Providers' perspectives on the reproductive decision-making of BRCA-positive women

BACKGROUND

Reproductive decision-making is difficult for BRCA-positive women. Our objective was to assess the complexities of decision-making and identify decisional supports for patients and providers when discussing reproductive options prior to risk-reducing salpingo-oophorectomy (RRSO).

METHODS

This study was of qualitive design, using data collection via semi-structured interviews conducted from November 2018 to October 2020. Individuals were included if they were identified to provide care to BRCA-positive women. In total, 19 providers were approached and 15 consented to participate. Providers were recruited from three clinics in Toronto, Ontario located at academic centers: [1] A familial ovarian cancer clinic, [2] A familial breast cancer clinic and [3] A fertility clinic, all of which treat carriers of the BRCA1/BRCA2 genetic mutation. The interview guide was developed according to the Ottawa Decision Support Framework and included questions regarding reproductive options available to patients, factors that impact the decision-making process and the role of decisional support. Interviews were transcribed and transcripts were analyzed thematically using NVIVO 12.

RESULTS

Providers identified three major decisions that reproductive-aged women face when a BRCA mutation is discovered: [1] "Do I want children?"; [2] "Do I want to take the chance of passing on this the mutation?"; and [3] "Do I want to carry a child?" Inherent decision challenges that are faced by both providers and patients included difficult decision type, competing options, scientifically uncertain outcomes, and challenging decision timing. Modifiable decisional needs included: inadequate knowledge, unrealistic expectations, unclear values and inadequate support or resources. Identified clinical gaps included counselling time constraints, lack of reliable sources of background information for patients or providers and need for time-sensitive, geographically accessible, and centralized care.

CONCLUSION

Our study identified a need for a patient information resource that can be immediately provided to patients who carry a BRCA genetic mutation. Other suggestions for clinical practice include more time during consultation appointments, adequate follow-up, value-centric counseling, access to psychosocial support, and a specialized decisional coach.

Cost-utility analysis of the universal pneumococcal vaccination programme for older adults in Norway

The aim of this study was to establish whether the universal pneumococcal vaccination for older adults in Norway is likely to be cost-effective from the perspective of the health care provider. A decision tree model developed by the Public Health Agency of Sweden was adapted to the Norwegian setting. Two cohorts, consisting of 65-year-olds and 75-year-olds grouped into vaccinated and unvaccinated, were followed over a 5-year time horizon. In the base case, the 23-valent polysaccharide vaccine (PPV23) was used while the 13-valent pneumococcal conjugate vaccine (PCV13) was included in scenario analyses only. The costs and health benefits (measured in quality adjusted life years (QALY) gained) were compared in the two cohorts between the vaccinated and unvaccinated groups. The impact of indirect effects of the vaccine, such as herd immunity and serotype replacement, were not investigated. The relative importance of change in price was assessed by performing one-way sensitivity analyses. Under base-case assumptions, the programme for the 75-year-old cohort is expected to be dominant (cost-effective) from the health care perspective at the current maximal pharmacy retail price and at 75% vaccination coverage. In comparison, for the 65-year-old cohort the cost per QALY gained is approximately NOK 601,784 (EUR 61,281) under the base-case assumptions. A reduction in the cost of the vaccine to one quarter of its current level also brings the cost per QALY gained within the acceptable ranges in a Norwegian context for both the 65- and 75-year-old cohorts. There is no exact cost-effectiveness threshold in Norway. However, introducing a vaccination programme against pneumococcal disease for 65-year-olds in Norway is likely to fall within the acceptable range while for the 75-year-old cohort the universal programme appears to be dominant (cost-effective).

Cost-effectiveness of varicella and herpes zoster vaccination in Sweden: An economic evaluation using a dynamic transmission model

OBJECTIVES

Comprehensive cost-effectiveness analyses of introducing varicella and/or herpes zoster vaccination in the Swedish national vaccination programme.

DESIGN

Cost-effectiveness analyses based on epidemiological results from a specifically developed transmission model.

SETTING

National vaccination programme in Sweden, over an 85- or 20-year time horizon depending on the vaccination strategy.

PARTICIPANTS

Hypothetical cohorts of people aged 12 months and 65-years at baseline.

INTERVENTIONS

Four alternative vaccination strategies; 1, not to vaccinate; 2, varicella vaccination with one dose of the live attenuated vaccine at age 12 months and a second dose at age 18 months; 3, herpes zoster vaccination with one dose of the live attenuated vaccine at 65 years of age; and 4, both vaccine against varicella and herpes zoster with the before-mentioned strategies.

MAIN OUTCOME MEASURES

Accumulated cost and quality-adjusted life years (QALY) for each strategy, and incremental cost-effectiveness ratios (ICER).

RESULTS

It would be cost-effective to vaccinate against varicella (dominant), but not to vaccinate against herpes zoster (ICER of EUR 200,000), assuming a cost-effectiveness threshold of EUR 50,000 per QALY. The incremental analysis between varicella vaccination only and the combined programme results in a cost per gained QALY of almost EUR 1.6 million.

CONCLUSIONS

The results from this study are central components for policy-relevant decision-making, and suggest that it was cost-effective to introduce varicella vaccination in Sweden, whereas herpes zoster vaccination with the live attenuated vaccine for the elderly was not cost-effective-the health effects of the latter vaccination cannot be considered reasonable in relation to its costs. Future observational and surveillance studies are needed to make reasonable predictions on how boosting affects the herpes zoster incidence in the population, and thus the cost-effectiveness of a vaccination programme against varicella. Also, the link between herpes zoster and sequelae need to be studied in more detail to include it suitably in health economic evaluations.

Willingness to Pay for Health Improvements Using Stated Preferences: Prevention Versus Treatment

OBJECTIVES

This study aimed to investigate whether there was a difference in willingness to pay (WTP) between prevention and treatment for health benefits of equal magnitude.

METHODS

We used a web-based survey instrument in a sample of the Swedish general population to perform a contingent valuation study assessing the WTP for prevention and treatment. We analyzed the WTP as a continuous variable using a two-part regression model to adjust for a mass point around 0 and a skewed distribution among respondents with a positive WTP.

RESULTS

The study found that people were less willing, on average, to pay at all for prevention than treatment, but those who were willing to pay for prevention had a higher WTP than for treatment. The latter effect was more substantial, and in total mean WTP for prevention was about 85% higher than for treatment.

CONCLUSIONS

The findings from this study contribute to the ongoing discussion on the appropriate cost-effectiveness thresholds by adding prevention as a parameter affecting the demand-side value of health improvements. As such, it can provide support to decision makers in healthcare and in health promotion priority setting.

Primordial germ cells do not migrate along nerve fibres in marmoset monkey and mouse embryos

Primordial germ cells (PGCs) are the embryonic precursors of spermatozoa and eggs. In mammals, PGCs arise early in embryonic development and migrate from their tissue of specification over a significant distance to reach their destinations, the genital ridges. However, the exact mechanism of translocation is still debated. A study on human embryos demonstrated a very close spatial association between migrating PGCs and developing peripheral nerves. Thus, it was proposed that peripheral nerves act as guiding structures for migrating PGCs. The goal of the present study is to test whether the association between nerves and PGCs may be a human-specific finding or whether this represents a general strategy to guide PGCs in mammals. Therefore, we investigated embryos of different developmental stages from the mouse and a non-human primate, the marmoset monkey (Callithrix jacchus), covering the phase from PGC emergence to their arrival in the gonadal ridge. Embryo sections were immunohistochemically co-stained for tubulin beta-3 chain (TUBB3) to visualise neurons and Octamer-binding protein 4 (OCT4 (POU5F1)) as marker for PGCs. The distance between PGCs and the nearest detectable neuron was measured. We discovered that in all embryos analysed of both species, the majority of PGCs (>94%) was found at a minimum distance of 50 µm to the closest neuron and, more importantly, that the PGCs had reached the gonads before any TUBB3 signal could be detected in the vicinity of the gonads. In conclusion, our data indicate that PGC migration along peripheral nerves is not a general mechanism in mammals.

Cost-effectiveness of pneumococcal vaccination for elderly in Sweden

INTRODUCTION

The aim was to assess cost-effectiveness of including pneumococcal vaccination for elderly in a national vaccination programme in Sweden, comparing health-effects and costs of pneumococcal related diseases with a vaccination programme versus no vaccination.

METHOD

We used a single-cohort deterministic decision-tree model to simulate the current burden of pneumococcal disease in Sweden. The model accounted for invasive pneumococcal disease (IPD) and pneumonia caused by pneumococci. Costs included in the analysis were those incurred when treating pneumococcal disease, and acquisition and administration of the vaccine. Health effects were measured as quality-adjusted life years (QALY). The time-horizon was set to five years, both effects and costs were discounted by 3% annually. Health-effects and costs were accumulated over the time-horizon and used to create an incremental cost-effectiveness ratio. The 23-valent polysaccharide vaccine (PPV23) was used in the base-case analysis. The 13-valent pneumococcal conjugate vaccine PCV13 was included in sensitivity analyses.

RESULTS

A vaccination programme using PPV23 would reduce the burden of pneumococcal related disease significantly, both when vaccinating a 65-year-old cohort and a 75-year-old cohort. IPD would decrease by 30% in the 65-year-old cohort, and by 29% in the 75-year-old cohort. The corresponding figures for CAP (communicable acquired pneumonia) are 19% and 15%. The cost per gained QALY was estimated to EUR 94,000 for vaccinating 65-year-olds and EUR 29,500 for 75-year-olds. With one dose PCV13 given instead of PPV23, the cost per gained QALY would increase by around 400% for both cohorts. The results were robust in sensitivity analyses.

CONCLUSION

Introducing a vaccination programme against pneumococcal disease for 65-year-olds in Sweden is unlikely to be cost-effective, whereas it for 75 year-olds and using PPV23 can be considered good value for money. Our model indicates that vaccine price needs to be reduced by 55% for vaccination of 65-year-olds to be cost-effective, given a threshold of EUR 50,000.

Organic Compounds in a Sub-Antarctic Ice Core: A Potential Suite of Sea Ice Markers

Investigation of organic compounds in ice cores can potentially unlock a wealth of new information in these climate archives. We present results from the first ever ice core drilled on sub-Antarctic island Bouvet, representing a climatologically important but understudied region. We analyze a suite of novel and more familiar organic compounds in the ice core, alongside commonly measured ions. Methanesulfonic acid shows a significant, positive correlation to winter sea ice concentration, as does a fatty acid compound, oleic acid. Both may be sourced from spring phytoplankton blooms, which are larger following greater sea ice extent in the preceding winter. Oxalate, formate, and acetate are positively correlated to sea ice concentration in summer, but sources of these require further investigation. This study demonstrates the potential application of organic compounds from the marine biosphere in generating multiproxy sea ice records, which is critical in improving our understanding of past sea ice changes.

Cost-effectiveness of sex-neutral HPV-vaccination in Sweden, accounting for herd-immunity and sexual behaviour

INTRODUCTION

The aim was to assess cost-effectiveness of expanding the Swedish HPV-vaccination program to include preadolescent boys, by comparing health-effects and costs of HPV-related disease, with a sex-neutral vaccination program versus only vaccinating girls.

METHODS

We used a dynamic compartmental model to simulate the burden of HPV16/18-related disease in Sweden, accounting for indirect effects of vaccination through herd-immunity. The model accounted for sexual behaviour, such as age preferences and men who have sex with men. The main outcome was number of individuals with HPV-related cancers (cervical, genital, anal and oropharyngeal cancer) and cervical intraepithelial neoplasia (CIN). Costs included in the analysis were those incurred when treating HPV-related cancer and CIN, production losses during sick-leave, and acquisition and administration of vaccine. Health effects were measured as quality-adjusted life years (QALY). The time horizon was set to 100 years, and both effects and costs were discounted by 3% annually. Health effects and costs were accumulated over the time horizon and used to create an incremental cost-effectiveness ratio.

RESULTS

A sex-neutral vaccination program would reduce HPV-related cancer and CIN, both due to direct effects among vaccinated as well as through herd-immunity, further decreasing HPV-related cancer burden annually by around 60 cases among men and women respectively in steady-state. The cost per gained QALY was estimated to 40,000 euro. Applying the procurement price of 2017, sex-neutral vaccination was dominant.

CONCLUSION

Introducing a sex-neutral HPV-vaccination program would be good value for money also in Sweden where there this 80% coverage in the current HPV-vaccination program for preadolescent girls. The cost-effectiveness of a sex-neutral program is highly dependent on the price of the vaccine, the lower the price the more favourable it is to also vaccinate boys.

Bisphenol A affects larval growth and advances the onset of metamorphosis in Drosophila melanogaster

Exposure to Bisphenol A (BPA) has been reported to dysregulate endocrine pathways in a wide array of vertebrate species. The effects of BPA on invertebrate species are less well understood. We tested the effects of BPA on growth and development in Drosophila as these processes are governed by well-studied endocrine pathways. In this study, we tested the effects of three concentrations of BPA (0.1mg/L, 1mg/L or 10mg/L) and found a statistically significant increase in larval growth for the low dose treatment group (0.1mg/L), but not statistically significant for the high dose treatment group (10mg/L). BPA exposure resulted in an increased body size in treated animals at 48, 72 and 96h after egg laying (AEL). This finding reflects a non-monotonic dose-response that has been observed for an increasing number of endocrine disrupting compounds. The increase in growth rate found for all treatment groups was associated with a statistically significant increase in food intake observed at 72h AEL. Furthermore, we observed that the increased growth rate was coupled with an earlier onset of pupariation consistent with previously reported phenotypes resulting from increased activity of insulin/insulin growth factor signaling (IIS) in Drosophila. Since the timing of the onset of pupariation in Drosophila is controlled through the complex interaction of the IIS and the ecdysone signaling pathways, our findings suggest that BPA exerts its effects through disruption of endocrine signaling in Drosophila.

Impact of chronic atrial fibrillation in patients with severe heart failure and indication for CRT: data of two registries with 711 patients (1999-2006 and 2007-6/2008)

AIMS

Atrial fibrillation (AF) is a relevant comorbidity in heart failure (HF) patients. In milestone cardiac resynchronization therapy (CRT) studies, patients with AF were excluded. We sought to investigate the influence of chronic atrial fibrillation (AF) on patients with CRT. AV node (AVN) ablation is frequently recommended. Converting AF to sinus rhythm (SR) is not a standard concept.

METHODS

A total of 584 consecutive patients with CRT devices were included in a single-center registry from 1999-2006 (retrospective registry) and 127/324 patients from 2007-06/2008 (prospective registry). The impact of persistent AF (group 1) on clinical and echocardiographic improvement compared with patients in SR (group 2) after 12 (6) months follow-up were analyzed. Re-establishing SR after initial cardioversion or need for AVN ablation was examined.

RESULTS

In the retrospective registry, 139 (24%) patients presented with AF (group 1) and 445 with SR (group 2). The groups differed in age, gender, and left atrium (LA) size but not in NYHA class, ejection fraction (EF), left ventricular end-diastolic dimension (LVEDD), B-type natriuretic peptide (BNP) levels, QRS width, and underlying disease. After 1 year, CRT improvement of NYHA class and EF was similar with higher mortality in group 1 (12% vs. 7%; OR 1.80; 95% confidence interval 0.95-3.4). The AF group presented with SR in 33/82 (40%) patients and 11% needed AVN ablation. The prospective data showed 27 (21%) patients in AF with conversion to SR in 41% after 6 months.

CONCLUSION

Patients with severe HF and chronic AF had a comparable improvement with CRT as those in SR. CRT is a successful treatment option in patients with chronic AF offering the potential to restore SR in a significant number of patients.

A new approach to overcome natural cholesterol interference during simultaneous determination of two stable isotope-enriched cholesterol tracers in human plasma

We have developed a validated gas chromatography/mass spectrometry (GC/MS) method with two labelled cholesterol tracers, i.e. (2)H(4) ([2H4]-Chol) and (2)H(7) ([2H7]-Chol) enriched moieties, with a new way of calculating the abundance of labelled cholesterol in plasma without natural cholesterol interference. The isotopomers of the analytes could interfere during analysis. Elimination of these interferences can be performed by the blank or mathematical subtraction method. Validation was performed with the two interference elimination methods. For both methods, linearity was obtained in the range 5 x 10(-4) to 10(-2) mM for both labelled cholesterol moieties. In the same range, repeatability and reproducibility were less than 6.5% and 7.5% for [2H4]-Chol and [2H7]-Chol, respectively. Accuracy was about 100% and recoveries always included 100% for the two labelled cholesterols. We demonstrate that measurement of blank plasma is not necessary when using the validated abundance isotope calculation method. This saves time, reagent and samples. This calculation strategy can be extrapolated to comparable tracer approaches.

Pediatric renal transplantation: a single center experience over 14 years

Between 1989 and 2003, 100 transplants were performed in 96 patients at the pediatric nephrology unit of the Calvo Mackenna Children's Hospital. Mean age 10.9 +/- 3.9 yr (1-17.6), 30% from LD. Donors were younger than 5 yr in five patients and all recipients received an 'en bloc' graft. Original disease was hypo/dysplasia 27%, reflux nephropathy 22 and 17% chronic glomerulonephritis. The immunosuppressive protocol during the first period (n = 56, 1989-2000): Cyclosporine, steroids and azathioprine, and during the second period (n = 44, 2001-2003): FK, steroids, MMF and anti-CD25 antibody (mAbs). AR was reported in 22 patients, 11% in LD, 31% in DD (p < 0.01). The AR rate decreased from 40 to 8% after anti-CD25 monoclonal induction. Patient actuarial survival rate at 1, 3 and 5 yr was 100% for LD and 96% for DD. The overall actuarial graft survival at 1,3, and 5 yr was 96.7, 96.7 and 71% for LD and 89, 76 and 73% for DD donors. Graft survival rate improved from the first period (1989-2000) to the second period (2001-2003; p = 0.05). No difference in graft survival rate with HLA-A,B,DR matching was found. Graft survival rate was better when cold ischemia time was <24 h (p < 0.01). CMV infections increased from 19 to 40% when MMF and anti-CD25 Ab were introduced (p < 0.01). The height/age Z score at 1, 3 and 5 yr post-transplant was -2.2, -2.1, -2.2, respectively, for children older than 7 yr and -1.8, -1.9, -2.1 for those transplanted younger than 7 yr of age who were switched to alternate day steroids (p < 0.01). The cause of graft lost was: chronic rejection eight, non-adherence four, AR four and vascular thrombosis two. The cause of death in two patients was fungus septicemia and accelerated rejection. Pediatric renal transplantation can be performed in our group with acceptable morbidity, low mortality and graft survival rates similar to other reports in North America and Western Europe. Graft survival rate improved with newer immunosuppression and greater experience at the center. Management of non-adherence and chronic rejection remain the major challenges.

Loss of 9p21 is embedded in a complex but consistent pattern of genomic imbalances in oral squamous cell carcinomas

35 oral squamous cell carcinomas examined previously by comparative genomic hybridization (CGH) exhibited 5 up to 47 copy number alterations (CNAs). 13 of those cases showed a loss of parts of the short arm of chromosome 9, band p21 being affected in all of these cases. A highly complex but strikingly consistent pattern of genomic imbalances with an average 31.5 CNAs per tumor was associated with this deletion, and gains clearly dominated over losses of genomic material. Comparable patterns, however, could also be found in tumors with a high number of CNAs (24 CNAs) but without the deletion. Low numbers of imbalances were accompanied by low consistency of the CNA patterns. None of these latter cases showed the deletion 9p21. 66.7% of the dim(9p21)-positive tumors were of class pT4 (vs. 22% in dim(9p21)-negative cases), 77% of stage III or IV (vs. 47% in the group without the deletion), but only 8% of the dim(9p21)-positive tumors were classified as grade 3 (vs. 41% in the negative group). Other clinicopathologic features like prevalence of relapse, or survival time could not be as clearly associated with the deletion. For instance, short relapse-free survival was clearly associated with a high number of CNAs, rather independent of presence or absence of dim(9p21) in the affected tumor. From these findings it is concluded that previously found associations of 9p21 deletion with clinical parameters can reasonably be estimated only in the context of the pattern and complexity of the genomic imbalances accompanying this chromosomal loss in the examined tumors.

[Anti-semitism in medicine and Jewish emancipation - the quarrel between the Gottingen obstetrician Friedrich Benjamin Osiander and his Jewish former student Joseph Jacob Gumprecht (circa 1800)]

This article analyzes the behavior of the renowned professor of obstetrics Friedrich Osiander towards his Jewish former student, the private lecturer Joseph Jacob Gumprecht. In a public academic debate between the two of them, Osiander made use of anti-Semitic arguments. He did so even though his medical ideas and practice were based on concepts of Enlightenment and especially religious tolerance. An analysis of Osiander's behavior shows that his denunciations were hardly emotional outbursts against Gumprecht. Rather, they were sober pedagogic attempts to cleanse Gumprecht from what Osiander saw as his "Jewishness", thereby helping him on his climb into bourgeois academic society. This interpretation fits well with the German "etatistic" version of Jewish emancipation: Jews were able to gain equal standing, but only under the condition of moral "improvement", or ridding themselves of all "Jewish attitudes." Thus, "Enlightened" ideas of Jewish emancipation were partly based on beliefs in Jewish moral inferiority. It is significant that the example under investigation happened in a medical faculty, since this was a prime location for acculturated Jews to meet Gentile scholars who represented the Enlightenment-influenced ideas of the times.

Enalapril and prednisone in children with nephrotic-range proteinuria

The effect of enalapril and low prednisone doses on the urinary protein electrophoretic pattern was studied in 13 pediatric patients with glomerular diseases and steroid-resistant nephrotic syndrome. Enalapril was administered at doses of 0.2-0.6 mg/kg per day for 24-84 months, and prednisone was introduced 2 months later in 11 patients at doses of 30 mg/m2 on alternate days. The urine protein electrophoretic pattern showed a reduction of 80% and 70% in the total protein and albumin, respectively, after enalapril. Total urinary protein decreased from 5.46 to 1.1 g/m2 per day (P<0.001). A marked change from a pattern of non-selective urinary protein loss to an albumin-selective proteinuria was observed. Mean total plasma proteins increased from 4.7 to 5.43 g/dl (P<0.001). Four patients became free of proteinuria 24 months after enalapril was started, but only 2 remained free of proteinuria at 48 months of follow-up. The other 11 patients had persistent albuminuria of between 0.5 and 2.6 g/m2 per day with a selective urinary electrophoretic pattern. No additional decrease was observed after steroids were introduced. A clinical improvement in edema was observed in all children. Three patients developed transient acute renal failure, during the course of an infectious disease; 2 developed peritonitis and 1 pneumopathy. In these patients withdrawal of enalapril was necessary until a complete recovery of renal function was observed. Four patients were hypertensive on admission, achieving normal blood pressure 1 month after enalapril was started. No episodes of systemic arterial hypotension were seen. Creatinine clearance and serum potassium showed no statistically significant change.

I-FISH control of CGH-detected gain of DNA sequence copy number in oral squamous cell carcinomas (OSCC)

Interphase fluorescence in situ hybridization (I-FISH) was used to control the gain of genomic material in 21 human oral squamous cell carcinomas (OSCC) which had been detected by comparative genomic hybridization (CGH). DNA probes for 3q27, for 5p15.2, and for the protooncogenes c-myc (8q24) and c-abl (9q34), were used for I-FISH examination of the interphase nuclei of paraffin sections of the tumors. The corresponding alphoid DNA probes for the centromeric regions of the respective chromosomes and a probe on 5q served as controls of aneusomy. Previous examinations with int2 (11q13) and erbB2 (17q11.2-13) were included for comparison. I-FISH analysis detected a gain of 3q27 in 17, of 5p15.2 in 7, of c-myc in 14, of c-abl in 10, and formerly, of int2 in 12 and of erbB2 in 10 of the examined tumors. There was an overall confirmation of the CGH findings by the I-FISH data in 63% (36-83% depending on the studied chromosomal site), and vice versa of 76% of the I-FISH results by the CGH data. Based on these results it is recommended to use a combination of both I-FISH and CGH for the detection of genomic changes in human solid tumors as the data obtained by both techniques ideally complete each other. For this reason both techniques have now enriched the spectrum of molecular histopathology.

Factor V Leiden mutation is a risk factor for cerebral venous thrombosis: a case-control study of 55 patients

BACKGROUND AND PURPOSE

Different coagulation disorders have been associated with cerebral venous thrombosis (CVT). Until now, fewer than 50 patients have been reported with CVT and the factor V Leiden (FVL) mutation. Although the prevalence of FVL-positive patients with CVT ranged from 10% to 25%, it was as low as 0.5% to 3% in the control groups. Most other studies had not systematically searched for concomitant risk factors or previous thromboembolic events. To better define the relevance of the FVL mutation in conjunction with additional risk factors in CVT, we conducted the present case-control study.

METHODS

Fifty-five patients with CVT were compared with 272 healthy controls. A standardized interview regarding established risk factors for venous thrombosis and the patients' and their families' histories for thromboembolic events was performed. The presence of the FVL mutation was determined by polymerase chain reaction on DNA obtained from peripheral blood leukocytes.

RESULTS

Of 55 patients, 8 (14.5%) were heterozygous for the FVL mutation compared with 17 of 272 controls (6.25%). The relative risk for the presence of FVL was 2.55 (95% confidence interval, 1.04 to 6.26; P=0.04). Additional risk factors for CVT were frequently found in both the presence and absence of FVL. Recurrence of venous thromboembolic events was more frequent in patients with the FVL mutation (5 of 8 patients, 62.5%) than in those without this anomaly (8 of 47 patients, 17%; P<0.005).

CONCLUSIONS

Our study confirms the FVL mutation as the most relevant hereditary risk factor for CVT. Coexisting risk factors are usually involved in the initiation of CVT. Patients with the FVL mutation are at an increased risk for recurrent venous thrombosis.

Prevalence of factor V Leiden mutation in young adults with cerebral ischaemia: a case-control study on 225 patients

Cerebral ischaemia in young adults is a well-recognised disease, and approximately half of the cases remain aetiologically unclear despite extensive investigations. Thrombophilias are known to cause a subset of ischaemic strokes in this population. The factor V Leiden (FVL) mutation, causing resistance to activated protein C, has recently been recognised as the most important genetic thrombophilia in the Western population. Carriers of this gene mutation have a sevenfold increased risk of phlebothrombosis. We undertook this study to evaluate whether the FVL mutation constitutes a risk factor for juvenile cerebral ischaemias. A total of 225 patients aged < or = 45 years at onset of cerebral ischaemia and 200 age-matched healthy controls were investigated. The overall frequency of heterozygosity for the FVL mutation did not differ significantly between patients (8.4%) and controls [6.0%; odds ratio (OR) 1.4, 95% confidence interval (CI) 0.7-3.1]. In the subgroup of patients with cryptogenic cerebral ischaemia (n = 94), however, a significantly higher frequency of this gene defect (15.9%) was found compared with the controls (OR 3.0, CI 1.3-6.6). Further trends towards higher frequencies of the FVL mutation were found in patients with patent foramen ovale (OR 1.9), individual (OR 2.1) or family history of previous thrombembolisms (OR 2.0), and in those aged 25 years at onset of disease (OR 1.9, all not significant). In conclusion, the FVL mutation is not a risk factor for cerebral ischaemia of the young. However, our results suggest that this gene mutation plays an aetiological role in the subgroup of patients suffering from 'cryptogenic' ischaemic events.

Pattern of genomic imbalances in oral squamous cell carcinomas with and without an increased copy number of 11q13

Among 23 squamous cell carcinomas (SCC) of the oral cavity which were screened for DNA copy number alterations (CNAs) using comparative genomic hybridization, 14 showed a gain of, and 5 of these 14 even an amplification of band 11q13. Amplification of 11q13 was also detected in three of the four studied SCC cell lines and was confirmed by interphase FISH. The number of CNAs in addition to 11q13 varied from 14 to 47 in these carcinomas. All these tumors had seven other specific CNAs in common, i.e. gain on 1p36.3-36.6, 5p15, 9q34, 12p12-13, 14q32, 19 and 20q, all but one showed also an increase of copy number in 7p22, 8q24, 10q26, 12q26, 15q24-25, 16p, 16q23-24, 17q and 22q12-qter. These imbalances were distinctly rarer in the tumors without CNA in 11q13. Loss of material apparently played a minor role in these tumors with gain of 11q13, the most frequent losses (3p12-14 and 5q21) being present in 10 of the 14 cases and loss of 9p13-21 in 5/14 tumors. The three tumors with the highest number of CNAs in addition to 11q13, were histologically classified as pT4, three of the five tumors with 11q13 amplification were highly node-positive (pN 2b-2c). Two of the pT4 tumors shared as many as 23 specific chromosomal segments affected by CNA. Thus, gain of 11q13, though being found at different stages of karyotypic evolution, is apparently associated with a rather specific pattern of other CNAs and involved in progressed stages of malignancy in oral squamous cell carcinoma. In addition, the proportion of patients deceased within one year after diagnosis was clearly higher in the group whose tumors showed an increased 11q13 copy number as compared to the group without this increase. This could point to an association of gain in 11q13 and aggressiveness of the respective tumor.

Oral squamous cell carcinomas are characterized by a rather uniform pattern of genomic imbalances detected by comparative genomic hybridisation

Total genomic DNA sampled from 20 oral squamous cell carcinomas (SCCs) and from four SCC cell lines, was examined for genomic imbalances using comparative genomic hybridisation (CGH). Gains and losses of DNA copy number aberrations (CNAs) were found in the primary tumours, but also in the cell lines at a varying number. The patterns of CNAs proved to be rather peculiar in oral SCCs, gains of genetic material clearly dominating compared with losses, and a rather high uniformity of these patterns was an impressive finding. Hypersomies of whole chromosomes, e.g. numbers 17 and 19 or of whole chromosome arms, e.g. 20q, were particularly evident. The segments most frequently gained in oral SCCs were 3q26-q27, 5p15 and 9q34 (16 of 20 tumours each), as well as 1p36.3, 8q24, 10q26, 19 and 20q (15/20 each). Among the 15 tumours with more than 10 CNAs, all showed these imbalances. 11q13 was a band often involved in increases (14/20 tumours), but in several tumours was involved in amplification of DNA copy number. Several other chromosomal segments over represented in more than 60% of the tumours, as, for example, 12q24, 15q22-q24, 16p13.2 and 17q (14/20 tumours each), 6q26-qter, 7p22, 12p12.2-p13, 14q31-q32.2 (13/20) and 1q32-q41, 2q37, 16q23-q24 (12/20 each). In contrast, loss of material affected only a few chromosomal segments, as, for example, 3p12 (12 of the 20 tumours), 5q21 (10/20), 6q13 (8/20). The peculiarities of these findings, in some respect, differ from those found in other epithelial tumours, suggesting a high impact of environmental factors in the generation and progression of these tumours.

[Chronic hemodialysis in children]

BACKGROUND

The final objective of every children that is admitted to a program o hemodialysis of peritoneodialysis is to receive a renal graft.

AIM

To report the experience in pediatric hemodialysis in two pediatric hospitals in Chile that are reference centers for renal transplantation.

PATIENTS AND METHODS

Sixty patients, 55% female, aged 2 to 15 years old, admitted to the dialysis and transplant program since 1987, with a creatinine clearance of less than 20 ml/min/1.73 m2, were studied.

RESULTS

Twenty percent of children were less than 5 years old at the moment of admittance to the program and 3.3% weighed less that 10 kg. Etiologies of end stage renal disease were glomerulopathies in 33.4%, reflux nephropathy in 27.7%, obstructive uropathy in 13.3%, hypoplasia/dysplasia in 10%, hereditary problems in 8.3% and vascular disorders in 5%. Eighty six percent of patients were dialyzed less than 2 years and 5% more than 4 years. Fifty percent had received prior medical treatment, 5% had been treated with intermittent peritoneal dialysis, 5% with chronic ambulatory peritoneal dialysis and 20% presented as a terminal renal failure. Sixty two percent received a renal graft, 25% is still on hemodialysis, 3.3% switched to chronic ambulatory peritoneal dialysis, 3.3% had a recovery of renal function and 6.7% died being on hemodialysis. Arterio-venous fistulae were the vascular accesses in 75% of patients, double lumen catheters in 50% and vein grafts in 5%. Malfunctioning or infections were the main complications of arterio-venous fistulae, accounting for 30% of hospital admissions.

CONCLUSIONS

The availability of new vascular accesses and new hemodialysis machines specially designed for children, along with specially trained health care personnel, should reduce the mortality and complication rates of hemodialysis in this age group.