Abnormal Stool Blood Tests and Colorectal Cancer Mortality in a Large United States Cohort

Our aim was to examine the association between fatal colorectal cancer (CRC) and time to colonoscopy among individuals who underwent diagnostic colonoscopy after abnormal stool blood test (SBT) in a cohort of United States Veterans. Methods: We performed a cohort study of Veterans aged 50–75 years, with an abnormal SBT using the Veterans Health Administration's (VA) national electronic health record data during the years 1999 and 2010. Colonoscopy receipt was ascertained using current procedural terminology codes after abnormal SBT. The study outcome, CRC death, was defined through National Death Index cause-specific mortality data. We followed patients through CRC-related death, other death, or until December 31, 2015. Multivariable Cox proportional hazards modeling was used to generate CRC-specific mortality hazard ratios (HRs) and 95% confidence intervals (CI) for 3-month colonoscopy intervals, with 3–6 months as the reference. Models were adjusted for age, sex, race/ethnicity, smoking, diabetes, body mass index, and Charlson Comorbidity Index. Results: We included 222,004 patients with abnormal SBTs; the average age was 63 with a standard deviation of 7.2 years, 97% were male, 72% were Non-Hispanic White and 20% were Black. Of the 222,004 patients, 69% completed diagnostic colonoscopy within 12 months of abnormal SBT, 4% were diagnosed with CRC, and 1% died of CRC specific death. Compared to patients with a colonoscopy at 3–6 months (standard of care), CRC-related mortality risk was significantly higher for patients with colonoscopies at 0–3 months (HR = 1.29; 95% CI, 1.14–1.47), 18–21 months (HR = 1.57; 95% CI, 1.19–2.06), and 21–24 months (HR = 1.46; 95% CI, 1.07–1.97). No significant increase in mortality risk was shown for 6–9 month, 9–12 month, 12–15 month, 15–18 months, and 24+ month intervals. Conclusion: Time to colonoscopy plays a significant role in CRC death after abnormal SBT. Compared to a colonoscopy performed during a 3–6-month window, a colonoscopy performed outside of the 15-month window had a higher risk for mortality. Given the impact of timely diagnostic colonoscopy on CRC mortality, development of interventions to increase timely diagnostic follow-up after abnormal SBT are essential to CRC outcome improvement.

Abstract P5-13-08: Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients

Introduction

Preoperative chemotherapy can demonstrate an individual's response to the chemotherapeutic regimen by comparing the amount of cancer at presentation to the amount remaining after treatment. Multiple previous studies have demonstrated that the amount of residual cancer, or final pathologic stage, is a better indicator of prognosis than the initial stage at presentation.

Tumor infiltrating lymphocytes have been recognized in breast cancer, and when found concentrated in breast cancer specimens, have been associated with a good prognosis. Breast cancer is not only a heterogeneous disease, but also displays varied presentation and behavior in patients of different race/ethnicities.

This study was performed to evaluate factors which predict response to chemotherapy. The effectiveness of different chemotherapeutic regimens, the effect of breast cancer subtype, and tumor infiltrating lymphocytes (TILs) were evaluated in our racial/ethnic minority population.

Methods

All patients at the safety net institution in Phoenix, AZ who underwent preoperative chemotherapy from 2002 to 2017 and had tissue available for evaluation were included in the study. Response to chemotherapy regimen was recorded. Pathologic complete response (pCR) was defined as no invasive cancer in the breast and lymph nodes in the final pathologic specimen. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal subtypes were classified based on Ki67 (>15%) and/or PR (<20%) for Luminal B. Her2 subtype was defined as Her2 IHC 3+ or Her2 FISH amplified. Triple negative breast cancer (TNBC) was defined as ER and PR (<5%) and Her2 negative. TILs concentration was determined from fixed formalin paraffin embedded (FFPE) core needle biopsy specimens.

Results

A total of 259 patients were included in the study. The mean age was 45 years. 80% of the population were racial/ethnic minorities. The vast majority (94%) were underinsured or uninsured, with 75% uninsured. The mean clinical tumor size at presentation was 6cm. 52% presented at clinical stage 2 while 48% presented at clinical stage 3. The overall pCR rate was 32%. pCR rate was impacted by breast cancer subtype with TNBC 52% and Her2 38% showing a better response to chemotherapy, while Luminal B was 16% and Luminal A 2% (p < 0.05). In TNBC, chemotherapy regimens with anthracycline and docetaxel may have improved efficacy with pCR of 56% (p = 0.05). In the subgroup available for TIL evaluation, breast cancer subtype appeared to show similar importance with pathologic complete response rates of TNBC 50%, Her2 44%, Luminal B 12%, and Luminal A 0%. TIL appeared to affect the likelihood of pCR. When TIL were less than 5% the pCR rate was 16% compared to when there were TIL of at least 5% or more the pCR rate was 41% (p < 0.05).

Conclusions

In our racial/ethnic minority population, breast cancer subtype and chemotherapy regimen did affect likelihood of pathologic complete response. Tumor infiltrating lymphocyte concentration as low as 5% may indicate a higher likelihood of pathologic complete response and could be used as an additional factor in the evaluation of patients for preoperative therapy.

Citation Format: Komenaka IK, Cocco D, Huliyar R, Hsu C-H, Martinez ME, Gago M, Nodora J, Mehta D, Caruso DM. Association of tumor infiltrating lymphocytes and chemotherapy regimen in response to preoperative chemotherapy in underserved patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-08.

Socio-demographic Moderators of Associations Between Psychological Factors and Latinas' Breast Cancer Screening Behaviors

This study tested whether socio-demographic factors moderated associations between psychological factors and Latinas' breast cancer screening behaviors. 222 churchgoing Latinas (40-65 years) in San Diego, CA completed surveys assessing socio-demographics (e.g., income and acculturation), psychological factors (e.g., perceived barriers to screening), and cancer screening behaviors. Multilevel models examined associations of socio-demographic and psychological factors (and their interactions) with adherence to annual mammography or clinical breast exam (CBE) screening. Although no main effects were found, there were moderation effects. Acculturation moderated associations between perceived barriers to screening and both screening outcomes, with inverse associations only among the high-acculturation group. Education moderated the relationship between perceived barriers to screening and CBE screening, with an inverse association only among the low-education group. Marital status moderated the relationship between depressive symptoms and CBE screening, with an inverse association only among single/non-partnered participants. Interventions are needed targeting psychological barriers to breast cancer screening among Latinas.

Increased aggression and lack of maternal behavior in Dio3-deficient mice are associated with abnormalities in oxytocin and vasopressin systems

Thyroid hormones regulate many aspects of brain development and function, and alterations in the levels of thyroid hormone action lead to abnormal anxiety- and depression-like behaviors. A complement of factors in the brain function independently of circulating levels of hormone to strictly controlled local thyroid hormone signaling. A critical factor is the type 3 deiodinase (DIO3), which is located in neurons and protects the brain from excessive thyroid hormone. Here, we examined whether a local increase in brain thyroid hormone action secondary to DIO3 deficiency is of consequence for social behaviors. Although we did not observe alterations in sociability, Dio3-/- mice of both sexes exhibited a significant increase in aggression-related behaviors and mild deficits in olfactory function. In addition, 85% of Dio3-/- dams manifested no pup-retrieval behavior and increased aggression toward the newborns. The abnormal social behaviors of Dio3-/- mice were associated with sexually dimorphic alterations in the physiology of oxytocin (OXT) and arginine vasopressin (AVP), 2 neuropeptides with important roles in determining social interactions. These alterations included low adult serum levels of OXT and AVP, and an abnormal expression of Oxt, Avp and their receptors in the neonatal and adult hypothalamus. Our results demonstrate that DIO3 is essential for normal aggression and maternal behaviors, and indicate that abnormal local regulation of thyroid hormone action in the brain may contribute to the social deficits associated with neurodevelopmental disorders.

Abstract P3-13-18: Technical skill of surgical residents may affect margin status of breast conserving operations

Background: Quality of patient care and surgical outcomes have come under increased scrutiny. Numerous other studies have examined outcomes at teaching hospitals compared to non-teaching hospitals. The most important factor to determine early success of breast conservation is the attainment of pathologically negative margins. Few studies, however, have examined the effect of teaching residents on margin status. The current study was performed to evaluate the effect teaching residents on margin status after lumpectomy.

Methods: Retrospective review of all patients from July 2006-June 2015 was evaluated. A resident was usually considered the primary surgeon. If the resident was unavailable or unprepared to operate, the attending surgeon was the primary surgeon. As part of the routine evaluation of surgical residents, technical ability was classified as satisfactory or unsatisfactory for level of training. All evaluations of the technical ability of the residents were completed prior to the collection of the current data. The effect of surgical residents' participation and their technical ability to perform lumpectomy was evaluated to determine if there was an effect on margin status. Logistic regression analysis was performed to adjust for clinical variables known to affect margin status.

Results: Of 292 patients, 15% of patients had positive margins. The attending surgeon has positive margin rate of 10.7% vs 16% for Residents (p = 0.32).When technical skill evaluation was included, Residents with unsatisfactory technical skills had positive margin rate of 27% compared to 10.2% for residents with satisfactory skills (p = 0.002). In multivariate logistic regression analysis, operating surgeon remained significantly associated with positive margins. Operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.39, 95% CI 0.22-0.86; p = 0.03). Patients who underwent preoperative chemotherapy were also less like to have positive margins (OR 0.40, 95% CI 0.18-0.91); p = 0.04). In patients with at least 2 years of followup (mean follow up of 48 months) breast cancer specific survival was 94% and 2% had local recurrences as a first event.

Conclusions: Technically ability of residents may affect margin status after lumpectomy. With the increased use of surgical outcomes to measure quality of care in medicine, the importance of teaching surgical residents needs to be considered in future quality of care evaluation.

Citation Format: Komenaka IK, Djenic B, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Technical skill of surgical residents may affect margin status of breast conserving operations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-18.

Abstract PD8-02: Tumor subtype and survival differences between Hispanic and non-Hispanic white breast cancer patients in the California cancer registry

Background: Prior studies show that Hispanic breast cancer patients are more likely than non-Hispanic white (NHW) women to be diagnosed with triple negative tumors but data on other subtypes are limited. Published data on survival differences between Hispanics and NHW breast cancer patients are inconsistent and vary depending on the covariates included in the multivariate models. We assessed differences in the distribution of the major tumor subtypes of breast cancer, as well as subtype-specific survival, between Hispanic and NHW patients according to nativity, and age and stage at diagnosis.

Methods: We used data from the population-based California Cancer Registry to include female invasive breast cancer cases diagnosed between 2004 and 2013 with follow-up through December 31, 2013, resulting in 90,236 total cases (69,693 NHW and 20,543 Hispanics). Tumor subtypes were classified into four categories: hormone receptor positive and HER2 negative (HR+/HER-), HR+/HER2+, HR-/HER2+, and triple negative (HR-/HER2-). Logistic regression was used to estimate differences in distribution of subtype between Hispanic and NHW women. Cox proportional hazard models were used to estimate differences in survival for Hispanics and NHWs by subtype, adjusting for clinical and sociodemographic characteristics.

Results: Compared to NHW patients, Hispanic women were more likely to be diagnosed with tumors that were HR+/HER2+ (OR=1.22; 95% CI, 1.16-1.29), HR-/HER2+ (OR=1.37; 95% CI, 1.29-1.47), and triple negative (OR=1.27; 95% CI, 1.21-1.34) than HR+/HER2-. Foreign-born Hispanics had a higher odds of having HER2+ than HR+/HER2- tumors compared to NHW women (OR=1.29 for HR+/HER2+ and OR=1.50 for HR-/HER2+); these differences were less pronounced among U.S.-born Hispanics (OR=1.04 for HR+/HER2+ and OR=1.16; 95% CI, 1.06-1.26 for HR-/HER2+). In age-adjusted models, Hispanic women had higher breast cancer mortality than NHW women (HR=1.23; 95% CI, 1.17-1.30), which was consistent across all tumor subtypes. However, the mortality differences disappeared after adjustment for clinical, sociodemographic characteristics, and marital status.

Conclusions: Hispanic women were more likely than NHWs to be diagnosed with triple negative breast cancer as well as tumors overexpressing HER2 than HR+/HER2- tumors. This pattern held true when stratified by nativity, although higher ORs for HER2+ tumors among foreign-born than U.S.-born Hispanic women were observed. Within each subtype, Hispanics had 20%-30% higher mortality than NHW, which appeared to be explained by a combination of sociodemographic and clinical factors.

Citation Format: Martinez ME, Cress R, Gomez S, Rodriguez D, Cook LS, Schwab R, Nodora JN, Porter P, Li C. Tumor subtype and survival differences between Hispanic and non-Hispanic white breast cancer patients in the California cancer registry [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD8-02.

Abstract P5-13-02: Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies

Background: The rate of obesity is increasing in many countries worldwide. Most populations are not aware of steady weight gain with age. In addition, obesity is increasingly being recognized as a risk factor for breast cancer. Some studies have also demonstrated that weight gain after diagnosis is associated with increased risk for recurrence. The current study was performed to evaluate weight gain in a population of patients seen at a safety net institution. Additionally, patients also gave their opinion on weight loss strategies.

Methods: A retrospective review of all breast cancer patients seen at the county, safety net institution from July 2001 to June 2014 who had at least 2 years of follow up were evaluated for change in weight. For the question on weight loss strategies, all patients from May 2014 to May 2015 were included. Sociodemographic, clinical, and treatment variables were evaluated.

Results: From July 2001 to June 2014, 225 breast cancer patients had follow up prior to January 2013. Of these patients 59% gained weight after their diagnosis of breast cancer. Overall these patients gained an average of 2 kg after their diagnosis.

Starting in January 2013, patients were given a simple message, “avoiding gaining weight” after their diagnosis. For 115 patients with follow up after January 2013, only 35% gained weight and on average, this group of patient lost 4 kg from diagnosis. Patients who initially gained weight were provided with basic weight loss strategies.

From May 2014 to May 2015, 1198 consecutive patients were seen. The average age was 45 years. 12% were non-Hispanic White. Only 30% of patients stated that their primary care provider discussed weight maintenance or weight loss as part of their routine health care. 40% of patients did feel that a permanent change was necessary to facilitate weight loss. However, fewer than half (44%) the patients felt that exercise was necessary. Dietary beliefs were varied, with the most commonly held belief was that vegetarian/vegan diet was necessary (28%). Patients rarely cited commonly recommended weight loss strategies: lower caloric intake (9%), eat frequently (0.3%), adequate fiber (0.1%), adequate protein (0.6%), enough sleep (0.1%), don't eat late (0.1%), no fast food (2%), avoid soda (1%), drink more water (1%). 6% of patients felt a low/no carbohydrate diet was important. By contrast, older strategies or popular ideas: low fat (8%), no flour/wheat/gluten (4%) were also felt to be important. 7.3% stated they did not know any strategy. 5% patients recommended stopping eating altogether to lose weight.

Conclusions: Similar to population wide data, breast cancer patients treated at a safety net institution tend to gain weight with follow up. Also similar to most populations, the population was not aware of recommended weight loss strategies and most do not feel that exercise is an important component of weight maintenance. As with the rest of the US population significant effort will be necessary to help patients avoid weight gain after diagnosis. Making patients aware of their weight may help patients avoid gaining weight.

Citation Format: Komenaka IK, VanderVelde J, Hsu C-H, Nodora J, Winton L, Bouton M, Martinez ME. Weight gain after breast cancer diagnosis and patients' opinion on weight loss strategies [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-02.

Abstract P6-12-06: Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population

Background: Although the Hispanic population is among the fastest growing in the United States, however, less is known about them then other populations. Breast cancer in different racial/ethnic populations display different behaviors. The current study was performed to examine response to preoperative chemotherapy regimen and by breast cancer subtype in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who underwent preoperative chemotherapy from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Response to chemotherapy regimen was recorded. Breast cancer subtypes were divided based on IHC and FISH testing. Luminal B subtype was classified based on Ki67 (>15%) and PR (<20%).

Results: The average age of the 133 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). The average size of the cancers at presentation was 5cm. Overall 86% of patients had a clinical response to preoperative chemotherapy and 35% had pathologic complete response (pCR). AC and TC regimens had the lowest rate of pCR at 16%. AC/T (every 3 week and weekly) had similar rates of pCR 23% and 29%, while dose dense regimens showed pCR 40%. Herceptin containing regimens had pCR 57%. 7 patients received TAC and 71% had pCR.

By subtype, Luminal A and B patients had low rates of pCR 9% and 14% respectively. Luminal B patients did benefit from preoperative chemotherapy as 86% of patients who were not candidates for breast conservation at presentation were able to undergo lumpectomy after preoperative chemotherapy. Her2 subtype patients who got Herceptin had pCR 57%. Triple negative patients had pCR 54%.

Conclusions: In this underinsured, Hispanic population who presented at advanced stages, differences in response to preoperative chemotherapy were seen based on breast cancer subtype. Differences were also seen based on chemotherapy regimen. TAC maybe a particularly effective regimen in triple negative Hispanic women.

Citation Format: Mehta D, Winton L, Walters J, Hsu C-H, Nodora J, Martinez ME, Bouton M, Komenaka IK. Preoperative chemotherapy regimens and breast cancer subtype in an underinsured Hispanic population. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-06.

Abstract P6-12-07: The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography

Background: Despite prospective clinical trials demonstrating the safety and effectiveness of preoperative chemotherapy for nearly 2 decades, it may still be underutilized in underserved, uninsured populations most likely to present with advanced cancers. The current study was performed to evaluate the effect of preoperative chemotherapy (PC) in a Hispanic safety net population.

Methods: A retrospective review of Hispanic breast cancer patients who presented at clinical stage 2 or higher and were treated from July 2001 to February May 2015 at a safety net hospital. Sociodemographic, clinical, and treatment variables were evaluated. Surgical outcomes were evaluated. Margin status was determined for those who underwent breast conservation.

Results: The average age of the 266 patients was 45 years. 93% of the patients were insured with Medicaid or uninsured (70%). Only 24% of patients underwent screening mammography. 133 underwent PC and 133 had primary operations. Patients who underwent PC presented with larger cancers (5cm vs 3.5cm, p < 0.001). 96% of patients in PC group were not candidates for lumpectomy at presentation. However, lumpectomy was performed more often in those who underwent PC (75% vs. 57%, p = 0.01). Re-excision for margins were necessary less often in those who underwent PC (10.3% vs 27%, p = 0.01). Patients who underwent PC were also less likely to require an ALND (33% vs 47%, p = 0.04). Despite presentation at higher average clinical stage in patients who underwent PC, at average follow up of 52 months, risk of IBTR and risk of regional recurrence were similar in the PC and no-PC groups (IBTR: 4.4% vs 3%, p = 0.99 and Regional: 1.5% vs. 1.5%, p = 0.99). Breast cancer specific survival was 86.5% in the PC group compared to 84% in the no-PC group (p = 0.68). Patients in the no-PC group were less likely to comply with recommended chemotherapy.Conclusions: In this underinsured, Hispanic population who did not use screening mammography, preoperative chemotherapy allowed many women to undergo breast conservation, undergo fewer operations, and were less likely to require ALND. Risk of local and regional recurrence is low in these patients and comparable to those who underwent primary operation.

Citation Format: Komenaka IK, Djenic B, Walters J, Hsu C-H, Nodora JN, Martinez ME, Bouton M, Mehta D. The benefit of preoperative chemotherapy in an underinsured Hispanic population with poor use of screening mammography. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-07.

Acculturation, Behavioral Factors, and Family History of Breast Cancer among Mexican and Mexican-American Women

BACKGROUND

Incidence rates for breast cancer are higher among Mexican-American (MA) women in the United States than women living in Mexico. Studies have shown higher prevalence of breast cancer risk factors in more acculturated than less acculturated Hispanic/Latinas in the United States. We compared the prevalence of behavioral risk factors and family history of breast cancer by level of acculturation and country of residence in women of Mexican descent.

METHODS

Data were collected from 1,201 newly diagnosed breast cancer patients living in Mexico (n = 581) and MAs in the United States (n = 620). MA participants were categorized into three acculturation groups (Spanish dominant, bilingual, and English dominant); women living in Mexico were used as the referent group. The prevalence of behavioral risk factors and family history of breast cancer were assessed according to acculturation level, adjusting for age at diagnosis and education.

RESULTS

In the adjusted models, bilingual and English-dominant MAs were significantly more likely to have a body mass index of 30 kg/m(2) or greater, consume more than one alcoholic beverage a week, and report having a family history of breast cancer than women living in Mexico. All three U.S. acculturation groups were significantly more likely to have lower total energy expenditure (≤533 kcal/d) than women in Mexico. English-dominant women were significantly less likely to ever smoke cigarettes than the Mexican group.

CONCLUSIONS

Our findings add to the limited scientific literature on the relationships among acculturation, health behavior, and family history of breast cancer in Mexican and MA women.

Abstract P2-18-16: Patients’ impression of the expected appearance of breasts in 2013

Background: Concern exists about the increasing rate of bilateral mastectomy for patients with unilateral breast cancer. Patient concern for second primary, use of breast MRI, and increased genetic cancer risk assessment all may influence choice of operation. In recent years, cosmetic breast augmentation has also become more common. This study was performed to evaluate women's perception of the current expected appearance of breasts.

Methods: From April 2012 to May 2013, all patients seen at a Breast Clinic were shown two pictures (A “natural” and B “augmented”) and asked “What is the expected appearance of breasts in 2012(2013)?” Sociodemographic, clinical, and treatment variables were collected. Univariate analysis was performed to identify variables which were associated with picture choice. All of the variables with a p-value <0.10 were included in the multivariate analysis.

Results: 1,177 consecutive patients were seen with mean age 45 years. 93% of the patients were insured with Medicaid or uninsured and 19% were non-Hispanic White (NHW). The mean monthly income was only $1104. Overall 70% of patients felt that the augmented appearance is “expected in 2013.” Age was strongly associated with augmented appearance as younger patients were significantly more likely to choose picture B: age less than 40 years (85%), age 40-49 years (67%), age 50-59 years (65%), and age 60+ years (51%). Patients of all race/ethnic groups felt that the augmented appearance was expected. NHW 65%, AA 67%, and Hispanic 71%. Multivariate analysis found that more years of education (p = 0.001), younger age and lower BMI were strongly associated (p < 0.0001) with choosing the augmented appearance as “expected in 2013.”

Of the 1177 patients, 337 breast cancer patients were seen. Overall 62% felt that the augmented appearance was expected. Of those who underwent an operation, 178 (58%) patients underwent breast conservation and 62% felt the augmented appearance was expected. Of 128 patients who underwent mastectomy, 36 (28%) underwent reconstruction. 23 patients underwent bilateral mastectomy. Of those who underwent mastectomy alone (41/83 = 49%) only about half felt the augmented appearance was expected. By contrast those who underwent reconstruction (33/36 = 92%; p < 0.001) or bilateral mastectomy (17/23 = 74%; p = 0.057), were significantly more likely than those who underwent mastectomy alone to feel the augmented appearance was expected.

Conclusions: The current study suggests women's perception of the expected appearance of breasts is changing. Younger age was strongly associated with the perception that the “augmented” appearance is expected. This change may affect patients’ choice in surgical operations with more mastectomies and reconstructions in the future. In October 2012 from a common women's periodical, when asked about her choice of operation for a small area of unilateral DCIS, one woman responded, “Just take them off and give me implants. Everybody has implants; it's no big deal.”

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-16.

Abstract P1-09-15: Perception of breast cancer risk in an underinsured safety net population

Background: Patient perception of breast cancer risk can affect compliance with screening mammography. In an underinsured population, we have previously found that being insured and adequate health literacy were strong predictors of use of screening mammography. Previous studies in other populations have found that patients with heighted perceived risk also have increased use of screening. Previous studies have found an average perceived risk of 30%. “Risk” and risk assessment are difficult concepts for many people and this may be problematic in undereducated populations. The current study was performed to evaluate women's perception of their lifetime risk of breast cancer in a safety net population.

Methods: From May 2012 to May 2013, all patients seen at a safety net Breast Clinic were asked to estimate their lifetime risk of breast cancer. “If 0 = no chance and 100% = for sure, what are your chances of getting breast cancer in your life?” Sociodemographic, clinical, and treatment variables were collected. Univariate analysis was performed to identify variables which were associated with picture choice. All of the variables with a p-value <0.10 were included in the multivariate analysis.

Results: 1,089 consecutive patients were seen. After exclusion of men and patients known to have breast cancer, 838 patients were included. The mean age was 43 years. 93% of the patients were uninsured or insured with Medicaid. Average education 10 years and 17% were non-Hispanic White (NHW). Overall the average perceived lifetime risk for the population was 29.7%. For all patients age 35 years+, the average Gail model Risk Assessment scores were 1.1% (5 year) and 9% (LT). Only 17% of patients would be considered at increased risk according to Gail model 5 year risk (> 1.6%).

In univariate analysis, continuous variables associated with higher perceived risk were higher BMI (p = 0.003), more years of education (p = 0.0009), and higher 5 year Gail model score (p = 0.0005). Categorical variables associated with higher perceived lifetime risk were being insured (34% vs 27%; p = 0.004) and NonHispanic patients (34% vs 27%; p = 0.003). Adequate health literacy (38% vs 27%; p = 0.0001) and family history of breast cancer in a first degree relative (FDR; 43% vs 27%; p = 0.0001) were the variables with the strongest association with perceived risk. In multivariate analysis after adjustment for the above factors, only family history in FDR remained significant (p = 0.003).

Over a similar time period, being insured (OR 1.52; 95% CI 1.18 – 1.95; p = 0.001) and adequate health literacy (OR 3.75; 95% CI 2.71 – 5.19; p < 0.0001) were the only variables significantly associated with the use of screening mammography.

Conclusions: Underinsured, minority women overestimate their lifetime risk of breast cancer (30%) at a magnitude similar to other populations. Family history has a strong influence on an underinsured populations’ perception of breast cancer risk. Patients who were insured or had adequate health literacy perceived a higher lifetime risk of breast cancer and were significantly more likely to use screening mammography.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-15.

Biochemical characterization of ecuadorian wild Solanum lycopersicum Mill. plants produced from non-cryopreserved and cryopreserved seeds

This paper presents some of the effects of cryopreservation of wild Solanum lycopersicum Mill. seeds on the early stages of germination post liquid nitrogen exposure. Percentage of germination, conversion into plantlets and plant fresh mass were evaluated after cryostorage. Levels of chlorophyll pigments (a, b, total), malondialdehyde, other aldehydes, phenolics (cell wall-linked, free, and total) and proteins were determined. Peroxidase and superoxide dismutase activities were recorded. Liquid nitrogen exposure increased the percentage of seed germination at 5 days but at 7 days, the conversion into plantlets and the plant fresh mass were not statistically different between non-cryopreserved and cryopreserved samples. Several significant effects of cryopreservation were recorded at the biochemical level at 7 days of germination under controlled conditions. Highly significant effects due to liquid nitrogen exposure were observed in leaves: increased levels of peroxidase enzymatic and specific activities and cell wall-linked phenolics. Very remarkable effects were also recorded in roots: decreased contents of chlorophylls and cell wall-linked phenolics.

Abstract PD08-04: Factors which affect surgical management in an underinsured, county hospital population

Background: Significant variation exists between institutions in the use of lumpectomy, mastectomy, and reconstruction. Much less is known about minorities and populations outside the large academic institutions. The current study was performed to evaluate variables that affect patient choice in surgical management in a county hospital population.

Methods: A retrospective review of all patients seen at the county, safety net institution with breast cancer from January 2010 to May 2012. Sociodemographic, clinical, and treatment variables were evaluated. Univariate analysis was performed to identify variables which were associated with type of operation. All of the variables with a p-value <0.10 were included in the multivariate analysis.

Results: 403 patients were seen with mean age 53 years. 92% of the patients were insured with Medicaid or uninsured and 29% were non-Hispanic White. Only 20% of patients underwent screening mammography and therefore presentation with palpable, Stage 2A/B cancer was most common (46%). 54 patients presented with T4 tumors and 13 (24%) were found to have metastases. Only 2 of 340 (0.6%) patients who presented at Stage 3A or earlier presented with metastatic disease. Patients with operable cancer underwent lumpectomy in 65%, mastectomy in 26%, and 9% mastectomy with reconstruction. With respect to breast conservation vs mastectomy, in adjusted analysis, married patients (OR 2.59, p = 0.003) and patients with larger tumors (p = 0.003) were more likely to undergo mastectomy, while patients who were Hispanic (OR 0.38, p = 0.004), underwent preoperative chemotherapy (OR 0.25, p = 0.002), or had their operation by breast surgical oncologist (OR 0.30, p = 0.005) were more likely to undergo breast conservation. When patients who underwent mastectomy alone were compared to those who underwent reconstruction, unadjusted analysis suggested that reconstruction patients were more likely to speak English, have adequate health literacy (HL), lower clinical stage, and be seen by a breast surgical oncologist. Adjusted analysis demonstrated that having been seen by a breast surgical oncologist (OR 18.4, p = 0.007), younger age (p = 0.05) and adequate HL (OR 3.13, p = 0.06) were associated with likelihood of reconstruction compared to mastectomy alone.

Conclusions: Breast conservation and mastectomy with reconstruction can be achieved in a significant proportion (74%) of underscreened and underinsured patients. Patients who underwent preoperative chemotherapy were more likely to undergo breast conservation. Younger patients and patients with adequate HL were more likely to choose reconstruction after mastectomy. Patients treated by breast surgical oncologists were more likely to have breast conservation or mastectomy with reconstruction. Even in an underscreened population, presentation with metastatic disease is uncommon in patients with operable breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD08-04.

Association between polymorphic variation in VDR and RXRA and circulating levels of vitamin D metabolites

The vitamin D metabolite 1,25(OH)2D is the bioactive ligand of the vitamin D receptor (VDR). VDR forms a heterodimer with the retinoid X receptors (RXRs) that when bound to ligand influences the transcriptional control of genes that regulate circulating levels of vitamin D metabolites. Whether genetic variation in VDR or RXRA affects circulating levels of 1,25(OH)2D or 25(OH)D has not been established. We used a single nucleotide polymorphism (SNP) tagging approach to evaluate the association between SNPs in VDR and RXRA and serum levels of 1,25(OH)2D and 25(OH)D. A total of 42 tagSNPs in VDR and 32 in RXRA were analyzed in a sample of 415 participants. Principal components analyses revealed a gene-level association between RXRA and serum 1,25(OH)2D concentrations (P=0.01), but not 25(OH)D. No gene-level association was found for VDR with either serum biomarker. At the single-SNP level, a significant positive trend was observed for increasing 1,25(OH)2D levels with each additional copy of the A allele for RXRA SNP rs9409929 (P-trend=0.003). After a multiple comparisons adjustment, no individual SNP in VDR or RXRA was significantly associated with either outcome. These results demonstrate an association between genetic variation in RXRA and 1,25(OH)2D serum concentrations.

Alendronate interacts with the inhibitory effect of 1,25(OH)2D3 on parathyroid hormone-related protein expression in human osteoblastic cells

The bisphosphonate alendronate is a potent inhibitor of bone resorption by its direct action on osteoclasts. In addition, there is some data suggesting that alendronate could also inhibit bone resorption indirectly by interacting with osteoblasts. Parathyroid hormone-related protein (PTHrP) produced by osteoblasts and 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] are regulators of bone remodeling, which have interrelated actions in these cells. In this study, we assessed whether alendronate can affect PTHrP expression in the presence or absence of 1,25(OH)2D3 in human primary osteoblastic (hOB) cells from trabecular bone. Cell total RNA was isolated, and semiquantitative reverse transcription-polymerase chain reaction (RT-PCR) was carried out using human PTHrP-specific primers. PTHrP in the hOB cell-conditioned medium was analyzed by a specific immunoradiometric assay. We found that PTHrP mRNA and secreted PTHrP were maximally inhibited by 10(-8) - 10(-6) M of 1,25(OH)2D3 treatment within 8-72 h in hOB cells. Alendronate (10(-14) - 10(-8) M) modified neither PTHrP mRNA nor PTHrP secretion, although it consistently abrogated the decrease in PTHrP production induced by 1,25(OH)2D3 in these cells. On the other hand, alendronate within the same dose range did not affect either the vitamin D receptor (VDR) mRNA or osteocalcin secretion, with or without 1,25(OH)2D3, in hOB cells. The inhibitory effect of alendronate on the 1,25(OH)2D3-induced decrease in PTHrP in these cells was mimicked by the calcium ionophore A23187 (5 x 10-6 M), while it was eliminated by 5 x 10(-5) M of nifedipine. Furthermore, although alendronate alone failed to affect [Ca2+]i in these cells, it stimulated [Ca2+]i after pretreatment of hOB cells with 10(-8) M of 1,25(OH)2D3, an effect that was abolished by 5 x 10(-5) M of nifedipine. These results show that alendronate disrupts the modulatory effect of 1,25(OH)2D3 on PTHrP production in hOB cells. Our findings indicate that an increase in calcium influx appears to be involved in the mechanism mediating this effect of alendronate.

Effects of polyethylene and alpha-alumina particles on IL-6 expression and secretion in primary cultures of human osteoblastic cells

The effect of two biomaterials, polyethylene and alpha-alumina, on interleukin-6 (IL-6) secretion and expression has been studied in human osteoblasts in primary culture. Human osteoblastic cells were derived from fresh trabecular bone explants removed during total knee arthroplasty. On reaching confluence, cells were subcultured in 6 well plates; the resulting subcultures were incubated until confluence and polyethylene or alpha-alumina particles were added to some while the rest were left as controls. The IL-6 mRNA levels were assessed by reverse transcription (RT) followed by polymerase chain reaction (PCR). IL-6 secretion was measured in the conditioned medium. The IL-6 expression was higher in the presence of both biomaterials. Maximum expression occurred in response to a dose of 50 mg particles well with both biomaterials and was greater after polyethylene particle addition than after alpha-alumina particle addition at this dose. The maximum IL-6 secretion elicited by alpha-alumina was produced at 10 mg particles well while maximum response with polyethylene required 50 mg well. At a dose of 10 mg/well, alpha-alumina particles induced more secretion than 10 mg of polyethylene particles. Nevertheless, at a dose of 50 mg/well maximum secretion was produced with polyethylene particles. In conclusion and in our experimental conditions, polyethylene as well as alpha-alumina increased both the expression and the secretion of IL-6 in human osteoblastic cells in primary culture and stimulation from polyethylene appears stronger than that from alpha-alumina at the same dose.

Polymorphism in the type I collagen (COLIA1) gene and risk of fractures in postmenopausal women

Twin and family studies have demonstrated that a large part of a population's variance in bone mineral density (BMD) is attributable to genetic factors. A polymorphism in the collagen type I alpha1 (COLIA1) gene has recently been associated with low bone mass and fracture incidence. We analyzed the relationship between COLIA1 gene polymorphism, lumbar spine and hip BMD, and fracture prevalence in a population of 319 postmenopausal women classified by WHO standards, including 98 nonosteoporotic women (NOPW) and 221 osteoporotic postmenopausal women (OPW), divided into 139 osteoporotic women without fracture (OPWnF) and 82 osteoporotic women with fracture (OPWwF). The COLIA1 genotype was assessed by polymerase chain reaction and BalI endonuclease digestion. Genotype frequencies for the total group were 49.2% GG homozygotes, 39.5% GT heterozygotes, and 11.3% TT homozygotes. We found significant differences in the percentage of homozygous TT between NOPW and OPW (6.1% and 13.6%, respectively). Significantly, the occurrence of genotype TT in OPWnF was 6.2%, and 28% in OPWwF. We observed no associations between the COLIA1 genotype and lumbar spine and hip BMD. The prevalence of fractures varied significantly by genotype: GG, 26.1%; GT, 15.9%; and TT, 58.3%. Logistic regression analysis of fracture prevalence showed that, for prevalent fractures, the women with the TT genotype had a 5.9-fold increased risk when compared with the other genotypes (GG + GT). When prevalence was adjusted for age, body mass index, and BMD, the fracture risk was 4.8 for the TT group vs. the genotype GG, whereas it was 0.6 for the GT genotype. In conclusion, we found the COLIA1 Sp1 TT genotype to be associated with an increased fracture risk in postmenopausal women. Interestingly, this genotype-dependent risk could not be explained completely by BMD differences.

Ki-ras proto-oncogene mutations in sporadic colorectal adenomas: relationship to histologic and clinical characteristics

BACKGROUND & AIMS

[corrected] The goal of this study was to examine the relationship between Ki-ras mutations in colorectal adenomas and characteristics of both the subject (age, gender, and family/personal history of colonic neoplasia) and the adenoma (multiplicity, size, location, and histologic features).

METHODS

Ki-ras mutations were detected by direct sequencing in 738 adenomatous polyps removed at baseline from 639 participants in a nutritional trial of adenoma recurrence.

RESULTS

Ki-ras mutations were detected in 17.2% of the adenomas. Ki-ras mutations were unrelated to gender, family, or personal history of colonic neoplasia, location within the colorectum, or adenoma multiplicity, but were more common in older subjects (P = 0.01 for trend), in larger adenomas (P < 0.0001 for trend), in adenomas with villous histology (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.1-4.9 vs. tubular), and in adenomas with high-grade dysplasia (32.0% vs. 13.6%; OR, 3.0; 95% CI, 1.9-4.6 vs. low-grade dysplasia). Multivariate analysis showed Ki-ras mutations to be independently associated with subject age (P = 0.01 for trend), tubulovillous/villous histology (OR, 2.3; 95% CI, 1.5-3.7), and high-grade dysplasia (OR, 1.9; 95% CI, 1.2-3.1). Adenoma size was not independently related to Ki-ras mutation.

CONCLUSIONS

Ki-ras mutations are associated with the histologic features of adenoma progression (villous histology and high-grade dysplasia) rather than with adenoma growth.

Parathyroid hormone-related protein (107-139) stimulates interleukin-6 expression in human osteoblastic cells

The N-terminal region of both parathyroid hormone (PTH) and PTH-related protein (PTHrP) binds to the same PTH/PTHrP receptor in osteoblasts. However, C-terminal PTHrP (107-139) inhibits growth and various functions of osteoblasts and osteoclasts apparently through PTHrP-specific receptors. PTH (1-34) and PTHrP (1-34) rapidly induce interleukin-6 (IL-6) expression by osteoblasts. The aim of the present study was to assess the effects of PTHrP (107-139) on IL-6 gene expression and secretion by osteoblastic cells from human trabecular bone (hOB). Using reverse transcription followed by PCR, it was found that IL-6 mRNA was twofold maximally increased by either PTHrP (1-34) or PTHrP (107-139), at 10 nM, over basal within 1 to 2 h in hOB cells. This effect of PTHrP (107-139), and that of PTHrP (1-34), were abolished by the transcription inhibitor actinomycin D. Meanwhile, puromycin, a protein synthesis inhibitor, superinduced IL-6 expression in the presence or absence of each PTHrP peptide. Both PTHrP (1-34) and PTHrP (107-139), but not PTHrP (38-64), stimulated IL-6 secretion to the hOB cell-conditioned medium at 24 h, dose dependently. In addition, this maximal stimulatory effect (twofold over basal) was similar with each PTHrP peptide alone, and not additive when added together. PTHrP (107-139) stimulation of mRNA and protein in hOB cells was abolished by bisindolylmaleimide I, a protein kinase C inhibitor, but not by either adenosine 3',5'-cyclic monophosphorothioate, Rp-isomer (Rp-cAMPS), or N-[2-((p-bromocinnamyl)amino)ethyl]-5-isoquinolinesulfonamide dihydrochloride (H89), two protein kinase A inhibitors. These results indicate that C-terminal PTHrP, like its N-terminal domain, induces IL-6 production by human osteoblastic cells. This effect of both PTHrP regions could provide a mechanism to modulate bone turnover.

Progress report: the Arizona phase III study of the effect of wheat bran fiber on recurrence of adenomatous colon polyps

A double-blind, placebo-controlled Phase III cancer prevention trial in subjects with previous resection of adenomatous colon polyps is nearing completion. The study's primary objective is to evaluate the effects of daily dietary supplementation with large (13.5 g/day) versus small (2.0 g/day) doses of wheat bran fiber for 3 years. A summary of the study design and a progress report are presented.

Reduced nicotinamide adenine dinucleotide phosphate-diaphorase activity in the paraventricular nucleus of the rat hypothalamus is modulated by estradiol

Based on previous studies demonstrating that reduced nicotinamide adenine dinucleotide phosphate (NADPH)-diaphorase (ND) activity is modulated by estradiol and the discovery of a new subtype of estrogen receptor highly expressed in the paraventricular nucleus of the hypothalamus (PVN), a possible estrogen influence on this activity was investigated in the neuronal populations (magno- and parvicellular) of this nucleus. Cryostat sections were cut and processed for the histochemical detection of the ND activity. Following ovariectomy (14 days), numerical data displayed a slight decrease in the number of ND-neurons, especially in the posterior magnocellular and the medial parvicellular subdivisions, which was reversed after daily treatment with estradiol benzoate. Administration of estradiol benzoate to male rats (14 days) induced a significant increase (P < 0.05) in the number of ND-neurons, mainly at the level of the posterior magnocellular subdivision. These data indicate that paraventricular ND-neurons are influenced by estradiol.

Postmenopausal hormone use and risk for colorectal cancer and adenoma

BACKGROUND

Accumulating evidence suggests that postmenopausal hormone use may decrease the risk for colorectal cancer.

OBJECTIVE

To examine the relation of postmenopausal hormone therapy to colorectal adenoma and cancer.

DESIGN

Prospective cohort and nested case-control studies.

SETTING

Nurses' Health Study, a study of registered nurses recruited from 11 U.S. states.

PARTICIPANTS

59 002 postmenopausal participants in the Nurses' Health Study.

MEASUREMENTS

Self-reported data on hormone use and cases of distal colorectal adenoma and colorectal cancer obtained from biennial questionnaires completed from 1980 to 1994. Cases of colorectal adenoma and cancer were confirmed by medical record review.

RESULTS

470 women developed colorectal cancer, and 838 developed distal colorectal adenomas. Current use of postmenopausal hormones was associated with a decreased risk for colorectal cancer (relative risk [RR], 0.65 [95% CI, 0.50 to 0.83]). This association was attenuated in past users (RR, 0.84 [CI, 0.67 to 1.05]) and disappeared 5 years after hormone use was discontinued (RR, 0.92 [CI, 0.70 to 1.21]). Longer duration of current use did not afford greater protection (RR with > or =5 years of use, 0.72 [CI, 0.53 to 0.96]). Even after exclusion of women who reported having screening sigmoidoscopy, the relative risk for colorectal cancer seen with current hormone use was 0.64 (CI, 0.49 to 0.82). This suggests that the apparent protection is unlikely to be due to more intensive screening among hormone users. Current users also had a lower risk for large (> or =1 cm) adenomas than did women who had never used hormones (RR, 0.74 [CI, 0.55 to 0.99]), although no overall material association was seen between colorectal adenoma and current hormone use (RR, 0.91 [CI,0.77 to 1.08]).

CONCLUSIONS

The risk for colorectal cancer was decreased among women currently receiving postmenopausal hormone therapy, but the apparent reduction substantially diminished upon cessation of therapy. Hormone use was inversely associated with large colorectal adenomas but not small ones.

Frequent recurrence of secondary hyperparathyroidism after pulse oral calcitriol withdrawal in PD patients

The aim of this study was to evaluate the role of pulse oral calcitriol in the control of secondary hyperparathyroidism in peritoneal dialysis (PD) patients, addressing the effects after withdrawal. We studied 15 patients with intact parathyroid hormone (iPTH) plasma levels above 250 pg/mL. The initial calcitriol dose was 8 or 4 micrograms/week, administered in two doses, according to whether the iPTH plasma levels were above or below 400 pg/mL. This dose was modified during the follow-up according to the response. Serum iPTH levels decreased in all patients after the first month (559 +/- 243 to 212 +/- 94 pg/mL, p < 0.001). Serum calcium levels significantly increased during therapy, while serum phosphorus levels did not change. The mean duration of the treatment was 95 +/- 57 days. Nine patients reached the target iPTH levels without complications, and in 6 patients the treatment was interrupted because of hypercalcemia. One month after finishing pulse therapy, a significant decrease in serum calcium levels and an increase in iPTH levels were observed. These values were similar to baseline data and were significantly higher than those found during the pulse calcitriol period. Pulse oral calcitriol administration seems to be a short-term, efficient therapy for secondary hyper-parathyroidism in PD patients. However, after the end of pulse therapy, iPTH serum levels return to baseline values, suggesting long-term therapeutic failure.

Parity and other reproductive factors and risk of adenomatous polyps of the distal colorectum (United States)

Evidence for an effect of reproductive factors on colorectal carcinogenesis is inconsistent and little is known about their role in development of precursor adenomatous polyps. We evaluated the relation between reproductive factors and distal colorectal adenomas (n = 982) during 14 years of follow up of 26,983 participants in the Nurses' Health Study (United States). The women were free of diagnosed cancer or polyps in 1980, underwent endoscopy 1980-94, and had reported on their parity, oral contraceptive (OC) use, and ages at menarche, first term-pregnancy, and menopause. We calculated relative risks (RR) and 95 percent confidence intervals (CI) using multiple logistic regression. Women with higher parity had an increased risk of adenomas of the distal colorectum (P trend = 0.004; 6+ cf 0 parity: RR = 1.3, CI = 0.9-1.8) or distal colon (P trend = 0.002, RR = 1.7, CI = 1.2-2.6). This association was significantly stronger among women with a family history of colorectal cancer (P interaction = 0.03); comparing 6+ term-pregnancies with nulliparity, among those with a family history, the RR for distal colon adenoma was 3.2 (CI = 1.4-7.2), while among those without a family history, the RR was 1.3 (CI = 0.8-2.2). We observed no association for distal colorectal adenoma and age at menarche, age at first term-pregnancy, ever use of OCs, or menopausal status. Further work is needed to clarify the relation of parity with colon adenoma risk.

Effects of luminal nutrients and small bowel transplants on congenital indirect hyperbilirubinemia

The Gunn rat is an excellent model of Crigler-Najjar syndrome, type 1. In previous studies we demonstrated that heterotopic 15-20-cm jejunal transplants from Wistar rats lowered serum bilirubin levels by 40%, and the reduction was transient (6 weeks). In contrast, orthotopic transplants decreased bilirubin levels by 60% and the effect persisted throughout the 8-week study. This study was initiated to identify the luminal substance(s) which are responsible for the persistent bilirubin-lowering effect of jejunal transplants. Thirty-one Wistar to Gunn 15-20-cm jejunal transplants were randomized to receive daily Thiry-Vella graft irrigation with 5 ml of normal saline (n = 8); bile salts (cholate + deoxycholate, 40 mg/ml, n = 5; fats (Microlipid, 20 mg/ml, n = 5); proteins (Casec caseinate, 40 mg/ml, n = 5); and sugars (Moducal + Polycose, 40 mg/ml, n = 8). Bilirubin levels were measured spectrophotometrically at weekly intervals. At 4 and 8 weeks, enzyme-induced bilirubin conjugation activity was measured using added known amounts of added bilirubin. Irrigation of the transplants with saline, protein, and sugar resulted in moderate (40%) lowering of serum total and indirect bilirubin levels. Fat was significantly more effective, lowering mean total bilirubin levels from 9.6 +/- 0.4 to 1.6 +/- 0.2 mg/dl at 6 weeks. After this time, bilirubin levels increased slightly. Bile salts were slightly less effective, lowering bilirubin levels at 6 weeks by only 75%. However, this effect persisted and at 8 weeks levels averaged 2.4 +/- 0.2 mg/dl. Conjugating enzyme activity in the transplants increased from 1.4 +/- 0.3 to 2.5 +/- 0.5 mg bilirubin conjugated/mg tissue/hr. Luminal fats and bile salts appear to augment enzyme-induced bilirubin conjugation in heterotopic jejunal transplant recipients.

The interaction of PTH and dietary phosphorus and calcium on serum calcitriol levels in the rat with experimental renal failure

BACKGROUND

Renal failure results in decreased calcitriol production, a key factor in the development of secondary hyperparathyroidism. Phosphorus accumulation and high parathyroid hormone (PTH) levels, both inherent to renal failure, have different effects on calcitriol production; moreover, dietary calcium loading may have a separate inhibitory effect on calcitriol production. This study was designed to evaluate the relative effects of PTH and dietary phosphorus and calcium on serum calcitriol levels.

METHODS

Renal failure was surgically induced and rats were divided into normal, moderate renal failure, and advanced renal failure based on the serum creatinine. Each group was subdivided and received either a high-phosphorus diet (HPD, 0.6% Ca, 1.2% P) or high-calcium diet (HCaD, 1.2% Ca, 0.6% P) for 14-16 days to determine the relative effects of dietary calcium and phosphorus loading on serum calcitriol. In addition the effect of PTH and phosphorus on calcitriol stimulation was determined with a 48-h PTH infusion combined with either a low (0.16%) or high (1%) phosphorus diet; both diets had negligible calcium (< 0.05%).

RESULTS

With decreasing renal function, PTH increased and was greater in rats fed the HPD than the HCaD; serum calcitriol decreased as renal function decreased and was lower in normal rats and rats with moderate renal failure fed a HCaD (P < 0.01). The calcitriol response to a PTH infusion decreased as renal function decreased (P < 0.05) but was greater on a low- (0.16%) than a high- (1%) phosphorus diet (P < 0.05).

CONCLUSIONS

Dietary calcium loading either directly decreases serum calcitriol or acts by modifying the stimulatory effect of PTH; the stimulatory effect of PTH on serum calcitriol is modified by dietary phosphorus; in moderate renal failure, serum calcitriol levels depend on a complex interaction between PTH and dietary calcium and phosphorus; and in advanced renal failure, serum calcitriol levels are low and are difficult to stimulate, presumably because of the loss of renal mass.

Remission of hypercalciuria in patients with tuberculosis after treatment

The hypercalciuria evolution and other bone metabolism parameters were evaluated in patients with tuberculosis after treatment. Twenty-two patients with tuberculosis and 54 normal subjects were studied; they consumed an average diet (calcium intake 1000 mg/day). Ten of these patients and nine normal subjects were also studied after a low calcium diet (400 mg/calcium/day) and after a load of oral calcium of 1000 mg (calcium absorption test). The study with an average diet was performed after 1 week (basal) and 3, 6, and 12 months after the antituberculosis treatment was started; the calcium absorption test was carried out 2 weeks, 3 and 12 months after the treatment was started. On an average diet, patients with tuberculosis presented, at baseline state, lower calcidiol levels than normal controls. Serum calcitriol levels at baseline were higher than at 6 and 12 months. Serum parathyroid hormone (PTH) levels in patients with tuberculosis were lower than in normal controls at baseline, but these levels were similar to controls at 3, 6, and 12 months after treatment. During the calcium absorption test and under basal conditions, patients with tuberculosis showed lower serum PTH and calcidiol levels in all the dietetic situations than in normal controls. However, serum calcitriol levels were higher than in controls after the restrictive diet. After 3 months of treatment, urinary calcium excretion was normal in patients with tuberculosis during the average and low diets, but higher than in control group after calcium load. After 12 months of treatment, all the biochemical parameters of the patients with tuberculosis were similar to the control group under all the dietetic situations. These data indicate that antituberculous treatment, although it may contribute to the production of some alteration in the calcium and vitamin D metabolism, basically favors the correction of disturbances associated with tuberculosis.

Serum osteocalcin concentrations in diabetic pregnant women and their newborns

Osteocalcin and PTH serum levels were measured in 41 insulin-dependent diabetic pregnant women through the three trimesters of pregnancy with a total of 106 determinations of osteocalcin and 137 of PTH. In parallel we quantified these parameters in 90 normal pregnant women throughout the three trimesters of pregnancy. In addition calcitriol, osteocalcin and PTH levels were quantified at delivery in 16 diabetic pregnant women and 16 normal pregnant women at delivery, in cord serum and in the infants during the first days of life. Non-pregnant women (n = 48) were the control group. In normal pregnant women PTH levels increased during the third trimester and total calcitriol increased at delivery. Osteocalcin levels decreased in the second trimester but returned to normal values during the third trimester of pregnancy. Diabetic pregnant women showed constant PTH levels throughout pregnancy. At delivery in diabetic pregnant women, total calcitriol levels increased to a smaller extent than in normal pregnant women. Osteocalcin concentrations in the second and third trimester of pregnancy were lower than in the non-pregnant group. Infants of diabetic mothers showed lower PTH and osteocalcin concentrations than infants of normal pregnant women, whereas their calcitriol levels were similar. These data indicate that diabetes decreases bone turnover during pregnancy in the mother and during the perinatal period in their offspring.

Factors in the development of secondary hyperparathyroidism during graded renal failure in the rat

Secondary hyperparathyroidism (2 degree HPT) develops as a result of renal failure. Hypocalcemia, phosphorus retention, calcitriol deficiency and skeletal resistance to the calcemic action of parathyroid hormone (PTH) are closely interrelated pathogenic factors important for the development of 2 degrees HPT in renal failure. Since previous studies have mainly focused on advanced renal failure, only limited data are available in early renal failure. The goal of the present study was to evaluate how alterations in the dietary calcium and phosphorus composition affect the factors known to contribute to the genesis of 2 degrees HPT in early and more advanced renal failure. To achieve this goal, graded differences in renal function were surgically induced in 453 rats while the dietary content of calcium and phosphorus was varied. Three different diets were used: (1) a high phosphorus diet (HPD), to induce phosphorus retention and stimulate 2 degrees HPT; (2) a high calcium diet (HCaD), to inhibit calcitriol synthesis; and (3) a moderate calcium-moderate phosphorus diet (MCaPD), to separate the effects of high dietary phosphorus and calcium. Based on the serum creatinine (SCr) concentration rats were assigned to one of four different groups: (1) normal renal function (SCr < or = 0.3 mg/dl); (2) mild renal failure (SCr 0.4 to 0.6 mg/dl); (3) moderate renal failure (SCr 0.7 to 0.8 mg/dl); or (4) advanced renal failure (SCr > or = 0.9 mg/dl). As the severity of renal failure increased, progressive 2 degrees HPT developed in each of the dietary groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adynamic bone disease with negative aluminium staining in predialysis patients: prevalence and evolution after maintenance dialysis

Aplastic bone disease (ABD) is a common form of renal osteodystrophy and is characterized by a defect in bone matrix formation and mineralization without an increase in osteoid thickness. The prevalence and pathogenesis of ABD in predialysis patients is largely unknown. We prospectively studied 92 unselected predialysis patients with a creatinine clearance < 10 ml/min/1.73 m2 and a mean age of 45 +/- 2 years (61 M, 31 F). None of the study patients had received any form of vitamin D therapy, and CaCO3 was the primary phosphate binder. Aplastic bone disease was observed in 30 (32%) patients. Stainable bone aluminium surface was < 3% in all ABD patients. Patients with ABD were older (52 +/- 3 versus 42 +/- 2 years; P < 0.01) and had reduced serum intact PTH compared to non-ABD patients (199 +/- 25 versus 561 +/- 87 pg/ml; P < 0.001). Patients with diabetes mellitus showed lower PTH values (179 +/- 31 versus 432 +/- 62 pg/ml; P < 0.001) and a lower incidence of advanced hyperparathyroidism bone lesions (16% versus 46%; P < 0.05) than non-diabetic patients. However, diabetes was not clearly associated with low bone turnover disease (56% in diabetics versus 41% in non-diabetics; P = 0.1). A second bone biopsy was obtained in eleven ABD patients after a period of 16.6 +/- 2.2 months on maintenance dialysis with a dialysate calcium of 7 mg/dl. Bone histology was unchanged in 10 patients, and one evolved to mild hyperparathyroidism. Trabecular bone volume did not change (22.7 +/- 1.7 versus 20.7 +/- 1.7%), and the stainable bone aluminium surface remained < 3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence of absorptive hypercalciuria in tuberculosis patients

In patients with granulomatous diseases, disturbances in calcium metabolism have been described. The aim of the study was to evaluate alterations in calcium metabolism in patients with tuberculosis. Forty patients with tuberculosis (TB) were studied in a baseline state (calcium intake 1000 mg/day). Fourteen of these patients were also studied after restrictive calcium diet (400 mg/calcium/day) and after a load of oral calcium of 1000 mg. In all the studies, calcium and phosphorus were measured in serum and urine, and parathyroid hormone (PTH) in plasma. In addition, serum 25OHD and 1,25(OH)2D (calcitriol) levels were measured in the baseline state and after the restrictive diet. In the baseline state, 25OHD levels were lower and urinary calcium higher in TB patients than in the control group. No patients had hypercalcemia, but hypercalciuria was present in 10 patients (25%). The patients with tuberculosis were divided according to the presence or absence of hypercalciuria. In both groups, the 25OHD levels were lower than in controls. Hypercalciuric patients had lower plasma parathyroid hormone levels and higher serum calcitriol levels than the control group and the TB patients without hypercalciuria. Urinary calcium excretion after a calcium load was higher in TB patients with hypercalciuria than in controls. A positive correlation was found between the calcitriol levels and postcalcium load urinary calcium excretion in patients with calcium hyperabsorption. These data indicate that absorptive hypercalciuria is frequently observed in patients with TB and is possible due to inappropriately high serum calcitriol levels.

Influence of calcium intake on calcitriol levels in idiopathic hypercalciuria in children

Twenty-four children with idiopathic absorptive hypercalciuria (IAH) and a control group (CG) of 11 healthy children were studied. Plasma 1,25-hydroxyvitamin D3 (calcitriol), parathyroid hormone (PTH), calcium (Ca) and phosphate (P) levels were measured during dietary manipulation. The three diets analyzed were: (A) calcium-restrictive diet (400 mg/1.73 m2/day) for 7 days; (B) supplemented diet (1,000 mg/1.73 m2/day) for 3 days; (C) supplemented diet continued for 15 days. The IAH group had higher levels of serum calcitriol than the control group for all three diets. Serum calcitriol levels in the IAH group decreased in diet B compared to diet A, and returned to levels observed with diet A during diet C. Serum Ca, P and plasma PTH levels did not vary throughout the study in either group. In IAH, two subgroups were observed. In one, serum calcitriol levels were elevated and in the other, serum calcitriol levels were not different from the controls. This second group had a lower P and maximum rate of tubular reabsorption of phosphate per 100 ml of glomerular filtrate than the IAH group with elevated serum calcitriol levels and the control group. These results suggest that IAH in children may be related both to increased serum calcitriol levels and to an altered Tmp/GFR.

Calcemic response to parathyroid hormone in renal failure: role of phosphorus and its effect on calcitriol

The calcemic response to parathyroid hormone (PTH) is decreased in renal failure. The reduction of hyperphosphatemia improves the calcemic response to PTH in animals with advanced renal failure. However, since low calcitriol levels in renal failure may also contribute to the decreased calcemic response to PTH, the improved calcemic response observed during the reduction of serum phosphorus may be partially mediated by an increase in serum calcitriol levels. The present study evaluated the calcemic response to PTH in rats with moderate and advanced renal failure and how this response was modified by a high and a low phosphorus diet. In addition, the effect of a change in dietary phosphorus on calcitriol levels was also evaluated. A 48-hour continuous infusion of 1-34 rat PTH increased the serum calcium level to 18.2 +/- 0.4 mg/dl in normal rats, versus 13.7 +/- 0.9 and 12.1 +/- 0.2 mg/dl in rats with moderate and advanced renal failure, respectively. During the PTH infusion, a high phosphorus diet increased the serum phosphorus and resulted in a reduced calcemic response to PTH at each level of renal function; respective serum calcium levels were 13.8 +/- 0.6 mg/dl in normals, 11.2 +/- 0.2 mg/dl in moderate renal failure and 9.6 +/- 0.5 mg/dl in advanced renal failure. In normal rats and in rats with moderate renal failure, dietary phosphorus restriction during the PTH infusion increased serum calcitriol levels. In rats with advanced renal failure, serum calcitriol levels were lower than in the other two groups and were not affected by changes in dietary phosphorus.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of aluminium on osteocalcin production in the rat

In renal failure, aluminium is an important factor in the development of osteomalacia. The mechanism by which aluminium produces osteomalacia is not clear; it may be toxic to the osteoblast, and as a result of its effect on osteoblasts, impair mineralisation. Another possibility is that aluminium may directly impair mineralisation independent of osteoblast function. Osteocalcin is considered to be a specific marker of osteoblast activity and its production is stimulated by calcitriol. In the present study, calcitriol-stimulated production of osteocalcin was studied as a marker of osteoblast activity in aluminium toxicity. Four groups of rats were evaluated: (1) normals; (2) normal renal function plus aluminium; (3) renal failure; and (4) renal failure plus aluminium. Osteocalcin production was determined by measuring serum osteocalcin at baseline and after stimulation with calcitriol. In rats receiving aluminium, the baseline serum osteocalcin levels were not different from their respective controls. After stimulation with calcitriol, the increase in serum osteocalcin was less in the renal failure group receiving aluminium. However, when corrected for the number of osteoblasts, the increase in serum osteocalcin was not decreased. In summary, although aluminium administration decreased the number of osteoblasts in rats with renal failure, osteocalcin production by the remaining osteoblasts was not decreased.

25(OH)D levels in diabetic pregnancies relation with neonatal hypocalcemia

The levels of 25(OH)D have been quantified in 42 insulin diabetic pregnancies (DP) through the three trimesters of pregnancy with a total of 177 determinations. In parallel we quantified this metabolite in 114 normal pregnant women (NP) and also in 116 normal controls (NC). In addition 25(OH)D was quantified in 18 (DP) and 19 (NP) at delivery in the 35-37th week of pregnancy, and ionic calcium was measured in their newborns at 24 h of life. Grouping by trimesters of gestation, the (NP) group had 25(OH)D levels similar to those of (NC) and none showed significant differences between trimesters of pregnancy. (DP) showed in all seasons lower (25(OH)D levels than (NC) but did not have differences in these levels between trimesters of pregnancy. The newborns of (DP) had lower ionic calcium levels than newborns of (NP). Eight newborns of (DP) had hypocalcemia and seven of their mothers showed 25(OH)D levels lower than 10 ng/ml. These findings suggest that lower 25(OH)D levels in (DP) can influence the neonatal hypocalcemia in their newborns.

Osteocalcin levels in uremic patients: influence of calcitriol treatment through two different routes and type of dialysis

Osteocalcin, the most abundant non-collagen protein of bone, is synthesized by the osteoblast. Serum osteocalcin concentration depends primarily on new cellular synthesis, and is a sensitive marker of bone turnover reflecting osteoblastic function. In uremic and hemodialysis (HD) patients, a direct relationship between serum osteocalcin and histological parameters of bone formation has been observed. The modality of dialysis may influence serum osteocalcin levels though the available data are controversial. The aim of this study is to assess the acute and chronic effects of calcitriol and the influence of modality of dialysis on serum osteocalcin levels. Twelve patients on continuous ambulatory peritoneal dialysis (CAPD) were treated with calcitriol. For control purposes, 24 patients, 12 on CAPD and 12 on HD, not treated with calcitriol serum osteocalcin levels were included. In CAPD patients previously treated with calcitriol, serum osteocalcin levels were higher than in nontreated patients. The higher levels occur independent of serum levels of parathyroid hormone (PTH), Ca and P. Hemodialysis patients had osteocalcin levels similar to those of CAPD patients under calcitriol treatment. However, the levels of HD patients were higher than CAPD nontreated patients. Serum ionized Ca was similar in CAPD and HD nontreated patients; however, total Ca was significantly higher in HD than in CAPD patients, both with and without calcitriol. After the intravenous administration of calcitriol, serum osteocalcin levels increased from 9.2 + 2.5 to 13.5 + 5.4 ng/ml (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Photomicrographic evidence of insertion tendonosis: the etiologic factor in pain for temporal tendonitis

A patient with the classic signs and symptoms of temporal tendonitis was treated with excisional surgery of the temporal tendon and its respective mandibular coronoid process. The excised tissue was submitted to pathology for microscopic analysis, and the results were confirmed by two pathologists. Degenerative signs of focal atrophy and tissue necrosis were evident and served to describe the focal nature of the painful condition of temporal tendonitis. The description for the pain pattern is given, along with the recommended method for diagnostic testing. The current method of surgical management using radiofrequency thermal ablation is described, which replaces the more tissue-destructive, excisional approach.

Effect of calcitriol on insulin secretion in uraemia

To evaluate the role of calcitriol on insulin secretion in uraemia, nine patients on maintenance haemodialysis, never treated with vitamin D nor with calcium-channel blockers, were studied. Baseline glucose, insulin, C peptide, calcium, intact PTH, and calcitriol serum values were measured, and after an oral load of 75 g glucose, insulin and C peptide were also determined at 15, 30, 45, 60, and 120 min. Following 14 days of treatment with oral calcitriol (0.5 microgram/day), the same study protocol was applied. Serum calcitriol values, which were low as expected, increased after therapy, but did not reach the values observed in healthy controls. Despite no change in total serum calcium, intact PTH values decreased significantly (182 vs 88.3 ng/ml, P less than 0.003). Baseline serum insulin was significantly increased after calcitriol (7.5 vs 35 microU/ml, P less than 0.001). Similarly, an enhancement in insulin secretion following calcitriol was observed at 15 min (34 vs 70, P less than 0.01) and 30 min (57 vs 96 microU/ml, P less than 0.01). Computation of the total area under the curve confirmed these results. Changes in C peptide profile paralleled those described for insulin. These data confirm that vitamin D modulates pancreatic beta-cell secretion and suggest that calcitriol may regulate insulin release in uraemic patients.

The effect of calcitriol on natural killer cell activity in hemodialyzed patients

We report the effect of calcitriol on natural killer (NK) cell activity in patients with chronic renal failure undergoing long-term hemodialysis. Natural killer cytotoxicity was significantly decreased in these patients when compared to healthy control subjects (13.1 +/- 1.3 vs 38.8 +/- 2.4%, P less than 0.001). These patients also have decreased levels of calcitriol (17 +/- 3 vs 36 +/- 3 pg/ml, P less than 0.001). After 14 days of oral treatment with calcitriol at a dose of 0.5 micrograms per day, a significant increase in NK activity was observed (20.2 +/- 1.6%, P less than 0.001). This increase was maintained after 28 days of treatment (21.1 +/- 2%, P less than 0.001). These results suggest that the decreased serum calcitriol might contribute to the diminished NK activity found in hemodialyzed patients, and suggests a new potential therapeutical utility of calcitriol as modulator of the immune function in these patients.

Ionic calcium levels during pregnancy, at delivery and in the first hours of life

Free calcium ion concentration (mmol/l) and pH were determined in whole blood using a semiautomatic electrode system (ICA-1 Radiometer, Copenhagen, Denmark) in 37 normal women, 90 pregnant women (30 from each trimester of gestation), 28 mothers at delivery and their respective newborns. The blood samples from normal controls, pregnant women, umbilical cord and 40-50-hour-old infants were collected anaerobically in vacuum tubes. Duplicate samples drawn from newborns shortly after birth by heel puncture were collected in special heparinized capillary tubes. We observed that Ca2+ concentrations in the second (1.20 +/- 0.04) and third (1.20 +/- 0.05) trimesters of pregnancy, and at delivery (1.18 +/- 0.05), were lower than in the control group (1.23 +/- 0.04). The [Ca2+] in samples from the umbilical vein (1.44 +/- 0.11) and artery (1.45 +/- 0.08) and from newborns 2-5 min after birth (1.34 +/- 0.12) was greater than in control samples. The [Ca2+] in newborns 40-50 hours after birth was lower (1.16 +/- 0.14) than in the control group.