1-weighted (T1W) magnetic resonance imaging (MRI) in the preoperative assessment of myometrial and cervical invasion by endometrial carcinoma and to identify imaging features that predict nodal metastases. Two radiologists retrospectively reviewed MR images of 96 patients with endometrial carcinoma. Tumor size, depth of myometrial and cervical invasion, and nodal enlargement were recorded and then correlated with histology. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the identification of any myometrial invasion (superficial or deep) were 0.94, 0.50, 0.93, 0.55 on T2W and 0.92, 0.50, 0.92, 0.50 on dynamic T1W, and for deep myometrial invasion were 0.84, 0.78, 0.65, 0.91 on T2W and 0.72, 0.88, 0.72, 0.88 on dynamic T1W. The sensitivity, specificity, PPV and NPV for any cervical invasion (endocervical or stromal) were 0.65, 0.87, 0.57, 0.90 on T2W and 0.50, 0.90, 0.46, 0.92 on dynamic T1W, and for cervical stromal involvement were 0.69, 0.95, 0.69, 0.95 on T2W and 0.50, 0.96, 0.57, 0.95 on dynamic T1W. Leiomyoma or adenomyosis were seen in 73% of misdiagnosed cases. Sensitivity and specificity for the detection of nodal metastases was 66% and 73%, respectively. Fifty percent of patients with cervical invasion on MRI had nodal metastases. In conclusion, MRI has a high sensitivity for detecting myometrial invasion and a high NPV for deep invasion. MRI has a high specificity and NPV for detecting cervical invasion. Dynamic enhancement did not improve diagnostic performance. MRI may allow accurate categorization of cases into low- or high-risk groups ensuring suitable extent of surgery and adjuvant therapy.

MR imaging of uterine sarcomas

OBJECTIVE

The MR imaging appearances of uterine sarcomas are not well described in the literature. We describe the MR imaging features of uterine sarcomas.

MATERIALS AND METHODS

MR images from all patients with histologically proven uterine sarcomas scanned between 1993 and 2000 were reviewed. Tumor size, its relationship to the uterus, signal characteristics, and enhancement pattern after IV injection of gadolinium were noted.

RESULTS

Twenty-five scans from 22 patients were reviewed. Findings from the scans included 11 leiomyosarcomas, five mixed müllerian tumors, two rhabdosarcomas, and four endometrial stromal sarcomas. Two patterns of disease were observed, including a characteristic large heterogenous pelvic mass (n = 17) and an endometrial mass indistinguishable from endometrial carcinoma (n = 8). On T2-weighted images, the large masses were characteristically of low or intermediate background signal intensity with pockets of very high T2 signal. The areas of high T2 signal corresponded to cystic necrosis in the tumor. Pockets of high T1-weighted signal corresponded to hemorrhage. Gadolinium enhancement was present in the solid components of all tumors. This pattern was observed in all recurrent sarcomas. Some correlation was shown between the histologic subtypes and the MR imaging appearances.

CONCLUSION

Uterine sarcomas show two patterns on MR imaging. The most common presentation is a large heterogenous mass. However, sarcomas can mimic endometrial carcinoma.

Effect of caffeine and ephedrine ingestion on anaerobic exercise performance

PURPOSE

Ingestion of a combination of caffeine (C) and ephedrine (E) prolongs time to exhaustion during high-intensity aerobic exercise. CNS stimulation by C and E was proposed as part of the mechanism for the improvement. It was thought that this arousal might also be of benefit during anaerobic exercise. The purpose of this study was to investigate the effect of C, E, and C+E ingestion on performance of anaerobic exercise.

METHODS

Two groups were used to evaluate the effect of C and E on anaerobic performance. Group 1 (WIN) consisted of 16 healthy untrained male subjects who performed a 30-s Wingate test. Group 2 (MAOD) consisted of 8 healthy untrained male subjects who performed a supramaximal (125%VO(2peak)) cycle exercise trial to exhaustion to determine maximum accumulated oxygen deficit. The trials commenced 1.5 h after ingesting either C (5 mg x kg(-1)), E (1 mg x kg(-1)), a combination of C+E, or a placebo (P). All trials were randomized and double blind. Blood samples were assayed for lactate and glucose post drug ingestion just before exercise, and again 3, 5, and 10 min post exercise. Catecholamines were measured in the preexercise and 10-min postexercise blood samples.

RESULTS

Ephedrine increased power output during the early phase of the Wingate test, whereas C increased time to exhaustion and O(2) deficit during the MAOD test. C, E, and C+E increased blood lactate, glucose, and catecholamine levels.

CONCLUSION

The improvement in anaerobic exercise performance is likely a result of both stimulation of the CNS by E and skeletal muscle by C.

Prevalence, frequency and problem rating of hot flushes persist in older postmenopausal women: impact of age, body mass index, hysterectomy, hormone therapy use, lifestyle and mood in a cross-sectional cohort study of 10,418 British women aged 54-65

OBJECTIVE

Hot flushes and night sweats (HFs/NSs) are the main menopausal symptoms, but few studies have been adequately powered to examine the dimensions or predictors of experiencing HFs/NSs. We report on these variables in a large UK cohort of postmenopausal women.

DESIGN

Cross-sectional cohort study.

SETTING

UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) cohort.

POPULATION

A cohort of 202,638 postmenopausal women, aged 50-74 years, without oophorectomy, recruited to UKCTOCS between 2001 and 2005.

METHODS

Women completed a follow-up questionnaire, and those aged 54-65 years were mailed a survey in July 2008.

MAIN OUTCOME MEASURES

  Hot flush prevalence and hot flush rating scale.

RESULTS

Of the 15,000 women mailed, 10,418 returned completed questionnaires; 90% had previously had HFs/NSs. Despite being on average 10 years postmenopausal, 54% experienced HFs/NSs (frequency of 33 per week with mean problem rating 4/10) that persisted across the age range. Past hysterectomy (OR 1.50, 95% CI 1.19-1.86), ever having smoked (OR 1.27, 95% CI 1.11-1.46) and alcohol consumption (current units) (OR 1.05, 95% CI 1.01-1.09) predicted ever having had HFs/NSs. Anxiety (OR 3.09, 95% CI 2.57-3.72), hysterectomy (OR 2.74, 95% CI 2.32-3.25), depressed mood (OR 1.57, 95% CI 1.24-1.99), years since last menstrual period (OR 0.95, 95% CI 0.94-0.96) and education (above and below 18 years) (OR 0.98, 95% CI 0.97-0.99) predicted the current prevalence of HFs/NSs. Few predictors of frequency were identified, but problem rating was associated with depressed mood, hysterectomy, skirt size increase and frequency of HFs/NSs. Past hormone therapy users who had discontinued treatment were more likely to have HFs/NSs that were more frequent and problematic.

CONCLUSIONS

To date, this is the largest UK study of the experience of HFs/NSs amongst older postmenopausal women. HFs/NSs are more prevalent in this age band than has previously been assumed. These findings and the associations of smoking, hysterectomy, anxiety, depressed mood and hormone therapy use with the experience of HFs/NSs have implications for prevention and symptom management.

Congenital and postnatally acquired cytomegalovirus infections: long-term follow-up

To determine long-term outcome of children with inapparent congenital cytomegalovirus infection, an assessment of congenitally infected children observed since birth was undertaken. Children with early postnatal acquisition of CMV infection were also evaluated. Cognitive, behavioral, neurologic, audiometric, and speech and language evaluations were performed in 48 patients, including 17 congenitally infected children, 10 children with postnatal infection, and 21 uninfected control subjects. Mean IQ of the three groups of children did not differ significantly. Behavioral, neurologic, speech and language examinations similarly failed to distinguish differences among the three groups. Audiologic abnormalities were present in four congenitally infected children, including one child with a severe unilateral sensorineural loss; in none of the children was hearing loss functionally significant. No hearing abnormalities were detected in postnatally infected children. Although inapparent CMV infection can result in audiologic sequelae, the continued lack of cognitive, behavioral, and neurologic sequelae in these school-age children reemphasizes the need to focus attention on prevention of primary maternal CMV infection to avoid the potentially devastating effects of intrauterine CMV infection.

Interaction between concurrent strength and endurance training

To assess the effects of concurrent strength (S) and endurance (E) training on S and E development, one group (4 young men and 4 young women) trained one leg for S and the other leg for S and E (S+E). A second group (4 men, 4 women) trained one leg for E and the other leg for E and S (E+S). E training consisted of five 3-min bouts on a cycle ergometer at a power output corresponding to that requiring 90-100% of oxygen uptake during maximal exercise (VO2 max). S training consisted of six sets of 15-20 repetitions with the heaviest possible weight on a leg press (combined hip and knee extension) weight machine. Training was done 3 days/wk for 22 wk. Needle biopsy samples from vastus lateralis were taken before and after training and were examined for histochemical, biochemical, and ultrastructural adaptations. The nominal S and E training programs were "hybrids", having more similarities as training stimuli than differences; thus S made increases (P less than 0.05) similar to those of S+E in E-related measures of VO2max (S, S+E: 8%, 8%), repetitions with the pretraining maximal single leg press lift [1 repetition maximum (RM)] (27%, 24%), and percent of slow-twitch fibers (15%, 8%); and S made significant, although smaller, increases in repetitions with 80% 1 RM (81%, 152%) and citrate synthase (CS) activity (22%, 51%). Similarly, E increased knee extensor area [computed tomography (CT) scans] as much as E+S (14%, 21%) and made significant, although smaller, increases in leg press 1 RM (20%, 34%) and thigh girth (3.4%, 4.8%). When a presumably stronger stimulus for an adaptation was added to a weaker one, some additive effects occurred (i.e., increases in 1 RM and thigh girth that were greater in E+S than E; increases in CS activity and repetitions with 80% 1 RM that were greater in S+E than S). When a weaker, although effective, stimulus was added to a stronger one, addition generally did not occur. Concurrent S and E training did not interfere with S or E development in comparison to S or E training alone.

Evaluation of serum CEA, CYFRA21-1 and CA125 for the early detection of colorectal cancer using longitudinal preclinical samples

Background:

Blood-borne biomarkers for early detection of colorectal cancer (CRC) could markedly increase screening uptake. The aim of this study was to evaluate serum carcinoembryonic antigen (CEA), CYFRA21-1 and CA125 for the early detection of CRC in an asymptomatic cohort.

Methods:

This nested case–control study within UKCTOCS used 381 serial serum samples from 40 women subsequently diagnosed with CRC, 20 women subsequently diagnosed with benign disease and 40 matched non-cancer controls with three to four samples per subject taken annually up to 4 years before diagnosis. CEA, CYFRA21-1 and CA125 were measured using validated assays and performance of markers evaluated for different pre-diagnosis time groups.

Results:

CEA levels increased towards diagnosis in a third of all cases (half of late-stage cases), whereas longitudinal profiles were static in both benign and non-cancer controls. At a threshold of >5 ng ml⁻¹ the sensitivities for detecting CRC up to 1 and 4 years before clinical presentation were 25% and 13%, respectively, at 95% specificity. At a threshold of >2.5 ng ml⁻¹, sensitivities were 57.5% and 38.4%, respectively, with specificities of 81% and 83.5%. CYFRA21-1 and CA125 had no utility as screening markers and did not enhance CEA performance when used in combination. CEA gave average lead times of 17–24 months for test-positive cases.

Conclusions:

CEA is elevated in a significant proportion of individuals with preclinical CRC, but would not be useful alone as a screening tool. This work sets a baseline from which to develop panels of biomarkers which combine CEA for improved early detection of CRC.

Views of BRCA gene mutation carriers on preimplantation genetic diagnosis as a reproductive option for hereditary breast and ovarian cancer

BACKGROUND

In May 2006, the UK Human Fertilization and Embryology Authority (HFEA) approved use of preimplantation genetic diagnosis (PGD) for lower penetrance, late onset cancer susceptibility syndromes such as hereditary breast and ovarian cancer (HBOC). This is the first report on views of BRCA gene mutation carriers on use of PGD for HBOC.

METHODS

Between December 2005 and February 2006, a postal survey of BRCA mutation carriers attending a Familial Cancer Clinic was undertaken.

RESULTS

Of 102 women sent questionnaires, 52 (51%) responded. Thirty-nine (75%) felt it was acceptable to offer PGD for HBOC. Fifteen (37.5%) of 40 who had completed their families would personally have considered PGD if it had been available. Only one of seven (14%) contemplating a future pregnancy would consider PGD. Eighteen (35%) wrote extensively about their concerns including increasing availability of effective treatment and good quality of life.

CONCLUSIONS

The majority of BRCA gene mutation carriers are supportive of offering PGD to others, thus endorsing the HFEA decision. However, most women would not consider it personally. Concerns raised highlight the need for regular HFEA reviews of the licensing criteria, as HBOC may cease to be a "serious life threatening illness" in the future.

Community attitudes towards performing cardiopulmonary resuscitation in Western Australia

OBJECTIVE

to determine the attitudes of the Western Australian community towards performing cardiopulmonary resuscitation, and the factors affecting these attitudes.

METHODS

telephone survey of a randomly selected sample of people from suburban Perth and rural Western Australia; practical assessment of a sub-sample of volunteers from those surveyed, to correlate survey answers with practical skills.

RESULTS

of 803 people surveyed, the majority (90.7%) definitely would give mouth-to-mouth ventilation to a friend or relative, but less than half (47.2%) would to a stranger. The reluctance was mostly (56%) because of health and safety concerns, particularly related to HIV infection. Higher percentages of people would definitely provide cardiac massage for a friend or relative (91.4%) or stranger (78.1%). People were more likely to give mouth-to-mouth and cardiac massage if they had been trained in cardiopulmonary resuscitation (CPR), trained several times, trained recently, and used their CPR skills in real life. There were no significant differences between city and country people in whether they would provide CPR, but older people were less willing to provide mouth-to-mouth or cardiac massage. On practical assessment of 100 volunteers, there were significant errors and omissions in airway assessment, mouth-to-mouth resuscitation and cardiac massage. Volunteers with better practical scores were more prepared to provide CPR.

DISCUSSION

our results indicate a significant reluctance of the Western Australia public to perform mouth-to-mouth, except to a friend or relative. Earlier CPR training, practice and use seemed to diminish this reluctance. Practical CPR skills were not well executed. Those with better skills were less reluctant to use them. We recommend increasing CPR training in the community, greater frequency of refresher courses and public education on the risks of CPR to improve rates of bystander CPR.

The adnexal mass: benign or malignant? Evaluation of a risk of malignancy index

OBJECTIVE

To validate a risk of malignancy index incorporating menopausal status, serum CA 125 level and pelvic ultrasound features in the pre-operative diagnosis of ovarian cancer.

DESIGN

A retrospective observational study.

SETTING

Department of Obstetrics and Gynaecology, The Royal London Hospital.

SUBJECTS

One hundred and twenty-four women admitted consecutively to the gynaecology department for surgical exploration of an adnexal mass.

MAIN OUTCOME MEASURES

The sensitivities and specificities of menopausal status, serum CA 125 level and ultrasound features, in isolation and combined (the risk of malignancy index (RMI)), for diagnosing ovarian cancer.

RESULTS

Tested on a new population of women, the RMI retained the high sensitivity for diagnosing ovarian cancer seen in the original report describing its derivation. The specificity, however, was lower. The study confirmed that the RMI is more accurate than the individual criteria in diagnosing ovarian cancer, and was comparable with other scoring systems.

CONCLUSIONS

The risk of malignancy index is a simple scoring system for ovarian cancer. Application of the risk of malignancy index in clinical practice may provide a rational basis for specialist referral of patients with ovarian cancer before diagnostic surgery.

Effects of caffeine, ephedrine and their combination on time to exhaustion during high-intensity exercise

This study investigated the effects of acute ingestion of caffeine (C), ephedrine (E) and their combination (C+E) on time to exhaustion during high-intensity exercise. Using a repeated-measures, double-blind design, eight male subjects exercised on a cycle ergometer at a power output that led to exhaustion after about 12.6 min during a placebo (P) control trial. They did this 1.5 h after ingesting either C (5 mg x kg[-1]), E (1 mg x kg[-1]), C+E, or P. Trials were separated by 1 week. Venous blood was sampled before and during exercise. The mean (SD) times to exhaustion were 12.6 (3.1) (P), 14.4 (4.1) (C), 15.0 (5.7) (E) and 17.5 (5.8) (C+E) min. Only the C+E treatment significantly increased time to exhaustion compared to P. Oxygen consumption (VO2), carbon dioxide production (VCO2), minute ventilation (VE) and the respiratory exchange ratio (RER) were similar during exercise for all trials. Heart rate during exercise was significantly increased for the C+E and C trials compared to P. Subjective ratings of perceived exertion during exercise were significantly lower after C+E compared to P. All treatments significantly increased lactate levels. Free fatty acid (FFA) levels were significantly increased by C ingestion. Glycerol levels were increased by C+E and C ingestion. Glucose levels were also higher with the drug treatments compared to P. Increased monamine availability after C+E treatment was suggested by measurements of catecholamines and dopamine. In conclusion, the combination of C+E significantly prolonged exercise time to exhaustion compared to P, while neither C nor E treatments alone significantly changed time to exhaustion. The improved performance was attributed to increased central nervous system stimulation.

Sprint training effects on muscle myoglobin, enzymes, fiber types, and blood lactate

The purpose of this study was to determine if changes in intra-muscular myoglobin concentration accompany histochemical and enzymatic adaptations to supra-maximal exercise training. Subjects were assigned to either a training group (N = 11), who trained 2 to 3 times weekly for 6 wk, or a control group (N = 6). Training progressed from two 15-s and two 30-s "all-out" sprints on a cycle ergometer during week 1 to six 15-s and six 30-s bouts per session during week 6. The Wingate test was performed before and after the 6 wk, but performance variables were not changed in either group. In the training group, peak lactate after the Wingate test was significantly higher after training. No significant changes in enzyme activities, myoglobin concentration, or fiber-type frequency were observed in the control group. In contrast, in the training group, the percent fast twitch oxidative fibers increased, myoglobin decreased, and both citrate synthase and phosphofructokinase activities increased (P less than 0.05). The results suggest that muscle myoglobin concentration is not increased by 6 wk of supra-maximal exercise training and that such training induces cellular adaptations without accompanying performance changes. Alternatively, the Wingate test is not a sensitive test of adaptations to the training.

Muscle glycogen and diet in elite soccer players

The top players in an elite soccer team volunteered as subjects in a study to determine intramuscular glycogen concentrations after a regular season match, and whether optimal glycogen levels could be re-attained prior to the team's next match. Fifteen players were biopsied in the M. vastus lateralis following a regular season game (Day I). Of these, eight were biopsied 24 h later in the evening of a free day during which no training session was held (Day II), and again 24 h later after a very light training session (Day III). Muscle glycogen concentrations for the eight players averaged (+/- SD) 45.9 +/- 7.9, 68.9 +/- 2.7, and 72.8 +/- 8.3 mmol glucose units x kg-1 wet muscle weight on Day I, Day II, and Day III respectively. Dietary records were analysed during a week of peak, season competition and training. The average daily total energy consumption and total quantity of carbohydrates consumed were less than what is normally consumed by athletes in similar sports. The inability of the players to maintain even normal, resting levels of muscle glycogen is probably related to their dietary practices.

Influences on multidisciplinary team decision-making

The objective is to explore how clinical decisions are made in a cancer multidisciplinary team meeting (MDM). The study design is qualitative based on participant observation, in depth interviews, and questionnaires. The research setting was weekly cancer MDM which provides a forum for clinical debate for practitioners in the field of women's health, working within one Cancer Network in England. The participants were 53 practitioners attending a weekly MDM over a 4-month period. Analysis of nonparticipant observation data and practitioner interview narratives identified key influences on the work of the MDM, and in particular decision-making. The research identified three major influences on the conduct of the MDM. First, MDM discussions are dominated by those with surgical, medical, or diagnostic expertise with limited contributions from those with a nursing, palliative, or psychosocial background. Second, decision-making is shaped by an overriding need to comply with policy initiatives concerning the organization of diagnosis and treatment. The third influence is whether the patient is known or unknown to some degree by members of the MDM. Where there is preexisting knowledge of the patient, the discussion and decision is inclusive of a wider range of disciplines. Team working in these circumstances is an acknowledged source of satisfaction and motivation. Where the patient is not known, discussion concerns only the physical details necessary to make a diagnosis and contributions from the wider team (including those with knowledge of psychosocial care) are rare. Practitioners' sphere of expertise, Department of Health policy, and familiarity of the team with the patient are key factors in shaping decision-making in MDMs.