Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Dietary intake of acrylamide and endometrial cancer risk in the European Prospective Investigation into Cancer and Nutrition cohort

BACKGROUND

Three prospective studies have evaluated the association between dietary acrylamide intake and endometrial cancer (EC) risk with inconsistent results. The objective of this study was to evaluate the association between acrylamide intake and EC risk: for overall EC, for type-I EC, and in never smokers and never users of oral contraceptives (OCs). Smoking is a source of acrylamide, and OC use is a protective factor for EC risk.

METHODS

Cox regression was used to estimate hazard ratios (HRs) for the association between acrylamide intake and EC risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Acrylamide intake was estimated from the EU acrylamide monitoring database, which was matched with EPIC questionnaire-based food consumption data. Acrylamide intake was energy adjusted using the residual method.

RESULTS

No associations were observed between acrylamide intake and overall EC (n=1382) or type-I EC risk (n=627). We observed increasing relative risks for type-I EC with increasing acrylamide intake among women who both never smoked and were non-users of OCs (HRQ5vsQ1: 1.97, 95% CI: 1.08-3.62; likelihood ratio test (LRT) P-value: 0.01, n=203).

CONCLUSIONS

Dietary intake of acrylamide was not associated with overall or type-I EC risk; however, positive associations with type I were observed in women who were both non-users of OCs and never smokers.

Effect of warfarin treatment on thrombin activatable fibrinolysis inhibitor (TAFI) activation and TAFI-mediated inhibition of fibrinolysis

BACKGROUND

Severe clotting deficiencies are associated with enhanced in vitro fibrinolysis due to insufficient thrombin activatable fibrinolysis inhibitor (TAFI) activation. Because oral anticoagulant therapy (OAT) with warfarin causes a partial deficiency of vitamin K-dependent factors, its effect on clot lysability remains unclear.

OBJECTIVES

To evaluate plasma and blood fibrinolytic capacity in patients under stable OAT (n = 221) as compared with controls (n = 132).

METHODS

Fibrinolysis resistance of plasma (turbidimetry) and blood (thromboelastography) clots was calculated as the lysis time of tissue factor-induced clots exposed to 30 and 100 ng mL(-1) t-PA, respectively.

RESULTS

Plasma PAI-1 was similar in the two groups, whereas TAFI was slightly lower in patients. OAT plasma clots lysed faster than controls (P = 0.001). The addition of the TAFIa inhibitor PTCI reduced lysis time by 14% in OAT and 34% in controls, and the difference between the groups disappeared. Similar data were obtained with blood clots. Thrombin and TAFIa generation in OAT plasma amounted to roughly 50% of controls, supporting a reduced thrombin-dependent TAFI activation. Clot resistance of OAT plasma was normalized by Ba-citrate plasma eluate or prothrombin but not by BaSO(4) serum eluate, rFVIIa or FX. Surprisingly, circulating levels of TAFIa and its inactive derivative TAFIai were higher in warfarin patients (P < 0.0001) and correlated with plasmin-antiplasmin (P = 0.0001) but not with prothrombin F(1) (+) (2) .

CONCLUSIONS

OAT enhances both plasma and blood fibrinolysis by reducing thrombin-dependent TAFI activation, a phenomenon largely determined by low prothrombin levels. At variance with in vitro data, 'basal' in vivo TAFIa/ai levels seem related to plasmin rather than thrombin generation.

Paget's Disease. A Case Report

Paget's disease (PD) is a common focal progressive osteometabolic disorder characterised by a disturbance in bone modelling and remodelling, because of an increase in osteoblastic and osteoclastic activity. It is a condition of unknown aetiology affecting approximately 3% of the population over 40 years of age and, approximately 10% of those over the age of 85 years. It is most common in Northern Europe and Australia and is rare in Asia and Africa. We describe the case of a 71-year-old man diagnosed with PD confined to the sacrum. After laboratory test, an imaging study with radiography, scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) was performed disclosing findings compatible with Paget's disease in middle pathologic phase. The diagnosis was confirmed at biopsy. The structural modification of the sacrum with spongiosa rarefaction, thickening of bone and intact bone cortical, confirmed by CT, are tipical of an intermediate phase of PD. This was also supported by signal MRI changes showing substitution of the red by the fat medulla, visualized by FS sequences. Once the treatment for the bone disease was established, the patient no longer complained of pain. Special attention should be paid to male and elderly patients with pain in the lumbar spine because of the potential risk cancer development (21). The radiologist must be attentive to the possible presentations and complications of PD, even in uncommon sites, trying whenever possible to correlate the radiological features with the patient's clinical symptoms.

The role of thrombin activatable fibrinolysis inhibitor and factor XI in platelet-mediated fibrinolysis resistance: a thromboelastographic study in whole blood

BACKGROUND

The resistance of platelet-rich thrombi to fibrinolysis is generally attributed to clot retraction and platelet PAI-1 release. The role of TAFI in platelet-mediated resistance to lysis is unclear.

OBJECTIVE

We investigated the contribution of TAFI to the antifibrinolytic effect of platelets in whole blood by thromboelastography.

METHODS

Platelet-poor (PP-WB, < 40 × 10(3) μL(-1) ) and platelet-rich (PR-WB, > 400 × 10(3) μL(-1) ) blood samples were obtained from normal human blood (N-WB, 150-220 × 10(3) μL(-1) ). Clot lysis time was measured by thromboelastography in recalcified blood supplemented with t-PA (100 ng mL(-1) ) and tissue factor (1:1000 Recombiplastin).

RESULTS

t-PA-induced lysis time increased in parallel with platelet concentration (up to 3-fold). Neutralization of TAFI, but not of PAI-1, shortened the lysis time by ∼ 50% in PR-WB and by < 10% in PP-WB. Accordingly, prothrombin F1+2 and TAFIa accumulation was greater in PR-WB than in PP-WB. A similar TAFI-dependent inhibition of fibrinolysis was observed when clot retraction was prevented by cytochalasin D or abciximab, or when platelet membranes were tested. Moreover, in blood with an intact contact system, platelet-mediated fibrinolysis resistance was attenuated by an anti-FXI but not by an anti F-XII antibody. Finally, platelets made the clots resistant to the profibrinolytic effect of heparin concentrations displaying a strong anticoagulant activity.

CONCLUSIONS

Our data indicate that TAFI activation is one major mechanism whereby platelets make clots resistant to fibrinolysis and underscore the importance of TAFI inhibitors as new antithrombotic agents.

Adaptive changes in pancreatic beta cell fractional area and beta cell turnover in human pregnancy

AIMS/HYPOTHESIS

We sought to establish the extent and basis for adaptive changes in beta cell numbers in human pregnancy.

METHODS

Pancreas was obtained at autopsy from women who had died while pregnant (n = 18), post-partum (n = 6) or were not pregnant at or shortly before death (controls; n = 20). Pancreases were evaluated for fractional pancreatic beta cell area, islet size and islet fraction of beta cells, beta cell replication (Ki67) and apoptosis (TUNEL), and indirect markers of beta cell neogenesis (insulin-positive cells in ducts and scattered beta cells in pancreas).

RESULTS

The pancreatic fractional beta cell area was increased by approximately 1.4-fold in human pregnancy, with no change in mean beta cell size. In pregnancy there were more small islets rather than an increase in islet size or beta cells per islet. No increase in beta cell replication or change in beta cell apoptosis was detected, but duct cells positive for insulin and scattered beta cells were increased with pregnancy.

CONCLUSIONS/INTERPRETATION

The adaptive increase in beta cell numbers in human pregnancy is not as great as in most reports in rodents. This increase in humans is achieved by increased numbers of beta cells in apparently new small islets, rather than duplication of beta cells in existing islets, which is characteristic of pregnancy in rodents.

Migraine and coronary artery disease: an open study on the genetic polymorphism of the 5, 10 methylenetetrahydrofolate (MTHFR) and angiotensin I-converting enzyme (ACE) genes

Genetic factors that increase susceptibility to oxidative stress, endothelial disfunction and, possibly, stroke include angiotensin-converting enzyme gene deletion polymorphism (ACE-DD) and the methylentetrahydropholate reductase (MTHFR) C677-TT polymorphism. The relationship of ACE-DD genotype to ischemic stroke and cardiovascular disease is controversial, but it has been independently linked to lacunar infarction, in the absence of carotid atheroma. Lea et al. (2005) reported that the ACE DD genotype acts in combination with the MTHFR T/T genotype to increase migraine susceptibility, with the greatest effect in those with aura. The "TT" polymorphism is also associated with an increased risk of migraine with aura, independent of other cardiovascular risk factors. The aim of our study was to evaluate the incidence of ACE and MTHFR genes polymorphisms in a consecutive series of migrainous patients and of patients affected by myocardial infarction. We studied a series of 103 migrainous patients (1), whose age was between 13 and 75 years (81 suffering from migraine without aura, MwA, 9 from migraine with aura, MWA, 13 from mixed forms MwA-MWA, according to ICHD-II 2004 criteria) and of 336 patients (2) suffering from ischaemic cardiopathy (myocardial infarction, MI). The analysis, based on Polymerase Chain Reaction (PCR) and on reverse-hybridization, showed as follows: MTHFR (C677T): 60 patients (58%) (1) and 186 (56%) (2) were heterozygous; 9 patients (9%) (1) and 54 (16%) (2) were mutated. The result of 1 patient (2) was unknown. MTHFR (A1298C): 54 patients (52%) (1) and 146 (44%) (2) were heterozygous, 7 patients (7%) (1) and 33 (10%) (2) were mutated. The result of 1 patient (2) was unknown. ACE (evaluated on 101 patients (1) and 245 (2)): 45 patients (43%) (1) and 133 (54%) (2) had an ID genotype; 42 (41%) (1) and 87 (36%) (2) had a DD genotype. The results of our study confirm the high incidence in the genetic polymorphisms ACE and MTHFR in migraineuse. These data are confirmed in the sample of patients affected by myocardial infarction. This gives evidence of a strong relationship between migraine and major vascular diseases and let us hypothesize an important role of ACE and MTHFR system in the pathogenetic model of migraine for its capability to interfere with the endothelial regulation tone. Once an effective role in the genesis of migraine and in the increased risk of migrainous patients to evolve into an ischemic pathology has been obviously assigned to this genetic mutation, future researches must aim through wider and more controlled casistics also to clarify the role that drugs acting on these systems may have on the resolution of these diseases.

Relationship between fractional pancreatic beta cell area and fasting plasma glucose concentration in monkeys

AIMS/HYPOTHESIS

We sought to establish the relationship between fasting plasma glucose concentrations and pancreatic fractional beta cell area in adult cynomolgus monkeys (Macaca fascicularis).

METHODS

Fasting plasma glucose and pancreatic fractional beta cell area were measured in 18 control and 17 streptozotocin-treated adult primates (17.0 +/- 1.2 vs 15.4 +/- 1.2 years old).

RESULTS

Fasting plasma glucose was increased (12.0 +/- 2.0 vs 3.4 +/- 0.1 mmol/l, p < 0.01) and fractional beta cell area was decreased (0.62 +/- 0.13% vs 2.49 +/- 0.35%, p < 0.01) in streptozotocin-treated monkeys. The relationship between fasting plasma glucose and pancreatic fractional beta cell area was described by a wide range of beta cell areas in controls. In streptozotocin-treated monkeys there was an inflection of fasting blood glucose at approximately 50% of the mean beta cell area in controls with a steep increase in blood glucose for each further decrement in beta cell area.

CONCLUSIONS/INTERPRETATION

In adult non-human primates a decrement in fractional beta cell area of approximately 50% or more leads to loss of glycaemic control.

Pancreatic duct replication is increased with obesity and type 2 diabetes in humans

AIMS/HYPOTHESIS

In a high-fat-fed rat model of type 2 diabetes we noted increased exocrine duct replication. This is a predisposing factor for pancreatitis and pancreatic cancer, both of which are more common in type 2 diabetes. The aim of the study reported here was to establish if obesity and/or type 2 diabetes are associated with increased pancreatic ductal replication in humans.

METHODS

We obtained pancreas at autopsy from 45 humans, divided into four groups: lean (BMI <25 kg/m(2)); obese (BMI >27 kg/m(2)); non-diabetic; and with type 2 diabetes. Pancreases were evaluated after immunostaining for the duct cell marker cytokeratin and Ki67 for replication.

RESULTS

We show for the first time that both obesity and type 2 diabetes in humans are associated with increased pancreatic ductal replication. Specifically, we report that (1) replication of pancreatic duct cells is increased tenfold by obesity, and (2) lean subjects with type 2 diabetes demonstrate a fourfold increase in replication of pancreatic duct cells compared with their lean non-diabetic controls.

CONCLUSIONS/INTERPRETATION

Pancreatic duct cell replication is increased in humans in response to both obesity and type 2 diabetes, potentially providing a mechanism for the increased risk of pancreatitis and pancreatic cancer in those with obesity and/or type 2 diabetes.

Management of vertebral re-fractures after vertebroplasty in osteoporotic patients

SUMMARY

This study illustrates the usefulness of vertebral biopsy in osteoporotic patients previously treated with vertebroplasty (VP) who present at follow-up with a new fracture in a vertebral soma adjacent or distant from the collapsed vertebral body. Five hundred and fifty patients with osteoporotic vertebral collapse underwent a minimally invasive treatment with vertebroplasty (VP) for a total of 980 vertebral bodies. The approach was unipedicular in 520 patients and bipedicular in 30. Only cases with unclear findings at MR or CT (23 patients) were scheduled for a vertebral biopsy before VP treatment. The biopsy results were positive for haematological disease in only eight patients. A vertebral biopsy was carried out during re-treatment with VP in all patients who presented a vertebral refracture in the three month follow-up at a site adjacent to or distant from the previously treated vertebra (21 patients). We have found new fractures of adjacent vertebrae in 15 patients and new fractures of distant vertebrae in 16 patients at three month follow-up examination. Five of the 31 cases (16%) of spinal refracture, where during vertebroplasty treatment a bone biopsy and a sternal medullary aspiration had been carried out, an anatomopathological response to multiple myeloma was responsible for the refracture. It is useful to perform a spinal bone biopsy during re-treatment of the vertebroplasty procedure to rule out multiple myeloma or other disease as the cause of the new collapse in patients with osteoporotic disease presenting a new vertebral fracture in an adjacent or distant site from the previously collapsed vertebral body.

A comparison of minimally invasive techniques in percutaneous treatment of lumbar herniated discs. A review

Low back pain is the commonest spine disease causing absence from work in developed countries. Low back pain with classical irradiation along the course of the nerve root affected is more frequently due to disc disease. In 60-80% of patients with herniated disc, radicular symptoms disappear with conservative treatment after about six weeks, the remainder are treated surgically with a 2-6% of incidence of true recurrence of herniation post-intervention and with failed back surgery syndrome in 15% of cases. Recently minimally invasive techniques have developed as "alternative" treatments to surgical intervention. This review aimed to assess the pathogenesis of low back pain caused by lumbar disc hernia as a basis for action of minimally invasive techniques; to illustrate the techniques already used or currently in use, to compare them in technical guidance, indications and complications, exposing for each of them the inclusion/exclusion criteria in enrolling patients and the imaging guide technique of choice. Minimally invasive techniques can be a valuable alternative to traditional surgery with low cost, low risk of complications, easy feasibility, and in the event of failure they do not exclude subsequent surgery.

Vertebroplasty as treatment of aggressive and symptomatic vertebral hemangiomas: up to 4 years of follow-up

INTRODUCTION

This study aimed to illustrate the validity of the treatment with vertebroplasty (VP) in patients with aggressive or symptomatic vertebral hemangioma (VH) with or without epidural extension.

METHODS

From January 2003 to December 2007, 24 consecutive patients have been treated with VP, for a total of 36 vertebral bodies affected by VH: two cervical, ten dorsal, 24 lumbar. All the patients complained of a pain syndrome resistant to continuous medical medication; four of 24 patients also presented aggressive magnetic resonance features of the vertebral lesion and two patients showed also epidural extension. A unipedicular approach has been performed in 16 patients; a bipedicular approach has been performed in six, while for the cervical spine an anterior-lateral approach with manual dislocation of the carotid axis has always been performed. Bone biopsy was never done. All procedures have been carried out with local anesthesia, except for the treatment of the cervical hemangiomas which has always been performed under general anesthesia. Four vertebral bodies in the same session have been treated in one case.

RESULTS

Results have been evaluated with the visual analog scale and the Oswestry Disability Index methods. In all the patients, in the following 24-72 h, a successful outcome has been observed with a complete resolution of pain symptom. Extravertebral vascular or discal cement leakage has been observed in four patients, without any onset of clinical radicular syndrome due to epidural diffusion. Clinical and radiological follow-up until 4 years has been performed in 12 patients and it showed stability of the treatment and absence of pain.

CONCLUSIONS

Percutaneous treatment with VP for aggressive and symptomatic vertebral hemangiomas even with epidural extension is a valuable, mini-invasive, and quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of fracture of a vertebral body adjacent or distant to the one treated.

Menstrual cycle length, serum lipids and lipoproteins in a cohort of Italian Mediterranean women: findings from Progetto ATENA

BACKGROUND AND AIMS

Clinical studies suggest that menstrual irregularities are associated with metabolic and hormonal abnormalities, insulin resistance and a hyperestrogenic/hyperandrogenic imbalance, that may influence the risk of cardiovascular disease.

METHODS AND RESULTS

The association of these abnormalities with the metabolic syndrome suggests that information on lipid patterns at different menstrual cycle length may be of interest in identifying women at higher cardiovascular risk. The association of lipid patterns with menstrual cycle length was evaluated in a cohort of 5062 women participating in the Progetto ATENA Study. Questions were administered to the participants about their cycle lengths at different periods of time over their reproductive life. The period between 20 and 50 years was investigated: normal cycle length was defined as short (<or=26 days), medium (between 27 and 29 days) or long (>30 days). Perimenopausal women were excluded and variables adjusted for age, BMI and menopausal status. In 4434 participants serum triglycerides were found to increase with an increased number of days in the menstrual cycle: 106 mg/dl in the short cycle pattern (21-26 days); 113 mg/dl in the medium cycle pattern (27-29 days); and 116 mg/dl in the long cycle pattern (30-31 days), whereas total and LDL cholesterol were found to be higher and HDL was lower in women with longer cycles, but the difference was not statistically significant. The results were very similar when the same adjusted analysis was restricted to a subgroup of 3823 women with a stable cycle length over the fourth and the fifth decade of life.

CONCLUSIONS

These results suggest that cycle length may be a marker of higher cardiovascular risk due to associated metabolic and hormonal patterns.

Modestly increased beta cell apoptosis but no increased beta cell replication in recent-onset type 1 diabetic patients who died of diabetic ketoacidosis

AIMS/HYPOTHESIS

Type 1 diabetes is characterised by a deficit in beta cell mass thought to be due to immune-mediated increased beta cell apoptosis. Beta cell turnover has not been examined in the context of new-onset type 1 diabetes with diabetic ketoacidosis.

METHODS

Samples of pancreas were obtained at autopsy from nine patients, aged 12 to 38 years (mean 24.3+/-3.4 years), who had had type 1 diabetes for less than 3 years before death due to diabetic ketoacidosis. Samples of pancreas obtained at autopsy from nine non-diabetic cases aged 11.5 to 38 years (mean 24.2+/-3.4 years) were used as control. Fractional beta cell area (insulin staining), beta cell replication (insulin and Ki67 staining) and beta cell apoptosis (insulin and TUNEL staining) were measured.

RESULTS

In pancreas obtained at autopsy from recent-onset type 1 diabetes patients who had died of diabetic ketoacidosis, the beta cell deficit varied from 70 to 99% (mean 90%). The pattern of beta cell loss was lobular, with almost all beta cells absent in most pancreatic lobules; islets in lobules not devoid of beta cells had reduced or a near-normal complement of beta cells. Beta cell apoptosis was increased in recent-onset type 1 diabetes, but to a surprisingly modest degree given the marked hyperglycaemia (30 mmol/l), acidosis and presumably high NEFA. Beta cell replication, scattered pancreatic beta cells and beta cells in exocrine ducts were not increased in recent-onset type 1 diabetes.

CONCLUSIONS/INTERPRETATION

These findings do not support the notion of active beta cell regeneration by replication in new-onset type 1 diabetes under conditions of diabetic ketoacidosis. The gluco-lipotoxicity reported in isolated human islets may be less evident in vivo.

Increased islet beta cell replication adjacent to intrapancreatic gastrinomas in humans

AIMS/HYPOTHESIS

Type 1 and type 2 diabetes are characterised by a beta cell deficit. Islet hyperplasia has been described in patients with Zollinger-Ellison syndrome secondary to gastrin-producing tumours (gastrinomas), and gastrin therapy has increased beta cell mass in rodents and human islets in vitro. In the present studies we addressed the following questions: (1) In pancreas specimens from gastrinoma cases, is the fractional beta cell area increased? (2) If so, is this restricted to tumour-adjacent islets or also present in tumour-distant islets? (3) Is new beta cell formation (beta cell replication and islet neogenesis) increased and beta cell apoptosis decreased in pancreas specimens from gastrinoma cases?

METHODS

Pancreas was obtained at surgery from four patients with Zollinger-Ellison syndrome caused by pancreatic gastrinomas and 15 control subjects at autopsy.

RESULTS

Islet fractional beta cell area (p<0.001), islet size (p<0.001) and beta cell replication (Ki67 staining) (p<0.05) were increased in islets adjacent to the tumours, but not in tumour-distant pancreas, compared with control subjects. We did not observe any differences in beta cell apoptosis or in the number of insulin-positive cells in ducts either adjacent to or distant from the tumour.

CONCLUSIONS/INTERPRETATION

One or more factors released by human gastrinomas increase beta cell replication in islets immediately adjacent to the tumour, but not in tumour-distant islets. While these findings demonstrate that adult human beta cells can be driven into the cell cycle, they caution against the therapeutic usefulness of gastrin, since islets located >1 cm away from the gastrinomas did not exhibit changes in beta cell turnover, despite markedly elevated systemic gastrin levels sufficient to cause severe gastrointestinal symptoms.

Direct evidence of attempted beta cell regeneration in an 89-year-old patient with recent-onset type 1 diabetes

AIMS/HYPOTHESIS

We investigated whether there was evidence of attempted beta cell regeneration in the pancreas obtained from a patient with recent-onset type 1 diabetes, and if so by what mechanism this occurred.

SUBJECTS, MATERIALS AND METHODS

We examined pancreas tissue from a lean 89-year-old patient (BMI 18.0 kg/m(2)) with recent-onset type 1 diabetes who had had a distal pancreatectomy to remove a low-grade pancreatic intraepithelial neoplasia.

RESULTS

In the tumour-free tissue, the fractional beta cell area was 0.54+/-0.2% of pancreas area (about one-third of that in non-diabetic humans). CD3-positive T lymphocytes and macrophages had infiltrated the majority of the islets. Subclassification of the T cell population revealed a predominance of CD8-positive cells over CD4-positive cells. Beta cell apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labelling [TUNEL] staining) was greatly increased, consistent with ongoing immune-mediated beta cell destruction. There was also a marked increase (more than approximately 100-fold) in the frequency of beta cell replication (0.69+/-0.15% Ki67-positive beta cells) in all blocks examined.

CONCLUSIONS/INTERPRETATION

The present report provides direct evidence of attempted beta cell regeneration through the mechanism of beta cell replication in a case of newly diagnosed type 1 diabetes, and affirms that beta cell apoptosis is an important mechanism for beta cell loss in type 1 diabetes.

Nutrient determinants of postprandial triglyceride response in a population-based sample of type II diabetic patients

BACKGROUND

Nutrient determinants of postprandial triglyceride (TG) are matter of debate, especially for type II diabetes.

OBJECTIVE

This study was performed to evaluate the impact of dietary habits on postprandial TG response in a population-based sample of type II diabetic patients.

DESIGN

One-hundred and forty type II diabetic patients (63 men/77 women, age 45-70 years) referring to the same health district, not on hypolipidemic drugs and without any other chronic disease, performed four TG profiles (at fasting, before, 2 and 3 h after lunch) with a specific device (Accutrend GCT, Roche Diagnostics Mannheim, Germany) validated previously. Dietary habits were recorded by a dietitian utilizing a previously validated semiquantitative questionnaire.

RESULTS

Triglyceride values (mmol/l, mean +/- s.d.) were 2.22 +/- 0.93 at fasting, decreased before lunch (2.03 +/- 0.81), reached peak values 3 h after lunch (2.73 +/- 1.11). Postprandial TG increments (3 h after lunch minus pre-lunch concentration) significantly correlated with the intake (g/day) of animal protein (r = 0.20, P < 0.02), total fat (r = 0.21, P < 0.01), animal fat (r = 0.19, P < 0.03) and vegetable fat (r = 0.19, P < 0.03), also after adjusting for fasting TG and high-density lipoprotein cholesterol levels. Expressing nutrient intake as percentage of total calorie intake, total and animal fat remained significantly and directly related to postprandial TG increment (r = 0.21, P < 0.01 for total fat; r = 0.19, P < 0.03 for animal fat) whereas the percentage of carbohydrates was inversely related (r = -0.23, P < 0.007).

CONCLUSIONS

Fat intake seems the major nutritional determinant of postprandial TG response in type II diabetic patients.

Plasma carotenoids as biomarkers of intake of fruits and vegetables: individual-level correlations in the European Prospective Investigation into Cancer and Nutrition (EPIC)

OBJECTIVE

The aim in this study was to assess the association between individual plasma carotenoid levels (alpha-carotene, beta-carotene, lycopene, beta-cryptoxanthin, lutein, zeaxanthin) and fruit and vegetable intakes recorded by a calibrated food questionnaire (FQ) and 24-h dietary recall records (24HDR) in nine different European countries with diverse populations and widely varying intakes of plant foods.

DESIGN

A stratified random subsample of 3089 men and women from nine countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC), who had provided blood samples and dietary and other lifestyle information between 1992 and 2000, were included.

RESULTS

beta-Cryptoxanthin was most strongly correlated with total fruits (FQ r = 0.52, 24HDR r = 0.39), lycopene with tomato and tomato products (FQ r = 0.38, 24HDR r = 0.25), and alpha-carotene with intake of root vegetables (r = 0.39) and of total carrots (r = 0.38) for FQ only. Based on diet measured by FQ and adjusting for possible confounding by body mass index (BMI), age, gender, smoking status, alcohol intake, and energy intake, the strongest predictors of individual plasma carotenoid levels were fruits (R(partial)(2) = 17.2%) for beta-cryptoxanthin, total carrots ((partial)(2) = 13.4%) and root vegetables (R(partial)(2) = 13.3%) for alpha-carotene, and tomato products (R(partial)(2) = 13.8%) for lycopene. For 24HDR, the highest R(partial)(2) was for fruits in relation to beta-cryptoxanthin (7.9%).

CONCLUSIONS

Intakes of specific fruits and vegetables as measured by food questionnaires are good predictors of certain individual plasma carotenoid levels in our multicentre European study. At individual subject levels, FQ measurements of fruits, root vegetables and carrots, and tomato products are, respectively, good predictors of beta-cryptoxanthin, alpha-carotene, and lycopene in plasma.

Should we continue to study high-dose chemotherapy in metastatic breast cancer patients? A critical review of the published data

Data from eight randomised trials on high-dose chemotherapy (HDC) for metastatic breast cancer (MBC) have been published, but only seven studies are evaluable after the Bezwoda trial was discredited. Moreover, overall survival (OS) has been evaluated in only four out of seven studies since three had a crossover design. OS was similar for the HDC and standard-dose chemotherapy (SDC) group in the four evaluable trials, while disease-free survival (DFS) was improved in the HDC group in six of the seven trials. The delay in relapse for patients with metastatic disease represents an important clinical outcome; furthermore, since none of the reported studies randomised more than 220 patients, their statistical power may have been too limited to detect meaningful survival differences. Finally, preliminary experiences have shown that HDC seems to be the ideal platform upon which to build novel therapies. In conclusion, HDC remains an important field of clinical research for breast cancer patients with stage IV disease and, from the studies reported in this article, there is some evidence for offering this therapeutic modality to selected patients who are interested in a medically aggressive approach.

Variability of fish consumption within the 10 European countries participating in the European Investigation into Cancer and Nutrition (EPIC) study

OBJECTIVE

To describe and compare the consumption of total fish (marine foods) and the fish sub-groups - white fish, fatty fish, very fatty fish, fish products and crustacea, in participants from the European Investigation into Cancer and Nutrition (EPIC) study.

DESIGN

Cross-sectional analysis of dietary intake using a computerised standardised 24-hour recall interview. Crude means, means and standard errors adjusted by age, season and day of the week were calculated, stratified by centre and gender.

SETTING

Twenty-seven redefined centres in the 10 European countries participating in the EPIC study.

SUBJECTS

In total, 35 955 subjects (13 031 men and 22 924 women), aged 35-74 years, selected from the main EPIC cohort.

RESULTS

A six- to sevenfold variation in total fish consumption exists in women and men, between the lowest consumption in Germany and the highest in Spain. Overall, white fish represented 49% and 45% of the intake of total fish in women and men, respectively, with the greatest consumption in centres in Spain and Greece and the least in the German and Dutch centres. Consumption of fatty fish reflected that of total fish. However, the greatest intake of very fatty fish was in the coastal areas of northern Europe (Denmark, Sweden and Norway) and in Germany. Consumption of fish products was greater in northern than in southern Europe, with white fish products predominating in centres in France, Italy, Spain, The Netherlands and Norway. Intake of roe and roe products was low. The highest consumption of crustacea was found in the French, Spanish and Italian centres. The number of fish types consumed was greater in southern than in northern Europe. The greatest variability in consumption by day of the week was found in the countries with the lowest fish intake.

CONCLUSIONS

Throughout Europe, substantial geographic variation exists in total fish intake, fish sub-groups and the number of types consumed. Day-to-day variability in consumption is also high.

Not traditional prognostic factors in human conventional renal carcinoma

The evaluation of know prognostic factors is an essential step of the assessment of the patients affected by primary renal carcinoma. As long as the major biological mechanisms of renal carcinomas remain unknown, it will be impossible to achieve an accurate prognostic judgement. The TNM classification has always been the main source of information. Nevertheless, recently several investigations evaluated the prognostic power of serum and cellular markers. The aim of this study is to identify those markers which show statistical reliability and can be used in the clinical practice. A literature search was performed on MEDLINE to identify potential not traditional prognostic factors for patients with renal cell carcinoma edited from January 1997 through April 2000 using prognosis and clear cell carcinoma and kidney as keywords. We considered also articles cited in references of first selected manuscript. The analysis of serum and cellular prognostic markers does not allow the identification of specific factors, reliable, independent, easy to dose, widely useful and whose informations are repeatable. Currently classical prognostic factors (staging, grading, hystologic type, patient clinical conditions, anaemia, presentation modalities, etc.) represent the only useful elements after surgical time in RCC patients. Among serum prognostic factors, CRP and ferritin play a crucial role. These proteins appear ideal in monitoring the disease over time, due to simple test execution and specimens repeatability. Among RCC molecular markers, proliferation index result promising for their reliability and reproducibility, the easy dosage and high series number tested. Literature data suggest that the ideal marker for renal carcinomas has not been identified yet. However, C-reactive protein, ferritin and the proliferative activity indexes (Ki67 and AgNOR) appear to be, at present, the best prognostic tools. To confirm obtained results and to use biomolecolar markers on a routinary base further studies on wide surgical series will be required. The improvement of technical tool and costs reduction represent also a necessary step toward the identification of efficient prognostic markers in RCC.

Site-specific atherosclerotic plaques in the carotid arteries of middle-aged women from southern Italy: associations with traditional risk factors and oxidation markers

BACKGROUND AND PURPOSE

Studies on cardiovascular disease have preferentially involved men because of the lower frequency of the disease in preelderly women. The aim of this analysis was to examine, with the use of a standardized ultrasound protocol, a cohort of women to differentiate early atherosclerotic lesions in different carotid segments in relation to traditional (lipoprotein abnormalities, high blood pressure, cigarette smoking) and nontraditional (oxidation markers) cardiovascular risk factors.

METHODS

More than 5000 clinically healthy, middle-aged women (n=5062; age range, 30 to 69 years) living in the area of Naples in southern Italy participated in the Progetto Atena, a population-based study on the etiology of cardiovascular disease and cancer in the female population. A subsample of 310 participants underwent high-resolution B-mode ultrasound to assess intima-media thickness of common carotid artery and carotid bifurcation.

RESULTS

Early atherosclerotic plaques (intima-media thickness >1.2 mm) were detected within the common carotid arteries in 37 women, in the carotid bifurcations in 77 women, and in both sites in 91 women. After age adjustment, common carotid plaques were found to be associated with higher systolic blood pressure (143 versus 138 mm Hg; P<0.05) and higher body mass index (29 versus 27 kg/m(2); P<0.01), while lesions at the carotid bifurcations were associated with higher LDL cholesterol (4.3 versus 3.8 mmol/L; P<0.01) and with smoking habit. Multivariate odds ratios for the presence of common carotid plaques were related to antibodies against oxidized LDL (odds ratio, 2.72; 95% CI, 1.46 to 5.07), and those for plaques at the bifurcation were related to lipid peroxides (odds ratio, 1.90; 95% CI, 1.04 to 3.47), and both relationships were independent of age, LDL cholesterol concentrations, body mass index, smoking habit, and systolic blood pressure.

CONCLUSIONS

In a cohort of clinically healthy, middle-aged women, we found a site-specific association of traditional risk factors and oxidation markers with early atherosclerotic lesions in arterial segments differing in geometry, shear stress, extracellular matrix composition, and cell type populations.

Assay of erythrocyte membrane fatty acids. Effects of storage time at low temperature

The study of the stability of saturated mono-, or polyunsaturated fatty acids, both esterified and not esterified, in plasma, circulating cells, and tissues is extremely important to validate the use of biological samples stored at low temperature in "biological banks", which are used for experimental, observational, dietary, or pharmacological studies. Since red blood cells are easily accessible cells, they are used as a marker of less-accessible tissues, especially in large-scale epidemiological studies. Data from the literature suggest that the addition of an antioxidant and the freezing of red blood cells do not cause any variation in the fatty acid composition for a period of 2-6 months up to 1 year. We evaluated the fatty acid concentration in red blood cells isolated from venous blood samples of one subject, preserved with butylated hydroxytoluene and N2 and stored at -80 degrees C for up to 2 years. Erythrocytes of venous samples of six subjects stored at -20 degrees C for 6 months without butylated hydroxytoluene and in the presence of air were used for comparison purposes. Our data demonstrate that a long storage time (2 years) does not significantly influence the erythrocyte fatty acid concentration when using very low temperatures (-80 degrees C) and antioxidants (butylated hydroxytoluene) in the presence of N2.

Large-scale hormone replacement therapy and life expectancy: results from an international comparison among European and North American populations

OBJECTIVES

An analysis was performed to determine the risks and benefits of a 10-year hormone replacement therapy regimen that had been applied to all women at 50 years of age in 8 countries.

METHODS

Cumulative mortality with and without hormone replacement therapy over 20 years was estimated, with both current and predicted total and disease-specific secular mortality trends and the influence of a generational cohort effect taken into account.

RESULTS

In countries with high ischemic heart disease frequency and predictable relative predominance of ischemic heart disease rates over breast cancer rates for the next 20 years, hormone replacement therapy could result in benefits with regard to overall mortality; this advantage decreases in younger-generation cohorts. In countries in which breast cancer mortality predominates over ischemic heart disease in early postmenopause and in which the predictable trends for both diseases reinforce this condition, a negative effect on overall mortality would be observed. In the United States, the effect of large-scale hormone replacement therapy would change over time.

CONCLUSIONS

The long-term effect of hormone replacement therapy on life expectancy of postmenopausal women may vary among countries.

Obesity and other health determinants across Europe: the EURALIM project

STUDY OBJECTIVE

EURALIM (EURope ALIMentation), a European collaborative study, aimed to determine and describe the extent to which European data on risk factor distributions from different populations could be pooled and harmonised in a common database for international comparisons.

SETTING

Seven independent population-based surveys from six European countries (France, Italy, Northern Ireland/United Kingdom, Spain, Switzerland, the Netherlands).

METHODS

Data for 18 381 women and 12 908 men aged 40-59 were pooled in a common database. Central statistical analyses on major cardiovascular risk factors were conducted with careful consideration of methodological issues, including differences in study designs, data assessment tools, and analytic techniques used.

MAIN RESULTS

Because of the detected variability among methods used, direct comparisons of risk factor distributions and prevalences between studies were problematic. None the less, comparisons of within population contrasts by sex, age group, and other health determinants were considered to be meaningful and apt, as illustrated here for obesity. Results were targeted and disseminated to both the general public and public health professionals and framed in the context of a European information campaign.

CONCLUSIONS

International and national comparisons between existing locally run studies are feasible and useful, but harmonisation methods need improvement. Development of an international risk factor surveillance programme based on decentralised data collection is warranted. In the meantime, risk factor contrasts across populations can be used as a basis for targeting needed public health intervention programmes.

Dietary patterns in six european populations: results from EURALIM, a collaborative European data harmonization and information campaign

OBJECTIVE

To determine and describe the extent to which European dietary data collected in disparate surveys can be meaningfully compared.

DESIGN

Seven independent population-based surveys from six European countries were initially included. Differences in study designs and methodological approaches were examined. Risk factor data for 31,289 adults aged 40-59 y were harmonized and pooled in a common, centralized database.

RESULTS

Direct comparisons of dietary measures across studies were not deemed appropriate due to methodological heterogeneity. Nonetheless, comparisons of intra-population contrasts by gender across sites were considered valid. Women consumed fruit and vegetables more often than men. Age-standardized gender differences in the prevalence of low fruit and vegetable consumption ranged from 7 to 18% and 5 to 15%, respectively. Data on energy intake showed good agreement across study populations. The proportion of total energy from macronutrients was similar for women and men. Gender differences for relative intakes of saturated fatty acids (percentage energy) were small and only in France were they significant. Dietary fibre density was significantly higher in women than in men. Overall, the participating Southern European populations from Italy and Spain exhibited more healthful food composition patterns.

CONCLUSIONS

Contrasts in dietary patterns by gender across populations may provide the basis for health promotion campaigns. The most favourable patterns observed may serve as attainable goals for other populations. An international risk factor surveillance programme based upon locally run, good quality studies has the potential to provide the needed data.

SPONSORSHIP

European Community (DG V), project 96CVVF3-446-0; Swiss Federal Office for Education and Science, OFES 96.0089.

[Cardiovascular risk and social classes: a comparison between adult female populations in rural and urban areas]

The distribution of cardiovascular risk factors and the prevalence of several risk conditions are analysed in two female cohorts in southern-central Italy, one living in an urban area (the city of Naples) and the other in a rural area (the province of Latina). Analysis of different social classes identified through the level of education was also performed. The distribution of risk factors is different in the two areas (body mass index, systolic and diastolic blood pressure are higher in the province of Latina, while serum total and HDL cholesterol are higher in Naples) as well as the prevalence of several risk conditions (the prevalence of hypertension is higher in the province of Latina, whereas hypercholesterolemia and smoking are more prevalent in Naples). Cardiovascular risk factors are unevenly distributed in the different social classes: body mass index and systolic and diastolic blood pressure decrease as the educational level increases in both cohorts; in the city of Naples, serum total and HDL cholesterol increase with the increase in educational level. An awareness of these differences is crucial to targeting primary prevention campaigns in specific social classes.

[Hormone replacement therapy and cardiovascular diseases: different populations, different risks]

Observational studies indicate that oral hormone replacement therapy (HRT) in menopause is associated with a 20-40% reduction of coronary risk. Population risk/benefit analyses on mortality after large-scale HRT use indicate that excess deaths can be counted when coronary heart disease is relatively less frequent than breast cancer before age 60 (as occurs in Italy). The decline in mortality trends for coronary heart disease support a word for caution for a large scale use of HRT in the next years even in those populations for which a relative advantage is presently estimated.

Short- and long-term association between uric acid and a natural disaster

OBJECTIVE

This paper analyzes the longitudinal relationship between serum uric acid level and a natural disaster.

METHODS

The sample consists of factory workers who were participating in a longitudinal epidemiological study of coronary heart disease risk factors. Participants were seen in 1975 (baseline), 1980 (5 year follow-up), and 1987 (12 year follow-up). The 5 year (1980) follow-up examination was interrupted by a major earthquake and resumed 2 weeks after the quake. At this examination, participants seen after the quake had, on the average, significantly lower serum uric acid than those seen before the earthquake. In 1987 (7 years after the quake), participants were questioned whether or not (in their own perception) they were still suffering from damages due to the 1980 earthquake.

RESULTS

At the examination in 1987, participants who reported suffering from damage due to the 1980 quake showed on the average significantly increased serum uric acid compared with participants who reported not suffering from damages due to the 1980 quake. The analyses of the data of 578 individuals who participated in all three examinations confirmed these findings and showed that they were independent from levels of uric acid measured prior to the disaster.

CONCLUSIONS

The reason for this apparent different association with uric acid and acute and long-term exposure to the quake remains to be clarified but these findings are consistent with the existence of diverse patterns of physiologic response to different stressors.

Lipoprotein(a) concentrations in non-insulin-dependent diabetes mellitus and borderline hyperglycemia: a population-based study

The objective of the study was to compare lipoprotein(a) [Lp(a)] concentrations in population-based samples of individuals with non-insulin-dependent diabetes mellitus (NIDDM), borderline hyperglycemia, and normoglycemia. From 2,740 male Italian Telephone Company employees aged 40 to 59 years participating in a health screening, we selected all those with NIDDM (n = 100) plus a random sample of 950 nondiabetic individuals. Diabetes was defined as fasting plasma glucose (FPG) of at least 140 mg/dL or current use of hypoglycemic drugs. Among nondiabetic individuals, 854 were defined as normoglycemic (FPG < 115 mg/dL) and 95 were defined as borderline hyperglycemic (115 < FPG < 140 mg/dL). Lp(a) level was measured on frozen plasma by enzyme-linked immunosorbent assay. Lp(a) concentrations were similar in people with NIDDM, borderline hyperglycemia, and normoglycemia: 11.2 +/- 14, 14.1 +/- 20, and 13.9 +/- 18 mg/dL, respectively (F = 1.03). Accordingly, the proportion of subjects with Lp(a) levels of at least 30 mg/dL was comparable in the three groups (12%, 15%, and 14%; chi 2 = 3.95, P = .41). Results were not confounded by differences in age, body mass index (BMI), waist to hip ratio, plasma lipids, alcohol consumption, physical activity, and use of drugs. Furthermore, within the diabetic group Lp(a) levels were not significantly different for those on diet only versus those on oral agents (10.8 +/- 14.1 v 11.7 +/- 14.7, P = .7) or for people with FPG of at least 180 as compared with people with FPG less than 180 mg/dL (9.9 +/- 12.8 v 11.5 +/- 14.8, P = .5).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum uric acid and hypertension: the Olivetti heart study

The association between serum uric acid and hypertension was evaluated in a sample of male workers in southern Italy enrolled in the Olivetti Heart Study, an ongoing longitudinal epidemiological investigation on risk factors for coronary heart disease carried out at the Olivetti factory in the suburban area of Naples. Participants were screened at baseline (1975) and at five year (1980) and 12 year (1987) follow-up examinations. The present report focuses on 619 male workers for whom information on coronary heart disease risk factors was available both at baseline and 12 year follow-up examination. At baseline, after excluding hypertensive participants (systolic blood pressure (SBP) > or = 140 mmHg and/or diastolic blood pressure (DBP), > or = 90 mmHg and/or on antihypertensive therapy; n = 72), serum uric acid was positively and significantly related to age, SBP, DBP, body mass index (BMI), serum total cholesterol (CHOL) and serum triglycerides (TG) in 547 normotensive participants. At 12 year follow-up examination, hypertension was defined by SBP > or = 140 mmHg and/or DBP > or = 90 mmHg and/or being on antihypertensive therapy. Multiple logistic regression analysis showed an independent positive association between serum uric acid levels and development of hypertension (RR = 1.23, 95% CI = 1.07-1.39; p = 0.011) after adjustment for age, BMI, CHOL and TG. Furthermore, according to more severe degrees of hypertension (SBP > or = 160 mmHg and/or DBP > or = 95 mmHg and/or being on antihypertensive therapy), the relative risk to develop hypertension was still significant (RR = 1.19; CI = 1.01-1.38; p = 0.051).(ABSTRACT TRUNCATED AT 250 WORDS)