A Prospective Study Assessing the Efficacy and Toxicity of Stereotactic Body Radiation Therapy for Oligometastatic Bone Metastases

PURPOSE/OBJECTIVE(S)

Stereotactic body radiation therapy (SBRT) is a promising treatment for oligometastatic disease in bone due to its delivery of high dose to target tissue and minimal dose to surrounding tissue. The purpose of this study is to assess efficacy and toxicity of this treatment in patients with previously unirradiated oligometastatic bony disease.

MATERIALS/METHODS

In this prospective phase II trial, patients with oligometastatic bone disease, defined as ≤3 active sites of disease, were treated with SBRT at one of two academic institutions between December 2016 and May 2019. Local progression-free survival (LPFS), progression-free survival (PFS), prostatic specific antigen (PSA) progression, and overall survival (OS) were reported. Treatment-related toxicity was also reported.

RESULTS

A total of 98 patients and 131 lesions arising from various tumor histologies were included in this study. The median age of patients enrolled in the study was 72.8 years (80.6% male, 19.4% female). Median follow-up was 26.7 months. The most common histology was prostate cancer (68.4%, 67/98). The most common dose prescriptions were 27/30 Gy in 3 fractions (26.0%, 34/131), 30 Gy in 5 fractions (19.1%, 25/131), or 30/35 Gy in 5 fractions (16.0%, 21/131). Multiple doses per treatment regimen reflect dose painting employing the lower dose to the clinical target volume (CTV) and higher dose to the gross tumor volume (GTV). Four patients (4.1%, 4/98) experienced local progression at one site for each patient (3.1%, 4/131). Among patients who progressed locally, the median time to local recurrence was 25.8 months (31.0 months among prostate cancer patients, N = 2, and 14.5 months among non-prostate cancer patients, N = 2). Among the entire cohort, 2-year LPFS (including death without local progression) was 85.0%, 2-year PFS (including deaths as well as local, distant, and PSA-based progression) was 47.0%, and 2-year OS was 87.5%. Twenty-seven patients (27.6%, 27/98) developed treatment-related toxicities, and most were Grade 1 (19.4%, 19/98) and 2 (4.1%, 4/98). Four patients (4.1%, 4/98) developed Grade 3 toxicities; there were no Grade 4 toxicities. The most common toxicity was fatigue (10.2%, 10/98). Of 68 treated spine metastases, there were four (5.9%, 4/68) vertebral fractures. Among these four patients, median time to fracture was 23.5 months (range 14.2-39.2 months).

CONCLUSION

Our study supports existing literature in showing that SBRT is effective and tolerable in patients with oligometastatic bone disease. Larger phase III trials are necessary and reasonable to determine long-term efficacy and toxicities.

Registry Study of the Working Group on Cervical Pathology and Colposcopy (AGCPC) on the Diagnostic Algorithm for the New Cervical Cancer Screening - Initial Data

Introduction

For the first time since 1971, new regulations were introduced for cervical cancer screening as an organized cancer screening guideline (oKFE-RL) starting 1 January 2020. From the age of 20, a cytological smear test is performed annually, and from the age of 35, so-called co-testing (cytology and test for high-risk HPVs) is performed every three years. In case of abnormalities, the algorithm is used as the basis for investigation. According to this diagnostic algorithm, even so-called low-risk groups receive early colposcopic evaluation. This approach has been heavily debated and serves as the basis for this registry study.

Methods

All patients who presented to the centers for a colposcopy as part of the diagnostic algorithm were included after signing an informed consent form. The following findings were obtained: Medical history, colposcopy, histology, and cytology findings, as well as possible therapies and their findings. The aim was to evaluate the frequency of the target lesions cervical intraepithelial neoplasia (CIN) 2+/CIN 3+ in the respective groups.

Result

A total of 4763 patients were enrolled in the study from July 2020 to October 2022. As a referral diagnosis, HPV persistence (HPV: human papillomavirus) with group I was determined in 23.9% (1139), HPV persistence with group II-a in 2.1% (100), II-p (ASC-US) in 11.2% (535), and II-g (AGC endocervical NOS) in 1.3% (64). III-p (ASC-H) and III-g (AGC endocervical favor neoplastic) were found in 9.4% (447) and 2.2% (107), respectively, IIID1 (LSIL) in 19% (906), IIID2 (HSIL, moderate dysplasia) in 18.9% (898), IVa-p (HSIL, severe dysplasia) in 10.7% (508), IVa-g (AIS) in 0.7% (31), IVb-p (HSIL with features suspicious for invasion) and IVb-g (AIS with features suspicious for invasion) in 0.3% (15), 0.1% (6), and 7 with suspected invasion V-p (squamous cell carcinoma)/V-g (endocervical adenocarcinoma) (0.1%). In the IVa-p group (HSIL, severe dysplasia), 67.7% had CIN 2+ and 56.5% had CIN 3+, adenocarcinoma in situ (AIS), and adenocarcinoma. If the histology of the excised tissue specifically based on the colposcope findings was also evaluated, CIN 2+ was found in 79.7% of cases, and CIN 3+ in 67.3% of cases. In IIID2 (HSIL, moderate dysplasia), CIN 2+ was detected in 50.9%, and CIN 3+/AIS in 28.3%. After evaluating patients who underwent surgery immediately, this increased to 53.0% for CIN 2+ and 29.3% for CIN 3+/AIS. In IIID1 (LSIL), CIN 2+ was detected in 27.4% and CIN 3+/AIS in 11.7%, and in II-p (ASC-US), CIN 2+ was detected in 23.4% and CIN 3+ and AIS in 10.8%, and in II-g (AGC endocervical NOS), CIN 2+ was detected in 34.4% and CIN 3+ in 23.4%. In the HPV persistence/II-a and I group, 21% showed CIN 2+, and 12.1% showed CIN 3+ and AIS, and 13% showed CIN 2+ and 5.9% showed CIN 3+ and AIS. In patients who were HPV-negative and had further diagnostics performed on the basis of cytologic smear alone, 27.9% had CIN 2+, and 14.1% had CIN 3 and AIS.

Discussion

In a synopsis of the present findings of our initial data of the registry study on the new cervical cancer screening, according to the organized early cancer screening guideline (oKFE-RL), we could show that the target lesion CIN 3+ and AIS is detected unexpectedly frequently in a not insignificant proportion, especially in the cytological low-risk group. Currently, we cannot answer whether this can reduce the incidence and mortality of cervical carcinoma, but this could be an initial indication of this and will be reviewed in further long-term evaluations.

The Map of Need: identifying and predicting the spatial distribution of financial hardship in Scotland's veteran community

INTRODUCTION

During military service, many household costs for both married and single service personnel are subsidised, and transition can leave veterans unprepared for the financial demands of civilian life. Armed Forces organisations such as Sailor, Soldier, Air Force Association (SSAFA) play a central role in understanding the financial challenges that UK veterans face and provide an insight into the financial hardship experienced by veterans. The aim of this study was to use SSAFA beneficiary data as a proxy to identify the nature of financial benefit, the spatial distribution of financial hardship in the Scottish SSAFA beneficiary community and explore factors that might predict where those recipients are located.

METHODS

Using an anonymised data set of Scottish SSAFA financial beneficiaries between 2014 and 2019, this study used a geographical methodology to identify the geospatial distribution of SSAFA benefit recipients and exploratory regression analysis to explore factors to explain where SSAFA beneficiaries are located.

RESULTS

Over half of benefit applicants (n=10 735) were concentrated in only 50 postcode districts, showing evidence of a clustered pattern, and modelling demonstrates association with area-level deprivation. The findings highlight strong association between older injured veterans and need for SSAFA beneficiary assistance.

CONCLUSION

The findings demonstrate that beneficiaries were statistically clustered into areas of high deprivation, experiencing similar challenges to that of the wider population in these areas. Military service injury or disability was strongly associated with areas of high SSAFA benefit use and in those areas high unemployment was also a significant factor to consider.

Evaluating the efficacy of Atriplex spp. in the phytoextraction of road salt (NaCl) from contaminated soil

Soil and freshwater salinization are growing issues worldwide. Road salt, primarily sodium chloride (NaCl), is a significant contributor to this issue in North America. In this study, the ability of three native Canadian halophytes (Atriplex patula, Atriplex hortensis, and Atriplex canescans) to remove Na⁺ and Cl^- from contaminated soil was investigated. Field and greenhouse studies determined plant survivability in roadside areas, as well as Na⁺ and Cl^- extraction levels. The Atriplex spp. accumulated 18-55 mg Na⁺ g^-1 dry weight (DW) and 41-64 mg Cl^- g^-1 DW when grown for a two-month period in soil spiked with NaCl to simulate a very highly contaminated roadside. Using A. patula, it would theoretically take 6 growing seasons to remove all salt from an area contaminated with 1540 μg Cl^- g^-1, while A. hortensis and A. canescens would take 19 and 9 years, respectively. Salt content in shoot components (seeds, stem, leaves) was determined to provide further insight on phytoextraction processes. In all three Atriplex species, the leaves had the highest Cl^- concentration, followed by the seeds (bracteoles included), with the lowest concentrations found in the stem. These novel findings provide important information for road salt remediation and indicate that using Atriplex spp. may be a viable way in which to reduce the environmental impact of road salting.

0007 Daytime Sleep in Night Shift Workers: Quantifying the Role of Circadian Misalignment

Introduction

Circadian misalignment is commonly cited as a culprit of daytime sleep disturbances in night shift workers; however, the specific impact and magnitude that circadian misalignment has on daytime sleep has not been well-characterized in larger samples of night shift workers.

Methods

Participants included fixed-night shift workers (n=52, ages 18–50) who completed an 8-hour daytime polysomnography (PSG) in the lab following a night shift. Measures of sleep disturbances included: difficulty falling asleep (sleep onset latency [SOL], latency to persistent sleep [LPS]), difficulty staying asleep (sleep efficiency [SE], wake after sleep onset [WASO]), and sleep duration (total sleep time [TST]). Melatonin samples were collected hourly for 24 hours under dim light (<10 lux) and used to determine dim light melatonin offset (DLMOff). Circadian misalignment (CM) was calculated as the time difference between bedtime and DLMOff (higher values represented sleeping after DLMOff), and correlated with PSG sleep variables.

Results

CM was significantly associated with difficulty staying asleep (WASO: r=0.48, p<0.001; SE: r=-0.45, p<0.001), and sleep duration (TST: r=-0.38, p<0.01). Specifically, every 3 hours of CM on average added 19.2 minutes of WASO and reduced TST by 15 minutes. In contrast, CM was not significantly correlated with sleep onset difficulties (SOL: r=-0.27; LPS: r=-0.02).

Conclusion

These data suggest that circadian misalignment in shift workers may be a better predictor of difficulties staying asleep and sleep duration during the day relative to difficulties falling asleep. Because longer work hours (10–12 hours) are common in night shift worker, it may be that sleep initiation difficulties associated with circadian misalignment is masked by elevated fatigue or an increased homeostatic drive from prolonged wakefulness. These results may help guide decisions about the magnitude of phase shifts required (e.g., with light therapy) for the desired improvement in daytime sleep.

Support

Support for this study was provided to PC by the NHLBI (K23HL138166)

Gut microbiota of the European Brown Hare (Lepus europaeus)

Diseases of the gastrointestinal tract due to changes in the bacterial flora have been described with increasing incidence in the European brown hare. Despite extensive demographic and phylogeographic research, little is known about the composition of its gut microbiota and how it might vary based on potential environmental or host factors. We analysed the intestinal and faecal microbiota of 3 hare populations by Illumina MiSeq 16S rRNA gene amplicon sequencing. The phyla and OTU abundance composition differed significantly between intestinal and faecal samples (PERMANOVA: P = 0.002 and P = 0.031, respectively), but in both sample types Firmicutes and Bacteroidetes dominated the microbial community composition (45.51% and 19.30% relative abundance). Intestinal samples contained an enrichment of Proteobacteria compared with faecal samples (15.71-fold change, P < 0.001). At OTU level, a significant enrichment with best BLAST hits to the Escherichia-Shigella group, Eubacterium limosum, Sphingomonas kyeonggiensis, Flintibacter butyricus and Blautia faecis were detected in intestinal samples (P < 0.05). In our statistical model, geographic location and possibly associated environmental factors had a greater impact on the microbiota composition than host factors. Population had a significant effect on the composition of abundant intestinal and faecal OTUs, and on the abundance of potential pathogenic bacteria of the family Enterobacteriaceae, regularly associated with intestinal dysbiosis in hares, in faecal samples. Our study is the first to describe the microbiota in brown hares and provides a foundation to generate hypothesis aiming to test the role of gut health in population fluctuations of the species.

Epimural bacterial community structure in the rumen of Holstein cows with different responses to a long-term subacute ruminal acidosis diet challenge

Subacute ruminal acidosis (SARA) is a prevalent metabolic disorder in cattle, characterized by intermittent drops in ruminal pH. This study investigated the effect of a gradual adaptation and continuously induced long-term SARA challenge diet on the epimural bacterial community structure in the rumen of cows. Eight rumen-cannulated nonlactating Holstein cows were transitioned over 1 wk from a forage-based baseline feeding diet (grass silage-hay mix) to a SARA challenge diet, which they were fed for 4 wk. The SARA challenge diet consisted of 60% concentrates (dry matter basis) and 40% grass silage-hay mix. Rumen papillae biopsies were taken at the baseline, on the last day of the 1-wk adaptation, and on the last day of the 4-wk SARA challenge period; ruminal pH was measured using wireless sensors. We isolated DNA from papillae samples for 16S rRNA gene amplicon sequencing using Illumina MiSeq. Sequencing results of most abundant key phylotypes were confirmed by quantitative PCR. Although they were fed similar amounts of concentrate, cows responded differently in terms of ruminal pH during the SARA feeding challenge. Cows were therefore classified as responders (n = 4) and nonresponders (n = 4): only responders met the SARA criterion of a ruminal pH drop below 5.8 for longer than 330 min/d. Data showed that Proteobacteria, Firmicutes, and Bacteroidetes were the most abundant phyla, and at genus level, Campylobacter and Kingella showed highest relative abundance, at 15.5 and 7.8%, respectively. Diversity analyses revealed a significant increase of diversity after the 1-wk adaptation but a decrease of diversity and species richness after the 4-wk SARA feeding challenge, although without distinction between responders and nonresponders. At the level of the operational taxonomic unit, we detected diet-specific shifts in epimural community structure, but in the overall epimural bacterial community structure, we found no differences between responders and nonresponders. Correlation analysis revealed significant associations between grain intake and operational taxonomic unit abundance. The study revealed major shifts in the 3 dominating phyla and, most importantly, a loss of diversity in the epimural bacterial communities during a long-term SARA diet challenge, in which 60% concentrate supply for 4 wk was instrumental rather than the magnitude of the drop of ruminal pH below 5.8.

Ovarian function after hematopoietic cell transplantation: a descriptive study following the use of GnRH agonists for myeloablative conditioning and observation only for reduced-intensity conditioning

Gonadal failure is a health and quality-of-life concern in hematopoietic cell transplant (HCT) survivors. While ovarian dysfunction is nearly universal following myeloablative (MA) conditioning, the risk is unclear after reduced-intensity conditioning (RIC). Gonadotropin-releasing hormone agonists decrease ovarian failure rates following conventional chemotherapy, but little is known about its effectiveness with HCT. We investigated the impact of leuprolide on ovarian function after MA conditioning and monitored ovarian function after RIC in this descriptive pilot study. Post-menarchal females <50 years undergoing HCT with adequate baseline ovarian function (follicle-stimulating hormone (FSH) level <40 mIU/mL and normal menstruation) were eligible. Prior to MA conditioning, leuprolide was administered. Those undergoing RIC were observed. FSH was measured at various time points. Seventeen women aged 12-45 years were evaluated (7 in the intervention group and 10 in the observation group). Compared to the historical high rate of ovarian failure after MA conditioning, 3 of 7 evaluable Lupron recipients had ovarian failure at a median of 703 days post transplant. Ovarian failure occurred in 1 of 10 recipients of RIC at a median follow-up of 901 days. In conclusion, leuprolide may protect ovarian function after MA conditioning. Additionally, RIC with cyclophosphamide, fludarabine and low-dose TBI has a low risk of ovarian failure.

High diversity of viable bacteria isolated from lymph nodes of slaughter pigs and its possible impacts for food safety

AIMS

Ileocaecal lymph nodes (ICLNs) of pigs, the key immune inductive site for bacterial systemic invasion, were examined in this study with emphasis on viable and cultivable bacteria.

METHODS AND RESULTS

Asymptomatic and pathologically altered ICLNs of slaughter pigs (n = 16) with hyperplasia, purulence or granulomatous formations were aerobically and anaerobically cultivated. In total, 209 isolates were collected and the near full-length 16S rRNA gene from each isolate was sequenced. Taxonomic classification revealed that 68% of the isolates belonged to Proteobacteria, 27% to Firmicutes and 5% to Actinobacteria. Purulent and granulomatous ICLNs generally tended to contain more Proteobacteria than asymptomatic and enlarged ICLNs (P = 0·061). The isolates could be assigned to 25 species belonging to 17 genera including Escherichia, Carnobacterium, Lactobacillus, Staphylococcus and Acinetobacter. Furthermore, pathogens such as Streptococcus suis and Salmonella enterica were detected. The most abundant isolate (57%) was most similar (>99%) to Escherichia coli. Random amplified polymorphic DNA (RAPD) profiling revealed a high genetic diversity among E. coli isolates and 24% of these isolates were positive for at least one gene associated with enterohemorrhagic disease (eae, fliC, stx1 or hlyA). Compared with a recently published DNA-based high-throughput sequencing data set including the same ICLNs, 4% of species detected were cultivable.

CONCLUSIONS

The presence of viable, commensal and pathogenic bacterial phylotypes could be proven in ICLNs with Proteobacteria being dominant.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study that broadly characterizes viable bacteria from ICLNs of pigs. The presence of bacteria in lymph nodes of farm animals has practical relevance for host colonization and possible chronic infection. It is also of great interest for basic research investigating translocation of bacteria from the gastrointestinal tract to ICLNs.

Pyrosequencing reveals shifts in the bacterial epimural community relative to dietary concentrate amount in goats

Ecological balance in the rumen is highly sensitive to concentrate-rich diets. Yet the effects of these feeding practices on the caprine bacterial epimural microbiome (CBEM), a microbial community with putative important physiological functions in the rumen, are largely unexplored. This study aimed to investigate the effect of dietary concentrate amount on ruminal CBEM. Seventeen growing goats were fed diets with 0 [n=5; 6.2MJ of metabolizable energy (ME)/d], 30 (n=6; 7.3MJ of /d), or 60% (n=6; 10.2MJ of ME/d) concentrate for 6 wk. Two hours after their last feeding, goats were euthanized and tissue samples of the ventral rumen wall were collected, washed in phosphate-buffered saline to detach loosely attached bacteria, and stored at -20°C for further processing. Genomic DNA was isolated from thawed rumen mucosa samples and used for Roche/454 Life Science (Branford, CT) 16S rRNA gene amplicon pyrosequencing yielding 122,458 reads. Pyrosequencing data were clustered into 1,879 operational taxonomic units (OTU; 0.03 distance level). Pyrosequencing revealed Proteobacteria, Bacteroidetes, Firmicutes, and Spirochaetes as the most abundant phyla (97.7%). Compared with the 30% group, both the 60 and 0% concentrate groups harbored significantly more Firmicutes and SR1, respectively. On an OTU level, a Bergeriella-related OTU was most abundant in the CBEM, followed by 2 Campylobacter OTU, which responded differently to diets: 1 OTU was significantly increased whereas the other significantly decreased with highest concentrate amount in the diet. At the genus level, the 0% concentrate group harbored increased Kingella-like sequences compared with the other feeding groups. Furthermore, the 0% concentrate group tended to have more Bergeriella than the 30 and 60% concentrate groups. The genus Bergeriella was significantly decreased in the 60% feeding group compared with the other diets. In conclusion, this is the first report of CBEM using deep-sequencing methods on the genus and OTU level, and our study revealed major shifts in the CBEM in response to concentrate-rich diets with potential health relevance in goats.

Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review

Elective surgery is usually preceded by preoperative diagnostics to minimize risk. The results are assumed to elicit preventive measures or even cancellation of surgery. Moreover, physicians perform preoperative tests as a baseline to detect subsequent changes. This systematic review aims to explore whether preoperative testing leads to changes in management or reduces perioperative mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery. We systematically searched all relevant databases from January 2001 to February 2011 for studies investigating the relationship between preoperative diagnostics and perioperative outcome. Our methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the Scottish Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic reviews. One hundred and one of the 25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled design and 98 studies used an observational design. The test grid studies show that in cataract surgery and ambulatory surgery, there are no significant differences between patients with indicated preoperative testing and no testing regarding perioperative outcome. The observational studies do not provide valid evidence that preoperative testing is beneficial in healthy adults undergoing non-cardiac surgery. There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults undergoing non-cardiac surgery. Testing according to pathological findings in a patient's medical history or physical examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized controlled trials, are needed to explore the effectiveness of indicated preoperative testing.

Clinicopathological differences between breast cancer in patients with primary metastatic disease and those without: a multicentre study

OBJECTIVE

Approximately 6% of breast cancer (BC) patients present with primary metastatic disease (pmBC) at first diagnosis. The clinicopathological differences between tumours from patients who have metastatic disease and those who do not are unclear.

METHODS

This study was an exploratory analysis of patients with pmBC treated in 8 German breast cancer centres between 1998 and 2010. Phenotypes were defined using the following immunohistochemical markers: oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (Her2). The control arm included the group of patients who had neither local recurrence nor distant metastases at a follow-up of at least 30 months after initial diagnosis.

RESULTS

A total of 2214 patients were included. Of these, 1642 had non metastatic BC, and 572 had pmBC. Eighty-five patients (15%) with pmBC were diagnosed at stage T1. On multivariate analysis, factors associated with pmBC were as follows: positive lymph node status, grade 3, lobular histology and Luminal B phenotype (Her 2 positive). Of the sample, 197 patients (34%) with pmBC were diagnosed as stage T2, 90 patients (16%) were diagnosed as stage T3, and 200 patients (35%) were diagnosed as stage T4. Only positive lymph node status and grade 3 were reported as risk factors for distant metastases in patients with stage T3 and T4 cancer.

CONCLUSION

There are differences in the clinicopathological features among breast cancer patients with primary metastases and those without. Receptor expression and histological type play a minor role in the risk for metastasis in patients with stage T3 and T4 disease when compared to patients with T1 pmBC tumours. On initial diagnosis, lobular histology and Luminal B positivity (Her 2 positive) in T1 pmBC were determined to be risk factors for primary metastatic disease.

P4-10-07: Clinico-Pathologic Features of Breast Cancer Patients with Primary Metastatic Disease Versus Localized Disease: A Multicenter Study

Objective: Approximately 6% of breast cancer patients present with primary metastatic disease (pmBC) at first diagnosis. Clinicopathological differences to non-metastatic patients are undetermined.

Methods: Exploratory analysis of patients with pmBC treated in 8 breast cancer units between 1998 and 2010. Tumor characteristics of these patients were compared with non-metastatic breast cancer patients (BC) of one breast cancer center who had neither local-recurrence nor distant metastases during 30 months of follow-up after first diagnosis. Standard staging in patients with first diagnosis of BC included chest X-ray, abdominal ultrasonography and bone scan. Molecular subtypes were analyzed and defined by immunohistochemical markers (ER, PR, Her2-receptor).

Results: 2.214 patients were included, 1.642 with BC and 572 with pmBC, respectively. Patients with pmBC were 7 years older (BC 58 years of age vs. pmBC 65 years; p=0.000) and were more likely to be postmenopausal (74% vs. 83%; p=0.000). Most common localizations of distant first metastases were bone (61,5%), liver (24%), lung (21%) and non-axillary lymph nodes (12%).

85 (15%) patients with pmBC were diagnosed in stage T1. Factors associated with pmBC in multivariate analysis for this group were positive lymph node status (OR 3.4; 95%CI 2.3−6.0; p=0.000), grading 3 (OR 2.3; 95%CI 1.3−4.0; p=0.003), lobular histology (OR 2.3; 95%CI 1.2−4.5; p=0,010) and phenotype Luminal B (OR 2.4; 95%CI 1.25−5.0; p=0.014). 197 (34%) patients with pmBC were diagnosed in stage T2; positive lymph node status (OR 4.8; 95%CI 1.1−3.0; p=0.017) and grading 3 (OR 1.6; 95% CI 1.6−2.3; p=0.019) were reported as risk factors for this group. 90 (16%) and 200 (35%) patients were diagnosed with stages T3 and T4, respectively. In T3/4 tumors a positive lymph node status (OR 5.2; 95% CI 2.9−9.3; p=0.000) and grading 3 (OR 2.2; 95%CI 1.2−3.9; p=0.009) could be defined as significant risk factors for distant metastases. Postmenopausal status was associated with primary metastases in stage T2 (OR 1.8; 95%CI 1.2−2.9; p=0.008) and T3/4 (OR 2.4; 95%CI 1.2−4.7; p=0.011) but not in T1 tumors (OR 1.3; 95%CI 0.7−2.1; p=0.420). There was no association with hormone or Her2 receptor status nor with a specific phenotype for T2-4 tumors.

Conclusion: The clinico-pathological features of breast cancer patients with or without primary metastases differ. In all stages positive lymph node status and higher grading were associated with pmBC significantly. Lobular histology was reported as a risk factor for T1-2 compared to patients without metastases. This feature was not found for T3/4 pmBC. T1 pmBC were likely to be associated with luminal B phenotype. T3-4 pmBC have not been associated with any phenotype or hormone receptor constellation as risk factor for metastases. Tumor biology seems to play a minor role for risk of metastases in T3-4 stages compared to patients with T1-tumors. Findings from this analysis should be considered in the choice of staging methods, especially in stage T1.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-10-07.

Small-area analysis of incidence and localisation of vulvar cancer

Objective. Vulvar cancer is a rare disease mainly in older women. HPV and non-HPV induced vulvar cancer reflect two types of oncogenesis. Controversies exist on most recent developments in vulvar cancer incidence, patients, and disease characteristics. Changes in incidence, age of disease onset, and tumor site in women treated for primary vulvar cancer in a single German university hospital unit will be described. Methods. A retrospective analysis of patient records of women treated between 1994 and 2008 was performed. The fifteen-year-spanning period was divided into three five year-spanning cohorts. Descriptive and statistical analyses were performed. Results. 104 patients were identified: cohort-1 from 1994 to 1998 (11 patients); cohort-2 from 1999 to 2003 (21 patients); cohort-3 from 2004 to 2008 (72 patients). Mean age (years) was 73.18 (confidence interval (CI): 64.04; 82.33), 58.9 (CI: 52.24; 65.57), and 61.19 (CI: 57.27; 65.12), respectively. Vulvar cancer confined to the region between clitoris and urethra was seen more often in cohort-3 (n = 20) compared to cohort-1 (n = 0) or cohort-2 (n = 1). Conclusion. This analysis supports the notion of rising incidence of vulvar cancer and a changing pattern of anatomical local extension. Disease onset is not restricted to older women.

Similarities and differences between excessive exercising anorexia nervosa patients compared with DSM-IV defined anorexia nervosa subtypes

This study describes anorexia nervosa (AN) patients who use excessive exercise for weight management and how this behaviour relates to the classical Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) sub-grouping of AN. The study compared 428 clinical AN patients with 119 age and gender-matched controls. The AN cases were initially dichotomised according to DSM-IV subtype criteria into restricting (RAN; N=198) and binge-purge (BPAN; N=230) anorexia. The psychometric instruments were chosen to reflect key features concerning the diagnosis of eating disorders and characteristics of eating and food behaviour and included the 26-item Eating Attitude Test (EAT-26), Three Factor Eating Questionnaire (TFEQ), Dutch Eating Behaviour Questionnaire (DEBQ), Eysenck Personality Inventory (EPI) and Rosenberg Self-Esteem scale (RSE). Structured clinical interviews (1) were carried out in order to identify the subgroup of patients who use excessive exercise in order to facilitate weight control (EAN). The three groups (RAN, BPAN, EAN) did not differ in measures of current age, current body mass index, age of onset of AN and measures of restrained eating. However, significant differences were observed on EAT-26, DEBQ emotional and external factors, TFEQ disinhibition and hunger factors, EPI extraversion and neuroticism, and self-esteem. The EAN were similar to the RAN on the majority of variables but showed significant differences on extraversion, neuroticism, self-esteem and disease pathology (EAT-26). Compared with BPAN, EAN had lower disease pathology (EAT-26 scores), scored higher on the EPI extraversion scale, lower on the neuroticism scale and had greater self-esteem. The EAN also displayed significantly lower emotional and external eating (DEBQ) than BPAN and significantly lower disinhibition and hunger scores (TFEQ). These data suggest that EAN group display a mixed profile of characteristics resembling both BPAN and RAN. When EAN are defined as a separate group they appear to be phenotypically more similar to RAN than BPAN on this particular profile of variables. However when DSM-IV criteria are applied they are almost exclusively classified as BPAN. This outcome suggests that EAN do constitute an identifiable group that can be distinguished from RAN and BPAN. Consequently it is likely that the behaviour of excessive exercising should be considered as clinically relevant on the outcome of treatment.

Knochendichte bei postmenopausalen Frauen mit proximaler Femurfraktur

INTRODUCTION

Osteoporosis associated proximal femoral fracture is a major public health problem. Diagnostic assessment includes patients history, laboratory testings and bone mineral density measurements. Hereby, dual X-ray absorptiometry (DXA) is regarded as the "Goldstandard". Quantitative ultrasonometry (QUS) of bone is a safe, simple, free of radiation, portable, cost-effective and therefore powerful diagnostic tool. QUS should be taken in account for primary assessment in patients with supposed osteoporosis in clinical practice.

AIM OF THE STUDY

We performed this cross sectional pilot study to evaluate the ability of two different QUS-devices (os calcis) in comparison to DXA (lumbar spine and femoral neck) to discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls.

PATIENTS AND METHODS

All together, 44 postmenopausal women were included. Of these, 22 suffered a proximal femoral fracture and were compared with 22 healthy, age- and BMI-matched controls. Bone assessments were performed by DXA (femoral neck and lumbar spine) and QUS of the heel using Achilles and Insight.

RESULTS

T- and Z-Score of DXA (femoral neck) were significantly lower in women with hip fracture compared to controls (p < 0.008 and p < 0.01). QUS-Insight also revealed significantly lower values of T- and Z-Score in women with hip fracture compared to controls (p < 0.01 and p < 0.005). QUS-Achilles measurement results also comprised significant differences between the groups (T-Score und Z-Score: p < 0.02). In accordance to the T-Score (femoral neck), all three devices (DXA femoral neck, Achilles and Insight) showed an equal significant correlation (p < 0.001). The correlation in between both QUS-devices was higher (0.956; p < 0.0001) than in between DXA-results (femoral neck vs. lumbar spine, 0.577; p < 0.01). The Z-Score also showed a significant correlation. DXA (lumbar spine) didn't show any significant differences in T- and Z-Score.

CONCLUSION

In comparison to the gold standard DXA (femoral neck), both QUS-devices showed an equal ability to significantly discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls. If our results are confirmed by more cross-sectional and longitudinal studies, QUS could be a helpful and valuable technique in clinical practice. Finally, all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment must be instituted.

Glomerul�re Krankheiten in der Nierenbiopsie

Renal biopsies studied by light and electron microscopy as well as by immunohistochemistry seem to be continually necessary for an adequate typing and therapy of glomerulonephritis (GN) and other glomerular diseases. Basing on 653 renal biopsies examined in Rostock from 1990 to 1999, the morphological classification in a total of 585 cases with glomerular diseases is presented in comparison to their clinical syndromes according to the WHO classification. A nephrotic syndrome was most frequent and clinically reported in 258 of the 585 biopsy cases with glomerular diseases (44%). It was seen in 77 of the 87 cases with minimal change nephropathy (55%), in 46 of the 74 cases with focal segmental glomerulosclerosis (62%), and in 19 of the 24 diffuse membranous GN cases (79%). The majority of the varying histological subtypes of diffuse GN was not combined with a specific clinical syndrome except of diffuse crescentic GN presenting with a rapidly progressive nephritic syndrome in 14 of 16 cases (88%). IgA nephropathy was the most often diagnosed entity of glomerular diseases found in 122 of the 502 cases with primary or secondary GN (24%). It is obvious that a given morphological GN type can but must not be combined with a specific clinical GN syndrome, so that the clinical importance of renal biopsy is stressed.

Improving pain management: breaking down the invisible barrier

There is compelling evidence that despite growing research into the complex neurophysiology of pain, the development of acute pain services, increasing educational interest in pain management and the proliferation of literature, many patients continue to suffer from unrelieved acute pain while in hospital. Educational efforts to bring about a change in practice have been relatively unsuccessful or slow to have real impact. Although it is still recognized that poor knowledge of pain control by all healthcare professionals is the major barrier to improving pain management, contemporary studies show that other, more subtle barriers can just as effectively inhibit a timely and effective response to patients' reports of pain. These barriers are not just the ones created by poor knowledge, myth and misconception; the most powerful barriers to change may be the invisible institutional barriers that can be entrenched within hospital policies and nursing rituals.

Effects of SU101 in combination with cytotoxic agents on the growth of subcutaneous tumor xenografts

SU101 (leflunomide, N-[4-(trifluoromethyl)-phenyl] 5-methylisoxazole-4-carboxamide), an inhibitor of platelet-derived growth factor receptor signaling, has shown promising clinical activity in Phase I and II studies. Currently, SU101 in combination with cytotoxic agents is in late-stage clinical development for the treatment of cancers. In previous reports, efficacy in vivo versus varied tumor xenografts was observed. As part of the preclinical development of SU101 as a cancer therapy, the combination of SU101 with cytotoxic agents was studied in athymic mice bearing small, established, s.c. human tumor cell xenografts of glioblastoma (SF763T cells), lung (Calu-6 cells), or head and neck (KB cells) origin. In the SF763T model, the combination of SU101 with carmustine resulted in a statistically significant growth inhibition of 74% compared with the vehicle control; this combination was more effective than either agent alone. In the Calu-6 model, the combination of SU101, cisplatin, and etoposide resulted in a growth inhibition of 75% that was statistically greater than that of the vehicle-treated control group and groups treated with one or two agents. In the KB model, the combination of SU101, 5-fluorouracil, and cisplatin resulted in a statistically significant growth inhibition of 69% compared with the vehicle control. Treatment with one or two agents did not significantly inhibit growth in this model. Importantly, in addition to enhanced efficacy resulting from combination therapies, the combination treatments tested were well tolerated, as evidenced by lack of mortality. These data suggest that SU101 in combination with cytotoxic agents may provide clinical benefit and warrant further clinical investigation.

Using acupuncture and acupressure to treat postoperative emesis

Interest in non-pharmacological strategies to manage health-care problems is increasing. Effective treatment for postoperative nausea and vomiting continues to be elusive, despite the introduction of new anti-emetic drugs. Acupuncture and acupressure might offer an effective, safe, simple and cheap therapy.

Combined high-intensity strength and aerobic training in diverse phase II cardiac rehabilitation patients

BACKGROUND

Developing adequate levels of muscular strength in the cardiac rehabilitation (CR) patient helps return the patient to an active lifestyle. This study evaluated the effects and safety of an 8-week high-intensity strength training (ST) program combined with a traditional aerobic-based CR program on the muscular strength of a diverse phase II CR population.

METHODS

Sixty-one phase II CR patients (age = 60.5 +/- 10.6 years) stratified by risk (high risk: n = 18, ejection fraction = 23.6 +/- 7.8%; intermediate risk: n = 19, ejection fraction = 40.0 +/- 4.6%; low risk: n = 24, ejection fraction = 58.0 +/- 7.7%) and gender (males = 46, females = 15) participated. One repetition maximum (1RM) testing was performed on the horizontal squat, shoulder press, leg extension, lat pulldown, and biceps curl. Patients performed two sets of each exercise 2 days per week at an intensity that started at 60% 1RM and progressed to 80% 1RM by week 4. Weeks 4 to 8 intensity was adjusted individually to maintain 8RM per set. Blood pressure and heart rate/rhythm responses to 1RM testing were monitored in high-risk patients. Muscle soreness and injury were monitored for all patients immediately after 1RM testing and on days 2 and 7.

RESULTS

All patient groups made significant gains (P < 0.05) in muscle strength (mean increase: lower body = 15.3%, upper body = 16.7%). No injury or significant muscle soreness occurred due to 1RM testing. No abnormal heart rate/rhythm or blood pressure responses occurred in high-risk patients.

CONCLUSIONS

Diverse phase II CR patients can improve their strength significantly with a combination of high-intensity strength and aerobic training.

Evaluation of accuracy and repeatability of identification of food-borne pathogens by automated bacterial identification systems

The performances of five automated microbial identification systems, relative to that of a reference identification system, for their ability to accurately and repeatedly identify six common food-borne pathogens were assessed. The systems assessed were the MicroLog system (Biolog Inc., Hayward, Calif.), the Microbial Identification System (MIS; MIDI Inc., Newark, Del.), the VITEK system (bioMérieux Vitek, Hazelwood, Mo.), the MicroScan WalkAway 40 system (Dade-MicroScan International, West Sacramento, Calif.), and the Replianalyzer system (Oxoid Inc., Nepean, Ontario, Canada). The sensitivities and specificities of these systems for the identification of food-borne isolates of Bacillus cereus, Campylobacter jejuni, Listeria monocytogenes, Staphylococcus aureus, Salmonella spp., and verotoxigenic Escherichia coli were determined with 40 reference positive isolates and 40 reference negative isolates for each pathogen. The sensitivities of these systems for the identification of these pathogens ranged from 42.5 to 100%, and the specificities of these systems for the identification of these pathogens ranged from 32.5 to 100%. Some of the systems had difficulty correctly identifying the reference isolates when the results were compared to those from the reference identification tests. The sensitivity of MIS for the identification of S. aureus, B. cereus, E. coli, and C. jejuni, for example, ranged from 47.5 to 72. 5%. The sensitivity of the Microlog system for the identification of E. coli was 72.5%, and the sensitivity of the VITEK system for the identification of B. cereus was 42.5%. The specificities of four of the five systems for the identification of all of the species tested with the available databases were greater than or equal to 97.5%; the exception was MIS for the identification of C. jejuni, which displayed a specificity of 32.5% when it was tested with reference negative isolates including Campylobacter coli and other Campylobacter species. All systems had >80% sensitivities for the identification of Salmonella species and Listeria species at the genus level. The repeatability of these systems for the identification of test isolates ranged from 30 to 100%. Not all systems included all six pathogens in their databases; thus, some species could not be tested with all systems. The choice of automated microbial identification system for the identification of a food-borne pathogen would depend on the availability of identification libraries within the systems and the performance of the systems for the identification of the pathogen.

Biochemical activities of extracts from Hypericum perforatum L. 3rd Communication: modulation of peroxidase activity as a simple method for standardization

Alcoholic extracts from the herb "St. John's wort" (Hypericum perforatum L.) are widely used to counteract depressive situations, where the question on the mainly active principle is still under discussion. Thus, standardization of the drug on the basis of dry matter has been chosen instead of the popular leading component, hypericin. Inhibition of myeloperoxidase-catalyzed dimerization of enkephalins by Hypericum extracts has recently been reported. This method is based on the separation and quantification of enkephalin dimers by HPLC. In order to simplify this assay myeloperoxidase could be substituted by the cheaper horseradish peroxidase and the enkephalins by the amino acid tyrosine without loss of significance. In this communication we represent a more rapid photometric method based on peroxidase-catalyzed indole acetic acid oxidation suitable for quick, simple and economic drug standardization.

Biochemical activities of extracts from Hypericum perforatum L. 4th Communication: influence of different cultivation methods

Extracts from the herb "St. John's wort" (Hypericum perforatum L.), know since ancient times as medical plant, besides other activities such as wound healing, antighout, antirheumatic and diuretic properties, is used in the treatment of mild to moderate depression. Increasing application continuously makes cultivation under controlled conditions of Hypericum perforatum L. more important. This report shows the results of three-years cultivation experiments with Hypericum perforatum L. The findings indicate that N-fertilizing yields more plant material but results in a drug with less quantity of secondary metabolites. Important components of the drug were quantified by HPLC and their activities were analyzed with the aid of biochemical test systems. Narrowleaved and broadleaved varieties of Hypericum perforatum L. show differences both in activity and quality. In this experiments the most active extract was a methanolic extract derived from non-fertilized, broadleaved plants.

Injuries and muscle soreness during the one repetition maximum assessment in a cardiac rehabilitation population

BACKGROUND

Strength training (ST) may be beneficial for preservation of lean tissue, increasing bone mineral content, decreasing falls, and enhancing quality of life. Strength training is becoming an appropriate mode of exercise for cardiac rehabilitation (CR) patients. One method for determining optimal exercise intensity for safe and effective ST requires one repetition maximum (1RM) testing. Clinicians may be reluctant to perform 1RM testing in CR patients because of potential muscle soreness/injury and adverse hemodynamic responses in deconditioned patients. The purpose of this investigation was to perform 1RM testing in CR patients and determine muscle soreness/injury rate.

METHODS

Seventy-four CR patients stratified by risk (low n = 30, intermediate n = 21, high n = 23) and sex (males = 55, females = 19) participated. Subject's ages ranged from 39 to 76 years and time from procedure ranged from 19 days to 2 years. No patient had ever undergone 1RM testing. The method of Kraemer and Fry was used to assess 1RM. High-risk patients' heart rates/rhythms and blood pressures were monitored. Patients were evaluated for occurrence of muscle soreness/injury immediately after 1RM testing and on days 2 and 7 using a soreness scale developed by Shaw et al. Muscle soreness/injury was considered significant if a patient reported altering or stopping physical activities.

RESULTS

No injury or significant muscle soreness occurred as a result of 1RM testing. No abnormal heart rate/rhythm or blood pressure responses occurred in high-risk patients.

CONCLUSIONS

Results indicate that with proper technique, 1RM testing may be performed in CR patients without injury or significant muscle soreness.

Epidural analgesia: have we got it right?

Epidural infusions are being employed more frequently for postoperative and posttraumatic pain. This paper looks at the possible complications involved in the use of epidural analgesia. The evidence concerning possible causes of infection and abscess formation is discussed. The small amount of literature available suggests that the potential for infection is increased when ward-based staff are involved with changing epidural infusions. The potential benefits of ready-prepared solutions for epidural analgesia are considered.

alpha-Amylase and salivary albumin adsorption onto titanium, enamel and dentin: an in vivo study

In vivo adsorption of salivary albumin and alpha-amylase onto titanium, enamel and dentin was analysed following their exposure to the oral cavity for 2h. Oral appliances in six adults served as a platform for carrying 4-mm discs of the three materials. Adherent proteins were eluted from the discs and the amounts of salivary albumin and alpha-amylase were measured by an enzyme-linked immunosorbent assay. While significant difference between the adsorption of albumin and alpha-amylase onto enamel as compared with dentin was observed, adsorption onto titanium was significantly lower. A sample of whole saliva was also collected from each participant. The mean total amounts of albumin and alpha-amylase in the participants' whole saliva were 0.03 and 0.54 mg ml-1, respectively. Titanium adsorbed significantly less (4.43%) of the total albumin than did enamel (14.30%) or dentin (18.80%). No significant difference was found in the relative amounts of alpha-amylase adsorbed by the three materials. This significantly selective adsorption of proteins may enable the attachment of specific bacteria and thus alter the composition of the dental plaque and its potential pathogenicity.