The complete BRCA2 gene and mutations in chromosome 13q-linked kindreds

Breast carcinoma is the most common malignancy among women in developed countries. Because family history remains the strongest single predictor of breast cancer risk, attention has focused on the role of highly penetrant, dominantly inherited genes in cancer-prone kindreds (1). BRCA1 was localized to chromosome 17 through analysis of a set of high-risk kindreds (2), and then identified four years later by a positional cloning strategy (3). BRCA2 was mapped to chromosomal 13q at about the same time (4). Just fifteen months later, Wooster et al. (5) reported a partial BRCA2 sequence and six mutations predicted to cause truncation of the BRCA2 protein. While these findings provide strong evidence that the identified gene corresponds to BRCA2, only two thirds of the coding sequence and 8 out of 27 exons were isolated and screened; consequently, several questions remained unanswered regarding the nature of BRCA2 and the frequency of mutations in 13q-linked families. We have now determined the complete coding sequence and exonic structure of BRCA2 (GenBank accession #U43746), and examined its pattern of expression. Here, we provide sequences for a set of PCR primers sufficient to screen the entire coding sequence of BRCA2 using genomic DNA. We also report a mutational analysis of BRCA2 in families selected on the basis of linkage analysis and/or the presence of one or more cases of male breast cancer. Together with the specific mutations described previously, our data provide preliminary insight into the BRCA2 mutation profile.

Prevalence and patterns of Gulf War illness in Kansas veterans: association of symptoms with characteristics of person, place, and time of military service

Gulf War veterans have reported health problems that they attribute to their military service, but little is understood about the nature or extent of these conditions. To determine whether Kansas Gulf War veterans are affected by excess health problems, a population-based survey of 1,548 veterans who served in the Persian Gulf War (PGW) and 482 veterans who served elsewhere (non-PGW) was conducted in 1998. Gulf War illness, defined as having chronic symptoms in three of six domains, occurred in 34% of PGW veterans, 12% of non-PGW veterans who reported receiving vaccines during the war, and 4% of non-PGW veterans who did not receive vaccines. The prevalence of Gulf War illness was lowest among PGW veterans who served on board ship (21%) and highest among those who were in Iraq and/or Kuwait (42%). Among PGW veterans who served away from battlefield areas, Gulf War illness was least prevalent among those who departed the region prior to the war (9%) and most prevalent among those who departed in June or July of 1991 (41%). Observed patterns suggest that excess morbidity among Gulf War veterans is associated with characteristics of their wartime service, and that vaccines used during the war may be a contributing factor.

Cancer risks in two large breast cancer families linked to BRCA2 on chromosome 13q12-13

The penetrance of the BRCA2 gene on chromosome 13q12-13 has been estimated in two large, systematically ascertained, linked families, by use of a maximum-likelihood method to incorporate both cancer-incidence data and 13q marker typings in the families. The cumulative risk of breast cancer in female gene carriers was estimated to be 59.8% by age 50 years (95% confidence interval [95% CI] 25.9%-78.5%) and 79.5% by age 70 years (95% CI 28.9%-97.5%). The cumulative risk of breast cancer in male carriers was estimated to be 6.3% (95% CI 1.4%-25.6%) by age 70 years. There was no evidence of any risk difference between the two families. These results indicate that the lifetime breast cancer risk in BRCA2 carriers, for at least a subset of mutations, is comparable to that for BRCA1. A significant excess of ovarian cancer in gene carriers was observed (relative risk 17.69, based on three cases), but the absolute risk of ovarian cancer was less than that reported for BRCA1. Significant excesses of laryngeal cancer (relative risk 7.67, based on two possible carriers) and prostate cancer (relative risk 2.89, based on five possible carriers) were also observed. One case of ocular melanoma, as well as a second eye cancer of unspecified histology, occurred in obligate gene carriers.

Tumor development in the Beckwith-Wiedemann syndrome is associated with a variety of constitutional molecular 11p15 alterations including imprinting defects of KCNQ1OT1

Dysregulation of imprinted genes on human chromosome 11p15 has been implicated in Beckwith-Wiedemann syndrome (BWS), an overgrowth syndrome associated with congenital malformations and tumor predisposition. The molecular basis of BWS is complex and heterogeneous. The syndrome is associated with alterations in two distinct imprinting domains on 11p15: a telomeric domain containing the H19 and IGF2 genes and a centromeric domain including the KCNQ1OT1 and CDKNIC genes. It has been postulated that disorders of imprinting in the telomeric domain are associated with overgrowth and cancer predisposition, whereas those in the centromeric domain involve malformations but not tumor development. In this study of 125 BWS cases, we confirm the association of tumors with constitutional defects in the 11p15 telomeric domain; six of 21 BWS cases with uniparental disomy (UPD) of 11p15 developed tumors and one of three of the rare BWS subtype with hypermethylation of the H19 gene developed tumors. Most importantly, we find that five of 32 individuals with BWS and imprinting defects in the centromeric domain developed embryonal tumors. Furthermore, the type of tumors observed in BWS cases with telomeric defects are different from those seen in BWS cases with defects limited to the centromeric domain. Whereas Wilms' tumor was the most frequent tumor seen in BWS cases with UPD for 11p15 or H19 hypermethylation, none of the embryonal tumors with imprinting defects at KCNQ1OT1 was a Wilms' tumor. This suggests that distinct tumor predisposition profiles result from dysregulation of the telomeric domain versus the centromeric domain and that these imprinting defects activate distinct genetic pathways for embryonal tumorigenesis.

Measles virus causes immunogenic cell death in human melanoma

Oncolytic viruses (OV) are promising treatments for cancer, with several currently undergoing testing in randomised clinical trials. Measles virus (MV) has not yet been tested in models of human melanoma. This study demonstrates the efficacy of MV against human melanoma. It is increasingly recognised that an essential component of therapy with OV is the recruitment of host antitumour immune responses, both innate and adaptive. MV-mediated melanoma cell death is an inflammatory process, causing the release of inflammatory cytokines including type-1 interferons and the potent danger signal HMGB1. Here, using human in vitro models, we demonstrate that MV enhances innate antitumour activity, and that MV-mediated melanoma cell death is capable of stimulating a melanoma-specific adaptive immune response.

Gene-centric meta-analysis in 87,736 individuals of European ancestry identifies multiple blood-pressure-related loci

Blood pressure (BP) is a heritable risk factor for cardiovascular disease. To investigate genetic associations with systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP), we genotyped ~50,000 SNPs in up to 87,736 individuals of European ancestry and combined these in a meta-analysis. We replicated findings in an independent set of 68,368 individuals of European ancestry. Our analyses identified 11 previously undescribed associations in independent loci containing 31 genes including PDE1A, HLA-DQB1, CDK6, PRKAG2, VCL, H19, NUCB2, RELA, HOXC@ complex, FBN1, and NFAT5 at the Bonferroni-corrected array-wide significance threshold (p < 6 × 10(-7)) and confirmed 27 previously reported associations. Bioinformatic analysis of the 11 loci provided support for a putative role in hypertension of several genes, such as CDK6 and NUCB2. Analysis of potential pharmacological targets in databases of small molecules showed that ten of the genes are predicted to be a target for small molecules. In summary, we identified previously unknown loci associated with BP. Our findings extend our understanding of genes involved in BP regulation, which may provide new targets for therapeutic intervention or drug response stratification.

The epidemiology of chronic fatigue in San Francisco

Despite considerable research on chronic fatigue syndrome (CFS) and conditions associated with unexplained chronic fatigue (CF), little is known about their prevalence and demographic distribution in the population. The present study describes the epidemiology and characteristics of self-reported CF and related conditions in a diverse urban community. The study used a cross-sectional telephone screening survey of households in San Francisco, followed by interviews with fatigued and nonfatigued residents. Respondents who appeared to meet case definition criteria for CFS, based on self-reported fatigue characteristics, symptoms, and medical history, were classified as CFS-like cases. Subjects who reported idiopathic chronic fatigue (ICF) that did not meet CFS criteria were classified as ICF-like cases. Screening interviews were completed for 8,004 households, providing fatigue and demographic information for 16,970 residents. Unexplained CF was extremely rare among household residents <18 years of age, but was reported by 2% of adult respondents. A total of 33 adults (0.2% of the study population) were classified as CFS-like cases and 259 (1.8%) as ICF-like cases. Neither condition clustered within households. CFS- and ICF-like illnesses were most prevalent among women and persons with annual household incomes below $40,000, and least prevalent among Asians. The prevalence of CFS-like illness was elevated among African Americans, Native Americans, and persons engaged in clerical occupations. Although CFS-like cases were more severely ill than those with ICF-like illness, a similar symptom pattern was observed in both groups. In conclusion, conditions associated with unexplained CF occur in all sociodemographic groups but appear to be most prevalent among women, persons with lower income, and some racial minorities.

Sphingomyelin-derived lipids differentially regulate the extracellular signal-regulated kinase 2 (ERK-2) and c-Jun N-terminal kinase (JNK) signal cascades in airway smooth muscle

In ASM cells platelet-derived growth factor stimulates rapid transient sphingosine phosphate formation, the activation of extracellular signal-regulated kinase 2 (ERK-2), the phosphorylation of p70(56K), and a ninefold increase in DNA synthesis. In contrast, this growth factor fails to activate c-Jun N-terminal kinase (JNK). Based upon these findings, we have tested whether the sphingomyelin-derived sphingolipids play a role in growth factor signalling by assessing their effect on ERK-2, JNK, and p70(56K). We demonstrate that sphingosine phosphate induces the activation of ERK-2, is ineffective against JNK, and fails to induce the phosphorylation of p70(56K). The latter may explain why it is a poor mitogen when added directly to ASM cells. In contrast, sphingosine and cell-permeable ceramides elicit the prominent tyrosyl phosphorylation and activation of JNK, are poor stimulators of ERK-2, and do not induce the phosphorylation of p70(56K). Therefore, the specificity of signalling through either ERK-2 or JNK cascades may be determined by the rapid agonist-dependent interconversion of these sphingomyelin-derived lipids. This may also provide a dynamic mechanism that enables growth factors and cytokines to elicit pleiotropic cell responses, such as proliferation and cell survival. For instance, both ceramide and sphingosine will elicit growth arrest via activation of JNK, whereas sphingosine phosphate will potentiate growth-factor-stimulated DNA synthesis, a consequence of the activation of ERK-2, Furthermore, under certain conditions, sphingosine and ceramide stimulate cAMP formation, a negative modulator of cell growth, whereas sphingosine phosphate depresses cAMP, thereby enhancing its own growth-promoting properties. From these studies, it is evident that sphingosine phosphate displays a signalling profile that is consistent with it mediating part of the action of platelet-derived growth factor.

Response to radiation therapy and prognosis in breast cancer patients with BRCA1 and BRCA2 mutations

BACKGROUND AND PURPOSE

The purpose of this study is to evaluate overall survival in BRCA1 or BRCA2 breast cancer patients, describe presenting stage, review histologic findings and evaluate response to radiotherapy.

MATERIALS AND METHODS

A retrospective study was performed evaluating breast cancer patients with known mutations of BRCA1 or BRCA2. Patients from 12 different pedigrees were cross-referenced with the Utah Cancer Registry (UCR), histologic findings were verified and radiotherapy records were reviewed for acute response to treatment. Actuarial survival calculations were performed and patients were matched for age, date of diagnosis and tumor size.

RESULTS

Thirty breast cancer patients with BRCA1 mutations were found to have 34 breast cancers (four had bilateral metachronous lesions) and 20 breast cancer patients with BRCA2 mutations were found to have 22 breast cancers (two had bilateral metachronous disease). The median age at diagnosis was 49 years (range 21-77 years) and 42 years (range 23-83 years), respectively, for BRCA1 and BRCA2 patients. Unusual histologic types of breast cancers were represented with 7% (4/56) medullary and 5% (3/56) lobular carcinomas. Complete staging was possible for 63% (35/56) of cancers. Stages I, II, III and IV represented 26, 63, 6 and 6% of cancers, respectively. The most severe radiation reaction was moist desquamation which was self-limiting and developed in 29% (6/21) of irradiated patients. The mean follow-up was 9.8 and 7.5 years for BRCA1 and BRCA2 cancers, respectively. Kaplan-Meier survival analysis demonstrated 5-year survival values of 75% for BRCA1 patients, 73% for BRCA2 patients, 70% for matched controls and 69% for UCR controls. No statistically significant differences were evident between the groups at 5 or 10 years.

CONCLUSIONS

Despite their younger age at presentation, breast cancer patients harboring BRCAI or BRCA2 mutations present at a similar stage, display a normal acute reaction to radiotherapy and have a similar prognosis when compared with sporadic breast cancer patients.

Inflammatory tumour cell killing by oncolytic reovirus for the treatment of melanoma

Reovirus is a promising unmodified double-stranded RNA (dsRNA) anti-cancer oncolytic virus, which is thought to specifically target cells with activated Ras. Although reovirus has been tested in a wide range of preclinical models and has entered early clinical trials, it has not previously been tested for the treatment of human melanoma. Here, we show that reovirus effectively kills and replicates in both human melanoma cell lines and freshly resected tumour; intratumoural injection also causes regression of melanoma in a xenograft in vivo model. Reovirus-induced melanoma death is blocked by caspase inhibition and is dependent on constituents of the Ras/RalGEF/p38 pathway. Reovirus melanoma killing is more potent than, and distinct from, chemotherapy or radiotherapy-induced cell death; a range of inflammatory cytokines and chemokines are released by infected tumour cells, while IL-10 secretion is abrogated. Furthermore, the inflammatory response generated by reovirus-infected tumour cells causes bystander toxicity against reovirus-resistant tumour cells and activates human myeloid dendritic cells (DC) in vitro. Hence, reovirus is suitable for clinical testing in melanoma, and may provide a useful danger signal to reverse the immunologically suppressive environment characteristic of this tumour.

Immune responses associated with chronic fatigue syndrome: a case-control study

An exploratory case-control study was conducted to assess whether the many reported differences in the immune function of chronic fatigue syndrome (CFS) patients are detectable in rigorously defined cases of CFS. Although many studies have reported differences between cases and controls in various measures of immune function, none of these differences were found in all studies. In this study, no differences were found in white blood cell numbers; immune complex, complement, or serum immunoglobulin levels; delayed type hypersensitivity and allergic responses; NK cell function; and proliferative responses to mitogens and antigens. Marginal differences were detected in cytokine responses and in cell surface markers in the total CFS population. However, when the patients were subgrouped by type of disease onset (gradual or sudden) or by how well they were feeling on the day of testing, more pronounced differences were seen.

Quantitative methods in research on complementary and alternative medicine. A methodological manifesto. NIH Office of Alternative Medicine

OBJECTIVES

This article summarizes the deliberations of the Quantitative Methods Working Group convened by the National Institutes of Health (NIH) in support of the NIH Office of Alternative Medicine.

METHODS

The working group was charged with identifying methods of study design and data analysis that can be applied to empirical research on complementary and alternative medicine. This charge was broad and inclusive and addressed the evaluation of alternative therapies, the investigation of the basic science of complementary medical systems, studies of health promotion and disease prevention, and health services research.

RESULTS

The working group produced a "methodological manifesto," a summary list of seven recommended methodological guidelines for research on alternative medicine. These recommendations emphasize the robustness of existing research methods and analytic procedures despite the substantive unconventionality of alternative medicine.

CONCLUSIONS

Contrary to the assertions of many researchers and alternative practitioners, established methodologies (eg, experimental trials, observational epidemiology, social survey research) and data-analytic procedures (eg, analysis of variance, logistic regression, multivariate modeling techniques) are quite satisfactory for addressing the majority of study questions related to alternative medicine, from clinical research on therapeutic efficacy to basic science research on mechanisms of pathogenesis and recovery.

Longitudinal study of dental health behaviors and other caries predictors in early childhood

This longitudinal study of 231 preschoolchildren from a medium sized Norwegian town had three aims: firstly, to examine the children's early dental behavior, secondly to study the variation of dental health behavior according to mother's education, mother's dental health, and her dental attendance pattern, and thirdly to identify any behavioral or social predictors of dental caries in 36-month-old children. Data were collected at health centers, using precoded questionnaires and examinations, when the children were 6, 18, and 36 months old. Data about the mothers were collected at the maternity ward. At 36 months of age, 80% of the children were caries free. Favorable dental behaviors were related to toothbrushing and use of fluorides. These behaviors were so well established and consistent at all ages that they can be regarded as norms for this community. The most unfavorable and inconsistent behavior was related to sugar consumption. Dental health education could be most usefully applied to this area, where the greatest potential for improvement in behavior exists. A relationship was found between the children's caries experience and the number of missing teeth of the mother, her dental attendance pattern and her level of education. None of the social or behavioral variables tested had a strong enough association with caries experience to justify their use as caries predictors in this age group.

A KRAS variant is a biomarker of poor outcome, platinum chemotherapy resistance and a potential target for therapy in ovarian cancer

Germ-line variants in the 3′ untranslated region (3′UTR) of cancer genes disrupting microRNA (miRNA) regulation have recently been associated with cancer risk. A variant in the 3′UTR of the KRAS oncogene, referred to as the KRAS-variant, is associated with both cancer risk and altered tumor biology. Here we test the hypothesis that the KRAS-variant can act as a biomarker of outcome in epithelial ovarian cancer (EOC), and investigate the cause of altered outcome in KRAS-variant positive EOC patients. As this variant appears to be associated with tumor biology, we additionally test the hypothesis that this variant can be directly targeted to impact cell survival.

EOC patients with complete clinical data were genotyped for the KRAS-variant and analyzed for outcome (n=536), response to neoadjuvant chemotherapy (n=125), and platinum resistance (n=306). Outcome was separately analyzed for women with known BRCA mutations (n=79). Gene expression was analyzed on a subset of tumors with available tissue. Cell lines were employed to confirm altered sensitivity to chemotherapy with the KRAS-variant. The KRAS-variant was directly targeted through siRNA/miRNA oligonucleotides in cell lines and survival was measured.

Post-menopausal EOC patients with the KRAS-variant were significantly more likely to die of ovarian cancer by multivariate analysis (HR=1.67, 95% CI=1.09–2.57, p=0.019, n=279). Possibly explaining this finding, EOC patients with the KRAS-variant were significantly more likely to be platinum resistant (OR=3.18, CI=1.31–7.72, p=0.0106, n=291). Additionally, direct targeting of the KRAS-variant led to a significant reduction in EOC cell growth and survival in vitro.

These findings confirm the importance of the KRAS-variant in EOC, and indicate that the KRAS-variant is a biomarker of poor outcome in EOC likely due to platinum resistance. In addition, this work supports the hypothesis that these tumors have continued dependence on such 3′UTR lesions, and that direct targeting may be a viable future treatment approach.

The clinical and genetic epidemiology of neuronal ceroid lipofuscinosis in Newfoundland

The neuronal ceroid lipofuscinoses (NCLs) are the commonest neurodegenerative disorders of children. The aims of this study were to determine the incidence of NCL in Newfoundland, identify the causative genes, and analyze the relationship between phenotype and genotype. Patients with NCL diagnosed between 1960 and 2005 were ascertained through the provincial genetics and pediatric neurology clinics. Fifty-two patients from 34 families were identified. DNA was obtained from 28/34 (82%) families; 18 families had mutations in the CLN2 gene, comprising five different mutations of which two were novel. One family had a CLN3 mutation, another had a novel mutation in CLN5, and five families shared the same mutation in CLN6. One family was misdiagnosed, and in two, molecular testing was inconclusive. Disease from CLN2 mutations had an earlier presentation (p = 0.003) and seizure onset (p < 0.001) compared with CLN6 mutation. There was a slower clinical course for those with CLN5 mutation compared with CLN2 mutation. NCL in Newfoundland has a high incidence, 1 in 7353 live births, and shows extensive genetic heterogeneity. The incidence of late infantile NCL, 9.0 per 100,000 (or 1 in 11,161) live births, is the highest reported in the world.

Seroepidemiology of chronic fatigue syndrome: a case-control study

We performed serological testing for a large number of infectious agents in 26 patients from Atlanta who had chronic fatigue syndrome (CFS) and in 50 controls matched by age, race, and sex. We did not find any agent associated with CFS. In addition, we did not find elevated levels of antibody to any of a wide range of agents examined. In particular, we did not find elevated titers of antibody to any herpesvirus, nor did we find evidence of enteroviral exposure in this group of patients.

The contribution of serum enzymes and carcinoembryonic antigen to the early diagnosis of metastatic colorectal cancer

The evolution of metastatic colorectal cancer in patients who have had surgical treatment for a primary lesion was studied in relation the progressive changes in the blood levels of carcinembryonic antigen (CEA), to gamma glutamyl transpeptidase (GGT) and routine liver function tests (LFTs). Involvement of the liver could ofter be reliably predicted many weeks in advance of clinical diagnosis while metastases to other sites were less likely to be detected early by this test. The association of the extent of disease with the patterns of biochemical changes is discussed with reference to several illustrative examples.

Solubilization of subtilisin in CO2 using fluoroether-functional amphiphiles

Carbon dioxide is a naturally abundant, environmentally benign solvent whose use, like water, in a process is not regulated by either EPA or FDA. Unfortunately, polar compounds such as amino acids and proteins are essentially insoluble in carbon dioxide. Further, alkyl-functional surfactants, which have been shown to allow extraction of proteins into conventional organic solvents, exhibit very poor or negligible solubility in CO2 at pressures below 50 MPa. Consequently, highly CO2-soluble fluoroether-functional surfactants have been generated and used to solubilize subtilisin Carlsberg from aqueous buffer and cell culture medium into CO2, with recovery accomplished by depressurization. Both the amount of protein solubilized in the emulsion and the extent of activity retention by the protein following recovery are functions of the initial protein concentration in the buffer. This, plus the observation that the presence of protein affects the stability of the emulsion, suggests that some of the protein is sacrificed to act as a stabilizer in these systems. In addition to solubilization via an inverse emulsion, it has also been shown that one can strip protein-surfactant aggregates from a middle phase emulsion using pure CO2, suggesting an ion-pairing type mechanism.

Recommended practices for surveillance. Association for Professionals in Infection Control and Epidemiology, Inc. Surveillance Initiative working Group

Demonstration of quality health care includes documentation of outcomes of care. Surveillance is a comprehensive method of measuring outcomes and related processes of care, analyzing the data, and providing information to members of the health care team to assist in improving those outcomes. Surveillance is an essential component of effective clinical programs designed to reduce the frequency of adverse events such as infection or injury. Although there is no single or "right" method of surveillance design or implementation, sound epidemiologic principles must form the foundation of effective systems and must be understood by key participants in the surveillance program and supported by senior management. Teamwork and collaboration across the health care spectrum are important for the development of surveillance plans. Each health care organization must tailor its surveillance systems to maximize resources by focusing on population characteristics, outcome priorities, and organizational objectives. To ensure quality of surveillance, the following elements must be incorporated: A written plan should serve as the foundation of any surveillance program. The plan should outline important objectives and elements of the surveillance process so that resources can be targeted appropriately. Thoroughness or intensity of surveillance for an area of interest must be maintained at the same level over time. Fluctuations of a surveillance rate have no meaning unless the same level of data collection is maintained. External rate comparisons are meaningless unless the systems used have comparable intensity. All the elements of surveillance should be used with consistency over time. This includes application of surveillance definitions and rate calculation methods. Personnel resources need to be appropriate for the type of surveillance being performed. This includes trained professionals who understand epidemiology and who have access to continuing professional education opportunities. Other resources essential to surveillance include computer support, information and technology services, clerical services, and administrative understanding and support to maintain a quality program. As a means of quality control and to ensure accuracy, the data and process of surveillance should undergo periodic evaluation and validation. This document is intended to assist professionals who plan and conduct surveillance programs as well as those who assure that there is appropriate organizational support to accomplish appropriate surveillance. While design of surveillance systems must be unique for each organization, incorporation of these seven core Recommended Practices for Surveillance provides a scientific framework to approach surveillance programs.

Rural and remote oral health, problems and models for improvement: a Western Australian perspective

Oral healthcare in rural communities shares many of the dilemmas faced by medicine in providing services to large geographical areas with dispersed populations. This study examined the population data and service provision data relevant to the geographical distribution of oral health care in Western Australia (WA). Of the 1.7 million people resident in WA, 72% were resident in the five major urban centres with only 13% in rural and remote regions. Of the 320 postcode regions, 186 had a population of less than 2500, 31 had a population from 2500 to 5000, 42 from 5000 to 10,000, 37 from 10,000 to 20,000, and 24 had a population greater that 20,000. Almost 80% of postcode regions with a population less than 2500 are in non-urban regions. Of the total of 690 dentists who were analysed in this study, it was found that the vast majority (greater than 85%) worked in practices in postcode regions within metropolitan Perth or the major urban centres. A total of 43 postcode regions did not have a dental practice within their bounds. In order to address this disparity in service availability, strategies including the development of training for medical practitioners and auxiliaries, the use of modern technology, school-based programs and the development of interdisciplinary links should be implemented. These strategies would also facilitate the development of closer links between medical and dental practitioners and the development of skills within the medical fraternity that would facilitate improved oral health in rural and remote communities.

Perinatal depressive symptomatology among lesbian and bisexual women

Lesbian and bisexual women who were pregnant (N=16), biological (N=18) or non-biological (N=15) parents completed the Edinburgh Postnatal Depression Scale (EPDS), and scores were compared to a previously published heterosexual sample. Lesbian and bisexual biological mothers had significantly higher EPDS scores than the previously published sample of heterosexual women. Results suggest that perinatal depression is not less common and may be more common among lesbian and bisexual women relative to heterosexual women. Additional, longitudinal studies are needed.

A heterogeneous outbreak of Enterobacter cloacae and Serratia marcescens infections in a surgical intensive care unit

OBJECTIVE

To investigate an outbreak of invasive disease due to Enterobacter cloacae and Serratia marcescens in a surgical intensive care unit (ICU).

DESIGN

Pulsed-field gel electrophoresis (PFGE) analysis of restriction fragments was used to characterize the outbreak isolate genotypes. A retrospective cohort study of surgical ICU patients was conducted to identify risk factors associated with invasive disease. Unit staffing data were analyzed to compare staffing levels during the outbreak to those prior to and following the outbreak.

SETTING

An urban hospital in San Francisco, California.

PATIENTS

During the outbreak period, December 1997 through January 1998, there were 52 patients with a minimum ICU stay of > or = 72 hours. Of these, 10 patients fit our case definition of recovery of E. cloacae or S. marcescens from a sterile site.

RESULTS

PFGE analysis revealed a highly heterogeneous population of isolates. Bivariate analysis of patient-related risk factors revealed duration of central lines, respiratory colonization, being a burn patient, and the use of gentamicin or nafcillin to be significantly associated with invasive disease. Both respiratory colonization and duration of central lines remained statistically significant in a multivariate analysis. Staffing data suggested a temporal correlation between understaffing and the outbreak period.

CONCLUSIONS

Molecular epidemiological techniques provided a rapid means of ruling out a point source or significant cross-contamination as modes of transmission. In this setting, patient-related risk factors, such as respiratory colonization and duration of central lines, may provide a focus for heightened surveillance, infection control measures, and empirical therapy during outbreaks caused by common nosocomial pathogens. In addition, understaffing of nurses may have played a role in this outbreak, highlighting the importance of monitoring staffing levels.

Combination of carcinoembryonic antigen and gamma glutamyl transpeptidase in the study of the evolution of colorectal cancer

Plasma CEA values and serum γ glutamyl transpeptidase activities have been compared in control subjects and 109 patients with colorectal carcinoma and 35 with non-malignant hepatic disease. CEA values alone differentiate hepatic metastases from non-malignant hepatic disease with a high degree of certainty. While CEA may be elevated with metastases, irrespective of site, γGT is elevated mainly in association with hepatic metastases. The combination of CEA and γGT is helpful in identifying hepatic metastases and in their differentiation from local recurrences or metastases to other sites.

New chromosome 11p15 epigenotypes identified in male monozygotic twins with Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is an overgrowth syndrome demonstrating heterogeneous molecular alterations of two imprinted domains on chromosome 11p15. The most common molecular alterations include loss of methylation at the proximal imprinting center, IC2, paternal uniparental disomy (UPD) of chromosome 11p15 and hypermethylation at the distal imprinting center, IC1. An increased incidence of female monozygotic twins discordant for BWS has been reported. The molecular basis for eleven such female twin pairs has been demonstrated to be a loss of methylation at IC2, whereas only one male monozygotic twin pair has been reported with this molecular defect. We report here two new pairs of male monozygotic twins. One pair is discordant for BWS; the affected twin exhibits paternal UPD for chromosome 11p15 whereas the unaffected twin does not. The second male twin pair is concordant for BWS and both twins of the pair demonstrate hypermethylation at IC1. Thus, this report expands the known molecular etiologies for BWS twins. Interestingly, these findings demonstrate a new epigenotype-phenotype correlation in BWS twins. That is, while female monozygotic twins with BWS are likely to show loss of imprinting at IC2, male monozygotic twins with BWS reflect the molecular heterogeneity seen in BWS singletons. These data underscore the need for molecular testing in BWS twins, especially in view of the known differences among 11p15 epigenotypes with respect to tumor risk.