Combined anatomic factors predicting risk of anterior cruciate ligament injury for males and females

BACKGROUND

Knee joint geometry has been associated with risk of suffering an anterior cruciate ligament (ACL) injury; however, few studies have utilized multivariate analysis to investigate how different aspects of knee joint geometry combine to influence ACL injury risk.

HYPOTHESES

Combinations of knee geometry measurements are more highly associated with the risk of suffering a noncontact ACL injury than individual measurements, and the most predictive combinations of measurements are different for males and females.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 88 first-time, noncontact, grade III ACL-injured subjects and 88 uninjured matched-control subjects were recruited, and magnetic resonance imaging data were acquired. The geometry of the tibial plateau subchondral bone, articular cartilage, and meniscus; geometry of the tibial spines; and size of the femoral intercondylar notch and ACL were measured. Multivariate conditional logistic regression was used to develop risk models for ACL injury in females and males separately.

RESULTS

For females, the best fitting model included width of the femoral notch at its anterior outlet and the posterior-inferior-directed slope of the lateral compartment articular cartilage surface, where a millimeter decrease in notch width and a degree increase in slope were independently associated with a 50% and 32% increase in risk of ACL injury, respectively. For males, a model that included ACL volume and the lateral compartment posterior meniscus to subchondral bone wedge angle was most highly associated with risk of ACL injury, where a 0.1 cm3 decrease in ACL volume (approximately 8% of the mean value) and a degree decrease in meniscus wedge angle were independently associated with a 43% and 23% increase in risk, correspondingly.

CONCLUSION

Combinations of knee joint geometry measurements provided more information about the risk of noncontact ACL injury than individual measures, and the aspects of geometry that best explained the relationship between knee geometry and the risk of injury were different between males and females. Consequently, a female with both a decreased femoral notch width and an increased posterior-inferior-directed lateral compartment tibial articular cartilage slope combined or a male with a decreased ACL volume and decreased lateral compartment posterior meniscus angle were most at risk for sustaining an ACL injury.

A prospective study of the use and effects of screening mammography in women aged 70 and older

OBJECTIVES

To prospectively examine how age and comorbidity affect screening mammography use, cancer detection, and overall survival.

DESIGN

Prospective, with median follow-up of 10.2 years.

SETTING

A population-based cohort of Vermont women with data in the Vermont Breast Cancer Surveillance System.

PARTICIPANTS

Women aged 70 and older with no history of breast cancer (N = 20,697).

MEASUREMENTS

Rates of screening, diagnostic procedure use, and breast cancer diagnosis were examined according to age and comorbidity. The effect of breast cancer on overall survival was assessed in relation to detection mode, tumor characteristics, and treatment.

RESULTS

Screening declined 9% per year after age 70 and 18% with each unit increase in comorbidity score, with corresponding increases in clinically detected breast cancer. Invasive cancer was associated with greater overall mortality (screen detected: hazard ratio (HR) = 1.22, 95% confidence interval (CI) = 1.07-1.40; clinically detected: HR = 1.68, 95% CI = 1.43-1.96). The latter HR reflects a much greater absolute risk of death for women in a population with high baseline mortality. Use of breast-conserving surgery as the only treatment for Stage I cancer increased markedly with age and was associated with shorter overall survival than radiation or mastectomy (relative risk = 2.23, 95% CI = 1.42-3.47).

CONCLUSION

Lower screening mammography use by older women is associated with more clinically detected breast cancers, which are associated with poorer survival. Treatment received for early-stage cancer influences the effect of screening on survival.

Tibial articular cartilage and meniscus geometries combine to influence female risk of anterior cruciate ligament injury

Tibial plateau subchondral bone geometry has been associated with the risk of sustaining a non-contact ACL injury; however, little is known regarding the influence of the meniscus and articular cartilage interface geometry on risk. We hypothesized that geometries of the tibial plateau articular cartilage surface and meniscus were individually associated with the risk of non-contact ACL injury. In addition, we hypothesized that the associations were independent of the underlying subchondral bone geometry. MRI scans were acquired on 88 subjects that suffered non-contact ACL injuries (27 males, 61 females) and 88 matched control subjects that were selected from the injured subject's teammates and were thus matched on sex, sport, level of play, and exposure to risk of injury. Multivariate analysis of the female data revealed that increased posterior-inferior directed slope of the middle articular cartilage region and decreased height of the posterior horn of the meniscus in the lateral compartment were associated with increased risk of sustaining a first time, non-contact ACL injury, independent of each other and of the slope of the tibial plateau subchondral bone. No measures were independently related to risk of non-contact ACL injury among males.

A decreased volume of the medial tibial spine is associated with an increased risk of suffering an anterior cruciate ligament injury for males but not females

Measurements of tibial plateau subchondral bone and articular cartilage slope have been associated with the risk of suffering anterior cruciate ligament (ACL) injury. Such single-plane measures of the tibial plateau may not sufficiently characterize its complex, three-dimensional geometry and how it relates to knee injury. Further, the tibial spines have not been studied in association with the risk of suffering a non-contact ACL injury. We questioned whether the geometries of the tibial spines are associated with non-contact ACL injury risk, and if this relationship is different for males and females. Bilateral MRI scans were acquired on 88 ACL-injured subjects and 88 control subjects matched for sex, age and sports team. Medial and lateral tibial spine geometries were characterized with measurements of length, width, height, volume and anteroposterior location. Analyses of females revealed no associations between tibial spine geometry and risk of ACL injury. Analyses of males revealed that an increased medial tibial spine volume was associated with a decreased risk of ACL injury (OR = 0.667 per 100 mm(3) increase). Smaller medial spines could provide less resistance to internal rotation and medial translation of the tibia relative to the femur, subsequently increasing ACL strains and risk of ACL injury.

What are cancer survivors' needs and how well are they being met?

PURPOSE

This study sought to identify the needs and unmet needs of the growing number of adult cancer survivors.

METHODS

Vermont survivor advocates partnered with academic researchers to create a survivor registry and conduct a cross-sectional survey of cancer-related needs and unmet needs of adult survivors. The mailed survey addressed 53 specific needs in 5 domains based on prior research, contributions from the research partners, and pilot testing. Results were summarized by computing proportions who reported having needs met or unmet.

RESULTS

Survey participants included 1668 of 2005 individuals invited from the survivor registry (83%); 65.7% were ages 60 or older and 61.9% were women. These participants had received their diagnosis 2 to 16 years earlier; 77.5% had been diagnosed ≥5 years previously; 30.2% had at least one unmet need in the emotional, social, and spiritual (E) domain; just 14.4% had at least one unmet need in the economic and legal domain. The most commonly identified individual unmet needs were in the E and the information (I) domains and included “help reducing stress” (14.8% of all respondents) and “information about possible after effects of treatment” (14.4%).

CONCLUSIONS

Most needs of these longerterm survivors were met, but substantial proportions of survivors identified unmet needs. Unmet needs such as information about late and long-term adverse effects of treatment could be met within clinical care with a cancer survivor care plan, but some survivors may require referral to services focused on stress and coping.

Comparison of mammographic density assessed as volumes and areas among women undergoing diagnostic image-guided breast biopsy

BACKGROUND

Mammographic density (MD), the area of non-fatty-appearing tissue divided by total breast area, is a strong breast cancer risk factor. Most MD analyses have used visual categorizations or computer-assisted quantification, which ignore breast thickness. We explored MD volume and area, using a volumetric approach previously validated as predictive of breast cancer risk, in relation to risk factors among women undergoing breast biopsy.

METHODS

Among 413 primarily white women, ages 40 to 65 years, undergoing diagnostic breast biopsies between 2007 and 2010 at an academic facility in Vermont, MD volume (cm(3)) was quantified in craniocaudal views of the breast contralateral to the biopsy target using a density phantom, whereas MD area (cm(2)) was measured on the same digital mammograms using thresholding software. Risk factor associations with continuous MD measurements were evaluated using linear regression.

RESULTS

Percent MD volume and area were correlated (r = 0.81) and strongly and inversely associated with age, body mass index (BMI), and menopause. Both measures were inversely associated with smoking and positively associated with breast biopsy history. Absolute MD measures were correlated (r = 0.46) and inversely related to age and menopause. Whereas absolute dense area was inversely associated with BMI, absolute dense volume was positively associated.

CONCLUSIONS

Volume and area MD measures exhibit some overlap in risk factor associations, but divergence as well, particularly for BMI.

IMPACT

Findings suggest that volume and area density measures differ in subsets of women; notably, among obese women, absolute density was higher with volumetric methods, suggesting that breast cancer risk assessments may vary for these techniques.

CREB-induced inflammation is important for malignant mesothelioma growth

Malignant mesothelioma (MM) is an aggressive tumor with no treatment regimen. Previously we have demonstrated that cyclic AMP response element binding protein (CREB) is constitutively activated in MM tumor cells and tissues and plays an important role in MM pathogenesis. To understand the role of CREB in MM tumor growth, we generated CREB-inhibited MM cell lines and performed in vitro and in vivo experiments. In vitro experiments demonstrated that CREB inhibition results in significant attenuation of proliferation and drug resistance of MM cells. CREB-silenced MM cells were then injected into severe combined immunodeficiency mice, and tumor growth in s.c. and i.p. models of MM was followed. We observed significant inhibition in MM tumor growth in both s.c. and i.p. models and the presence of a chemotherapeutic drug, doxorubicin, further inhibited MM tumor growth in the i.p. model. Peritoneal lavage fluids from CREB-inhibited tumor-bearing mice showed a significantly reduced total cell number, differential cell counts, and pro-inflammatory cytokines and chemokines (IL-6, IL-8, regulated on activation normal T cell expressed and secreted, monocyte chemotactic protein-1, and vascular endothelial growth factor). In vitro studies showed that asbestos-induced inflammasome/inflammation activation in mesothelial cells was CREB dependent, further supporting the role of CREB in inflammation-induced MM pathogenesis. In conclusion, our data demonstrate the involvement of CREB in the regulation of MM pathogenesis by regulation of inflammation.

Relationship Between the Risk of Suffering a First-Time Noncontact ACL Injury and Geometry of the Femoral Notch and ACL: A Prospective Cohort Study With a Nested Case-Control Analysis

BACKGROUND

The morphometric characteristics of the anterior cruciate ligament (ACL) and the femoral intercondylar notch within which it resides have been implicated as risk factors for injuries to this important stabilizer of the knee. Prior research has produced equivocal results with differing methodologies, and consequently, it is unclear how these characteristics affect the injury risk in male and female patients.

HYPOTHESIS

The morphometric characteristics of the ACL and femoral intercondylar notch are individually and independently associated with the risk of suffering a noncontact ACL injury, and these relationships are different in male and female patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Magnetic resonance imaging scans of the bilateral knees were obtained on 88 case-control pairs (27 male, 61 female) matched for age, sex, and participation on the same sports team. Patients had suffered a grade III, first-time, noncontact ACL tear. The femoral notch width at 4 locations, the thickness of the bony ridge at the anteromedial outlet of the femoral notch, the femoral notch volume, ACL volume, and ACL cross-sectional area were measured.

RESULTS

Multivariate analysis of combined data from male and female patients revealed that decreased ACL volume (odds ratio [OR], 0.829), decreased femoral notch width (OR, 0.700), and increased bony ridge thickness at the anteromedial outlet of the femoral notch (OR, 1.614) were significant independent predictors of an ACL injury. Separate analyses of male and female patients indicated that the femoral notch ridge may be more strongly associated with a risk in female patients, while ACL volume is more strongly associated with a risk in male patients. However, statistical analysis performed with an adjustment for body weight strengthened the association between ACL volume and the risk of injuries in female patients.

CONCLUSION

Morphometric features of both the ACL and femoral notch combine to influence the risk of suffering a noncontact ACL injury. When included together in a multivariate model that adjusts for body weight, the effects of the morphometric measurements are similar in male and female patients. If body weight is not taken into consideration, ACL volume is not associated with a risk in female patients.

The Effects of Level of Competition, Sport, and Sex on the Incidence of First-Time Noncontact Anterior Cruciate Ligament Injury

BACKGROUND

Anterior cruciate ligament (ACL) injuries are disabling and are associated with the early onset of posttraumatic osteoarthritis. Little is known regarding the incidence rate of first-time noncontact ACL injuries sustained during athletic events and how they are independently influenced by level of competition, type of sport, and the participant's sex.

HYPOTHESIS

Level of competition (college or high school), type of sport (soccer, basketball, lacrosse, field hockey, football, rugby, volleyball), and the athlete's sex independently influence the incidence rate of first-time noncontact ACL injuries.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between fall 2008 and spring 2012, first-time noncontact ACL injury data were collected from 8 colleges and 18 high schools across 7 sports. Athlete exposure was computed retrospectively using team rosters and numbers of scheduled practices and games. Injury incidence rates (IRs) were computed per 1000 athlete exposures. The independent effects of level of competition, sport, and sex on ACL injury risk were estimated by Poisson regression.

RESULTS

Colleges reported 48 ACL injuries with 320,719 athlete exposures across all sports studied (IR = 0.150 per 1000 person-days), while high schools reported 53 injuries with 873,057 athlete exposures (IR = 0.061). After adjustment for differences in sport and sex, college athletes had a significantly higher injury risk than did high school athletes (adjusted relative risk [RR], 2.38; 95% CI, 1.55-3.54). The overall IR for female athletes was 0.112 compared with 0.063 for males. After adjustment for sport and level of play, females were more than twice as likely to have a first-time ACL injury compared with males (RR, 2.10; 95% CI, 1.34-3.27). With lacrosse as the reference group, risk of first-time noncontact ACL injury was significantly higher for soccer players (RR, 1.77) and for rugby players (RR, 2.23), independent of level of play and sex.

CONCLUSION

An athlete's risk of having a first-time noncontact ACL injury is independently influenced by level of competition, the participant's sex, and type of sport, and there are no interactions between their effects. Female college athletes have the highest risk of having a first-time noncontact ACL injury among the groups studied.

Changes in breast cancer risk distribution among Vermont women using screening mammography

BACKGROUND

Screening mammography utilization in Vermont has declined since 2009 during a time of changing screening guidelines and increased interest in personalized screening regimens. This study evaluates whether the breast cancer risk distribution of the state's screened population changed during the observed decline.

METHODS

We examined the breast cancer risk distribution among screened women between 2001 and 2012 using data from the Vermont Breast Cancer Surveillance System. We estimated each screened woman's 5-year risk of breast cancer using the Breast Cancer Surveillance Consortium risk calculator. Annual screening counts by risk group were normalized and age-adjusted to the Vermont female population by direct standardization.

RESULTS

The normalized rate of low-risk (5-year breast cancer risk of <1%) women screened increased 8.3% per year (95% confidence interval [CI] = 4.8 to 11.9) between 2003 and 2008 and then declined by -5.4% per year (95% CI = -8.1 to -2.6) until 2012. When stratified by age group, the rate of low-risk women screened declined -4.4% per year (95% CI = -8.8 to 0.1; not statistically significant) for ages 40 to 49 years and declined a statistically significant -7.1% per year (95% CI = -12.1 to -2.0) for ages 50 to 74 years during 2008 to 2012. These declines represented the bulk of overall decreases in screening after 2008, with rates for women categorized in higher risk levels generally exhibiting small annual changes.

CONCLUSIONS

The observed decline in women screened in Vermont in recent years is largely attributable to reductions in screening visits by women who are at low risk of developing breast cancer.

Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched case-control analysis

BACKGROUND

There is an emerging consensus that increased posterior-inferior directed slope of the subchondral bone portion of the tibial plateau is associated with increased risk of suffering an anterior cruciate ligament (ACL) injury; however, most of what is known about this relationship has come from unmatched case-control studies. These observations need to be confirmed in more rigorously designed investigations.

HYPOTHESIS

Increased posterior-inferior directed slope of the medial and lateral tibial plateaus are associated with increased risk of suffering a noncontact ACL injury.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

In sum, 176 athletes competing in organized sports at the college and high school levels participated in the study: 88 suffering their first noncontact ACL injury and 88 matched controls. Magnetic resonance images were acquired, and geometry of the subchondral bone portion of the tibial plateau was characterized on each athlete bilaterally by measuring the medial and lateral tibial plateau slopes, coronal tibial slope, and the depth of the medial tibial plateau. Comparisons between knees of the same person were made with paired t tests, and associations with injury risk were assessed by conditional logistic regression analysis of ACL-injured and control participants.

RESULTS

Controls exhibited side-to-side symmetry of subchondral bone geometry, while the ACL-injured athletes did not, suggesting that the ACL injury may have changed the subchondral bone geometry. Therefore, the uninjured knees of the ACL-injured athletes and the corresponding limbs of their matched controls were used to assess associations with injury risk. Analyses of males and females as a combined group and females as a separate group showed a significant association between ACL injury risk and increased posterior-inferior directed slope of the lateral tibial plateau slope. This relationship was not apparent when males were analyzed as a group. Multivariate analyses indicated that these results were independent of the medial tibial plateau slope, coronal tibial slope, and depth of the medial tibial plateau, which were not associated with ACL injury.

CONCLUSION

There is a 21.7% increased risk of noncontact ACL injury with each degree increase of the lateral tibial plateau slope among females but not among males. The medial tibial plateau slope, coronal tibial slope, and depth of the medial tibial plateau were not associated with risk of injury for females or males.

Changes in the Breast Cancer Risk Distribution among Women Utilizing Screening Mammography in Vermont Between 2001 and 2012

We previously reported a decline in overall breast cancer screening rates in Vermont following 2009. During this period, there has been debate regarding the role of patient context in decisions about when and how often to get screened, as well as increased interest in risk- based screening to optimize the balance between the potential benefits and harms of screening. The purpose of the current study was to evaluate whether the breast cancer risk distribution of the screened population in Vermont has changed during the observed decline in utilization rates. We examined the distribution of breast cancer risk among the screened population in Vermont from 2001 to 2012 using cross-sectional data from the statewide Vermont Breast Cancer Surveillance System. We employed the Breast Cancer Surveillance Consortium risk model to estimate each individual's risk of developing breast cancer within 5 years according to age, breast density, race/ethnicity, family history of breast cancer, and biopsy history. Among women ages 40 to 74 who received screening mammograms, the absolute number of visits dropped by 4,257, from 54,415 to 50,158 (−7.3%; 95% CI: −7.5, −7.1) between 2009 and 2012. Concurrently, the number of screened women who were estimated to be at low risk of developing breast cancer decreased by 4,240 (95% CI: 3,907, 4,573), representing the bulk of the overall decrease. There was no significant change in the aggregate number of women estimated to be at higher risk (−17 women; 95% CI: −350, 316). The outsized proportion of the decline attributed to women at low estimated risk held across younger and older age groups: among women ages 40 to 49, the absolute number screened dropped by 3,337, with 2,495 (95% CI: 2,389, 2,601) reflected by declines among women at low risk; among women ages 50 to 74, the absolute number screened dropped by only 920, however this value reflects a decrease of 1,763 (95% CI: 1,519, 2,007) for the low risk category, and gains totaling 843 (95% CI: 599, 1,087) among higher risk categories. We conclude that the observed decline in women screened in Vermont since 2009 is largely attributable to reductions in visits by women who are estimated to be at low risk of developing breast cancer, and that this trend generally holds across age groups.

Registry-based study of trends in breast cancer screening mammography before and after the 2009 U.S. Preventive Services Task Force recommendations

PURPOSE

To determine whether the 2009 U.S. Preventive Services Task Force (USPSTF) guidelines for breast cancer mammography screening were followed by changes in screening utilization in the state of Vermont.

MATERIALS AND METHODS

This retrospective study was HIPAA compliant and approved by the institutional review board, with waiver of informed consent. Trends in screening mammography utilization during 1997-2011 were examined among approximately 150,000 women aged 40 years and older in the state of Vermont using statewide mammography registry data.

RESULTS

The percentage of Vermont women aged 40 years and older screened in the past year declined from 45.3% in 2009% to 41.6% in 2011 (an absolute decrease of -3.7 percentage points; 95% confidence interval [CI]: -3.3, -4.1). The largest decline in utilization was among women aged 40-49 years (-4.8 percentage points; 95% CI: -4.1, -5.4), although substantial declines were also observed among women aged 50-74 years (-3.0 percentage points; 95% CI: -2.6, -3.5) and women aged 75 years and older (-3.1 percentage points; 95% CI: -2.3, -4.0). The percentage of women aged 50-74 years screened within the past 2 years declined by -3.4 percentage points (95% CI: -3.0, -3.9) from 65.4% in 2009 to 61.9% in 2011.

CONCLUSION

After years of increasing screening mammography utilization in Vermont, there was a decline in screening, which coincided with the release of the 2009 USPSTF recommendations. The age-specific patterns in utilization were generally consistent with the USPSTF recommendations, although there was also evidence that the percentage of women aged 50-74 years screened in the past 2 years declined since 2009.

Reliability of a new stabilized dynamometer system for the evaluation of hip strength

BACKGROUND

Hip strength is associated with numerous orthopaedic and neuromuscular injuries and/or pathologies and may be assessed with a variety of anatomic testing positions and techniques. Isokinetic dynamometers are generally too cumbersome and intricate for efficient use in mass screenings (for prognostic studies of risk for injury) as well as with special populations. The reliability of isometric testing devices has demonstrated varied reliability, generally examining only 1 or 2 motions of the hip and reporting values of force, not torque. Consequently, there is a need for an efficient hip strength-testing device to quantify torque that tests subjects in 1 anatomic position, while evaluating multiple hip motions.

HYPOTHESIS

Evaluation of supine hip abduction, adduction, flexion, and extension torque using a new stabilized dynamometer system will produce good to excellent intra- and interexaminer reliability results.

STUDY DESIGN

A blinded, randomized, repeated-measures study design was used in this descriptive laboratory investigation.

METHODS

Supine isometric hip flexion, extension, abduction, and adduction torques were evaluated with a cage-stabilized dynamometer in 19 collegiate and professional-level ice hockey athletes by 2 investigators at 3 time intervals. Inter- and intrarater reliability was assessed.

RESULTS

Supine hip flexion, extension, abduction, and adduction torque was performed with good to excellent inter- and intrarater reliability (intraclass correlation coefficients ranging from 0.74 to 0.92 and 0.78 to 0.92, respectively) for all motions tested.

CONCLUSIONS

We have developed an isometric hip strength-testing device that can be assembled around an examination table to efficiently and reliably evaluate torque developed for multiple motions of the hip.

CLINICAL RELEVANCE

This device and testing protocol may be used to efficiently evaluate hip strength in numerous settings; it allows decreased subject burden and increased comfort (which may be important following an injury in case-control investigations); and it may be well tolerated when testing athletes as well as special populations in the clinical setting.

Geometric profile of the tibial plateau cartilage surface is associated with the risk of non-contact anterior cruciate ligament injury

The purpose of this study was to determine if geometry of the articular surfaces of the tibial plateau is associated with non-contact anterior cruciate ligament (ACL) injury. This was a longitudinal cohort study with a nested case-control analysis. Seventy-eight subjects who suffered a non-contact ACL tear and a corresponding number of controls matched by age, sex, and sport underwent 3 T MRI of both knees. Surface geometry of the tibial articular cartilage was characterized with polynomial equations and comparisons were made between knees on the same person and between ACL-injured and control subjects. There was no difference in surface geometry between the knees of the control subjects. In contrast, there were significant differences in the surface geometry between the injured and normal knees of the ACL-injured subjects, suggesting that the ACL injury changed the cartilage surface profile. Therefore, comparisons were made between the uninjured knees of the ACL-injured subjects and the corresponding knees of their matched controls and this revealed significant differences in the surface geometry for the medial (p < 0.006) and lateral (p < 0.001) compartments. ACL-injured subjects tended to demonstrate a posterior-inferior directed orientation of the articular surface relative to the long axis of the tibia, while the control subjects were more likely to show a posterior-superior directed orientation.

Cognitive Change across Cognitive-Behavioral and Light Therapy Treatments for Seasonal Affective Disorder: What Accounts for Clinical Status the Next Winter?

Efficacious treatments for seasonal affective disorder include light therapy and a seasonal affective disorder-tailored form of cognitive-behavioral therapy. Using data from a parent clinical trial, these secondary analyses examined the relationship between cognitive change over treatment with cognitive-behavioral therapy, light therapy, or combination treatment and mood outcomes the next winter. Sixty-nine participants were randomly assigned to 6-weeks of cognitive-behavioral therapy, light therapy, or combination treatment. Cognitive constructs (i.e., dysfunctional attitudes, negative automatic thoughts, and rumination) were assessed at pre- and post-treatment. Dysfunctional attitudes, negative automatic thoughts, and rumination improved over acute treatment, regardless of modality; however, in participants randomized to solo cognitive-behavioral therapy, a greater degree of improvement in dysfunctional attitudes and automatic thoughts was uniquely associated with less severe depressive symptoms the next winter. Change in maladaptive thoughts during acute treatment appears mechanistic of solo cognitive-behavioral therapy's enduring effects the next winter, but is simply a consequence of diminished depression in light therapy and combination treatment.

Cognitive-behavioral therapy vs. light therapy for preventing winter depression recurrence: study protocol for a randomized controlled trial

BACKGROUND

Seasonal affective disorder (SAD) is a subtype of recurrent depression involving major depressive episodes during the fall and/or winter months that remit in the spring. The central public health challenge in the management of SAD is prevention of winter depression recurrence. Light therapy (LT) is the established and best available acute SAD treatment. However, long-term compliance with daily LT from first symptom through spontaneous springtime remission every fall/winter season is poor. Time-limited alternative treatments with effects that endure beyond the cessation of acute treatment are needed to prevent the annual recurrence of SAD.

METHODS/DESIGN

This is an NIMH-funded R01-level randomized clinical trial to test the efficacy of a novel, SAD-tailored cognitive-behavioral group therapy (CBT) against LT in a head-to-head comparison on next winter outcomes. This project is designed to test for a clinically meaningful difference between CBT and LT on depression recurrence in the next winter (the primary outcome). This is a concurrent two-arm study that will randomize 160 currently symptomatic community adults with major depression, recurrent with seasonal pattern, to CBT or LT. After 6 weeks of treatment in the initial winter, participants are followed in the subsequent summer, the next winter, and two winters later. Key methodological issues surround timing study procedures for a predictably recurrent and time-limited disorder with a focus on long-term outcomes.

DISCUSSION

The chosen design answers the primary question of whether prior exposure to CBT is associated with a substantially lower likelihood of depression recurrence the next winter than LT. This design does not test the relative contributions of the cognitive-behavioral treatment components vs. nonspecific factors to CBT's outcomes and is not adequately powered to test for differences or equivalence between cells at treatment endpoint. Alternative designs addressing these limitations would have required more patients, increased costs, and reduced power to detect a difference in the primary outcome.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT01714050.

Extracellular signal-regulated kinase 5: a potential therapeutic target for malignant mesotheliomas

PURPOSE

Malignant mesothelioma is a devastating disease with a need for new treatment strategies. In the present study, we showed the importance of extracellular signal-regulated kinase 5 (ERK5) in malignant mesothelioma tumor growth and treatment.

EXPERIMENTAL DESIGN

ERK5 as a target for malignant mesothelioma therapy was verified using mesothelial and mesothelioma cell lines as well as by xenograft severe combined immunodeficient (SCID) mouse models.

RESULTS

We first showed that crocidolite asbestos activated ERK5 in LP9 cells and mesothelioma cell lines exhibit constitutive activation of ERK5. Addition of doxorubicin resulted in further activation of ERK5 in malignant mesothelioma cells. ERK5 silencing increased doxorubicin-induced cell death and doxorubicin retention in malignant mesothelioma cells. In addition, shERK5 malignant mesothelioma lines exhibited both attenuated colony formation on soft agar and invasion of malignant mesothelioma cells in vitro that could be related to modulation of gene expression linked to cell proliferation, apoptosis, migration/invasion, and drug resistance as shown by microarray analysis. Most importantly, injection of shERK5 malignant mesothelioma cell lines into SCID mice showed significant reduction in tumor growth using both subcutaneous and intraperitoneal models. Assessment of selected human cytokine profiles in peritoneal lavage fluid from intraperitoneal shERK5 and control tumor-bearing mice showed that ERK5 was critical in regulation of various proinflammatory (RANTES/CCL5, MCP-1) and angiogenesis-related (interleukin-8, VEGF) cytokines. Finally, use of doxorubicin and cisplatin in combination with ERK5 inhibition showed further reduction in tumor weight and volume in the intraperitoneal model of tumor growth.

CONCLUSION

ERK5 inhibition in combination with chemotherapeutic drugs is a beneficial strategy for combination therapy in patients with malignant mesothelioma.

Sensitivity and specificity of mammographic screening as practised in Vermont and Norway

OBJECTIVE

The aim of this study was to examine the sensitivity and specificity of screening mammography as performed in Vermont, USA, and Norway.

METHODS

Incident screening data from 1997 to 2003 for female patients aged 50-69 years from the Vermont Breast Cancer Surveillance System (116 996 subsequent screening examinations) and the Norwegian Breast Cancer Screening Program (360 872 subsequent screening examinations) were compared. Sensitivity and specificity estimates for the initial (based on screening mammogram only) and final (screening mammogram plus any further diagnostic imaging) interpretations were directly adjusted for age using 5-year age intervals for the combined Vermont and Norway population, and computed for 1 and 2 years of follow-up, which ended at the time of the next screening mammogram.

RESULTS

For the 1-year follow-up, sensitivities for initial assessments were 82.0%, 88.2% and 92.5% for 1-, 2- and >2-year screening intervals, respectively, in Vermont (p=0.022). For final assessments, the values were 73.6%, 83.3% and 81.2% (p=0.047), respectively. For Norway, sensitivities for initial assessments were 91.0% and 91.3% (p=0.529) for 2- and >2-year intervals, and 90.7% and 91.3%, respectively, for final assessments (p=0.630). Specificity was lower in Vermont than in Norway for each screening interval and for all screening intervals combined, for both initial (90.6% vs 97.8% for all intervals; p<0.001) and final (98.8% vs 99.5% for all intervals; p<0.001) assessments.

CONCLUSION

Our study showed higher sensitivity and specificity in a biennial screening programme with an independent double reading than in a predominantly annual screening program with a single reading.

ADVANCES IN KNOWLEDGE

This study demonstrates that higher recall rates and lower specificity are not always associated with higher sensitivity of screening mammography. Differences in the screening processes in Norway and Vermont suggest potential areas for improvement in the latter.

Application of a clinic-based algorithm as a tool to identify female athletes at risk for anterior cruciate ligament injury: a prospective cohort study with a nested, matched case-control analysis

BACKGROUND

When landing from a jump, the production of increased intersegmental knee abduction moments and coupled valgus motions has been associated with an increased risk of suffering a noncontact anterior cruciate ligament (ACL) injury in one study. This research has led to the development of a clinic-based algorithm that utilizes measures of knee valgus motion, knee flexion range of motion, body mass, tibial length, and quadriceps-to-hamstring strength ratio data to predict the probability of a high knee abduction moment (pKAM) when landing from a jump in female athletes. The ability of this algorithm to identify athletes at increased risk of suffering ACL injury has not been assessed.

HYPOTHESIS

The pKAM is associated with ACL injury in female athletes.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study was based on secondary analysis of data obtained from a previous investigation that focused on the use of the drop vertical jump (DVJ) test to assess the risk of ACL injury in female athletes. The DVJ screenings were performed on 1855 female high school and college athletes over 3 years. Knee valgus motion, knee flexion range of motion, and tibial length were measured from videos of the DVJ obtained during preseason screenings. Mass was measured using a physician's scale, and quadriceps-to-hamstring strength ratio was included using a surrogate value. These data were entered into the clinic-based algorithm that determined the pKAM. The association of pKAM with ACL injury was assessed using conditional logistic regression.

RESULTS

A total of 20 athletes sustained ACL injury and were matched with 45 uninjured control athletes who were recruited from the same teams. There was no relationship between the risk of suffering ACL injury and pKAM, as determined by the clinic-based algorithm.

CONCLUSION

The pKAM was not associated with noncontact ACL injury in our group of injured athletes and matched controls.

Relationship between mammographic density and breast cancer death in the Breast Cancer Surveillance Consortium

BACKGROUND

Women with elevated mammographic density have an increased risk of developing breast cancer. However, among women diagnosed with breast cancer, it is unclear whether higher density portends reduced survival, independent of other factors.

METHODS

We evaluated relationships between mammographic density and risk of death from breast cancer and all causes within the US Breast Cancer Surveillance Consortium. We studied 9232 women diagnosed with primary invasive breast carcinoma during 1996-2005, with a mean follow-up of 6.6 years. Mammographic density was assessed using the Breast Imaging Reporting and Data System (BI-RADS) density classification. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by Cox proportional hazards regression; women with scattered fibroglandular densities (BI-RADS 2) were the referent group. All statistical tests were two-sided.

RESULTS

A total of 1795 women died, of whom 889 died of breast cancer. In multivariable analyses (adjusted for site, age at and year of diagnosis, American Joint Committee on Cancer stage, body mass index, mode of detection, treatment, and income), high density (BI-RADS 4) was not related to risk of death from breast cancer (HR = 0.92, 95% CI = 0.71 to 1.19) or death from all causes (HR = 0.83, 95% CI = 0.68 to 1.02). Analyses stratified by stage and other prognostic factors yielded similar results, except for an increased risk of breast cancer death among women with low density (BI-RADS 1) who were either obese (HR = 2.02, 95% CI = 1.37 to 2.97) or had tumors of at least 2.0 cm (HR = 1.55, 95% CI = 1.14 to 2.09).

CONCLUSIONS

High mammographic breast density was not associated with risk of death from breast cancer or death from any cause after accounting for other patient and tumor characteristics. Thus, risk factors for the development of breast cancer may not necessarily be the same as factors influencing the risk of death after breast cancer has developed.

Reproducibility of BI-RADS breast density measures among community radiologists: a prospective cohort study

Using data from the Vermont Breast Cancer Surveillance System (VBCSS), we studied the reproducibility of Breast Imaging Reporting and Data System (BI-RADS) breast density among community radiologists interpreting mammograms in a cohort of 11,755 postmenopausal women. Radiologists interpreting two or more film-screen screening or bilateral diagnostic mammograms for the same woman within a 3- to 24-month period during 1996-2006 were eligible. We observed moderate-to-substantial overall intra-rater agreement for use of BI-RADS breast density in clinical practice, with an overall intra-radiologist percent agreement of 77.2% (95% confidence interval (CI), 74.5-79.5%), an overall simple kappa of 0.58 (95% CI, 0.55-0.61), and an overall weighted kappa of 0.70 (95% CI, 0.68-0.73). Agreement exhibited by individual radiologists varied widely, with intra-radiologist percent agreement ranging from 62.1% to 87.4% and simple kappa ranging from 0.19 to 0.69 across individual radiologists. Our findings underscore the need for additional evaluation of the BI-RADS breast density categorization system in clinical practice.

A prospective evaluation of the Landing Error Scoring System (LESS) as a screening tool for anterior cruciate ligament injury risk

BACKGROUND

Anterior cruciate ligament (ACL) injuries are immediately disabling, costly, take a significant amount of time to rehabilitate, and are associated with an increased risk of developing posttraumatic osteoarthritis of the knee. Specific multiplanar movement patterns of the lower extremity, such as those associated with the drop vertical jump (DVJ) test, have been shown to be associated with an increased risk of suffering noncontact ACL injuries. The Landing Error Scoring System (LESS) has been developed as a tool that can be applied to identify individuals who display at-risk movement patterns during the DVJ.

HYPOTHESIS

An increase in LESS score is associated with an increased risk of noncontact ACL injury.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Over a 3-year interval, 5047 high school and college participants performed preseason DVJ tests that were recorded using commercial video cameras. All participants were followed for ACL injury during their sports season, and video data from injured participants and matched controls were then assessed with the LESS. Conditional logistic regression analysis was used to examine the association between LESS score and ACL injury risk in all participants as well as subgroups of female, male, high school, and college participants.

RESULTS

There was no relationship between the risk of suffering ACL injury and LESS score whether measured as a continuous or a categorical variable. This was the case for all participants combined (odds ratio, 1.04 per unit increase in LESS score; 95% confidence interval, 0.80-1.35) as well as within each subgroup (odds ratio range, 0.99-1.14).

CONCLUSION

The LESS did not predict ACL injury in our cohort of high school and college athletes.

Measures of genotoxicity in Gulf war I veterans exposed to depleted uranium

Exposure to depleted uranium (DU), an alpha-emitting heavy metal, has prompted the inclusion of markers of genotoxicity in the long-term medical surveillance of a cohort of DU-exposed Gulf War veterans followed since 1994. Using urine U (uU) concentration as the measure of U body burden, the cohort has been stratified into low-u (<0.10 μg U/g creatinine) and high-u groups (≥ 0.10 μg U/g creatinine). Surveillance outcomes for this cohort have historically included markers of mutagenicity and clastogenicity, with past results showing generally nonsignificant differences between low- vs. high-U groups. However, mean hypoxanthine-guanine phosphoribosyl transferase (HPRT) mutant frequencies (MFs) have been almost 50% higher in the high-U group. We report here results of a more comprehensive protocol performed in a 2009 evaluation of a subgroup (N = 35) of this cohort. Four biomarkers of genotoxicity [micronuclei (MN), chromosome aberrations, and MFs of HPRT and PIGA] were examined. There were no statistically significant differences in any outcome measure when results were compared between the low- vs. high-U groups. However, modeling of the HPRT MF results suggests a possible threshold effect for MFs occurring in the highest U exposed cohort members. Mutational spectral analysis of HPRT mutations is underway to clarify a potential clonal vs. a threshold uU effect to explain this observation. This study provides a comprehensive evaluation of a human population chronically exposed to DU and demonstrates a relatively weak genotoxic effect of the DU exposure. These results may explain the lack of clear epidemiologic evidence for U carcinogenicity in humans. Environ. Mol. Mutagen., 2011. © 2011 Wiley-Liss, Inc.

1,3-Butadiene: Biomarkers and application to risk assessment

1,3-Butadiene (BD) is a known rodent and human carcinogen that is metabolized mainly by P450 2E1 to three epoxides, 1,2-epoxy-3-butene (EB), 1,2:3,4-diepoxybutane (DEB) and 1,2-epoxy-3,4-butanediol (EB-diol). The individual epoxides vary up to 200-fold in their mutagenic potency, with DEB being the most mutagenic metabolite. It is important to understand the internal formation of the individual epoxides to assign the relative risk for each metabolite and to understand the molecular mechanisms responsible for major species differences in carcinogenicity. We have conducted extensive exposure-biomarker studies on mice, rats and humans. Using low exposures that range from current occupational levels to human exposures from tobacco smoke has provided evidence that mice are very different from humans, with mice forming ∼200 times more DEB than humans at exposures of 0.1-1.5ppm BD. While no gender differences have been noted in mice and rats for globin adducts or N-7 guanine adducts, female rats and mice had 2-3-fold higher Hprt mutations and DNA-DNA cross-links, suggesting a gender difference in DNA repair. Numerous molecular epidemiology studies have evaluated globin adducts and Hprt mutations, SCEs and chromosomal abnormalities. None of the blinded studies have shown evidence of human genotoxicity at current occupational exposures and studies of globin adducts have shown similar or lower formation of adducts in females than males. If one calculates the EB dose-equivalents for the three species, mice clearly differ from rats and humans, being ∼44 and 174 times greater than rats and humans, respectively. These data provide a scientific basis for improved risk assessment of BD.

Mortality in Vermont granite workers and its association with silica exposure

OBJECTIVES

To assess mortality in Vermont granite workers and examine relationships between silica exposure and mortality from lung cancer, kidney cancer, non-malignant kidney disease, silicosis and other non-malignant respiratory disease. Methods Workers employed between 1947 and 1998 were identified. Exposures were estimated using a job-exposure matrix. Mortality was assessed through 2004 and standardised mortality ratios (SMRs) were computed. Associations between mortality and exposure to silica were assessed by nested case-control analyses using conditional logistic regression. Results 7052 workers had sufficient data for statistical analysis. SMRs were significantly elevated for lung cancer (SMR 1.37, 95% CI 1.23 to 1.52), silicosis (SMR 59.13, 95% CI 44.55 to 76.97), tuberculosis (SMR 21.74, 95% CI 18.37 to 25.56) and other non-malignant respiratory disease (SMR 1.74, 95% CI 1.50 to 2.02) but not for kidney cancer or non-malignant kidney disease. In nested case-control analyses, significant associations with cumulative exposure to respirable free silica were observed for silicosis (OR 1.13, 95% CI 1.05 to 1.21 for each 1 mg/m(3)-year increase in cumulative exposure) and other non-malignant respiratory disease (OR 1.10, 95% CI 1.03 to 1.16) but not for lung cancer (OR 0.99, 95% CI 0.94 to 1.03), kidney cancer (OR 0.96, 95% CI 0.84 to 1.09) or non-malignant kidney disease (OR 0.95, 95% CI 0.84 to 1.08). Conclusions Exposure to crystalline silica in Vermont granite workers was associated with increased mortality from silicosis and other non-malignant respiratory disease, but there was no evidence that increased lung cancer mortality in the cohort was due to exposure. Mortality from malignant and non-malignant kidney disease was not significantly increased or associated with exposure.

Silica exposure assessment in a mortality study of Vermont granite workers

A study of past silica and respirable dust exposures in the Vermont granite industry was conducted to develop a job exposure matrix (JEM) that used 5204 industrial hygiene measurements made from 1924-2004. The construction of the JEM involved data entry from several original sources into an Excel database that was reviewed later to ensure accuracy. Exposure measurements by job or location were grouped in two broad categories of quarry or shed and then into 22 job classes. Missing exposure data by time period were computed, taking into account improvements in dust control and periods of significant reduction in dustiness. Percent free silica (α-quartz) in respirable dust was estimated to be 11.0% based on previous published studies in Vermont and on data in the current database. About 60% of all measurement data (primarily from years prior to 1972) were obtained using the impinger and expressed in millions of particles per cubic foot (mppcf), which were converted to equivalent respirable free silica concentrations using the conversion of 10 mppcf = 0.1 mg/m(3) of respirable silica. For impinger data, respirable dust was calculated by multiplying respirable silica by a factor of 9.091 to reflect that the respirable silica was 11.0% respirable dust. This JEM has been used in a recent epidemiologic study to assess mortality in Vermont granite workers and to examine the relationships among mortality from silicosis, lung cancer, and other nonmalignant respiratory diseases.

ERK2 is essential for the growth of human epithelioid malignant mesotheliomas

Members of the extracellular signal-regulated kinase (ERK) family may have distinct roles in the development of cell injury and repair, differentiation and carcinogenesis. Here, we show, using a synthetic small-molecule MEK1/2 inhibitor (U0126) and RNA silencing of ERK1 and 2, comparatively, that ERK2 is critical to transformation and homeostasis of human epithelioid malignant mesotheliomas (MMs), asbestos-induced tumors with a poor prognosis. Although MM cell (HMESO) lines stably transfected with shERK1 or shERK2 both exhibited significant decreases in cell proliferation in vitro, injection of shERK2 cells, and not shERK1 cells, into immunocompromised severe combined immunodeficiency (SCID) mice showed significant attenuated tumor growth in comparison to shControl (shCon) cells. Inhibition of migration, invasion and colony formation occurred in shERK2 MM cells in vitro, suggesting multiple roles of ERK2 in neoplasia. Microarray and quantitative real-time PCR analyses revealed gene expression that was significantly increased (CASP1, TRAF1 and FAS) or decreased (SEMA3E, RPS6KA2, EGF and BCL2L1) in shERK2-transfected MM cells in contrast to shCon-transfected MM cells. Most striking decreases were observed in mRNA levels of Semaphorin 3 (SEMA3E), a candidate tumor suppressor gene linked to inhibition of angiogenesis. These studies demonstrate a key role of ERK2 in novel gene expression critical to the development of epithelioid MMs. After injection of sarcomatoid human MM (PPMMill) cells into SCID mice, both shERK1 and shERK2 lines showed significant decreased tumor growth, suggesting heterogeneous effects of ERKs in individual MMs.

Blocking of ERK1 and ERK2 sensitizes human mesothelioma cells to doxorubicin

BACKGROUND

Malignant mesotheliomas (MM) have a poor prognosis, largely because of their chemoresistance to anti-cancer drugs such as doxorubicin (Dox). Here we show using human MM lines that Dox activates extracellular signal-regulated kinases (ERK1 and 2), causally linked to increased expression of ABC transporter genes, decreased accumulation of Dox, and enhanced MM growth. Using the MEK1/2 inhibitor, U0126 and stably transfected shERK1 and shERK2 MM cell lines, we show that inhibition of both ERK1 and 2 sensitizes MM cells to Dox.

RESULTS

U0126 significantly modulated endogenous expression of several important drug resistance (BCL2, ABCB1, ABCC3), prosurvival (BCL2), DNA repair (BRCA1, BRCA2), hormone receptor (AR, ESR2, PPARγ) and drug metabolism (CYP3A4) genes newly identified in MM cells. In comparison to shControl lines, MM cell lines stably transfected with shERK1 or shERK2 exhibited significant increases in intracellular accumulation of Dox and decreases in cell viability. Affymetrix microarray analysis on stable shERK1 and shERK2 MM lines showed more than 2-fold inhibition (p ≤ 0.05) of expression of ATP binding cassette genes (ABCG1, ABCA5, ABCA2, MDR/TAP, ABCA1, ABCA8, ABCC2) in comparison to shControl lines. Moreover, injection of human MM lines into SCID mice showed that stable shERK1 or shERK2 lines had significantly slower tumor growth rates in comparison to shControl lines after Dox treatment.

CONCLUSIONS

These studies suggest that blocking ERK1 and 2, which play critical roles in multi-drug resistance and survival, may be beneficial in combination with chemotherapeutic drugs in the treatment of MMs and other tumors.

Mechanisms of oxidative stress and alterations in gene expression by Libby six-mix in human mesothelial cells

BACKGROUND

Exposures to an amphibole fiber in Libby, Montana cause increases in malignant mesothelioma (MM), a tumor of the pleural and peritoneal cavities with a poor prognosis. Affymetrix microarray/GeneSifter analysis was used to determine alterations in gene expression of a human mesothelial cell line (LP9/TERT-1) by a non-toxic concentration (15×10(6) μm2/cm2) of unprocessed Libby six-mix and negative (glass beads) and positive (crocidolite asbestos) controls. Because manganese superoxide dismutase (MnSOD; SOD2) was the only gene upregulated significantly (p < 0.05) at both 8 and 24 h, we measured SOD protein and activity, oxidative stress and glutathione (GSH) levels to better understand oxidative events after exposure to non-toxic (15×10(6) μm2/cm2) and toxic concentrations (75×10(6) μm2/cm2) of Libby six-mix.

RESULTS

Exposure to 15×10(6) μm2/cm2 Libby six-mix elicited significant (p < 0.05) upregulation of one gene (SOD2; 4-fold) at 8 h and 111 gene changes at 24 h, including a 5-fold increase in SOD2. Increased levels of SOD2 mRNA at 24 h were also confirmed in HKNM-2 normal human pleural mesothelial cells by qRT-PCR. SOD2 protein levels were increased at toxic concentrations (75×10(6) μm2/cm2) of Libby six-mix at 24 h. In addition, levels of copper-zinc superoxide dismutase (Cu/ZnSOD; SOD1) protein were increased at 24 h in all mineral groups. A dose-related increase in SOD2 activity was observed, although total SOD activity remained unchanged. Dichlorodihydrofluorescein diacetate (DCFDA) fluorescence staining and flow cytometry revealed a dose- and time-dependent increase in reactive oxygen species (ROS) production by LP9/TERT-1 cells exposed to Libby six-mix. Both Libby six-mix and crocidolite asbestos at 75×10(6) μm2/cm2 caused transient decreases (p < 0.05) in GSH for up to 24 h and increases in gene expression of heme oxygenase 1 (HO-1) in LP9/TERT-1 and HKNM-2 cells.

CONCLUSIONS

Libby six-mix causes multiple gene expression changes in LP9/TERT-1 human mesothelial cells, as well as increases in SOD2, increased production of oxidants, and transient decreases in intracellular GSH. These events are not observed at equal surface area concentrations of nontoxic glass beads. Results support a mechanistic basis for the importance of SOD2 in proliferation and apoptosis of mesothelial cells and its potential use as a biomarker of early responses to mesotheliomagenic minerals.

Abstract 347: Inhibition of ERK1/2 can sensitize human malignant mesothelioma cells and tumors to doxorubicin

Malignant mesothelioma (MM) has a poor prognosis because of its resistance towards different drugs. Extracellular signal regulated kinase (ERK) family is known to have important roles in tumorigenesis and drug resistance. Here we show that Doxorubicin (Dox) treatment activates ERK1/2 in different MM lines. Activated ERK1/2 play a significant role in cell survival as inhibition of ERK1/2 by U0126 in the presence of Dox results in significantly enhanced cell killing. We show here using small molecule inhibitor and RNA silencing approaches that ERK1/2 inhibition sensitizes human MM cells to Dox treatment. ERK1/2 inhibition by U0126 significantly inhibited certain important drug resistance and proapoptotic genes in human MM cells as measured by PCR Array using human drug resistance and metabolism template. MM cell lines stably transfected with shERK1 or shERK2 exhibited significant increases in the accumulation of Dox and decreases in the cell viability when treated with Dox as compared to shCon line. Microarray analysis performed on stable shERK1 and shERK2 lines showed more than 2 fold inhibitions in selected ATP binding cassette genes, which may be responsible in part for increased Dox accumulation and sensitivity. Finally, subcutaneous injection of stable human MM lines inhibited for ERK1 or ERK2 into SCID mice showed that inhibition of ERK1/2 sensitizes in vivo tumors to Dox. These studies demonstrate a key role of ERK1/2 in MM tumor drug resistance. This work is supported by National Cancer Institute grant P01CA114047 and VCC/LCCRO grant.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 347.

Winter depression recurrence one year after cognitive-behavioral therapy, light therapy, or combination treatment

The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies (N=69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.

Mutagenicity and potential carcinogenicity of thiopurine treatment in patients with inflammatory bowel disease

The thiopurines azathioprine and 6-mercaptopurine (6-MP) are effective immune modulators and cytotoxic agents extensively used in the treatment of autoimmune diseases, graft rejection, and cancer. There is compelling epidemiologic evidence that thiopurine treatment increases the risk for a variety of tumors by mechanisms that are unclear. We investigated the in vivo mutagenicity of long-term thiopurine treatment by determining the frequency and spectra of somatic mutation events at the hypoxanthine phosphoribosyltransferase (HPRT) locus in peripheral T lymphocytes as well as the prevalence of mutant clonal proliferation in a cross-sectional analysis of data from 119 children and adults with inflammatory bowel disease (IBD). ANOVA and regression were performed to assess relationships among the frequency and spectra of HPRT mutations with disease, duration of illness, duration of treatment, and total therapeutic dose of azathioprine and 6-MP. We observed a significant increase in the frequency of somatic mutations in 56 subjects treated with thiopurines for IBD compared with 63 subjects not treated with thiopurines. This increase was related to both total dose (P < 0.001) and duration of treatment (P < 0.001). Comparative mutation spectra analysis of 1,020 mutant isolates revealed a significant increase in the proportion of all transitions (P < 0.001), particularly G:C to A:T transitions (P < 0.001). Combined analyses of two signatures for mutant clonality, HPRT mutation, and T-cell receptor beta CDR3 region unique gene sequence also showed a significant thiopurine-dependent increase in mutant cell clonal proliferation (P < 0.001). These findings provide in vivo evidence for mutation induction as a potential carcinogenic mechanism associated with chronic thiopurine intervention.

Alterations in gene expression in human mesothelial cells correlate with mineral pathogenicity

Human mesothelial cells (LP9/TERT-1) were exposed to low and high (15 and 75 microm(2)/cm(2) dish) equal surface area concentrations of crocidolite asbestos, nonfibrous talc, fine titanium dioxide (TiO2), or glass beads for 8 or 24 hours. RNA was then isolated for Affymetrix microarrays, GeneSifter analysis and QRT-PCR. Gene changes by asbestos were concentration- and time-dependent. At low nontoxic concentrations, asbestos caused significant changes in mRNA expression of 29 genes at 8 hours and of 205 genes at 24 hours, whereas changes in mRNA levels of 236 genes occurred in cells exposed to high concentrations of asbestos for 8 hours. Human primary pleural mesothelial cells also showed the same patterns of increased gene expression by asbestos. Nonfibrous talc at low concentrations in LP9/TERT-1 mesothelial cells caused increased expression of 1 gene Activating Transcription Factor 3 (ATF3) at 8 hours and no changes at 24 hours, whereas expression levels of 30 genes were elevated at 8 hours at high talc concentrations. Fine TiO2 or glass beads caused no changes in gene expression. In human ovarian epithelial (IOSE) cells, asbestos at high concentrations elevated expression of two genes (NR4A2, MIP2) at 8 hours and 16 genes at 24 hours that were distinct from those elevated in mesothelial cells. Since ATF3 was the most highly expressed gene by asbestos, its functional importance in cytokine production by LP9/TERT-1 cells was assessed using siRNA approaches. Results reveal that ATF3 modulates production of inflammatory cytokines (IL-1 beta, IL-13, G-CSF) and growth factors (VEGF and PDGF-BB) in human mesothelial cells.

Comparing screening mammography for early breast cancer detection in Vermont and Norway

BACKGROUND

Most screening mammography in the United States differs from that in countries with formal screening programs by having a shorter screening interval and interpretation by a single reader vs independent double reading. We examined how these differences affect early detection of breast cancer by comparing performance measures and histopathologic outcomes in women undergoing opportunistic screening in Vermont and organized screening in Norway.

METHODS

We evaluated recall, screen detection, and interval cancer rates and prognostic tumor characteristics for women aged 50-69 years who underwent screening mammography in Vermont (n = 45 050) and in Norway (n = 194 430) from 1997 through 2003. Rates were directly adjusted for age by weighting the rates within 5-year age intervals to reflect the age distribution in the combined data and were compared using two-sided Z tests.

RESULTS

The age-adjusted recall rate was 9.8% in Vermont and 2.7% in Norway (P < .001). The age-adjusted screen detection rate per 1000 woman-years after 2 years of follow-up was 2.77 in Vermont and 2.57 in Norway (P = .12), whereas the interval cancer rate per 1000 woman-years was 1.24 and 0.86, respectively (P < .001). Larger proportions of invasive interval cancers in Vermont than in Norway were 15 mm or smaller (55.9% vs 38.2%, P < .001) and had no lymph node involvement (67.5% vs 57%, P = .01). The prognostic characteristics of all invasive cancers (screen-detected and interval cancer) were similar in Vermont and Norway.

CONCLUSION

Screening mammography detected cancer at about the same rate and at the same prognostic stage in Norway and Vermont, with a statistically significantly lower recall rate in Norway. The interval cancer rate was higher in Vermont than in Norway, but tumors that were diagnosed in the Vermont women tended to be at an earlier stage than those diagnosed in the Norwegian women.

Analysis of genetic alterations and clonal proliferation in children treated for acute lymphocytic leukemia

The development of risk-directed treatment protocols over the last 25 years has resulted in an increase in the survival rates of children treated for cancer. As a consequence, there is a growing population of pediatric cancer survivors in which the long-term genotoxic effects of chemotherapy is unknown. We previously reported that children treated for acute lymphocytic leukemia have significantly elevated somatic mutant frequencies at the hypoxanthine-guanine phosphoribosyltransferase (HPRT) gene in their peripheral T cells. To understand the molecular etiology of the increase in mutant frequencies following chemotherapy, we investigated the HPRT mutation spectra and the extent of clonal proliferation in 562 HPRT T cell mutant isolates of 87 blood samples from 47 subjects at diagnosis, during chemotherapy, and postchemotherapy. We observed a significant increase in the proportion of CpG transitions following treatment (13.6-23.3%) compared with healthy controls (4.0%) and a significant decrease in V(D)J-mediated deletions following treatment (0-6.8%) compared with healthy controls (17.0%). There was also a significant change in the class type percentage of V(D)J-mediated HPRT deletions following treatment. In addition, there was a >5-fold increase in T cell receptor gene usage-defined mean clonal proliferation from diagnosis compared with the completion of chemotherapeutic intervention. These data indicate that unique genetic alterations and extensive clonal proliferation are occurring in children following treatment for acute lymphocytic leukemia that may influence long-term risks for multifactorial diseases, including secondary cancers.

Using the European guidelines to evaluate the Norwegian Breast Cancer Screening Program

This is an evaluation of selected process indicators achieved during the first 10 years of performance of the Norwegian Breast Cancer Screening Program (NBCSP). The indicators are compared with the recommended levels given in the European Guidelines. The program invites all female residents aged 50-69 years old to two-view mammography biennially. The attendance rate was 76.2%. The recall rates due to positive mammography were 4.6% and 2.6%, and the detection rates were 6.4 and 4.9 per 1,000 screens, in prevalent and subsequent screens, respectively. Mean tumor size was 14.7 mm for screening detected and 21.2 mm for interval cancers. Axillary lymph node metastases were present in 25.4% and 43.8%, respectively. Detection mode (screening detected or interval cancer) was shown to be an independent predictor for axillary lymph node metastases and high-grade (Grade 3) tumors. The NBCSP meets the recommendations given in the European Guidelines for most of the process indicators evaluated in this study. Based on the results, we anticipate a future mortality reduction from breast cancer in women invited to the NBCSP.

Breast density in relation to risk of ductal carcinoma in situ of the breast in women undergoing screening mammography

OBJECTIVE

To examine the association between breast density and risk of breast ductal carcinoma in situ (DCIS).

METHODS

We assessed breast density in relation to DCIS risk using combined data from statewide mammography registries in NH and VT. The prospective analyses were based on 572 DCIS cases arising in 154,936 women (58,496 premenopausal and 96,440 postmenopausal). Women in the study were followed on average 4.1 years. Breast density was scored by community radiologists using BIRADS categories (fatty, scattered density, heterogeneous density, extreme density).

RESULTS

In premenopausal women, based on 157 cases, the RR for DCIS risk were 0.29 (95% CI: 0.0.04, 2.24) for fatty breasts, 2.06 (95% CI: 1.39, 3.05) for heterogeneous density, and 2.40 (95% CI: 1.47, 3.91) for extreme density, relative to scattered density. In postmenopausal women, based on 369 cases, the RR for DCIS risk were 0.58 (95% CI: 0.37, 0.93) for fatty breasts, 1.41 (95% CI: 1.12, 1.78) for heterogeneous density, and 1.49 (95% CI: 0.93, 2.37) for extreme density, relative to scattered density. The possible interaction between breast density and menopausal status in relation to DCIS risk was not statistically significant.

CONCLUSIONS

We observed an association between breast density and DCIS risk. Although the association seemed stronger in premenopausal women, there was no evidence of an interaction involving breast density and menopausal status.

Induction of V(D)J-mediated recombination of an extrachromosomal substrate following exposure to DNA-damaging agents

V(D)J recombinase normally mediates recombination signal sequence (RSS) directed rearrangements of variable (V), diversity (D), and joining (J) germline gene segments that lead to the generation of diversified T cell receptor or immunoglobulin proteins in lymphoid cells. Of significant clinical importance is that V(D)J-recombinase-mediated rearrangements at immune RSS and nonimmune cryptic RSS (cRSS) have been implicated in the genomic alterations observed in lymphoid malignancies. There is growing evidence that exposure to DNA-damaging agents can increase the frequency of V(D)J-recombinase-mediated rearrangements in vivo in humans. In this study, we investigated the frequency of V(D)J-recombinase-mediated rearrangements of an extrachromosomal V(D)J plasmid substrate following exposure to alkylating agents and ionizing radiation. We observed significant dose- and time-dependent increases in V(D)J recombination frequency (V(D)J RF) following exposure to ethyl methanesulfonate (EMS) and methyl methanesulfonate (MMS) but not a nonreactive analogue, methylsulfone (MeSulf). We also observed a dose-dependent increase in V(D)J RF when cells were exposed to gamma radiation. The induction of V(D)J rearrangements following exposure to DNA-damaging agents was not associated with an increase in the expression of RAG 1/2 mRNA compared to unexposed controls or an increase in expression of the DNA repair Ku70, Ku80 or Artemis proteins of the nonhomologous end joining pathway. These studies demonstrate that genotoxic alkylating agents and ionizing radiation can induce V(D)J rearrangements through a cellular response that appears to be independent of differential expression of proteins involved with V(D)J recombination.

Longitudinal measurement of clinical mammographic breast density to improve estimation of breast cancer risk

BACKGROUND

Whether a change over time in clinically measured mammographic breast density influences breast cancer risk is unknown.

METHODS

From January 1993 to December 2003, data that included American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) breast density categories (1-4 in order of increasing density) were collected prospectively on 301,955 women aged 30 and older who were not using postmenopausal hormone replacement therapy and underwent at least two screening mammography examinations; 2639 of the women were diagnosed with breast cancer within 1 year of the last examination. Women's first and last BI-RADS breast density (average 3.2 years apart) and logistic regression were used to model the odds of having invasive breast cancer or ductal carcinoma in situ diagnosed within 12 months of the last examination by change in BI-RADS category. Rates of breast cancer adjusted for age, mammography registry, and time between screening examinations were estimated from this model. All statistical tests were two-sided.

RESULTS

The rate (breast cancers per 1000 women) of breast cancer was higher if BI-RADS breast density category increased from 1 to 2 (5.6, 95% confidence interval [CI] = 4.7 to 6.9) or 1 to 3 (9.9, 95% CI = 6.4 to 15.5) compared to when it remained at BI-RADS density of 1 (3.0, 95% CI = 2.3 to 3.9; P<.001 for trend). Similar and statistically significant trends between increased or decreased density and increased or decreased risk of breast cancer, respectively, were observed for women whose breast density category was initially 2 or 3 and changed categories. BI-RADS density of 4 on the first examination was associated with a high rate of breast cancer (range 9.1-13.4) that remained high even if breast density decreased.

CONCLUSION

An increase in BI-RADS breast density category within 3 years may be associated with an increase in breast cancer risk and a decrease in density category with a decrease in risk compared to breast cancer risk in women in whom breast density category remains unchanged. Two longitudinal measures of BI-RADS breast density may better predict a woman's risk of breast cancer than a single measure.

Risk factors for breast carcinoma in situ versus invasive breast cancer in a prospective study of pre- and post-menopausal women

Risk factors for breast carcinoma in situ and invasive breast cancer were compared using data from 61,844 women (61% post-menopausal) with no prior breast cancer and at least one screening mammogram between April 1, 1996 and June 30, 2001. The women were followed until a subsequent mammogram before July 1, 2001, or a benign biopsy or breast cancer diagnosis before June 30, 2002. A total of 1,191 breast cancers (300 in situ and 891 invasive) were diagnosed during an average follow-up of 3.1 years. Multivariate Cox regression models were used to estimate the relative risks (RR) of in situ and invasive cancer associated with family history of breast cancer, age at first childbirth or nulliparity, post-menopausal hormone use, body mass index (BMI), and mammographic breast density. Separate analyses were done for pre- and post-menopausal women. BMI was unrelated to risk of in situ cancer regardless of menopausal status, but was associated with an increased risk of invasive cancer in post-menopausal women (RR = 1.9 for BMI > or = 30 vs. BMI < 22, 95% confidence interval 1.4-2.5). Later childbearing and nulliparity were more strongly associated with in situ than invasive cancer in pre-menopausal women. Post-menopausal hormone use was more strongly associated with invasive disease. RR associated with family history and breast density were similar for in situ cancer and invasive cancer. Results indicating that BMI is related to post-menopausal invasive cancers but unrelated to in situ cancers are consistent with the hypothesis that concomitants of obesity activate proliferation.

Prospective breast cancer risk prediction model for women undergoing screening mammography

BACKGROUND

Risk prediction models for breast cancer can be improved by the addition of recently identified risk factors, including breast density and use of hormone therapy. We used prospective risk information to predict a diagnosis of breast cancer in a cohort of 1 million women undergoing screening mammography.

METHODS

There were 2,392,998 eligible screening mammograms from women without previously diagnosed breast cancer who had had a prior mammogram in the preceding 5 years. Within 1 year of the screening mammogram, 11,638 women were diagnosed with breast cancer. Separate logistic regression risk models were constructed for premenopausal and postmenopausal examinations by use of a stringent (P<.0001) criterion for the inclusion of risk factors. Risk models were constructed with 75% of the data and validated with the remaining 25%. Concordance of the predicted with the observed outcomes was assessed by a concordance (c) statistic after logistic regression model fit. All statistical tests were two-sided.

RESULTS

Statistically significant risk factors for breast cancer diagnosis among premenopausal women included age, breast density, family history of breast cancer, and a prior breast procedure. For postmenopausal women, the statistically significant factors included age, breast density, race, ethnicity, family history of breast cancer, a prior breast procedure, body mass index, natural menopause, hormone therapy, and a prior false-positive mammogram. The model may identify high-risk women better than the Gail model, although predictive accuracy was only moderate. The c statistics were 0.631 (95% confidence interval [CI] = 0.618 to 0.644) for premenopausal women and 0.624 (95% CI = 0.619 to 0.630) for postmenopausal women.

CONCLUSION

Breast density is a strong additional risk factor for breast cancer, although it is unknown whether reduction in breast density would reduce risk. Our risk model may be able to identify women at high risk for breast cancer for preventive interventions or more intensive surveillance.

Molecular epidemiological studies in 1,3-butadiene exposed Czech workers: female-male comparisons

Results of a recent molecular epidemiological study of 1,3-butadiene (BD) exposed Czech workers, conducted to compare female to male responses, have confirmed and extended the findings of a previously reported males only study (HEI Research Report 116, 2003). The initial study found that urine concentrations of the metabolites 1,2-dihydroxy-4-(acetyl) butane (M1) and 1-dihydroxy-2-(N-acetylcysteinyl)-3-butene (M2) and blood concentrations of the hemoglobin adducts N-[2-hydroxy-3-butenyl] valine (HB-Val) and N-[2,3,4-trihydroxy-butyl] valine (THB-Val) constitute excellent biomarkers of exposure, both being highly correlated with BD exposure levels, and that GST genotypes modulate at least one metabolic pathway, but that irreversible genotoxic effects such as chromosome aberrations and HPRT gene mutations are neither associated with BD exposure levels nor with worker genotypes (GST [glutathione-S-transferase]-M1, GSTT1, CYP2E1 (5' promoter), CYP2E1 (intron 6), EH [epoxide hydrolase] 113, EH139, ADH [alcohol dehydrogenase]2 and ADH3). The no observed adverse effect level (NOAEL) for chromosome aberrations and HPRT mutations was 1.794 mg/m(3) (0.812 ppm)--the mean exposure level for the highest exposed worker group in this initial study. The second Czech study, reported here, initiated in 2003, included 26 female control workers, 23 female BD exposed workers, 25 male control workers and 30 male BD exposed workers (some repeats from the first study). Multiple external exposure measurements (10 full 8-h shift measures by personal monitoring per worker) over a 4-month period before biological sample collections showed that BD workplace levels were lower than in the first study. Mean 8-h TWA exposure levels were 0.008 mg/m(3) (0.0035 ppm) and 0.397 mg/m(3) (0.180 ppm) for female controls and exposed, respectively, but with individual single 8-h TWA values up to 9.793 mg/m(3) (4.45 ppm) in the exposed group. Mean male 8-h TWA exposure levels were 0.007 mg/m(3) (0.0032 ppm) and 0.808 mg/m(3) (0.370 ppm) for controls and exposed, respectively; however, the individual single 8-h TWA values up to 12.583 mg/m(3) (5.72 ppm) in the exposed group. While the urine metabolite concentrations for both M1 and M2 were elevated in exposed compared to control females, the differences were not significant, possibly due to the relatively low BD exposure levels. For males, with greater BD exposures, the concentrations of both metabolites were significantly elevated in urine from exposed compared to control workers. As in the first study, urine metabolite excretion patterns in both sexes revealed conjugation to be the minor detoxification pathway (yielding the M2 metabolite) but both M1 and M2 concentration values were lower in males in this second study compared to their concentrations in the first, reflecting the lower external exposures of males in this second study compared to the first. Of note, females showed lower concentrations of both M1 and M2 metabolites in the urine per unit of BD exposure than did males while exhibiting the same M1/(M1+M2) ratio, reflecting the same relative utilization of the hydrolytic (producing M1) and the conjugation (producing M2) detoxification pathways as males. Assays for the N,N-(2,3-dihydroxy-1,4-butadyl) valine (pyr-Val) hemoglobin (Hb) adduct, which is specific for the highly genotoxic 1,2,3,4-diepoxybutane (DEB) metabolite of BD, have been conducted on blood samples from all participants in this second Czech study. Any adduct that may have been present was below the limits of quantitation (LOQ) for this assay for all samples, indicating that production of this important BD metabolite in humans is below levels produced in both mice and rats exposed to as little as 1.0 ppm BD by inhalation (J.A. Swenberg, M.G. Bird, R.J. Lewis, Future directions in butadiene risk assessment, Chem. Biol. Int. (2006), this issue). Results of assays for the HB-Val and THB-Val hemoglobin adducts are pending. HPRT mutations, determined by cloning assays, and multiple measures of chromosome level changes (sister-chromatid exchanges [SCE], aberrations determined by conventional methods and FISH) again showed no associations with BD exposures, confirming the findings of the initial study that these irreversible genotoxic changes do not arise in humans occupationally exposed to low levels of BD. Except for lower production of both urine metabolites in females, no female-male differences in response to BD exposures were detected in this study. As in the initial study, there were no significant genotype associations with the irreversible genotoxic endpoints. However, as in the first, differences in the metabolic detoxification of BD as reflected in relative amounts of the M1 and M2 urinary metabolites were associated with genotypes, this time both GST and EH.

The relationship between menstrual cycle phase and anterior cruciate ligament injury: a case-control study of recreational alpine skiers

BACKGROUND

Female athletes suffer a greater incidence of anterior cruciate ligament tears compared with male athletes when participating in common sports; however, very little is known about the factors that explain this disparity.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Female recreational alpine skiers with an anterior cruciate ligament rupture and age-matched control skiers provided a serum sample and self-reported menstrual history data immediately after injury. Both serum concentrations of progesterone and menstrual history were then used to group subjects into either preovulatory or postovulatory phases of the menstrual cycle.

RESULTS

Analysis of serum concentrations of progesterone revealed that alpine skiers in the preovulatory phase of the menstrual cycle were significantly more likely to tear their anterior cruciate ligaments than were skiers in the postovulatory phase (odds ratio, 3.22; 95% confidence interval, 1.09-9.52; P = .027). Analysis of menstrual history data found similar results, but the difference was not statistically significant (odds ratio, 2.38; 95% confidence interval, 0.86-6.54; P = .086).

CONCLUSION

The likelihood of sustaining an anterior cruciate ligament injury does not remain constant during the menstrual cycle; instead, the risk of suffering an anterior cruciate ligament disruption is significantly greater during the preovulatory phase of the menstrual cycle compared with the postovulatory phase.

CLINICAL RELEVANCE

Phase of menstrual cycle may be one of the risk factors that influence knee ligament injury among female alpine skiers. The findings from this study should be considered in subsequent studies designed to identify persons at risk for anterior cruciate ligament injury and to develop intervention strategies.

First-time inversion ankle ligament trauma: the effects of sex, level of competition, and sport on the incidence of injury

BACKGROUND

Inversion ankle trauma is disabling, yet little is known regarding the incidence rate of first-time ankle sprains and how it is influenced by factors including sex, level of competition, and sport.

HYPOTHESIS

The incidence rates of first-time ankle ligament sprains are influenced by sex, level of competition (high school vs college), and type of sports participation (basketball, soccer, lacrosse, and field hockey).

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 1999 and 2003, high school and college athletes were evaluated before participation in their sports. Subjects were included in the study if they had not experienced a prior ankle or lower extremity injury and were then followed during participation in soccer, basketball, lacrosse, or field hockey to document their days of exposure to sport and injuries sustained. The relative risk associated with sex, level of competition, and sport was estimated by Cox regression.

RESULTS

A total of 901 athletes had 50 680 person-days of exposure to sports, and 43 (4.8%) had an inversion injury that produced an ankle ligament sprain. Overall, the injury incidence rate was 0.85 sprains per 1000 person-days of exposure to sport. There were 0.68 and 0.97 ankle sprains per 1000 person-days of exposure to sport for the men and women, respectively. Although the risk of suffering an ankle sprain was higher for women than for men (relative risk, 1.51), the difference was not statistically significant (P = .21) and was owing to the increased risk in female basketball athletes compared to male basketball athletes (relative risk, 4.11; P = .045). Risk of injury was similar for the high school athletes in comparison to the college athletes (relative risk, 1.16). For the men, there was no difference in the risk of suffering an ankle sprain between the sports of basketball, soccer, and lacrosse, whereas for the women, the risk of suffering an ankle sprain was significantly greater during participation in basketball compared to lacrosse.

CONCLUSION

In this study of first-time ankle sprains, for most sports, the incidence rate of inversion injury is less than 1 per 1000 days of exposure to sport, a value lower than previously reported. Among female athletes, ankle injury is associated with type of sport. Risk is highest for female basketball athletes, who are at significantly greater risk than male basketball athletes and female lacrosse athletes. The risk of first-time ankle injury is similar for high school and college-level athletes.

The use of additional imaging increased specificity and decreased sensitivity in screening mammography

BACKGROUND AND OBJECTIVES

To examine the use of additional imaging after standard mammographic screening views to better understand the value of these additional testing in improving accuracy.

MATERIALS AND METHODS

Statewide population data on screening mammography were used to report accuracy measures at screening and after additional imaging tests. Pathology data from biopsies performed within 1 year following the screening mammogram were used to determine cancer outcome (489 in situ and invasive cancers). Pathologic and population characteristics of women receiving different types of imaging were assessed by chi-square or t-tests. Similar tests compared women with the same imaging and differing outcomes.

RESULTS

Of 77,799 women with screening mammograms 9.9% had additional imaging. Additional imaging reduced false positives from 7,765 (100/1,000 mammograms) to 1,112 (14/1,000 mammograms). The majority of false negatives (82%) occurred in women receiving only screening views, and additional imaging increased the number of false negatives from 82 (1/1,000 mammograms) to 115 (1.5/1,000 mammograms).

CONCLUSION

Additional imaging can reduce unnecessary biopsy but at the cost of some additional false negatives. Additional imaging's potential for improving the sensitivity of screening is limited because most missed cancers occur in women who do not have additional imaging.

Predicting Biopsy Outcome After Mammography: What Is the Likelihood the Patient Has Invasive or In Situ Breast Cancer?

BACKGROUND

As many as 1,000,000 breast biopsies are performed annually in the United States. Although substantial effort has been devoted to estimating breast cancer risk, there have been no studies to predict outcome in women undergoing breast biopsy.

METHODS

A population-based study was undertaken to develop and test models for predicting the probability of invasive breast cancer and/or ductal carcinoma-in-situ in 7670 women undergoing breast biopsy after mammography. Logistical prediction models were developed by using data from 6129 randomly selected women and tested with data from the remaining women.

RESULTS

The overall cancer prevalence among women undergoing biopsy was 22.4%. Prevalence in women with mammograms highly suggestive of malignancy (category 5) was 84.6%, with minimal variation in individual cancer probabilities due to age. A total of 24.6% of women with suspicious mammograms (category 4) had cancer, but individual probability estimates ranged from .01 to .86, depending on age, presence of a lump, previous biopsy, menopausal status, and use of postmenopausal hormone therapy. These variables also influenced biopsy outcome in women with other mammography assessments (categories 0-3), but the overall prevalence was lower (8.6%), and estimated probabilities ranged from .01 to .45. When cancer was present, the probability of invasive disease was influenced by mammogram assessment category, absence of mammogram calcifications, and presence of a lump.

CONCLUSIONS

The probabilities of invasive cancer and ductal carcinoma-in-situ in women undergoing biopsy can be more accurately predicted by using clinical characteristics in addition to mammography findings. This information could potentially influence decisions regarding immediate biopsy or continued surveillance.