Discovery of Gamma Rays from the Quiescent Sun with HAWC

We report the first detection of a TeV γ-ray flux from the solar disk (6.3σ), based on 6.1 years of data from the High Altitude Water Cherenkov (HAWC) observatory. The 0.5-2.6 TeV spectrum is well fit by a power law, dN/dE=A(E/1  TeV)^{-γ}, with A=(1.6±0.3)×10^{-12}  TeV^{-1} cm^{-2} s^{-1} and γ=3.62±0.14. The flux shows a strong indication of anticorrelation with solar activity. These results extend the bright, hard GeV emission from the disk observed with Fermi-LAT, seemingly due to hadronic Galactic cosmic rays showering on nuclei in the solar atmosphere. However, current theoretical models are unable to explain the details of how solar magnetic fields shape these interactions. HAWC's TeV detection thus deepens the mysteries of the solar-disk emission.

Abstract A09: Predicting recurrence or second breast cancer using linked claims and cancer registry data with limited gold-standard information: A gradient-boosting approach

Background: Cancer recurrence is a major event affecting the burden of the disease and is a critical decision point for patients and their providers. Population-based information on the risk of cancer recurrence is lacking because it is not routinely collected by cancer registries.

Objective: To develop and implement a scalable, supervised learning algorithm to predict breast cancer recurrence status using information about disease at diagnosis from registry data and information about health care utilization from medical claims.

Data: Medical claims from private insurers and Medicare (2011-2016) linked with the Puget Sound SEER Cancer Registry were made available via the Hutch Institute for Cancer Outcomes Research (HICOR). Gold-standard information on the recurrence of initially localized breast cancer was provided by investigators on the BRAVO study of breast cancer survivors diagnosed 2004-2016 in the Puget Sound area. The HICOR and BRAVO data were linked. The analysis dataset consisted of 111 patients with a recurrence or second breast cancer event and 689 patients without a recurrence or second breast cancer event who had adequate claims (insurance enrollment before and after their second event or for at least 12 consecutive months after primary treatment) available for analysis.

Methods: A gradient-boosting algorithm (XGBoost) was harnessed to predict month-level recurrence status, i.e., whether any given month was before or after a recurrence event. Features included registry information on patient demographics, initial extent of disease, and hormone-receptor, and engineered features based on the counts of diagnosis, procedure and drug claims within groups determined by a blend of previously defined groups and groups customized for this application. Time-varying features included monthly counts of codes within each group, months since the most recent and subsequent occurrence of each code group, and cumulative sums of each code group. Subjects were split into a training (n=94) and test (n=17) set for reporting performance results. The training data were further split 5:1 for cross-validation purposes.

Results: The list of most important variables included time since coding of secondary malignancy, cumulative sum of codes related to pathology, and codes related to catheter placement. The month-specific AUC on a validation subset (n=17 patients) was 0.89; individual-level (sensitivity, specificity) ranged from (0.824, 0.946) to (0.706,0.982).

Conclusions: Data sources that link claims, cancer registry, and gold-standard disease status information are critical for the development of novel, automated approaches for detecting cancer recurrence. Gradient-boosted learning with engineered time-varying features shows promise for identifying recurrence events in administrative claims. Proper coding of procedure and drug groups is likely to be key to the performance of such algorithms. Incompleteness of claims data is a major challenge.

Citation Format: Teresa A'mar, Daniel Markowitz, Jessica Chubak, David Beatty, Catherine Fedorenko, Christopher Li, Kathi Malone, Ruth Etzioni. Predicting recurrence or second breast cancer using linked claims and cancer registry data with limited gold-standard information: A gradient-boosting approach [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr A09.

Constraints on Lorentz Invariance Violation from HAWC Observations of Gamma Rays above 100 TeV

Because of the high energies and long distances to the sources, astrophysical observations provide a unique opportunity to test possible signatures of Lorentz invariance violation (LIV). Superluminal LIV enables the decay of photons at high energy. The high altitude water Cherenkov (HAWC) observatory is among the most sensitive gamma-ray instruments currently operating above 10 TeV. HAWC finds evidence of 100 TeV photon emission from at least four astrophysical sources. These observations exclude, for the strongest of the limits set, the LIV energy scale to 2.2×10^{31}  eV, over 1800 times the Planck energy and an improvement of 1 to 2 orders of magnitude over previous limits.

Multiple Galactic Sources with Emission Above 56 TeV Detected by HAWC

We present the first catalog of gamma-ray sources emitting above 56 and 100 TeV with data from the High Altitude Water Cherenkov Observatory, a wide field-of-view observatory capable of detecting gamma rays up to a few hundred TeV. Nine sources are observed above 56 TeV, all of which are likely galactic in origin. Three sources continue emitting past 100 TeV, making this the highest-energy gamma-ray source catalog to date. We report the integral flux of each of these objects. We also report spectra for three highest-energy sources and discuss the possibility that they are PeVatrons.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Publisher Correction: Very-high-energy particle acceleration powered by the jets of the microquasar SS 433

In this Letter, owing to a production error, the penultimate version of the PDF was published. The HTML version was always correct. The PDF has been corrected online.

Extended gamma-ray sources around pulsars constrain the origin of the positron flux at Earth

The unexpectedly high flux of cosmic-ray positrons detected at Earth may originate from nearby astrophysical sources, dark matter, or unknown processes of cosmic-ray secondary production. We report the detection, using the High-Altitude Water Cherenkov Observatory (HAWC), of extended tera-electron volt gamma-ray emission coincident with the locations of two nearby middle-aged pulsars (Geminga and PSR B0656+14). The HAWC observations demonstrate that these pulsars are indeed local sources of accelerated leptons, but the measured tera-electron volt emission profile constrains the diffusion of particles away from these sources to be much slower than previously assumed. We demonstrate that the leptons emitted by these objects are therefore unlikely to be the origin of the excess positrons, which may have a more exotic origin.

Young, Male and Feeling Suicidal in Ireland: Is Help or Harm Just One Click Away?

Reports suggest an association between internet use and the elevated risk of suicide and self harm. This study examined the resources a suicidal person might find when searching the internet 'front page' for help. Voluntary suicide help websites accounted for 7/12 front page hits. The National Suicide Research Foundation (NSRF) and the National Office for Suicide Prevention (NOSP), a blog and a newspaper article made up the remainder. Sites were difficult to navigate and highly variable in content. Phone credit was required in many cases in order to contact helplines; opening hours and locations were limited. Most statutory websites referred help-seekers to the voluntary sector, mainly the Samaritans. Information on fundraising and volunteering competed with other sources of help. Of concern, the front page also included links to methods to complete suicide. Irish professional medical bodies offered very limited advice. Our findings suggest that online information is variable and potentially harmful. There is an opportunity for all agencies and providers to generate a co-ordinated internet front page tailored for at-risk groups.

A genome-wide association study of early-onset breast cancer identifies PFKM as a novel breast cancer gene and supports a common genetic spectrum for breast cancer at any age

Early-onset breast cancer (EOBC) causes substantial loss of life and productivity, creating a major burden among women worldwide. We analyzed 1,265,548 Hapmap3 single-nucleotide polymorphisms (SNP) among a discovery set of 3,523 EOBC incident cases and 2,702 population control women ages ≤ 51 years. The SNPs with smallest P values were examined in a replication set of 3,470 EOBC cases and 5,475 control women. We also tested EOBC association with 19,684 genes by annotating each gene with putative functional SNPs, and then combining their P values to obtain a gene-based P value. We examined the gene with smallest P value for replication in 1,145 breast cancer cases and 1,142 control women. The combined discovery and replication sets identified 72 new SNPs associated with EOBC (P < 4 × 10(-8)) located in six genomic regions previously reported to contain SNPs associated largely with later-onset breast cancer (LOBC). SNP rs2229882 and 10 other SNPs on chromosome 5q11.2 remained associated (P < 6 × 10(-4)) after adjustment for the strongest published SNPs in the region. Thirty-two of the 82 currently known LOBC SNPs were associated with EOBC (P < 0.05). Low power is likely responsible for the remaining 50 unassociated known LOBC SNPs. The gene-based analysis identified an association between breast cancer and the phosphofructokinase-muscle (PFKM) gene on chromosome 12q13.11 that met the genome-wide gene-based threshold of 2.5 × 10(-6). In conclusion, EOBC and LOBC seem to have similar genetic etiologies; the 5q11.2 region may contain multiple distinct breast cancer loci; and the PFKM gene region is worthy of further investigation. These findings should enhance our understanding of the etiology of breast cancer.

Abstract 3669: Bisphosphonate use following first primary ER+ breast cancer and risk of second primary breast cancer

Background: Recent studies suggest that bisphosphonates, drugs commonly prescribed for the prevention and treatment of osteoporosis, may reduce risk of developing a first breast cancer. This is the first population-based assessment of the effect of bisphosphonate use on risk of developing a second breast cancer among breast cancer survivors.

Methods: Within a population-based nested case-control study of women diagnosed with a first primary ER+ invasive breast cancer (BC) at ages 40-79, we assessed the association between bisphosphonate use after first breast cancer diagnosis and risk of asynchronous primary in the contralateral breast (CBC). Conditional logistic regression was used to compare 359 CBC cases to 649 incidence density matched controls (women not diagnosed with CBC). Analyses of duration were restricted to women followed for similar time periods.

Results: Use of nitrogenous bisphosphonates for ≥12 months following first primary ER+ BC diagnosis was associated with a 56% decrease in CBC risk relative to no bisphosphonate use in this period (95% CI: 0.24-0.80, p-value: 0.008). Increasing duration of bisphosphonate use was associated with greater reductions in CBC risk (OR≥6months: 0.52, 95% CI: 0.31-0.89, p-value: 0.02; OR≥16months: 0.42, 95% CI: 0.21-0.83, p-value: 0.01; OR≥36months: 0.25, 95% CI: 0.07-0.84, p-value: 0.03). Use within 6 months also appeared protective (OR: 0.50, CI: 0.29-0.88, p-value: 0.02).

Conclusions: This study suggests that use of nitrogenous bisphosphonates, following diagnosis with ER+ BC, may reduce second primary CBC. Given bisphosphonate tolerability and other potential benefits in this high-risk population, bisphosphonate therapy may be a feasible approach for CBC risk reduction, and merits further investigation.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3669. doi:10.1158/1538-7445.AM2011-3669

Sleep hygiene use in a psychiatry outpatient setting

Non-pharmacological measures are recommended prior to use of hypnotics in the latest NICE guidance. This study investigated if non-pharmacological measures are utilised prior to hypnotic prescribing in a general adult psychiatry outpatient setting, and further reviewed patient's sleep quality following implementation of sleep hygiene education. Interviews were conducted with 85 patients, and poor adherence with NICE guidance was found among the 74 (87%) patients previously prescribed a hypnotic. Just five (6.8%) patients recalled use of non-pharmacological measures prior to hypnotic prescription, 47 (63.5%) indicated non-pharmacological measures had not been discussed, while a further 22 (29.7%) could not remember. Improvement in Pittsburgh Sleep Quality Index scores following implementation of sleep hygiene education was also noted (P = 0.03). These findings suggest that increased awareness of sleep hygiene education for clinicians may be beneficial.

Abstract 5739: Lifetime recreational physical activity, hormone therapy use and breast cancer risk in postmenopausal women

Studies consistently demonstrate that physical activity is inversely associated with postmenopausal breast cancer. Whether the strength of this association varies with exposure to menopausal hormone therapy (HT) is clearly important given the marked decline in HT use since 2002. The Women's Contraceptive and Reproductive Experiences Study, a multi-center population-based case-control study of invasive breast cancer recruited white women and black women ages 35-64 years, and collected histories of lifetime exercise activity and HT use. Unconditional logistic regression models assessed possible associations between lifetime exercise activity measures (hr/wk/yr and metabolic equivalents of energy expenditure [MET]-hrs/wk/yr) and breast cancer among postmenopausal women (1908 case patients, 2013 control subjects) stratified by duration of HT use (never, ≤5 years of use, or ≥5 years of use), and current HT-use status (current use of estrogen-alone therapy [ET], current use of estrogen plus progestin therapy [EPT], or past HT use). Breast cancer risk decreased as level of physical activity increased among women who had never used HT, among women who used HT for fewer than 5 years, and among current ET users; Ptrend values ranged from 0.004 to 0.019. Despite the lack of association among long-term HT users, current EPT users, and past HT users, no statistical heterogeneity of trends was observed across duration-of-use categories or by current-use status. Although the inverse association between physical activity and breast cancer was limited to women with no HT use, short duration of HT use or current ET use, this study did not demonstrate effect modification by HT use.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5739.

Possible socioeconomic and ethnic disparities in quality of life in a cohort of breast cancer survivors

BACKGROUND

This paper describes the ethnic and socioeconomic correlates of functioning in a cohort of long-term nonrecurring breast cancer survivors.

METHODS

Participants (n = 804) in this study were women from the Health, Eating, Activity, and Lifestyle (HEAL) Study, a population-based, multicenter, multiethnic, prospective study of women newly diagnosed with in situ or Stages I to IIIA breast cancer. Measurements occurred at three timepoints following diagnosis. Outcomes included standardized measures of functioning (MOS SF-36).

RESULTS

Overall, these long-term survivors reported values on two physical function subscales of the SF-36 slightly lower than population norms. Black women reported statistically significantly lower physical functioning (PF) scores (P = 0.01), compared with White and Hispanic women, but higher mental health (MH) scores (P < 0.01) compared with White and Hispanic women. In the final adjusted model, race was significantly related to PF, with Black participants and participants in the "Other" ethnic category reporting poorer functioning compared to the White referent group (P < 0.01, 0.05). Not working outside the home, being retired or disabled and being unemployed (on leave, looking for work) were associated with poorer PF compared to currently working (both P < 0.01).

CONCLUSION

These data indicate that race/ethnicity influences psychosocial functioning in breast cancer survivors and can be used to identify need for targeted interventions to improve functioning.

Association between Antibiotic use Prior to Breast Cancer Diagnosis and Breast Tumour Characteristics (United States)

OBJECTIVE

To determine if breast tumour characteristics varied by antibiotic use prior to diagnosis in 2,266 women with primary, invasive breast cancer.

METHODS

Subjects were women enrolled at Group Health Cooperative, a health plan in western Washington state, for at least 1 year and diagnosed with breast cancer between 1 January 1993 and 30 June 2001. Case status, tumour features, and patient characteristics were ascertained from the Surveillance, Epidemiology, and End Results cancer registry and Group Health Cooperative electronic files. Prescription information was obtained from electronic pharmacy records.

RESULTS

Compared to non-use, antibiotic use prior to breast cancer diagnosis was not associated with a less favourable tumour profile (as measured by cancer stage, grade, and size), oestrogen receptor negative tumours, or lobular histology, after controlling for age and length of enrollment. Nonetheless, while not achieving statistical significance, our results suggest that antibiotic use may be associated with less favourable breast tumour features.

CONCLUSIONS

Overall, we found no association between antibiotic use and breast tumour features and no dose-response gradient. However, the results are consistent with the possibility that antibiotic use may increase the risk of less favourable tumours. Larger studies are required to further investigate this hypothesis.

Mouse models of human cancer web-based resources

The Mouse Models of Human Cancers Consortium (MMHCC) is a collaborative program designed to derive and characterize mouse models of human malignancies. To enhance information and resource exchange among the MMHCC investigators and other cancer research scientists, the NCI Center for Bioinformatics (NCICB, http://ncicb.nci.nih.gov/) has developed web-based resources that are freely available to the cancer research community. These resources include a website (http://emice.nci.nih.gov) and databases for cancer models (http://cancermodels.nci.nih.gov) and cancer images (http://cancerimages.nci.nih.gov).

Do thyroid disorders increase the risk of breast cancer?

The objective of this study was to determine whether thyroid disorders or treatment of such disorders affects the risk of breast cancer. Subjects aged 35-64 years were participants in the National Institute of Child Health and Human Development Women's Contraceptive and Reproductive Experiences Study, a population-based, case-control study of invasive breast cancer that was carried out at five sites in the United States. In-person interviews were completed for 4575 women (cases) with breast cancer (2953 white and 1622 black) and 4682 control women (3021 white and 1661 black). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multiple logistic regression methods. Models included adjustment for age (5-year age groups), race (white or black), and site. A history of any thyroid disorder (OR = 1.1, 95% CI = 0.9-1.2) was not associated with breast cancer risk. Only women with a history of thyroid cancer had an increased risk, but this was restricted to parous women (parous OR = 3.4, 95% CI = 1.5-8.1; nulliparous OR = 0.5, 95% CI = 0.04-5.1). Breast cancer risk was not associated with treatment for thyroid disorders. There was no statistical interaction between thyroid disorders, thyroid treatments, and race, menopausal status, or parity. We found no association between thyroid disorders or their associated treatments and the risk of breast cancer.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Risk of subsequent breast cancer in relation to characteristics of screening mammograms from women less than 50 years of age

This investigation was conducted to assess the predictive value of calcifications and densities in mammograms from women <50 years of age for subsequent diagnosis of breast cancer. In a population-based study, prior screening mammograms taken before age 50 in 547 women with breast cancer and 472 controls were reviewed by a single radiologist. The relative risk (RR) of subsequent breast cancer increased with the percentage of the area of the mammogram that was mammographically dense [RR in succeeding quartiles of density = 1.0, 1.7 (1.1-2.6), 3.3 (2.2-5.0), and 4.0 (2.7-6.0)]; in relation to Wolfe parenchymal pattern class P2 [RR = 3.1 (2.2-4.3)] or DY [RR = 5.6 (3.2-10.0)]; and in relation to calcifications of class 1 (pleomorphic of any distribution) or class 2 (various morphological types that are regional, grouped, clustered, segmental, or linear in distribution) [RR = 3.0 (1.4-7.1), and 1.8 (1.2-2.6), respectively]. Women with radiographically dense mammograms and class 1 or 2 calcifications were at >10- and approximately 6-fold greater risk, respectively, than women with breasts of low density and no calcifications. Densities and parenchymal patterns were most strongly associated with breast cancer being diagnosed in the next 3 years. Class 1 and 2 calcifications were most strongly predictive of an increased risk in 3-6 years. Class 1 calcifications were strongly predictive of the breast in which the subsequent cancer occurred. Women <50 years of age with class 1 or 2 calcifications or mammographically dense breasts, or both, should receive high priority for further evaluation and regular breast cancer screening.

Outcomes of family-centered residential treatment

This article describes a family-centered residential treatment model and presents results from a quasiexperimental study examining its effectiveness in achieving permanency outcomes for children. Greater postdischarge stability was achieved for participants in the family-centered program than in the agency's standard residential treatment service. Implications for child welfare policy and practice are highlighted.

Comparison of a 6-hour and 9-hour protocol for evaluation of moderate-to-low risk chest pain patients in an emergency department diagnostic unit

OBJECTIVE

To compare the 30-day outcomes of patients enrolled in a 6-hour and 9-hour emergency department (ED)-based chest pain centre (CPC) protocol.

METHODS

All patients with the chief complaint of chest pain, who were older than 25 years, or with cocaine usage within 96 hours of initial presentation, were eligible for enrolment. Exclusion criteria included acute ST-segment elevation or depression >1 mm in 2 contiguous leads, history of coronary artery disease (CAD), haemodynamic instability or clinical syndromes consistent with unstable angina. Outcomes included ED disposition and cardiac events at 30 days (defined as acute myocardial infarction (AMI), percutaneous trans-luminal coronary angiography (PTCA), coronary artery bypass graft surgery (CABG),ventricular tachycardia or fibrillation (VT/VF) arrest, congestive heart failure (CHF) admission or cardiac-related death). The 9-hour protocol consisted of ST-segment monitoring,serial CK-MB draws at 0, 3,6 and 9 hours as well as a graded exercise test (GXT) prior to ED disposition. The 6-hour protocol eliminated the 9-hour serum marker determination, included cardiac Troponin-I (cTn-I) and allowed a GXT, 3 hours earlier. Follow-up was obtained by medical record review, phone contact, letter and also review of national and state death registries.

RESULTS

The 9-hour protocol (October 1991-December 1997) included 2,133 patients and the 6-hour protocol (January 1998- August 1998) had 184 patients enrolled. The 6-hour protocol was not different from the 9-hour one in terms of percentage admissions (9-hour: 310, 14.5%; 6-hour: 33, 17.9%; p=0.213), Coronary Care Unit admission (9-hour: 59, 2.8%; 6-hour: 5, 2.7%; p=0.303) or 30-day cardiac events (9-hour: 38, 1.9%; 6-hour: 2, 1.3%; p=0.605).

CONCLUSION

The 6-hour CPC strategy is an effective and safe evaluation method for patients at low to moderate risk for acute coronary syndromes.

Participation in breast cancer risk counseling among women with a family history

Recent scientific breakthroughs in the genetics of breast cancer may have had effects on women's perceptions of risk and subsequent worry about breast cancer. Here, we present the rates of interest in counseling among women identified from diverse sources, their levels of cancer worry and perceived risk, and predictors of their agreement to participate in breast cancer risk counseling. Women were identified through breast cancer cases and through media offers. They completed a telephone survey and were ultimately either entered or not entered into a counseling trial. Overall, almost half (46%) of cases who were approached responded to the contact letter asking for information about potentially interested relatives. A total of 588 women responded to the brief media solicitations over a 15-week period. Participants recruited from media contacts reported slightly but significantly higher levels of worry about getting cancer, compared to case-recruited participants. Cancer worry negatively and significantly predicted entry into the counseling project. The results presented here may have implications for recruiting women in the general population with a family history of breast cancer for counseling about their risk for the disease.

Identifying and mapping novel retinal-expressed ESTs from humans

PURPOSE

The goal of this study was to develop efficient methods to identify tissue-specific expressed sequence tags (ESTs) and to map their locations in the human genome. Through a combination of database analysis and laboratory investigation, unique retina-specific ESTs were identified and mapped as candidate genes for inherited retinal diseases.

METHODS

DNA sequences from retina-specific EST clusters were obtained from the TIGR Human Gene Index Database. Further processing of the EST sequence data was necessary to ensure that each EST cluster represented a novel, non-redundant mapping candidate. Processing involved screening for homologies to known genes and proteins using BLAST, excluding known human gene sequences and repeat sequences, and developing primers for PCR amplification of the gene encoding each cDNA cluster from genomic DNA. The EST clusters were mapped using the GeneBridge 4.0 Radiation Hybrid Mapping Panel with standard PCR conditions.

RESULTS

A total of 83 retinal-expressed EST clusters were examined as potential novel, non-redundant mapping candidates. Fifty-five clusters were mapped successfully and their locations compared to the locations of known retinal disease genes. Fourteen EST clusters localize to candidate regions for inherited retinal diseases.

CONCLUSIONS

This pilot study developed methodology for mapping uniquely expressed retinal ESTs and for identifying potential candidate genes for inherited retinal disorders. Despite the overall success, several complicating factors contributed to the high failure rate (33%) for mapping EST-clustered sequences. These include redundancy in the sequence data, widely dispersed sequences, ambiguous nucleotides within the sequences, the possibility of amplifying through introns and the presence of repetitive elements within the sequence. However, the combination of database analysis and laboratory mapping is a powerful method for identification of candidate genes for inherited diseases.

Characteristics of women who use perineal powders

OBJECTIVE

To examine demographic and behavioral factors related to perineal application of powders.

METHODS

Controls from three case-control studies (N = 1206) were asked identical questions about the use of genital powders by direct perineal application. The relationship of perineal powder application with demographic factors, reproductive factors, body mass index (BMI), douching, and alcohol and tobacco use was assessed. Data were analyzed by multiple logistic regression.

RESULTS

Women who douched (prevalence odds ratio [prevalence OR] 2.0, 95% confidence interval [CI] 1.0, 3.9), drank alcohol (prevalence OR 1.8, 95% CI 1.2, 2.8), smoked cigarettes (prevalence OR 1.3, 95% CI 1.0, 1.8), or were in the highest BMI quartile were more likely to engage in perineal use of powder (prevalence OR 1.6, 95% CI 1.1, 2.6). There appeared to be a close response relationship between the number of perineal applications of powder and BMI (P < .002).

CONCLUSION

Body mass index might confound the relationship between perineal powder application and the development of ovarian cancer. Other factors, such as alcohol and tobacco use and douching, are related to perineal use of powder and may represent similar behavioral characteristics.

Standards and practice guidelines as the foundation for clinical practice

The structure and organization of health care delivery are in the midst of rapid change. Health care providers from a variety of disciplines are being challenged to define their practice and the expected patient outcomes resulting from their processes of care delivery. Standards and clinical practice guidelines are important tools for enhancing the quality of health care delivery and for documenting care. The article describes a process for developing standards and clinical practice guidelines and presents an organizational scheme for them. Based on recommendations from diverse national groups, a format for practice guidelines is presented, and a system for implementation and ongoing evaluation is recommended.

Breast cancer and hormonal contraceptives: further results. Collaborative Group on Hormonal Factors in Breast Cancer

The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on breast cancer risk and use of hormonal contraceptives. Original data from 54 studies, representing about 90% of the information available on the topic, were collected, checked and analysed centrally. The 54 studies were performed in 26 countries and include a total of 53,297 women with breast cancer and 100,239 women without breast cancer. The studies were varied in their design, setting and timing. Most information came from case-control studies with controls chosen from the general population; most women resided in Europe or North America and most cancers were diagnosed during the 1980s. Overall 41% of the women with breast cancer and 40% of the women without breast cancer had used oral contraceptives at some time; the median age at first use was 26 years, the median duration of use was 3 years, the median year of first use was 1968, the median time since first use was 16 years, and the median time since last use was 9 years. The main findings, summarised elsewhere, are that there is a small increase in the risk of having breast cancer diagnosed in current users of combined oral contraceptives and in women who had stopped use in the past 10 years but that there is no evidence of an increase in the risk more than 10 years after stopping use. In addition, the cancers diagnosed in women who had used oral contraceptives tended to be less advanced clinically than the cancers diagnosed in women who had not used them. Despite the large number of possibilities investigated, few factors appeared to modify the main findings either in recent or in past users. For recent users who began use before age 20 the relative risks are higher than for recent users who began at older ages. For women whose use of oral contraceptives ceased more than 10 years before there was some suggestion of a reduction in breast cancer risk in certain subgroups, with a deficit of tumors that had spread beyond the breast, especially among women who had used preparations containing the highest doses of oestrogen and progestogen. These findings are unexpected and need to be confirmed. Although these data represent most of the epidemiological evidence on the topic to date, there is still insufficient information to comment reliably about the effects of specific types of oestrogen or of progestogen. What evidence there is suggests, however, no major differences in the effects for specific types of oestrogen or of progestogen and that the pattern of risk associated with use of hormonal contraceptives containing progestogens alone may be similar to that observed for preparations containing both oestrogens and progestogens. On the basis of these results, there is little difference between women who have and have not used combined oral contraceptives in terms of the estimated cumulative number of breast cancers diagnosed during the period from starting use up to 20 years after stopping. The cancers diagnosed in women who have used oral contraceptives are, however, less advanced clinically than the cancers diagnosed in never users. Further research is needed to establish whether the associations described here are due to earlier diagnosis of breast cancer in women who have used oral contraceptives, to the biological effects of the hormonal contraceptives or to a combination of both. Little information is as yet available about the effects on breast cancer risk of oral contraceptive use that ceased more than 20 years before and as such data accumulate it will be necessary to re-examine the worldwide evidence.

Casting in sport

Attempts by sports medicine professionals to return high school athletes with hand and wrist injuries to competition quickly and safely have been the source of confusion and debate on many playing fields around the country. In addition to the differing views regarding the appropriateness of playing cast usage in high school football, a debate exists among sports medicine professionals as to which material is best suited for playing cast construction. Materials used in playing cast construction should be hard enough to provide sufficient stabilization to the injured area and include adequate padding to absorb blunt impact forces. The purpose of the biomechanical portion of this investigation was to attempt to determine the most appropriate materials for use in constructing playing casts for the hand and wrist by assessing different materials for: 1) hardness using a Shore durometer, and 2) ability to absorb impact using a force platform. Results revealed that RTV11 and Scotchcast were the "least hard" of the underlying casting materials and that Temper Stick foam greatly increased the ability of RTV11 to absorb impact. Assessment of the mechanical properties of playing cast materials and review of current developments in high school football rules are used to aid practitioners in choosing the most appropriate materials for playing cast construction.

Characterization of lymphocytic infiltrates in normal, preneoplastic, and neoplastic mouse mammary tissues

Lymphocytic infiltrates were isolated from normal, preneoplastic, and neoplastic mouse mammary tissues. The surface markers on the infiltrating lymphocytes were characterized by immunofluorescent staining and flow cytometry. Preneoplastic and neoplastic tissues contained 10- to 20-fold more in situ lymphocytes than did the normal pregnant gland. Most of these lympocytes were T-cells. Relative to the T-cells in normal gland, the T-cells in C4 preneoplastic hyperplastic alveolar nodules and their spontaneous tumors have shifted in favor of the killer-suppressor subpopulation. This shift of T-cell subpopulations was a localized phenomenon and was not seen in the lymph nodes of hyperplastic alveolar nodules and tumor bearing mice. C4 lesion infiltrating cells also contained a subpopulation of lymphocytes that expressed 5- to 6-fold more LFA-1 antigen (lymphocyte function associated antigen-1) than did normal lymph node cells. The infiltrating lymphocytes of mammary tumors from cloned cell lines, on the contrary, had the same staining profile as did the lymphocytes from normal gland. Since most studies with human breast cancer infiltrates have demonstrated increased killer/suppressor T-cells and the presence of activated lymphocytes (J. Hurlimann and P. Saraga, Int. J. Cancer, 35: 753-762, 1985; H.L. Whitwell, H.P.A. Hughes, M. Moore, and A. Ahmed, Br. J. Cancer, 49: 161-172, 1984; and J.A. Ledbetter, R.V. Rouse, H. Spedding Micklem, and L. Herzenberg, J. Exp. Med., 152: 280-295, 1980) the C4 hyperplastic alveolar nodules and spontaneous tumor system may be a more relevant model for studying breast cancer infiltrates.