Age-related phenotypes in breast cancer: A population-based study

Breast cancer in young (<40 years) is associated with a higher frequency of aggressive tumor types and poor prognosis. It remains unclear if there is an underlying age-related biology that contributes to the unfavorable outcome. We aim to investigate the relationship between age and breast cancer biology, with emphasis on proliferation. Clinico-pathologic information, immunohistochemical markers and follow-up data were obtained for all patients aged <50 (Bergen cohort-1; n = 355, not part of a breast screening program) and compared to previously obtained information on patients aged 50 to 69 years (Bergen cohort-2; n = 540), who participated in the Norwegian Breast Cancer Screening Program. Young breast cancer patients presented more aggressive tumor features such as hormone receptor negativity, HER2 positivity, lymph-node metastasis, the HER2-enriched and triple-negative subtypes and shorter survival. Age <40 was significantly associated with higher proliferation (by Ki67). Ki67 showed weaker prognostic value in young patients. We point to aggressive phenotypes and increased tumor cell proliferation in breast cancer of the young. Hence, tumors of young breast cancer patients may present unique biological features, also when accounting for screen/interval differences, that may open for new clinical opportunities, stratifying treatment by age.

Patient-Tailored Levothyroxine Dosage with Pharmacokinetic/Pharmacodynamic Modeling: A Novel Approach After Total Thyroidectomy

Background: After seven decades of levothyroxine (LT4) replacement therapy, dosage adjustment still takes several months. We have developed a decision aid tool (DAT) that models LT4 pharmacometrics and enables patient-tailored dosage. The aim of this was to speed up dosage adjustments for patients after total thyroidectomy. Methods: The DAT computer program was developed with a group of 46 patients post-thyroidectomy, and it was then applied in a prospective randomized multicenter validation trial in 145 unselected patients admitted for total thyroidectomy for goiter, differentiated thyroid cancer, or thyrotoxicosis. The LT4 dosage was adjusted after only two weeks, with or without application of the DAT, which calculated individual free thyroxine (fT4) targets based on four repeated measurements of fT4 and thyrotropin (TSH) levels. The individual TSH target was either <0.1, 0.1-0.5, or 0.5-2.0 mIU/L, depending on the diagnosis. Initial postoperative LT4 dosage was determined according to clinical routine without using algorithms. A simplified DAT with a population-based fT4 target was used for thyrotoxic patients who often went into surgery after prolonged TSH suppression. Subsequent LT4 adjustments were carried out every six weeks until target TSH was achieved. Results: When clinicians were guided by the DAT, 40% of patients with goiter and 59% of patients with cancer satisfied the narrow TSH targets eight weeks after surgery, as compared with only 0% and 19% of the controls, respectively. The TSH was within the normal range in 80% of DAT/goiter patients eight weeks after surgery as compared with 19% of controls. The DAT shortened the average dosage adjustment period by 58 days in the goiter group and 40 days in the cancer group. For thyrotoxic patients, application of the simplified DAT did not improve the dosage adjustment. Conclusions: Application of the DAT in combination with early postoperative TSH and fT4 monitoring offers a fast approach to LT4 dosage after total thyroidectomy for patients with goiter or differentiated thyroid cancer. Estimation of individual TSH-fT4 dynamics was crucial for the model to work, as removal of this feature in the applied model for thyrotoxic patients also removed the benefit of the DAT.

A prospective, blind investigation of immunological reactions in chronic inflammatory bowel disease. Suppressor activity and immune capacity

In a paired, blind and prospective study including 36 patients with chronic inflammatory bowel disease, i.e. ulcerative colitis (UC) and Crohn's disease (CD), and 36 healthy volunteers, the immune capacity has been examined by three different test systems using peripheral blood mononuclear cells: spontaneous mitotic activity (SMA), concanavalin A (con A) activated lymphoblast transformation test (LTT) and autologous mixed lymphocyte reaction (AMLR). The same patients and controls were examined simultaneously for their suppressor activity by a con A induced suppressor activity (CAISA) test. SMA was similar in UC patients and controls. The lymphoblast transformation (LT) in UC patients was significantly reduced with submaximal concentrations of con A (1 and 2 micrograms), whereas AMLR was only non-significantly decreased. However, the results registered by these two test systems revealed a significantly positive correlation. CAISA in UC patients was significantly enhanced, but this finding showed no correlation to the reduced LTT and AMLR, indicating a primary defect in the mitotic capacity independent of the observed increment in CAISA. SMA, con A activated LT, AMLR and CAISA were similar in CD patients and controls.

Inflammatory bowel disease evaluated by low-field magnetic resonance imaging. Comparison with endoscopy, 99mTc-HMPAO leucocyte scintigraphy, conventional radiography and surgery

BACKGROUND

To evaluate the use of low-field magnetic resonance imaging (MRI) in active inflammatory bowel disease (IBD).

METHODS

MRI was executed in a consecutive cohort of 28 patients with Crohn disease (CD) and in 17 with ulcerative colitis (UC) prior to glucocorticoid treatment (1 mg prednisolone orally/kg body weight/day). MRI was repeated after 2-3 weeks (22 CD, 12 UC), and again after treatment completion or prior to surgery (18 CD, 6 UC). Five bowel segments were evaluated separately. MRIs were blindly evaluated by two observers, and findings compared with 39 leucocyte scintigraphies, 38 endoscopies, 15 double-contrast barium enemas, 66 small-bowel radiographic examinations and surgery in 23 patients.

RESULTS

In CD, blinded evaluation revealed a kappa (kappa) of 0.84 (95% confidence interval (CI) 0.78-0.91). In UC, kappa was 0.66 (95% CI 0.55-0.78). Agreements regarding disease extension between MRI and other modalities in CD were found in 345 bowel segments out of 391 (88.2%) at risk, and in UC in 209/235 (88.9%). Colonic disease activity gradings by radiography and endoscopy correlated significantly with T2-signal intensity (SI(T2)) and increments in T1-signal intensity (%SI(T1)) in both diseases. Significant correlations between MRI indices of disease activity and CDAI in CD (MRI-SI(T2): P <0.0001: MRI% SI(T1): P=0.0008) and the Powell-Tuck index in UC (MRI% SI(T1): P=0.008) were found.

CONCLUSIONS

With low interobserver variation and high concordance of findings with other examinations. low-field MRI seems a valuable modality in active IBD. In addition, MRI expressions of disease activity correlate to clinical, radiographic and endoscopic disease activity.

An open-labeled, randomized study comparing systemic interferon-alpha-2A and prednisolone enemas in the treatment of left-sided ulcerative colitis

OBJECTIVE

The aim of this study was to compare the treatment efficacies of subcutaneous interferon-alpha-2A (IFN-alpha-2A) injections versus prednisolone enemas in active left-sided ulcerative colitis in an open-labeled, randomized study.

METHODS

Sixteen ulcerative colitis patients received IFN-alpha-2A subcutaneously (dosage: first wk, 9 MIU three times weekly [t.i.w.]; second wk, 6 MIU t.i.w.; wk 3-12, 3 MIU t.i.w.), and 16 received prednisolone enemas for 30 days (100 ml once daily, 0.25 mg of prednisolone/ml). The Powell-Tuck Index, Inflammatory Bowel Disease Questionnaire (IBDQ) score, and rectal histological activities were assessed before and after treatment. Thirteen patients in the IFN-alpha-2A group and all 16 in the prednisolone enema group completed the treatment.

RESULTS

IFN-alpha-2A treatment showed significant improvements in the Powell-Tuck Index (p = 0.0002), IBDQ score (p = 0.002), and rectal histological activity scores (p = 0.02). In the enema group, significant improvements were found in the Powell-Tuck Index (p = 0.0009), whereas no significant improvements were detected in the IBDQ scores (p = 0.055) or rectal histological scores (p = 0.052). There were no differences between scores of the two groups either before or after treatment. Only moderate side effects from the IFN-alpha-2A treatment were seen during the first 2-4 wk of treatment.

CONCLUSION

IFN-alpha-2A treatment resulted in significant depression of the disease activity as reflected by the Powell-Tuck Index, IBDQ score, and histological disease activity scoring. The preliminary trial thus suggests that IFN-alpha-2A may be effective in the treatment of active left-sided ulcerative colitis. Larger, randomized trials are, however, warranted to confirm this finding, owing to possible type II errors in group comparisons.

Ethical aspects of clinical trials: the attitudes of participants in two non-cancer trials

OBJECTIVES

To investigate attitudes to clinical trials in non-cancer trial participants.

DESIGN

Questionnaires at entry, during, and after participation in a clinical study.

SETTING

Participants in: (i) ROC: a clinical study comparing systemic interferon-alpha-2A treatment vs. prednisolone enemas in ulcerative colitis; and (ii) MRCRUC: a clinical study investigating low-field magnetic resonance imaging as a new modality for the evaluation of patients with inflammatory bowel disease.

SUBJECTS

Thirty-two patients in ROC and 47 patients in MRCRUC.

OUTCOME MEASURES

Attitudes towards different aspects of clinical research.

RESULTS

The majority found scientific testing of clinical methods necessary, having positive attitudes towards both participation by themselves and others. The creation of a personal moral problem by denying participation was rejected by a large majority, and still both personal and altruistic motives for participation were highly rated. An important motive for accepting inclusion was the expectation of being 'a special patient' during the trial. The presence of research ethics committees controlling clinical research had a significant positive impact on decisions to participate, and drawing lots and blinding were found problematic by only a minority. Patients valued their satisfaction with participation in the trials highly, and would almost all accept a request to participate in future trials. The most important reason for this was a feeling of receiving better care and information than expected outside a trial setting, primarily determined by the patients seeing only one physician during the trials. A pronounced wish to obtain follow-up information was expressed.

CONCLUSION

Attitudes towards medical research are positive with both altruistic and nonaltruistic motives for participation. Expectations of being treated as 'a special patient' in the trial were important in accepting to participate. Seeing the same physician at control visits was an important factor for satisfaction with participation.

Magnetic resonance imaging of Crohn disease: early recognition of treatment response and relapse

A patient with active Crohn disease was evaluated by MRI at admission, clinical remission, and a new relapse. The MRI-estimated disease extension correlated with surgical findings, whereas ultrasonography underestimated and a small bowel series overestimated the extension. MRI disclosed the disappearance of intestinal edema at the time of clinical remission and, in contrast to ultrasonography, showed an abscess and a fistula, confirmed by surgery, at the new relapse.

Tolerability of interferon alpha-2b, a possible new treatment of active Crohn's disease

BACKGROUND AND AIMS

Due to the need for new principles for the treatment of Crohn's disease and due to the documented immunomodulatory effects of interferon alpha, the tolerability and effect(s) of interferon alpha-2b (Introna) in active Crohn's disease were examined in a pilot study.

METHODS

Five patients with active Crohn's disease (activity index (CDAI) scores of 235-517), were treated with interferon alpha-2b for 12 weeks.

RESULTS

All patients tolerated the treatment, but developed influenza-like symptoms, which were fully controlled by paracetamol. Two patients obtained partial remission with a decline in activity index scores of 39% and 50%. The activity of 2',5'-oligoadenylate synthetase, which together with two other interferon-induced proteins, neopterin and beta 2-microglobulin were increased during treatment, indicated clearly an in vivo uptake of interferon. Sedimentation rate, C-reactive protein, orosomucoid, albumin, specific inflammatory markers: soluble interleukin-2 alpha-receptors (sIL-2R) and intercellular adhesion molecule-1 (ICAM-1) did not show any changes before or after treatment.

CONCLUSION

Future multicentre investigations are required to evaluate the clinical effect of interferon alpha-2b treatment in active Crohn's disease.

The effect of metoprolol upon blood pressure, cerebral blood flow and oxygen consumption in patients subjected to craniotomy for cerebral tumours

Hypertension and cerebral hyperperfusion are often seen in the immediate postoperative period after craniotomy for supratentorial tumours. Metoprolol is known to attenuate the postoperative hypertensive response after hypotensive anaesthesia and this study was carried out to evaluate the effect of metoprolol on cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) before extubation and cerebral arteriovenous oxygen content difference (AVDO2), mean arterial blood pressure (MABP), PaO2 and PaCO2 in a 180-min period after extubation. Twenty patients anaesthetized with thiopentone, fentanyl, nitrous oxide 67%, and halothane 0.5% were randomized to receive intravenous metoprolol or placebo at the end of the peroperative period. There were no significant differences in CBF- and CMRO2 values between the two groups. In the period between closure of the dura and 5 min after extubation, an increase in MABP was observed in the control group (P < 0.05), but not in the metoprolol group. During the same period a decrease in AVDO2 was observed in both groups (P < 0.05); during the next 10 min an increase was observed, but with no difference in AVDO2 values between the groups. A higher level of PaO2 in the metoprolol group was observed in the postoperative period. These findings suggest that peroperative treatment with metoprolol reduces postoperative MABP but does not influence the cerebral blood flow and metabolism.

Thromboembolism in patients with advanced mitral valve prolapse

Thromboembolism in mitral valve prolapse (MVP) has been suggested to occur in relation to valvular cul-de-sac recesses and endothelial wear-and-tear denudations. Such pathology would be suspected to be prominent in advanced cases of MVP necessitating open-heart operation. We therefore analysed the prevalence of perivalvular thrombi and episodes of systemic arterial embolism (SE) prior to operation in 21 consecutive patients with MVP and severe valve regurgitation. No perivalvular or left atrial thrombi were found during open-heart surgery, but three of the patients (14%, 3-36% with 95% confidence limits) experienced SE, in one case despite long-term anticoagulation. All cases of SE took place less than 3 months before operation. The results indicate that persistent thrombi are rare in MVP and severe valve regurgitation. However, such patients run a substantial risk of SE when they reach a clinical and haemodynamic stage that makes valve surgery mandatory.

Lymphocyte subpopulations, lymphoblast transformation activity, and concanavalin A-induced suppressor activity in patients with ulcerative colitis and Crohn's disease

The following immunologic in vitro tests were applied on peripheral blood mononuclear cells (PBMC) from patients with chronic inflammatory bowel disease (IBD): concanavalin A (Con A)-induced suppressor test, Con A-activated lymphoblast transformation test, and spontaneous lymphoblast transformation test. Concomitant phenotypic characterization of subsets of PBMC was performed with monoclonal antibodies. Patients with ulcerative colitis and a control group with rheumatoid arthritis showed significantly reduced activity in the Con A-activated lymphoblast transformation test compared with healthy controls and patients with Crohn's disease. The distribution of PBMC subsets and the results of the other in vitro tests were similar for patients with IBD and healthy controls. Thus the decrease in Con A-activated lymphoblast activity was not due to an increased suppressor function as measured either by functional Con A-induced suppressor test or indirectly by T8 phenotype.

Concanavalin A induction of suppressor activity in the T-helper subset defined by monoclonal antibodies

Human monocyte-depleted peripheral blood mononuclear cells were separated in T4+ and T8+ populations by a panning technique. Petri dishes coated with goat anti-mouse antibodies were plated by peripheral blood mononuclear cells coated by monoclonal antibodies, either T4 or T8. The cell populations were separated into adherent and non-adherent populations based on binding to the goat anti-mouse-coated plastic dishes. The purity of the adherent populations was 96%. T4+ and T8+ populations were used as effector cells in the concanavalin A-induced suppressor test. The T4+ population revealed a pronounced suppressor activity similar to that exhibited by the T8+ population. This finding was independent of two different sources of monoclonal antibodies, T4/T8 and OKT4/OKT8. The registered suppressor activity in the monoclonal antibody-defined helper population could not be explained either by a switch of the membrane phenotype from T4+ to T8+ cells or by an increased interleukin 2 consumption of the concanavalin A-treated cells.

Monocyte/T-cell interactions in Con A induced suppressor activity

It is well documented that peripheral blood mononuclear cells (PBMC) can exert a Con A induced suppressor activity. The PBMC content of monocytes and its impact on registered suppressor activity of PBMC populations was examined. It was found that monocytes were unnecessary for the Con A induction of PBMC, and monocytes exhibited no Con A dependent suppressor potential. Furthermore, the presence of monocytes was found to be unnecessary for the Con A activated lymphocytes in order to exert their suppressor activity against the responder system, i.e. a Con A stimulated lymphoblast-transformation.

A continued evaluation of the experimental conditions of a Con A-induced suppressor test system

As shown previously, the suppressor activity measured by the Con A mixed lymphocyte culture assay exhibited a pronounced dependence on the technical parameters. In the present study it is shown that the length of the suppressor generation period, between 24 and 96 hours, had only a modest influence on the suppressor activity. However, when the activity in the responder system was high, there seemed to be a trend towards a slight increase of the suppressor level using a long generation period, i.e. 72 to 96 hours. An increase of the suppressor cell/responder cell ratio from 1/10 to 1/2 was followed by a rising suppressor level; a further increase of the ratio had no significant influence on the suppressor activity. A decrease of the ratio below 1/10 showed variable results: stimulation, no effect and suppressor activity. This variability might be due to technical reasons. DNA-synthesis was not necessary for the mechanisms involved in the Con A-elicited suppressor activity. No suppressor activity was obtained by Con A treatment of cells other than peripheral blood mononuclear cells, viz. autologous erythrocytes, allogeneic fibroblasts and allogeneic osteogenic sarcoma cells.

Con A induced suppressor test: an evaluation of the experimental conditions

The suppressor activity measured by the Con A mixed lymphocyte culture assay exhibited a pronounced dependence on the technical performance as well as a marked inter-individual variation. The activity exerted by the induced suppressor cells depended on the Con A concentration in the induction phase, and on the mitotic activity in the responder system. The patterns of suppressor activities obtained in an allogeneic and an autologous suppressor test system were identical. When calculating the suppressor activity it is suggested, that one uses the total activities of the test system, without any reduction corresponding to the activity of the mixed lymphocyte culture. It is suggested that the suppressor activity is expressed by a "suppressor profile" to make the results more applicable and the interpretation of different works meaningful.