The impact of more restrictive hydrocodone rescheduling on unintentional pediatric opioid exposures

PURPOSE

To evaluate the impact of rescheduling hydrocodone combination products (HCPs) from schedule III of the Controlled Substances Act to the more restrictive schedule II on unintentional pediatric exposures (≤5 years old).

METHODS

Using U.S. data on outpatient retail pharmacy dispensing, emergency department (ED) visits, and poison center (PC) exposure cases, we assessed trends in prescriptions dispensed and unintentional pediatric exposure cases involving hydrocodone (rescheduled from III to II) compared to oxycodone (schedule II) and codeine (schedule III for combination products) using descriptive and interrupted time-series (ITS) analyses during the 16 quarters before and after the October 2014 rescheduling of HCPs.

RESULTS

Dispensing of hydrocodone products was declining before rescheduling but declined more steeply post-rescheduling. In ITS analyses, both hydrocodone and oxycodone had significant slope decreases in PC case rates in the post versus pre-period that was larger for hydrocodone, while codeine had a small but significant slope increase in PC case rates. An estimated 4202 ED visits for pediatric hydrocodone exposures occurred in the pre-period and 2090 visits occurred in the post-period, a significant decrease of 50.3%. Oxycodone exposures showed no significant decrease.

CONCLUSIONS

Pediatric hydrocodone unintentional exposure ED visits and PC cases decreased after HCP rescheduling more than would be expected had the pre-rescheduling trend continued; the acceleration in the decrease in hydrocodone PC cases was partially offset by a slowing in the decrease in codeine-involved cases. The trend changes were likely due to multiple factors, including changes in dispensing that followed the rescheduling. Unintentional pediatric medication exposures and poisonings remain a public health concern requiring ongoing, multifaceted mitigation efforts.

The impact of hydrocodone rescheduling on utilization, abuse, misuse, and overdose deaths

PURPOSE

To evaluate the impact of increased federal restrictions on hydrocodone combination product (HCP) utilization, misuse, abuse, and overdose death.

METHODS

We assessed utilization, misuse, abuse, and overdose death trends involving hydrocodone versus select opioid analgesics (OAs) and heroin using descriptive and interrupted time-series (ITS) analyses during the nine quarters before and after the October 2014 rescheduling of HCPs from a less restrictive (CIII) to more restrictive (CII) category.

RESULTS

Hydrocodone dispensing declined >30% over the study period, and declines accelerated after rescheduling. ITS analyses showed that immediately postrescheduling, quarterly hydrocodone dispensing decreased by 177M dosage units while codeine, oxycodone, and morphine dispensing increased by 49M, 62M, and 4M dosage units, respectively. Postrescheduling, hydrocodone-involved misuse/abuse poison center (PC) case rates had a statistically significant immediate drop but a deceleration of preperiod declines. There were small level increases in codeine-involved PC misuse/abuse and overdose death rates immediately after HCP's rescheduling, but these were smaller than level decreases in rates for hydrocodone. Heroin-involved PC case rates and overdose death rates increased across the study period, with exponential increases in PC case rates beginning 2015.

CONCLUSIONS

HCP rescheduling was associated with accelerated declines in hydrocodone dispensing, only partially offset by smaller increases in codeine, oxycodone, and morphine dispensing. The net impact on hydrocodone and other OA-involved misuse/abuse and fatal overdose was unclear. We did not detect an immediate impact on heroin abuse or overdose death rates; however, the dynamic nature of the crisis and data limitations present challenges to causal inference.

KRAS, NRAS, BRAF, and PIK3CA mutation rates, clinicopathological association, and their prognostic value in Iranian colorectal cancer patients

AIM

Mutations in KRAS, NRAS, BRAF, and PIK3CA genes are critical factors in clinical evaluation of colorectal cancer (CRC) development and progression. In Iran, however, the data regarding genetic profile of CRC patients is limited except for KRAS exon2 and BRAF V600F mutations. This study aimed to investigate the mutational spectrum and prognostic effects of these genes and explore the relationship between these mutations and clinicopathological features of CRC.

METHOD

To achieve these objectives, mutations in KRAS (exons 2, 3, and 4), NRAS (exons 2, 3, and 4), PIK3CA (exons 9 and 20), and BRAF (exon 15) was determined using PCR and pyrosequencing in a total of 151 patients with colorectal cancer.

RESULTS

KRAS, BRAF, NRAS, and PIK3CA mutations were identified in 41%, 5.96%, 3.97%, and 13.24% of the cases, respectively. There were some significant correlations between clinicopathological features and KRAS, PIK3CA, BRAF, and NRAS mutations. Mutations in KRAS and PIK3CA were shown to be independent risk factors for poor survival of the patients at stage I-IV (p < 0.0001 and p = 0.001, respectively). No significant impact on prognosis was observed in patients with BRAF mutations.

CONCLUSION

Our study revealed the prevalence of CRC biomarkers mutations in Iranian patients and emphasized the role of KRAS and PIK3CA on shorter overall survival rates in this population.

Trends in pediatric nonprescription analgesic/antipyretic exposures during the COVID-19 pandemic

OBJECTIVE

To examine pediatric exposure trends involving selected nonprescription analgesics/antipyretics, before and during the COVID-19 pandemic.

METHODS

Using descriptive and interrupted time-series analyses, we assessed monthly United States poison center data involving pediatric (<18 years) exposures to nonprescription paracetamol (acetaminophen), ibuprofen, acetylsalicylic acid, and naproxen before (January 2015-February 2020) and during (March 2020-April 2021) the pandemic. Statins and proton pump inhibitors (prescription or nonprescription) served as controls.

RESULTS

Most nonprescription analgesic/antipyretic exposures (75-90%) were single-substance; unintentional exposures typically involved children <6 years (84-92%), while intentional exposures involved females (82-85%) and adolescents, 13-17 years (91-93%). Unintentional exposures among children <6 years, declined for all four analgesics/antipyretics immediately after the World Health Organization declared COVID-19 a pandemic (March 11, 2020), but most significantly for ibuprofen (30-39%). Most intentional exposures were classified as suspected suicide. Intentional exposures were relatively low and stable among males. Intentional exposures in females declined immediately after the pandemic was announced but subsequently increased to pre-pandemic levels for acetylsalicylic acid and naproxen and above pre-pandemic levels for paracetamol and ibuprofen. For paracetamol, female intentional exposures increased from 513 average monthly cases in the pre-pandemic to 641 average monthly cases during the pandemic; and reached 888 cases by the end of the study period in April 2021. While for ibuprofen, average monthly cases rose from 194 in the pre-pandemic, to 223 during the pandemic; and reached 352 cases in April 2021. Patterns were similar among females 6-12 and 13-17 years.

CONCLUSION

Nonprescription analgesic/antipyretic unintentional exposure cases declined among young children, while intentional exposure cases increased among females, 6-17 years, during the pandemic. Findings highlight the importance of safely storing medications and being alert to signs that adolescents may be in need of mental health support services; caregivers should seek medical care or call poison control centers for any suspected poisoning event.

Cannabidiol exposures in the United States, National Poison Data System, July 2014-June 2021

INTRODUCTION

There has been an increase in the interest and availability of products asserting to contain cannabidiol (CBD).

OBJECTIVE

To describe demographic and clinical patterns in cases involving CBD exposures documented by the America's Poison Centers (AAPCC).

METHODS

We extracted human exposure cases involving CBD from the U.S. National Poison Data System between July 2014 and June 2021. We described monthly case counts and data on demographics, exposure reason, clinical effects, medical outcomes, and co-exposures, overall and by U.S. Food and Drug Administration (FDA) approval status.

RESULTS

We identified 6,496 cases, of these, 85.2% involved exposures to non-FDA approved CBD. The monthly number of cases peaked at 336 in March 2021. Cases often occurred in children ages 2-12 years (36.2%). Although in this age group unintentional exposures represented most cases (94.1%), we identified therapeutic errors (3.9%), intentional use (3.0%), and adverse reactions (1.6%) in cases involving exposures to non-FDA approved CBD. Among the 5,248 (80.8%) cases involving exposure to a single product, we identified 44 major medical outcomes, all related to exposures to non-FDA approved CBD. The most frequent clinical effects included neurological, cardiac, and gastrointestinal effects. Among the 1,248 (19.2%) involving exposure to more than one product, the most frequent co-exposures included stimulants and street drugs, sedatives-hypnotics, antipsychotics, and analgesics.

CONCLUSIONS

This case series identified an increasing trend in CBD exposure cases managed by AAPCC. It showed serious medical outcomes in temporal association with exposure to non-FDA approved CBD products. Our findings also suggest both unintentional and intentional use of non-FDA approved CBD in children. Consumers should keep these products out of reach of children and exercise caution when purchasing and using non-FDA approved CBD products.

The effect of photovoltaic industry on the two variables of temperature and wind and possible impact on dust storm in Tehran province

Introduction: Recently, the industry of launching solar power plants in arid/ semi-arid regions has developed. A considerable part of Iran is covered by dry/semi-arid areas, which are exposed to severe wind erosion. Considering the occurrence of dust in these areas, this study investigated the possible impact of the photovoltaic industry on the prevention of dust storms. Materials and methods: The effect of solar power plant construction on atmospheric variables and its possible effect on the occurrence of dust were investigated in Tehran province. The criterion is to compare the monthly average wind and temperature respectively at the height of 10 and 2 m inside and outside the power plant (obtained from the TerraClimate database for 2020 and 2021) on the western side and at the closest point to the power plant. Results: The monthly average of wind and temperature respectively at the height of 10 and 2 m in 2020-2021 decreased inside of the power plant with respect to the outside of that. Significant differences were observed on temperature and wind inside and outside of the power plant during the peak heat in the summer, which increase with increasing temperature. The maximum of differences of monthly average of wind and temperature variables inside and outside of the power plant for Pars Ray Energy Bahar, Tehran Wastewater and Sohail Power Plants respectively are (0.5 °C, 0.55 m/s), (0.6 °C, 0.3 m/s), and (0.7 °C, 0.3 m/s). Conclusion: The photovoltaic industry can change the effective solar radiation, and possibly decrease the occurrence of dust storms by weakening wind power.

Investigating the mechanism of dust transferring from Iraq to the north of Alborz mountains in Iran

Introduction: Recently, due to climate change, the number and intensity of dust sources are increasing, which leads to the occurrence of dust storms. Atmospheric patterns governing the region, topography and surface features are effective on transportation and dispersion of dust particles. Materials and methods: In this study, a severe dust phenomenon on the 3th and 4th March, 2022, was investigated. The dust was emitted from the east of Iraq and passed through the Zagros and Alborz mountain ranges toward the Caspian sea. Meteorological data of the country, satellite data, ERA5 reanalysis data and HYSPLIT and output from the Weather Research and Forecasting Model coupled with Chemistry (WRF-Chem) were used. Results: Aerosol Optical Depth (AOD) anomaly compared to the long-term indicated that the intense transport of dust particles from eastern Iraq and reaching the Caspian Sea is not a common phenomenon. Synoptic analysis showed that the dust particles in the source area ascended to the mid-levels of the atmosphere and a large part of the particles passed through the Zagros Mountains. Then, the dust entered the Caspian Sea by passing through the Manjil valley. The vertical profile of WRF-Chem model output showed the ascent of dust particles up to 600 hPa near the dust source and its passage over mountainous areas. Conclusion: The main factors in the formation of this unusual dust phenomenon are: severe two-year drought in the Middle East, reduction of vegetation and cold front of the dynamic low-pressure located in the east of the Black Sea, east of Turkey and northern Iraq moving eastward to the Caspian sea in the following hours.

Benzonatate Exposure Trends and Adverse Events

BACKGROUND AND OBJECTIVES

Adverse events (AE), including death, occur in children with benzonatate use. This study aims to understand recent trends in benzonatate exposure and clinical consequences in pediatric patients.

METHODS

This retrospective analysis of data from IQVIA pharmacy drug dispensing, National Poison Data System, National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project, FDA Adverse Event Reporting System, and the medical literature evaluated exposure trends and medication-related AEs with benzonatate. Trends for comparator narcotic and nonnarcotic antitussive medications were analyzed where possible for context.

RESULTS

During the study period, pediatric benzonatate prescription utilization increased but remained low compared with pediatric utilization of dextromethorphan-containing prescription antitussive medications. Among the 4689 pediatric benzonatate exposure cases reported to US poison control centers from 2010 to 2018, 3727 cases (80%) were for single-substance exposures. Of these, 3590 cases (77%) were unintentional exposures and most involved children 0 to 5 years old (2718 cases, 83%). Cases involving intentional benzonatate exposure increased among children 10 to 16 years old with a more pronounced increase for multiple-substance exposures. Most benzonatate cases involving misuse or abuse were for children 10 to 16 years old (59 cases, 61%). The proportion of cases with serious adverse effects was low. There were few cases annually of serious AEs with benzonatate in children.

CONCLUSIONS

There were rising patterns of unintentional ingestion of benzonatate in children 0 to 5 years old and intentional benzonatate ingestion in children 10 to 16 years old. Rational prescribing and improved provider and caregiver awareness of benzonatate toxic effects may reduce risks associated with benzonatate exposure.

Improving Methods of Identifying Anaphylaxis for Medical Product Safety Surveillance Using Natural Language Processing and Machine Learning

We sought to determine whether machine learning and natural language processing (NLP) applied to electronic medical records could improve performance of automated health-care claims-based algorithms to identify anaphylaxis events using data on 516 patients with outpatient, emergency department, or inpatient anaphylaxis diagnosis codes during 2015-2019 in 2 integrated health-care institutions in the Northwest United States. We used one site's manually reviewed gold-standard outcomes data for model development and the other's for external validation based on cross-validated area under the receiver operating characteristic curve (AUC), positive predictive value (PPV), and sensitivity. In the development site 154 (64%) of 239 potential events met adjudication criteria for anaphylaxis compared with 180 (65%) of 277 in the validation site. Logistic regression models using only structured claims data achieved a cross-validated AUC of 0.58 (95% CI: 0.54, 0.63). Machine learning improved cross-validated AUC to 0.62 (0.58, 0.66); incorporating NLP-derived covariates further increased cross-validated AUCs to 0.70 (0.66, 0.75) in development and 0.67 (0.63, 0.71) in external validation data. A classification threshold with cross-validated PPV of 79% and cross-validated sensitivity of 66% in development data had cross-validated PPV of 78% and cross-validated sensitivity of 56% in external data. Machine learning and NLP-derived data improved identification of validated anaphylaxis events.

Anti-inflammatory function of apolipoprotein B-depleted plasma is impaired in non-alcoholic fatty liver disease

Background

Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular events. HDL exerts various protective functions on the cardiovascular system including anti-inflammatory activity by suppressing adhesion molecules expression in inflammation-induced endothelial cells. This study was designed to search if the anti-inflammatory capacity of apolipoprotein B-depleted plasma (apoB-depleted plasma) is altered in NAFLD patients.

Methods

A total of 83 subjects including 42 NAFLD and 41 control subjects were included in this cross-sectional study. Anti-inflammatory function of HDL was determined as the ability of apoB-depleted plasma to inhibit tumor necrosis factor-α (TNF-α)-induced expression of adhesion molecules in human umbilical vein endothelial cells (HUVECs).

Results

Incubation of inflammation-stimulated HUVECs with the NAFLD patients’ apo-B depleted plasma led to higher levels of expression of adhesion molecules compared to the control subjects’ plasma samples, reflecting an impaired anti-inflammatory capacity of apoB-depleted plasma in the NAFLD patients. Impaired anti-inflammatory capacity of apoB-depleted plasma was correlated with fatty liver and obesity indices. After adjustment with obesity indices, the association of anti-inflammatory capacity of apoB-depleted plasma with NAFLD remained significant.

Conclusion

Impaired anti-inflammatory activity of apoB-depleted plasma was independently associated with NAFLD.

The study of a severe dust storm over Persian Gulf, the Gulf of Oman and parts of the Indian Ocean with two operational dust forecasting models

Introduction: The entry of dust particles into water areas, which has increased sharply in recent years, causes a lot of environmental damage. The Persian Gulf and the Gulf of Oman are among the water areas that are covered with dust many times of the year. Materials and methods: In this study, a severe dust from July 27 to 31, 2018 is analyzed, in which a large part of the Persian Gulf, Oman Sea and the western part of the Indian Ocean was involved. To study this phenomenon from different perspectives, satellite products, visibility from synoptic stations and synoptic maps were analyzed and the output of two numerical dust models of NASA-GEOS and DREAM8-MACC were examined. To qualitative and quantitative evaluate of the model outputs, the Aerosol Optical Depth (AOD) of TERRA/MODIS was used. Results: Satellite imagery shows that in this case study, parts of the Persian Gulf and the Sea of Oman were affected by dust, and on July 30, dust particles entered the western half of the Indian Ocean. Comparison of model outputs with satellite data resulted that both models underestimate the AOD values, especially over water, and do not show well the entrance of dust particles into the eastern part of the Persian Gulf, the Gulf of Oman and the western half of the Indian Ocean. Conclusion: Qualitative and quantitative comparison of AOD output of the two models with satellite data showed that the NASA-GEOS model had better performance and its output correlation with observational data was higher.    

Association of anti-oxidative capacity of HDL with subclinical atherosclerosis in subjects with and without non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) patients are at a substantial risk for developing cardiovascular disease (CVD). High-density lipoprotein (HDL) is well known to have protective effects against the development of atherosclerotic CVD. One of the major antiatherogenic effects of HDL is its anti-oxidative function.

OBJECTIVES

This study investigated the association of anti-oxidative capacity of HDL with subclinical atherosclerosis in NAFLD and non-NAFLD subjects.

METHODS

A total of 143 subjects including 51 NAFLD and 92 control subjects were included in this case-control study. HDL oxidative index (HOI) was determined spectrophotometrically using a cell-free method in the presence of a fluorescent substrate dichlorofluorescein diacetate (DCFDA). Paraoxonase 1 (PON1) activity, superoxide dismutase (SOD) activity, and malondialdehyde (MDA) plasma levels were assessed in both groups.

RESULTS

The NAFLD patients with impaired HDL anti-oxidative function (HOI  ≥ 1) had higher MDA levels, aspartate amino transferase (AST), liver stiffness (LS), and carotid intima-media thickness (cIMT) values compared to the controls. HDL oxidative index (HOI) was positively correlated with MDA levels and cIMT and negatively correlated with SOD activity.

CONCLUSIONS

Higher circulating levels of MDA were associated with the impaired anti-oxidative function of HDL in NAFLD. The impaired anti-oxidative capacity of HDL might be related to NAFLD severity and subclinical atherosclerosis in NAFLD patients.

Circulating levels of FAM19A5 are inversely associated with subclinical atherosclerosis in non-alcoholic fatty liver disease

BACKGROUND

Family with sequence similarity 19 (chemokine (C-C motif)-like) member A5 (FAM19A5) is a newly identified adipokine. There is a limited number of studies linking FAM19A5 to metabolic disorders. In the current study, we aimed to explore if FAM19A5 is associated with nonalcoholic fatty liver disease (NAFLD). We also sought to determine the possibility of FAM19A5 association with subclinical atherosclerosis in NAFLD patients.

METHODS

A total of 69 subjects including 37 NAFLD and 32 control subjects were included in this cross-sectional study. Plasma concentration of FAM19A5 was measured with the ELISA method. Carotid artery intima-media thickness (cIMT) was assessed by the ultrasonography.

RESULTS

Plasma concentration of FAM19A5 in patients with NAFLD was significantly lower in NAFLD patients than controls. Moreover, we observed significant negative correlations between plasma level of FAM19A5 and body mass index (BMI), visceral fat, alanine amino transferase (ALT), aspartate amino transferase (AST), liver stiffness (LS), and cIMT. Following stepwise multiple linear regression analysis, ALT and cIMT were the only determinants of FAM19A5 level.

CONCLUSIONS

This is the first report to describe association of circulating FAM19A5 levels with NAFLD. Our findings provide further evidence showing relation of FAM19A5 with the risk of atherosclerosis. However, more studies are necessary to unravel the contribution of lower FAM19A5 levels to the NAFLD pathogenesis and the higher risk of atherosclerosis in these patients.

Dietary pattern, colonic microbiota and immunometabolism interaction: new frontiers for diabetes mellitus and related disorders

In this review, the numerous possible mechanisms that provide supportive evidence for how colonic dysbiosis denotes metabolic dysfunction, dysregulates glucose homeostasis and leads to diabetes mellitus and related metabolic disorders are defined. Information was gathered from articles identified by systematic reviews and searches using Google, PubMed and Scopus. The composition of the colonic microbiota plays an integral role in maintaining host homeostasis by affecting both metabolic activities and underlying functional gene transcription in individuals with diabetes and related metabolic disorders. Increased colonic microbiome-derived concentrations of lipopolysaccharides, also known as 'metabolic endotoxaemia', as well as alterations in bile acid metabolism, short-chain fatty acids, intestinal hormones and branched-chain amino acid secretion have been associated with the diverse production of pro-inflammatory cytokines and the recruitment of inflammatory cells. It has been shown that changes to intestinal bacterial composition are significant even in early childhood and are associated with the pathogenesis of both types of diabetes. We hope that an improved understanding of related mechanisms linking the colonic microbiome with glucose metabolism might provide for innovative therapeutic approaches that would bring the ideal intestinal ecosystem to a state of optimal health, thus preventing and treating diabetes and related metabolic disorders.

Investigation of dust storms in Ilam and the performance analysis of simulation of 6 numerical prediction models at a severe dust storm in west of Iran

Introduction: Many countries encounter dust storms phenomenon that is one of the meteorological problems leading to many disturbances. Materials and methods: Although the dust storm is historically recorded as an old event in some provinces of Iran, but it becomes a new event in some parts such as Ilam province. Results: After statistical investigation of dust storms in Ilam province, the dust storm from 3td to 6th July 2016 are studied. The source of this dust storm was the eastern areas of Syria and central Iraq base on the satellite images, the outputs of HYSPLIT and WRF-Chem models. Conclusion: Model outputs in intensity of surface dust concentration of MACC-ECMWF, NASA-GEOS, NCEP-NGAC, NMMB-BSC, and BSCDREAM8b models are compared to the observation data in Ilam city and results show that NASA-GEOS model has better performance. In display of dust dispersion on Iran, the middle of all models is more compatible with reality.

The Role of Nanomaterials in the Treatment of Diseases and Their Effects on the Immune System

Nanotechnology has been widely exploited in recent years in various applications. Different sectors of medicine and treatment have also focused on the use of nanoproducts. One of the areas of interest in the treatment measures is the interaction between nanomaterials and immune system components. Engineered nanomaterials can stimulate the inhibition or enhancement of immune responses and prevent the detection ability of the immune system. Changes in immune function, in addition to the benefits, may also lead to some damage. Therefore, adequate assessment of the novel nanomaterials seems to be necessary before practical use in treatment. However, there is little information on the toxicological and biological effects of nanomaterials, especially on the potential ways of contacting and handling nanomaterials in the body and the body response to these materials. Extensive variation and different properties of nanomaterials have made it much more difficult to access their toxicological effects to the present. The present study aims to raise knowledge about the potential benefits and risks of using the nanomaterials on the immune system to design and safely employ these compounds in therapeutic purposes.

Evaluating the use of bootstrapping in cohort studies conducted with 1:1 propensity score matching-A plasmode simulation study

PURPOSE

Bootstrapping can account for uncertainty in propensity score (PS) estimation and matching processes in 1:1 PS-matched cohort studies. While theory suggests that the classical bootstrap can fail to produce proper coverage, practical impact of this theoretical limitation in settings typical to pharmacoepidemiology is not well studied.

METHODS

In a plasmode-based simulation study, we compared performance of the standard parametric approach, which ignores uncertainty in PS estimation and matching, with two bootstrapping methods. The first method only accounted for uncertainty introduced during the matching process (the observation resampling approach). The second method accounted for uncertainty introduced during both PS estimation and matching processes (the PS reestimation approach). Variance was estimated based on percentile and empirical standard errors, and treatment effect estimation was based on median and mean of the estimated treatment effects across 1000 bootstrap resamples. Two treatment prevalence scenarios (5% and 29%) across two treatment effect scenarios (hazard ratio of 1.0 and 2.0) were evaluated in 500 simulated cohorts of 10 000 patients each.

RESULTS

We observed that 95% confidence intervals from the bootstrapping approaches but not the standard approach, resulted in inaccurate coverage rates (98%-100% for the observation resampling approach, 99%-100% for the PS reestimation approach, and 95%-96% for standard approach). Treatment effect estimation based on bootstrapping approaches resulted in lower bias than the standard approach (less than 1.4% vs 4.1%) at 5% treatment prevalence; however, the performance was equivalent at 29% treatment prevalence.

CONCLUSION

Use of bootstrapping led to variance overestimation and inconsistent coverage, while coverage remained more consistent with parametric estimation.

Extension of Disease Risk Score-Based Confounding Adjustments for Multiple Outcomes of Interest: An Empirical Evaluation

Use of disease risk score (DRS)-based confounding adjustment when estimating treatment effects on multiple outcomes is not well studied. We designed an empirical cohort study to compare dabigatran initiators and warfarin initiators with respect to risks of ischemic stroke and major bleeding in 12 sequential monitoring periods (90 days each), using data from the Truven Marketscan database (Truven Health Analytics, Ann Arbor, Michigan). We implemented 2 approaches to combine DRS for multiple outcomes: 1) 1:1 matching on prognostic propensity scores (PPS), created using DRS for bleeding and stroke as independent variables in a propensity score (PS) model; and 2) simultaneous 1:1 matching on DRS for bleeding and stroke using Mahalanobis distance (M-distance), and compared their performance with that of traditional PS matching. M-distance matching appeared to produce more stable results in the early marketing period than both PPS and traditional PS matching; hazard ratios from unadjusted analysis, traditional PS matching, PPS matching, and M-distance matching after 4 periods were 0.72 (95% confidence interval (CI): 0.51, 1.03), 0.61 (95% CI: 0.31, 1.09), 0.55 (95% CI: 0.33, 0.91), and 0.78 (95% CI: 0.45, 1.34), respectively, for stroke and 0.65 (95% CI: 0.53, 0.80), 0.78 (95% CI: 0.60, 1.01), 0.75 (95% CI: 0.59, 0.96), and 0.78 (95% CI: 0.64, 0.95), respectively, for bleeding. In later periods, estimates were similar for traditional PS matching and M-distance matching but suggested potential residual confounding with PPS matching. These results suggest that M-distance matching may be a valid approach for extension of DRS-based confounding adjustments for multiple outcomes of interest.

Relative Performance of Propensity Score Matching Strategies for Subgroup Analyses

Postapproval drug safety studies often use propensity scores (PSs) to adjust for a large number of baseline confounders. These studies may involve examining whether treatment safety varies across subgroups. There are many ways a PS could be used to adjust for confounding in subgroup analyses. These methods have trade-offs that are not well understood. We conducted a plasmode simulation to compare relative performance of 5 methods involving PS matching for subgroup analysis, including methods frequently used in applied literature whose performance has not been previously directly compared. These methods varied as to whether the overall PS, subgroup-specific PS, or no rematching was used in subgroup analysis as well as whether subgroups were fully nested within the main analytical cohort. The evaluated PS subgroup matching methods performed similarly in terms of balance, bias, and precision in 12 simulated scenarios varying size of the cohort, prevalence of exposure and outcome, strength of relationships between baseline covariates and exposure, the true effect within subgroups, and the degree of confounding within subgroups. Each had strengths and limitations with respect to other performance metrics that could inform choice of method.

Abstract P6-07-10: The ERβ4 variant induce transformation of the normal breast mammary epithelial cell line MCF-10A; the ERβ variants ERβ2, ERβ4 and ERβ5 increase aggressiveness of TNBC by regulation of hypoxic signaling

Triple negative breast cancer (TNBC) still remains a challenge to treat in the clinic due to a lack of good targets for treatment. Although TNBC lacks expression of ERα, the expression of ERβ and its variants are detected quite frequently in this cancer type and can represent an avenue for treatment. We show that the variants of ERβ, namely ERβ1, ERβ2, ERβ4, and ERβ5, regulate aggressiveness of TNBC by regulating hypoxic signaling. RNA-seq of patient derived xenografts (PDX) from TNBC show expression of ERβ4 and ERβ5 variants in more than half of the samples. Furthermore, expression of ERβ4 in the immortalized, normal mammary epithelial cell line MCF-10A that is resistant to mammosphere formation caused transformation and development of mammospheres. By contrast, ERβ1, ERβ2 or ERβ5 were unable to support mammosphere formation. We have previously shown that all variants except ERβ1 stabilizes HIF-1α but only ERβ4 appear to have the ability to transform normal mammary epithelial cells, pointing towards a unique property of ERβ4. We propose that ERβ variants may be good diagnostic tools and also serve as novel targets for treatment of breast cancer.

Citation Format: Faria M, Karami S, Granados-Principal S, Dey P, Verma A, Choi DS, Elemento O, Bawa-Khalfe1 T, Chang JC, Gustafsson J-A, Strom AM. The ERβ4 variant induce transformation of the normal breast mammary epithelial cell line MCF-10A; the ERβ variants ERβ2, ERβ4 and ERβ5 increase aggressiveness of TNBC by regulation of hypoxic signaling [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-07-10.

Abstract P1-04-08: Non-nuclear SUMO dynamics regulate mammary epithelial cell transformation

Objective: The reversible SUMO-posttranslational modification of protein substrates regulates various cellular processes and consistently is important for normal cell physiology. Disruption of SUMO enzymatic components supports onset of various pathophysiological disorders, including cancer. Our recent study identified a splicing event that differentially modulates expression of 2 SENP7 isoforms. The novel SENP7 variant SENP7S is the predominant SUMO protease in normal mammary epithelia; however onset of precancerous ductal carcinoma in situ (DCIS) reduces SENP7S significantly and stays low in all breast cancer (BCa) subtypes. Inversely, the full-length SENP7L isoform is upregulated in BCa and directly leads to BCa metastasis. Unlike SENP7L, SENP7S isoform contribution to carcinogenesis is unclear. Our objective is to define the biological function of this novel deSUMOylase SENP7S in normal versus cancerous epithelial cells.

Results: Consistently with mRNA levels, protein levels of the 2 SENP7 isoforms are also inversely expressed in human BCa versus normal mammary epithelia. SENP7S is localized in the cytosol of MCF10-2A unlike other SUMO proteases including SENP7L that are predominantly nuclear enzymes. Beta-catenin and a component of the Beta-catenin destruction complex, Axin1 are substrates for SENP7S catalytic activity as in the absence of SENP7S, Beta-catenin and Axin 1 are both SUMOylated. Consistently, SENP7S regulates Beta-catenin signaling pathway. SUMOylated Axin1 loses its interaction with Beta-catenin, allowing the Beta-catenin to escape ubiquitylation and further proteasomal degradation. SUMOylated Beta-catenin translocates to the nucleus and activates multiple target genes that potentiate cell proliferation. Increase in cell proliferation and anchorage dependent growth of non-cancerous MCF10-2A cells was observed with inhibition of SENP7S. Additionally, SENP7S depletion potentiates anchorage independent growth of MCF10-2A with significantly greater number and size of spheroids. In comparison to the control. Loss of SENP7S also potentiates the self-renewal properties of the cells, indicative of mammary epithelial cell transformation.

Conclusion: SENP7S modulates Beta-catenin stability and signaling and consequently is critical for normal mammary epithelial cell physiology. Loss of SENP7S, as observed in DCIS, initiates mammary epithelial cell transformation.

Citation Format: Karami S, Lin F-M, Kumar S, Ren J, Bahnassy S, Bawa-Khalfe T. Non-nuclear SUMO dynamics regulate mammary epithelial cell transformation [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 P1-04-08.

Telomere structure and maintenance gene variants and risk of five cancer types

Telomeres cap chromosome ends, protecting them from degradation, double-strand breaks, and end-to-end fusions. Telomeres are maintained by telomerase, a reverse transcriptase encoded by TERT, and an RNA template encoded by TERC. Loci in the TERT and adjoining CLPTM1L region are associated with risk of multiple cancers. We therefore investigated associations between variants in 22 telomere structure and maintenance gene regions and colorectal, breast, prostate, ovarian, and lung cancer risk. We performed subset-based meta-analyses of 204,993 directly-measured and imputed SNPs among 61,851 cancer cases and 74,457 controls of European descent. Independent associations for SNP minor alleles were identified using sequential conditional analysis (with gene-level p value cutoffs ≤3.08 × 10-5 ). Of the thirteen independent SNPs observed to be associated with cancer risk, novel findings were observed for seven loci. Across the DCLRE1B region, rs974494 and rs12144215 were inversely associated with prostate and lung cancers, and colorectal, breast, and prostate cancers, respectively. Across the TERC region, rs75316749 was positively associated with colorectal, breast, ovarian, and lung cancers. Across the DCLRE1B region, rs974404 and rs12144215 were inversely associated with prostate and lung cancers, and colorectal, breast, and prostate cancers, respectively. Near POT1, rs116895242 was inversely associated with colorectal, ovarian, and lung cancers, and RTEL1 rs34978822 was inversely associated with prostate and lung cancers. The complex association patterns in telomere-related genes across cancer types may provide insight into mechanisms through which telomere dysfunction in different tissues influences cancer risk.

Risk of Renal Cell Carcinoma Among Kidney Transplant Recipients in the United States

Renal cell carcinoma (RCC) is a common malignancy following kidney transplantation. We describe RCC risk and examine RCC risk factors among US kidney recipients (1987-2010). The Transplant Cancer Match Study links the US transplant registry with 15 cancer registries. Standardized incidence ratios (SIRs) were used to compare RCC risk (overall and for clear cell [ccRCC] and papillary subtypes) to the general population. Associations with risk factors were assessed using Cox models. We identified 683 RCCs among 116 208 kidney recipients. RCC risk was substantially elevated compared with the general population (SIR 5.68, 95% confidence interval 5.27-6.13), especially for papillary RCC (SIR 13.3 versus 3.98 for ccRCC). Among kidney recipients, RCC risk was significantly elevated for blacks compared to whites (hazard ratio [HR] 1.50) and lower in females than males (HR 0.56). RCC risk increased with prolonged dialysis preceding transplantation (p-trend < 0.0001). Risk was variably associated for RCC subtypes with some medical conditions that were indications for transplantation: ccRCC risk was reduced with polycystic kidney disease (HR 0.54), and papillary RCC was increased with hypertensive nephrosclerosis (HR 2.02) and vascular diseases (HR 1.86). In conclusion, kidney recipients experience substantially elevated risk of RCC, especially for papillary RCC, and multiple factors contribute to these cancers.

The rationale behind antibiotic resistance pattern in Klebsiella pneumoniae

Presently, there is an increase in antibiotic resistance in bacteria, due to relax prescription of antibiotics, especially in Iran. Undoubtedly, in toxin antitoxin (TA) system, a toxin neutralized by antitoxin, which known as a potent antimicrobial target; but there is no extensive survey on the prevalence of TA loci in large scale of Klebsiella pneumoniae. Therefore, this study aims to determine the prevalence of different TA loci in clinical and environmental K. pneumoniae isolates. For this reason, 48 K. pneumoniae clinical isolates and 49 K. pneumoniae environmental isolates were subjected for evaluation of different TA loci. The results of current study indicated that there is no association between antibiotic resistances and presence of TA loci in clinical and environmental K. pneumoniae. The role of TA loci as a potent target in antibiotic resistant K. pneumoniae has been complicated. Therefore, more studies should be performed to explain why TA loci are presented in K. pneumoniae and what is the rationale behind antibiotic resistant K. pneumoniae?

Analgesic use and risk of renal cell carcinoma: A case-control, cohort and meta-analytic assessment

Analgesics are the most commonly consumed drugs worldwide. Evidence that analgesics increase kidney cancer risk has been mixed. We investigated the association between renal cell carcinoma (RCC) and analgesic use in a large population-based case-control study and a post-trial observational cohort study. Findings were used to update a recent meta-analytic review. We analyzed data from 1,217 RCC cases and 1,235 controls in the US Kidney Cancer Study and 98,807 participants in the US Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO: n = 137 RCCs). Self-reported acetaminophen, aspirin and nonsteroid anti-inflammatory drug (NSAID) use and duration information was assessed in relation to RCC. For the US Kidney Cancer Study, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression. For PLCO, we computed hazard ratios (HRs) and 95%CIs using Cox regression. Among case-control participants, RCC risk was associated with over-the-counter acetaminophen use (OR = 1.35, 95%CI = 1.01-1.83). There was a positive trend with increasing duration (p-trend = 0.01), with a two-fold risk for use ≥10 years (OR = 2.01, 95%CI = 1.30-3.12). No association with prescription acetaminophen use was detected. In PLCO, acetaminophen use was also associated with increased RCC risk (HR = 1.68, 95%CI = 1.19-2.39), although elevated risk was absent among the few long-term users. No association with RCC risk was detected for aspirin or NSAIDs use in either study. An association between acetaminophen use and kidney cancer was supported by meta-analytic cohort (n = 4; summary relative risk = 1.34; 95%CI = 1.13-1.59; p-heterogeneity  = 0.40) and case-control (n = 9, summary OR = 1.20; 95%CI = 1.01-1.42; p-heterogeneity  = 0.05) findings. In brief, acetaminophen use may increase the risk of developing RCC.

Abstract A1-31: Molecular characteristics and predictors of poor prognosis in sporadic clear cell renal cancer among central/eastern European and United States patients

We investigated patient/tumor characteristics/inherited variants, hypoxia inducible factor 1 and 2 alpha (HIF1A/HIF2A) protein expression, and patient survival among Central European (CE) and United States (US) clear cell renal cancer (ccRCC) patients from two case-control studies. VHL inactivation, HIF1A, and HIF2A expression have been implicated in RCC and angiogenesis. GWAS studies have identified EPAS1 variants encoding the protein HIF2A associated with RCC risk. We conducted a hospital-based case-control study in Central/Eastern Europe (CE) and a population-based study in the US (Detroit, Chicago) that included whites and blacks. We used data on: i) patient/tumor characteristics, ii) inherited tagging single nucleotide polymorphisms (SNPs) in genes involved in the VHL-HIF pathway (HIF1A, EPAS1, VHL), HIF1A and HIF2A protein expression using immunohistochemical (IHC) methods, and survival from 696 CEERCC and 328 US ccRCC cases. ccRCC patients from CE Europe were older, presented at a higher grade, stage, with larger tumors, had lower BMI, less family history and smoked less (all p&lt;0.0001) compared to US cases. US cases demonstrated higher intensity HIF1A and HIF2A protein expression compared to CE cases (p&lt;0.0001). Black US ccRCC cases were more likely to be hypertensive (p&lt;0.0001) and have lower HIF2A protein expression compared to white US cases. HIF1A and HIF2A were examined for associations with patient/tumor characteristics. In the US study, younger patients had higher levels of HIF2A expression compared to older cases and high BMI was associated with HIF1A expression. In both studies, tumor grade, stage and size at diagnosis were associated with lower HIF1A and HIF2A expression. In analyses adjusted for center, race, sex, age, hypertension, BMI, smoking, tumor grade and stage, HIF1A expression was significantly associated with HIF2A expression (P-trend&lt;0.0001). We assessed associations of variants in EPAS1 (N=16), HIF1A (N=11), and VHL (N=9) with HIF1A and HIF2A expression in ccRCC tissue using tissue microarrays. Seven HIF1A SNPs were significantly associated with HIF1A expression and one EPAS1 SNP (rs1374748) with HIF2A expression. Median survival time was longer in CE compared to USRCC cases (100.3 vs. 86.0 months, p=0.001), women than men (97.1 vs 91.0 months, p=0.02) but similar among whites and blacks in the US study (86.0 vs 87.0 months). In Cox proportional hazard models, in both studies combined, risk of death was higher for those with large tumors (&gt;4cm, p&lt;0.0001) and with a higher stage 1 vs 2, 3+4 (p&lt;0.0001, both) In contrast, ccRCC-specific survival was higher among USRCC than CE patients (19.8 vs 38.0 months, p=0.04) but similar among white compared to black US ccRCC patients (37.0 vs 40.0 months, p=0.50).

Citation Format: Lee Moore, Petra Lenz, Meredith Yeager, Ruth Pfeiffer, Ghislaine Scelo, Mark Purdue, David Zaridze, Kendra Schwartz, Neonilia szeszenia-Dabrowska, Faith Davis, Joanne Colt, vladimir Janout, Marie Navritalova, Paolo Boffetta, Laurie Burdette, Sara Karami, Paul Brennan, Jon Hofmann, Michael Nickerson, Wong-Ho Chow, Margaret Tucker, Stephen Chanock, Stephen Hewitt, Jorge Toro, Nat Rothman. Molecular characteristics and predictors of poor prognosis in sporadic clear cell renal cancer among central/eastern European and United States patients. [abstract]. In: Proceedings of the AACR Special Conference on Translation of the Cancer Genome; Feb 7-9, 2015; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2015;75(22 Suppl 1):Abstract nr A1-31.

A case-control study of occupational sunlight exposure and renal cancer risk

Epidemiological evidence of a relationship between vitamin D and kidney cancer risk has been inconsistent despite experimental data indicating that vitamin D and its metabolites may inhibit carcinogenesis. Previously we reported an inverse association between renal cell carcinoma (RCC) risk and occupational ultraviolet (UV) exposure among European men. In this study, we examined the association between occupational UV exposure and RCC risk among US residents and investigated whether this association varied by race and sex. Lifetime occupational data for 1,217 RCC cases and 1,235 controls in a population-based case-control study, conducted from 2002 to 2007, were assessed for occupational UV exposure. We evaluated exposure metrics in quartiles based on control exposure levels and calculated associations between RCC risk and occupational UV exposure using unconditional logistic regression adjusted for sex, race, body mass index, smoking, hypertension, center, education, family history of cancer and dietary vitamin D intake. A general pattern of decreasing RCC risk with increasing UV exposure was observed. Cases had significantly lower cumulative occupational UV exposure than controls (fourth quartile vs. first: odds ratio = 0.74 [95% confidence interval = 0.56-0.99], p-trend = 0.03). Similar results were observed for other UV exposure metrics. The association with occupational UV exposure was stronger for women than for men, but did not differ by race. Our findings suggest an inverse association between occupational UV exposure and RCC, particularly among women. Given the sex finding discrepancies in this study versus our previous study, additional research is need to clarify whether the protective effects of occupational UV exposure and RCC risk are real.

Abstract 4609: Risk loci in telomere structure and maintenance genes across five cancer types: GAME-ON Consortium

Telomeres are complex structures that cap chromosome ends, protecting them from degradation, double strand breaks and end-to-end fusions. Telomeres are maintained by the enzyme telomerase, which is made up of a reverse transcriptase encoded by TERT, and an RNA template encoded by TERC. The telomere structure itself is composed of proteins encoded by ACD, ACYP2, BICD1, DKC1, DCLRE1B, MPHOSPH6, NAF1, NOLA1, NOLA2, NOLA3, OBFC1, PIK3C3, POT1, RTEL1, TEP1, TERF1, TERF2, TERF21P, TINF2, TNKS/PINX1, TPP1 and ZNF208. Several single nucleotide polymorphisms (SNPs) in the TERT and adjoining CLPTM1L gene region are associated with multiple cancer types, and some are associated with both increased and decreased risks across different cancer types. We systematically characterized the patterns of association between variants in these 25 telomere structure and maintenance genes and risk across five cancer types in the Genetic Association and Mechanisms in Oncology (GAME-ON) consortium.

We performed a subset-based meta-analysis (ASSET) of 209,367 directly measured and imputed SNPs, one megabase up- and downstream of these genes, across genome-wide association studies of colorectal (5,100 cases, 4,831 controls), lung (12,160 cases, 16,838 controls), breast (15,748 cases, 18,084 controls), ovarian (4,369 cases, 9,123 controls) and prostate (14,160 cases, 12,724 controls) cancers. Correlations (r2) between SNPs were examined in Haploview using the 1000 Genomes Project CEU population.

A total of 87 TERT, 123 TERC and 26 DCLRE1B SNPs were associated with cancer risk at gene-level Bonferroni-corrected p-values of 4.2-7.8×10−6. Patterns of association were similar for prostate and colorectal cancers in DCLRE1B. Much stronger associations were observed in TERT and TERC, with 63 and 24 SNPs reaching genome-wide significance (p&lt;5.0×10−8), respectively. Of these, 9 TERT and 9 TERC SNPs were correlated at r2&lt;0.75. The most strongly associated SNPs in TERT (rs37004, p = 2.6×10−11) and TERC (rs76925190, p = 1.5×10−15) are in regions containing documented risk loci for lung and prostate cancers, respectively. TERT rs37004 (p = 1.2×10−13) and 6 of the other 9 SNPs in TERT were associated only with lung cancer risk. For the other 2 SNPs, there was a suggestion that patterns of risk were opposite for lung and prostate cancers. While TERC rs76925190 was strongly associated with prostate cancer risk (p = 5.4 x10−17), it was also suggestively associated with colorectal cancer risk (p&lt;0.005). This pattern was similar for another 2 of the 9 SNPs, while for the rest, associations were limited to prostate cancer.

The complex patterns of association in telomere structure and maintenance genes observed across cancer types may provide insight about the mechanisms through which telomere dysfunction in different tissues influences cancer risk.

Citation Format: Sara Karami, Younghun Han, Fredrick R. Schumacher, Zsofia Kote-Jarai, Sara Lindstrom, John S. Witte, Iona Cheng, Shenying Fang, Jiali Han, Peter Kraft, Fengju Song, Rayjean J. Hung, James McKay, Stephen J. Chanock, Mala Pande, Angela Risch, Hongbing Shen, Christopher A. Haiman, Lisa Boardman, Cornelia M. Ulrich, Graham Casey, Ulrike Peters, Nilanjan Chatterjee, Brandon Pierce, Wei Zheng, Christopher I. Amos, Jennifer A. Doherty. Risk loci in telomere structure and maintenance genes across five cancer types: GAME-ON Consortium. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4609. doi:10.1158/1538-7445.AM2015-4609

LINE1 methylation levels in pre-diagnostic leukocyte DNA and future renal cell carcinoma risk

Higher levels of LINE1 methylation in blood DNA have been associated with increased kidney cancer risk using post-diagnostically collected samples; however, this association has never been examined using pre-diagnostic samples. We examined the association between LINE1 %5mC and renal cell carcinoma (RCC) risk using pre-diagnostic blood DNA from the United States-based, Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) (215 cases/436 controls), and the Alpha-tocopherol, Beta-carotene Cancer Prevention Study (ATBC) of Finnish male smokers (191 cases/575 controls). Logistic regression adjusted for age at blood draw, study center, pack-years of smoking, body mass index, hypertension, dietary alcohol intake, family history of cancer, and sex was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) using cohort and sex-specific methylation categories. In PLCO, higher, although non-significant, RCC risk was observed for participants at or above median methylation level (M2) compared to those below the median (M1) (OR: 1.37, 95% CI: 0.96-1.95). The association was stronger in males (M2 vs. M1, OR: 1.54, 95% CI: 1.00-2.39) and statistically significant among male smokers (M2 vs. M1, OR: 2.60, 95% CI: 1.46-4.63). A significant interaction for smoking was also detected (P-interaction: 0.01). No association was found among females or female smokers. Findings for male smokers were replicated in ATBC (M2 vs. M1, OR: 1.31, 95% CI: 1.07-1.60). In a pooled analysis of PLCO and ATBC male smokers (281 cases/755 controls), the OR among subjects at or above median methylation level (M2) compared to those below the median (M1) was 1.89 (95% CI: 1.34-2.67, P-value: 3 x 10(-4)); a trend was also observed by methylation quartile (P-trend: 0.002). These findings suggest that higher LINE1 methylation levels measured prior to cancer diagnosis may be a biomarker of future RCC risk among male smokers.

A prospective study of alcohol consumption and renal cell carcinoma risk

Recent epidemiological studies suggest that alcohol consumption may reduce renal cell carcinoma (RCC) risk, although inconsistent findings have been reported by sex and alcoholic beverage type. To better understand the relationship between alcohol consumption and RCC risk, we conducted an analysis within the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. We followed up participants in the analytic cohort (N = 107,998) through 2010 for incident RCC (N = 408), and computed hazard ratios (HRs) and 95% confidence intervals (CIs) for alcohol intake using Cox regression with adjustment for age, sex, race, study center, hypertension, body mass index, and smoking status. In this study population increasing alcohol consumption was associated with reduced RCC risk compared to non-drinkers (>9.75 g day(-1) : HR, 0.67; 95%CI, 0.50 to 0.89; p trend = 0.002). We observed similar patterns of association for men and women as well as by alcohol beverage type. In analyses stratified by smoking status, the inverse association with consumption was apparent for ever smokers (HR, 0.51; 95%CI, 0.36 to 0.73; p trend<0.0001) but not among never smokers (HR, 1.08; 95%CI, 0.66 to 1.76; P trend = 0.78; p interaction = 0.01). Our study findings offer further support that alcohol consumption is associated with reduced RCC risk, regardless of sex or alcoholic beverage type. The finding of interaction with smoking is novel and requires confirmation.

Hysterectomy and kidney cancer risk: a meta-analysis

Recent cohort findings suggest that women who underwent a hysterectomy have an elevated relative risk of kidney cancer, although evidence from past studies has been inconsistent. We conducted a systematic review and meta-analysis of published cohort and case-control studies to summarize the epidemiologic evidence investigating hysterectomy and kidney cancer. Studies published from 1950 through 2012 were identified through a search of PubMed and of references from relevant publications. Meta-analyses were conducted using random-effects models to estimate summary relative risks (SRRs) and 95% confidence intervals (CIs) for hysterectomy, age at hysterectomy (<45, 45+ years) and time since hysterectomy (<10, 10+ years). The SRR for hysterectomy and kidney cancer for all published studies (seven cohort, six case-control) was 1.29 (95% CI, 1.16-1.43), with no evidence of between-study heterogeneity or publication bias. The summary effect was slightly weaker, although still significant, for cohorts (SRR, 1.26; 95% CI, 1.11-1.42) compared with case-control findings (1.37; 95% CI, 1.09-1.73) and was observed irrespective of age at hysterectomy, time since the procedure and model adjustment for body mass index, smoking status and hypertension. Women undergoing a hysterectomy have an approximate 30% increased relative risk of subsequent kidney cancer. Additional research is needed to elucidate the biological mechanisms underlying this association.

LINE1 methylation levels associated with increased bladder cancer risk in pre-diagnostic blood DNA among US (PLCO) and European (ATBC) cohort study participants

Global methylation in blood DNA has been associated with bladder cancer risk in case-control studies, but has not been examined prospectively. We examined the association between LINE1 total percent 5-methylcytosine and bladder cancer risk using pre-diagnostic blood DNA from the United States-based, Prostate, Lung, Colorectal, Ovarian Cancer Screening Trial (PLCO) (299 cases/676 controls), and the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) cohort of Finnish male smokers (391 cases/778 controls). Logistic regression adjusted for age at blood draw, study center, pack-years of smoking, and sex was used to estimate odd ratios (ORs) and 95% confidence intervals (CIs) using study- and sex-specific methylation quartiles. In PLCO, higher, although non-significant, bladder cancer risks were observed for participants in the highest three quartiles (Q2-Q4) compared with the lowest quartile (Q1) (OR = 1.36, 95% CI: 0.96 -1.92). The association was stronger in males (Q2-Q4 vs. Q1 OR = 1.48, 95% CI: 1.00-2.20) and statistically significant among male smokers (Q2-Q4 vs. Q1 OR = 1.83, 95% CI: 1.14-2.95). No association was found among females or female smokers. Findings for male smokers were validated in ATBC (Q2-Q4 vs. Q1: OR = 2.31, 95% CI: 1.62-3.30) and a highly significant trend was observed (P = 8.7 × 10(-7)). After determining that study data could be combined, pooled analysis of PLCO and ATBC male smokers (580 cases/1119 controls), ORs were significantly higher in Q2-Q4 compared with Q1 (OR = 2.03, 95% CI: 1.52-2.72), and a trend across quartiles was observed (P = 0.0001). These findings suggest that higher global methylation levels prior to diagnosis may increase bladder cancer risk, particularly among male smokers.

Pesticide exposure and inherited variants in vitamin d pathway genes in relation to prostate cancer

BACKGROUND

Vitamin D and its metabolites are believed to impede carcinogenesis by stimulating cell differentiation, inhibiting cell proliferation, and inducing apoptosis. Certain pesticides have been shown to deregulate vitamin D's anticarcinogenic properties. We hypothesize that certain pesticides may be linked to prostate cancer via an interaction with vitamin D genetic variants.

METHODS

We evaluated interactions between 41 pesticides and 152 single-nucleotide polymorphisms (SNP) in nine vitamin D pathway genes among 776 prostate cancer cases and 1,444 male controls in a nested case-control study of Caucasian pesticide applicators within the Agricultural Health Study. We assessed Pinteraction values using likelihood ratio tests from unconditional logistic regression and a false discovery rate (FDR) to account for multiple comparisons.

RESULTS

Five significant interactions (P < 0.01) displayed a monotonic increase in prostate cancer risk with individual pesticide use in one genotype and no association in the other. These interactions involved parathion and terbufos use and three vitamin D genes (VDR, RXRB, and GC). The exposure-response pattern among participants with increasing parathion use with the homozygous CC genotype for GC rs7041 compared with unexposed participants was noteworthy [low vs. no exposure: OR, 2.58, 95% confidence interval (CI), 1.07-6.25; high vs. no exposure: OR, 3.09, 95% CI, 1.10-8.68; Pinteraction = 3.8 × 10(-3)].

CONCLUSIONS

In this study, genetic variations in vitamin D pathway genes, particularly GC rs7041, an SNP previously linked to lower circulating vitamin D levels, modified pesticide associations with prostate cancer risk.

IMPACT

Because our study is the first to examine this relationship, additional studies are needed to rule out chance findings.

Use of OMIC technologies to study arsenic exposure in human populations

Exposure to arsenic (As) in drinking water is a major health concern. More than 100 million individuals are exposed to levels over the current World Health Organization standard of 10 µg/L worldwide. Arsenic is one of the few agents established as a human carcinogen prior to understanding its mechanism of carcinogenicity. OMIC technologies have enabled researchers to utilize agnostic approaches to explore new, unknown mechanisms through which As causes disease in exposed human populations. In this article, we present recent studies in which OMIC technologies have been used to explore differences in human biological samples to identify markers of exposure, disease susceptibility, and effect in As-exposed and/or diseased tissues.

Reproductive factors and kidney cancer risk in 2 US cohort studies, 1993-2010

Clinical and experimental findings suggest that female hormonal and reproductive factors could influence kidney cancer development. To evaluate this association, we conducted analyses in 2 large prospective cohorts (the National Institutes of Health-AARP Diet and Health Study (NIH-AARP), 1995-2006, and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), 1993-2010). Cohort-specific and aggregated hazard ratios and 95% confidence intervals relating reproductive factors and kidney cancer risk were computed by Cox regression. The analysis included 792 incident kidney cancer cases among 283,952 postmenopausal women. Women who had undergone a hysterectomy were at a significantly elevated kidney cancer risk in both NIH-AARP (hazard ratio = 1.28, 95% confidence interval: 1.09, 1.50) and PLCO (hazard ratio = 1.41, 95% confidence interval: 1.06, 1.88). Similar results were observed for both cohorts after analyses were restricted to women who had undergone a hysterectomy with or without an oophorectomy. For the NIH-AARP cohort, an inverse association was observed with increasing age at menarche (P for trend = 0.02) and increasing years of oral contraceptive use (P for trend = 0.02). No clear evidence of an association with parity or other reproductive factors was found. Our results suggest that hysterectomy is associated with increased risk of kidney cancer. The observed associations with age at menarche and oral contraceptive use warrant further investigation.

Abstract 686: LINE-1 %5-Methylcytosine levels in pre-diagnostic leukocyte DNA and subsequent renal cell cancer risk

Background: Alteration of DNA methylation is thought to promote carcinogenesis by weakening chromosomal stability and changing normal gene expression patterns. These epigenetic alterations that occur throughout the genome are considered early events in the carcinogenic process. Lately, long interspersed nucleotide element (LINE-1) methylation levels in blood DNA have been examined in relation to risk of several cancers. One previous renal cell cancer (RCC) case-control study reported higher LINE-1 methylation levels in blood DNA for cases than controls. Since DNA samples from that study were collected post-diagnostically, it remains unclear if the observed difference occurred prior to, or as a result of carcinogenesis. Thus, we examined the association between global methylation and RCC risk using prospectively collected blood samples.

Methods: A nested RCC case-control study was conducted amid subjects in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) cohort, a study of Finnish male Caucasian smokers, 50 to 69 years old. LINE-1 percent 5-methylcytosine (LINE-1 %5-MeC) levels from 191 cases and 575 controls, matched on age at randomization (+/-5 years), were quantified using bisulfite treated blood DNA and pyrosequencing. Cancer risk was assessed in quartiles (Q1:&lt;78.0, Q2:78.0-78.5, Q3:78.6-79.5, Q4:&gt;79.5) of methylation based on control levels. Unconditional logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) adjusting for pack-years of smoking, age at randomization, hypertension, family history of cancer, body mass index (BMI) and intervention group.

Results: RCC risk was significantly increased with increasing LINE-1 %5-MeC levels (Q1REF. vs. Q2OR= 1.12 (0.63-1.92), Q3OR= 1.78 (1.06-3.00), Q4OR= 1.78 (1.00-3.03); p-trend= 0.01). Associations appeared more pronounced for males with a higher BMI: (BMI &lt;25kg/m2: Q1 vs. Q2-Q4OR= 0.89 (0.35-2.23); BMI 25-&lt;30kg/m2: Q1 vs. Q2-Q4OR= 1.21 (0.67-2.17); BMI ≥30kg/m2: Q1 vs. Q2-Q4OR= 8.86 (2.20-35.68); p-interaction= 0.01). Decreasing LINE-1 %5-MeC levels were observed with increasing BMI for controls (p-trend= 0.004) but not cases (p-trend=0.19). Analyses for pack-years of smoking showed no association with LINE-1 %5-MeC levels in cases or controls; pack-years of smoking was not shown to modify associations.

Conclusion: Our study findings that increasing LINE-1 %5-MeC levels were associated with higher RCC risk using pre-diagnostically collected blood DNA are consistent with results reported in a previous case-control study. Yet, stratified results for BMI and smoking observed post-diagnostically in that case-control study are not supported in pre-diagnostic samples used here. Our results suggest that higher methylation levels are reflective of elevated RCC risk prior to diagnosis. Additional studies are being conducted in a second cohort to replicate these findings.

Citation Format: Sara Karami, Gabriella Andreotti, Ruth M. Pfeiffer, Linda M. Liao, Stephanie Weinstein, Demetrius Albanes, Jarmo Virtamo, Nathaniel Rothman, Lee E. Moore. LINE-1 %5-Methylcytosine levels in pre-diagnostic leukocyte DNA and subsequent renal cell cancer risk . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 686. doi:10.1158/1538-7445.AM2013-686

Abstract PR1: LINE-1 %5-methyl cytosine levels in prediagnostic leukocyte DNA and future bladder cancer risk among PLCO and ATBC cohort subjects

Background: Low global methylation levels measured in post-diagnostic case compared to healthy control blood DNA have been associated with elevated bladder cancer risk.

Objective: To examine this association using blood DNA collected prior to bladder cancer diagnosis.

Methods: Cases (n=437) and controls (N=847) were selected from the Prostate, Lung, Colorectal, Ovarian Cancer Screening Trial (PLCO). A replication case-control study was conducted among males from the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) cohort (391 cases/778 controls). LINE-1 percent 5-methyl-cytosine (LINE-1 %5-MeC) levels were quantified using bisulfite treated blood DNA and pyrosequencing. Cancer risk was assessed in deciles (D1-D10: 10-100%) and quartiles (Q1-Q4:25-100%) of methylation levels based on controls. Logistic regression was used to evaluate individual and pooled study data.

Findings: In PLCO, significantly lower bladder cancer risk was associated with the lowest LINE-1 %5-MeC decile (D1) compared to D2-D10 subjects adjusted for sex and pack-years of smoking (OR=0.35; 95% CI: 0.18-0.68, p=0.002). Findings were corroborated in the ATBC study, (D1 vs. D2-D10: OR=0.31;95% CI:0.17-0.57, p&lt;0.001) adjusting for pack-years of smoking and intervention assignment. When male data were pooled, a similar association was observed comparing D1 to D2-D10 subjects (OR=0.35;95% CI:0.21-0.57, p&lt;0.001) and by quartiles (OR Q1=0.53;95% CI:0.41-0.70, p&lt;0.001). Smoking status did not modify the associations.

Interpretation: Findings observed in two independent studies using pre-diagnostically collected bladder cancer case/control subject DNA support that higher methylation levels may reflect higher bladder cancer risk prior to diagnosis. Associations using pre-diagnostically collected blood DNA were opposite to those from previous case-control studies using post-diagnostic DNA, suggesting changes in methylation levels associated with the carcinogenic process. Additional prospective studies evaluating LINE1 and gene-specific CpG methylation levels are needed to replicate and extend these findings.

This proffered talk is also presented as Poster 11.

Citation Format: Gabriella Andreotti, Sara Karami, Ruth Pfeiffer, Lauren Hurwitz, Linda Liao, Stephanie Weinstein, Demetrius Albanes, Jarmo Virtamo, Debra Silverman, Nathaniel Rothman, Lee Moore. LINE-1 %5-methyl cytosine levels in prediagnostic leukocyte DNA and future bladder cancer risk among PLCO and ATBC cohort subjects. [abstract]. In: Proceedings of the AACR Special Conference on Post-GWAS Horizons in Molecular Epidemiology: Digging Deeper into the Environment; 2012 Nov 11-14; Hollywood, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(11 Suppl):Abstract nr PR1.

A case-control study of occupation/industry and renal cell carcinoma risk

Background

The role of occupation in the etiology of renal cell carcinoma (RCC) is unclear. Here, we investigated associations between employment in specific occupations and industries and RCC, and its most common histologic subtype, clear cell RCC (ccRCC).

Methods

Between 2002 and 2007, a population-based case–control study of Caucasians and African Americans (1,217 cases; 1,235 controls) was conducted within the Detroit and Chicago metropolitan areas to investigate risk factors for RCC. As part of this study, occupational histories were ascertained through in-person interviews. We computed odds ratios (ORs) and 95% confidence intervals (CIs) relating occupation and industry to RCC risk using adjusted unconditional logistic regression models.

Results

Employment in the agricultural crop production industry for five years or more was associated with RCC (OR = 3.3 [95% CI = 1.0-11.5]) and ccRCC in particular (OR = 6.3 [95% CI = 1.7-23.3], P for trend with duration of employment = 0.0050). Similarly, RCC risk was elevated for employment of five years or longer in non-managerial agricultural and related occupations (OR_RCC = 2.1 [95% CI = 1.0-4.5]; OR_ccRCC = 3.1 [95% CI = 1.4-6.8]). Employment in the dry-cleaning industry was also associated with elevated risk (OR_RCC = 2.0 [95% CI = 0.9-4.4], P for trend = 0.093; OR_ccRCC = 3.0 [95% CI = 1.2-7.4], P for trend = 0.031). Suggestive elevated associations were observed for police/public safety workers, health care workers and technicians, and employment in the electronics, auto repair, and cleaning/janitorial services industries; protective associations were suggested for many white-collar jobs including computer science and administrative occupations as well employment in the business, legislative, and education industries.

Conclusions

Our findings provide support for an elevated risk of RCC in the agricultural and dry-cleaning industries and suggest that these associations may be stronger for the ccRCC subtype. Additional studies are needed to confirm these findings.

Evaluation of metal pollution in fish and water collected from Gorgan coast of the Caspian Sea, Iran

In this study, concentrations of zinc, chromium, cadmium and lead were determined in water and three species of fish sampled from 10 selected stations along Gorgan coast using atomic absorption spectrophotometery, summer 2009. Mean lead levels in water and fish samples (119.50 ± 22.24 μg/L and 113.80 ± 33.11 μg/kg) were significantly higher than that of cadmium and chromium (p < 0.05). Cyprinus carpio had highest metals content than Mugila auratus and Rutilus frisikutum. The evaluated metals values in water collected from Gomishan wetland (Pb, Cd, Cr and Zn values are 145.31 ± 35.32, 120.46 ± 11.44, 96.47 ± 6.05 and 82.02 ± 34.37 μg/L, respectively) were higher than the other sampling sites. The result is consistent with the findings accessed by evaluation of the metals in fish specimens. The metals concentrations in the fish and water samples were below the recommended limits. But, elevating levels of metals in water and fish made a serious concern about ecosystem and food chain contamination.

Genomic copy number alterations in clear cell renal carcinoma: associations with case characteristics and mechanisms of VHL gene inactivation

Array comparative genomic hybridization was used to identify copy number alterations in clear cell renal cell carcinoma (ccRCC) patient tumors to identify associations with patient/clinical characteristics. Of 763 ccRCC patients, 412 (54%) provided frozen biopsies. Clones were analyzed for significant copy number differences, adjusting for multiple comparisons and covariates in multivariate analyses. Frequent alterations included losses on: 3p (92.2%), 14q (46.8%), 8p (38.1%), 4q (35.4%), 9p (32.3%), 9q (31.8%), 6q (30.8%), 3q (29.4%), 10q (25.7%), 13q (24.5%), 1p (23.5%) and gains on 5q (60.2%), 7q (39.6%), 7p (30.6%), 5p (26.5%), 20q (25.5%), 12q (24.8%), 12p (22.8%). Stage and grade were associated with 1p, 9p, 9q, 13q and 14q loss and 12q gain. Males had more alterations compared with females, independent of stage and grade. Significant differences in the number/types of alterations were observed by family cancer history, age at diagnosis and smoking status. Von Hippel–Lindau (VHL) gene inactivation was associated with 3p loss (P<E-05), and these cases had fewer alterations than wild-type cases. The fragile site flanking the FHIT locus (3p14.2) represented a unique breakpoint among VHL hypermethylated cases, compared with wild-type cases and those with sequence changes. This is the first study of its size to investigate copy number alterations among cases with extensive patient, clinical/risk factor information. Patients characterized by VHL wild-type gene status (vs sequence alterations) and male (vs female) cases had more copy number alterations regardless of diagnostic stage and grade, which could relate to poor prognosis.