Longitudinal changes of the femoral bone mineral density from first to third trimester of pregnancy: bone health assessment by means of non-ionizing REMS technology

BACKGROUND

Throughout the pregnancy, there is a substantial transfer of calcium from the maternal skeleton to the fetus, which leads to a transient net reduction of the maternal bone mineral density.

AIMS

To assess longitudinally the changes in the bone mineral density at the femoral neck between the first and third trimester of pregnancy in a cohort of healthy participants using Radiofrequency Echographic Multi Spectrometry (REMS) technology.

METHODS

Prospective, cohort study conducted at the University hospital of Parma, Italy between July 2022 and February 2023. We recruited healthy participants with an uncomplicated singleton pregnancy before 14 completed weeks of gestation. All included participants were submitted to a sonographic examination of the femoral neck to assess the bone mineral density (and the corresponding Z-score values) using REMS at 11-13 and 36-38 weeks of pregnancy. The primary outcome was the change in the bone mineral density values at the maternal femoral neck between the first and third trimester of pregnancy.

RESULTS

Over a period of 7 months, a total of 65 participants underwent bone mineral density measurement at the femoral neck at first and third trimester of the pregnancy using REMS. A significant reduction of the bone mineral density at the femoral neck (0.723 ± 0.069 vs 0.709 ± 0.069 g/cm2; p < 0.001) was noted with a mean bone mineral density change of - 1.9 ± 0.6% between the first and third trimester of pregnancy. At multivariable linear regression analysis, none of the demographic or clinical variables of the study population proved to be independently associated with the maternal bone mineral density changes at the femoral neck.

CONCLUSIONS

Our study conducted on a cohort of healthy participants with uncomplicated pregnancy demonstrates that there is a significant reduction of bone mineral density at femoral neck from early to late gestation.

Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years

BACKGROUND

Accurate estimation of the imminent fragility fracture risk currently represents a challenging task. The novel Fragility Score (FS) parameter, obtained during a Radiofrequency Echographic Multi Spectrometry (REMS) scan of lumbar or femoral regions, has been developed for the non-ionizing estimation of skeletal fragility.

AIMS

The aim of this study was to assess the performance of FS in the early identification of patients at risk for incident fragility fractures with respect to bone mineral density (BMD) measurements.

METHODS

Data from 1989 Caucasians of both genders were analysed and the incidence of fractures was assessed during a follow-up period up to 5 years. The diagnostic performance of FS to discriminate between patients with and without incident fragility fracture in comparison to that of the BMD T-scores measured by both Dual X-ray Absorptiometry (DXA) and REMS was assessed through ROC analysis.

RESULTS

Concerning the prediction of generic osteoporotic fractures, FS provided AUC = 0.811 for women and AUC = 0.780 for men, which resulted in AUC = 0.715 and AUC = 0.758, respectively, when adjusted for age and body mass index (BMI). For the prediction of hip fractures, the corresponding values were AUC = 0.780 for women and AUC = 0.809 for men, which became AUC = 0.735 and AUC = 0.758, respectively, after age- and BMI-adjustment. Overall, FS showed the highest prediction ability for any considered fracture type in both genders, resulting always being significantly higher than either T-scores, whose AUC values were in the range 0.472-0.709.

CONCLUSION

FS displayed a superior performance in fracture prediction, representing a valuable diagnostic tool to accurately detect a short-term fracture risk.

AB1033 RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS) FOR THE ASSESSMENT OF FEMORAL BONE HEALTH IN A MALE POPULATION

Background

Bone mass reaches the peak during the third decade of life. By this age, men reach an increased bone mass that starts declining in their fifties, however less rapidly than women after menopause. However, men and women lose bone mass at the same rate by age 65-70, becoming fragile and more likely to have fracture.

Objectives

This study aimed to evaluate the diagnostic accuracy in osteoporosis diagnosis of Radiofrequency Echographic Multi Spectrometry (REMS) technology applied on the proximal femur in an adult male population in comparison with the Dual-energy X-ray Absorptiometry (DXA).

Methods

A cohort of Caucasian males was enrolled in the study. Inclusion criteria were: age between 30 and 90 years, body mass index (BMI) less than 40 kg/m2, no significant walking impairments and proximal femur DXA medical prescription. All the enrolled patients underwent proximal femur scans with both DXA and REMS. The agreement between REMS and DXA-measured BMD was expressed by Pearson correlation coefficient and Bland-Altman method. The classification into patients “with osteoporosis” or “without osteoporosis” was carried out considering the conventional threshold of T-score (-2.5) for both techniques independently. The accuracy was evaluated by the assessment of sensitivity and specificity considering the DXA outcome as reference [1].

Results

A total of 219 men were included in the analysis, with mean age of 55.5 (± 15.3) years. The Pearson correlation coefficient between REMS- and DXA-measured BMD values was r=0.94. At Bland-Altman analysis, Bias ± 1.96 Standard Deviation were -0.004 ± 0.04 g/cm2. The REMS capability to discriminate osteoporotic patients from non-osteoporotic ones was very high: a sensitivity of 90.0% and specificity of 91.8% was detected.

Conclusion

REMS, applied to the proximal femur site, is a reliable technology for the diagnosis of osteoporosis also in men, thus confirming the diagnostic performance already observed in studies carried out in female populations [1, 2].

References

[1]Di Paola P et al. Osteoporos Int. 2019; 30(2):391-402.

[2]Adami G et al. Bone 2020; 134:115297.

Disclosure of Interests

Fiorella Anna Lombardi: None declared, Paola Pisani: None declared, Alessandra Natale: None declared, Ernesto Casciaro Shareholder of: Ernesto Casciaro owns stocks of Echolight Spa, Marco Di Paola: None declared, Roberto Franchini: None declared, Maurizio Muratore: None declared, Francesco Conversano Shareholder of: Francesco Conversano owns stocks of Echolight Spa, Sergio Casciaro Shareholder of: Sergio Casciaro owns stocks of Echolight Spa

AB1373 RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS) AS AN ALTERNATIVE APPROACH TO BIOELECTRICAL IMPEDANCE ANALYSIS (BIA) FOR THE ASSESSMENT OF BODY COMPOSITION

Background

The evaluation of human body composition is crucial for body weight management, especially in pathological conditions. Patients whose body weight greatly exceeds or remain below the reference range, need regular monitoring in order to personalise the nutritional treatment plan. To this end, bioelectrical impedance analysis (BIA) is a widely accepted tool, along with ultrasound techniques.

Among emerging ultrasound-based technologies, Radiofrequency Echographic Multi Spectrometry (REMS) is a powerful approach that can be effectively used for body composition analysis.

Objectives

The present study aims to assess the accuracy of REMS in comparison to BIA for body composition assessment.

Methods

The cohort included 141 males and females aged between 60 and 80 years. All subjects underwent body mass measurement by REMS and BIA and both body fat percentage (BFP) and basal metabolic rate (BMR) parameters were assessed.

Results

The estimation of BFP measured with BIA resulted in 40.4% (interquartile range [IQR]: 35.5% to 45.2%), which value did not differ from 41.1% (IQR: 36.5% to 47.1%) obtained with REMS (p=0.6). The BMR determined by BIA was 1329.0 kcal/day (IQR: 1270.5 to 1423.5 kcal/day), which was in a similar range as the value of 1323.5 kcal/day (IQR: 1266.0 to 1420.0 kcal/day) assessed by REMS (p=0.7).

Conclusion

The present study demonstrated the excellent ability of REMS to accurately determine the body composition, resulting as an alternative approach to conventional BIA.

Disclosure of Interests

Paola Pisani: None declared, Alessandra Natale: None declared, Fiorella Anna Lombardi: None declared, Francesco Conversano Shareholder of: Francesco Conversano owns stocks of Echolight Spa, Ernesto Casciaro Shareholder of: Ernesto Casciaro owns stocks of Echolight Spa, Maurizio Muratore: None declared, Sergio Casciaro Shareholder of: Sergio Casciaro owns stocks of Echolight Spa

Novel artificial intelligence approach for automatic differentiation of fetal occiput anterior and non-occiput anterior positions during labor

OBJECTIVES

To describe a newly developed machine-learning (ML) algorithm for the automatic recognition of fetal head position using transperineal ultrasound (TPU) during the second stage of labor and to describe its performance in differentiating between occiput anterior (OA) and non-OA positions.

METHODS

This was a prospective cohort study including singleton term (> 37 weeks of gestation) pregnancies in the second stage of labor, with a non-anomalous fetus in cephalic presentation. Transabdominal ultrasound was performed to determine whether the fetal head position was OA or non-OA. For each case, one sonographic image of the fetal head was then acquired in an axial plane using TPU and saved for later offline analysis. Using the transabdominal sonographic diagnosis as the gold standard, a ML algorithm based on a pattern-recognition feed-forward neural network was trained on the TPU images to discriminate between OA and non-OA positions. In the training phase, the model tuned its parameters to approximate the training data (i.e. the training dataset) such that it would identify correctly the fetal head position, by exploiting geometric, morphological and intensity-based features of the images. In the testing phase, the algorithm was blinded to the occiput position as determined by transabdominal ultrasound. Using the test dataset, the ability of the ML algorithm to differentiate OA from non-OA fetal positions was assessed in terms of diagnostic accuracy. The F₁ -score and precision-recall area under the curve (PR-AUC) were calculated to assess the algorithm's performance. Cohen's kappa (κ) was calculated to evaluate the agreement between the algorithm and the gold standard.

RESULTS

Over a period of 24 months (February 2018 to January 2020), at 15 maternity hospitals affiliated to the International Study group on Labor ANd Delivery Sonography (ISLANDS), we enrolled into the study 1219 women in the second stage of labor. On the basis of transabdominal ultrasound, they were classified as OA (n = 801 (65.7%)) or non-OA (n = 418 (34.3%)). From the entire cohort (OA and non-OA), approximately 70% (n = 824) of the patients were assigned randomly to the training dataset and the rest (n = 395) were used as the test dataset. The ML-based algorithm correctly classified the fetal occiput position in 90.4% (357/395) of the test dataset, including 224/246 with OA (91.1%) and 133/149 with non-OA (89.3%) fetal head position. Evaluation of the algorithm's performance gave an F₁ -score of 88.7% and a PR-AUC of 85.4%. The algorithm showed a balanced performance in the recognition of both OA and non-OA positions. The robustness of the algorithm was confirmed by high agreement with the gold standard (κ = 0.81; P < 0.0001).

CONCLUSIONS

This newly developed ML-based algorithm for the automatic assessment of fetal head position using TPU can differentiate accurately, in most cases, between OA and non-OA positions in the second stage of labor. This algorithm has the potential to support not only obstetricians but also midwives and accoucheurs in the clinical use of TPU to determine fetal occiput position in the labor ward. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

First assessment of bone mineral density in healthy pregnant women by means of Radiofrequency Echographic Multi Spectrometry (REMS) technology

OBJECTIVE

The maternal bone structure is the largest calcium reserve for the fetus during pregnancy, and this is claimed to lead to a bone mineral density (BMD) reduction in pregnant women. The primary outcome of the present work was to assess the BMD in a group of healthy pregnant women.

STUDY DESIGN

In this prospective case - control observational study, a non-consecutive group of pregnant women with uncomplicated pregnancy at or >37 weeks were enrolled at the unit of Obstetrics and Gynecology, University of Parma, from February to December 2020. The study subjects were submitted to a sonographic examination of the proximal femur with Radiofrequency Echographic Multi Spectrometry (REMS) technology to quantify the BMD of the femur. The BMD values obtained in the study group were compared with those of a control group of non-pregnant women matched for age, ethnicity and pre-pregnant body mass index (BMI).

RESULTS

Overall, 78 pregnant women at 39.1 ± 1.5 weeks were assessed. Compared with non-pregnant women, the femoral BMD values measured in pregnancy using REMS were significant lower (0.769 ± 0.094 g/cm² vs 0.831 ± 0.101 g/cm², p = 0.0001) with a mean BMD reduction of 8.1%. The femoral neck BMD presented a positive correlation with the pre-pregnant BMI (p = 0.0004) and a negative correlation with the maternal age (p < 0.0001). In addition, a lower femoral neck BMD in Caucasian ethnicity compared with non-Caucasian was noted (p < 0.0001).

CONCLUSION

In this exploratory and proof of concept study, for the first time, a decreased BMD has been objectively demonstrated in pregnant compared with non-pregnant women by means of REMS technology. New studies are required to assess the longitudinal changes of maternal bone density throughout the pregnancy.

POS0163 INCIDENT FRACTURE RISK PREDICTION USING THE FRAGILITY SCORE CALCULATED BY LUMBAR SPINE RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS) SCANS

Background:

The main consequence of osteoporosis is the occurrence of fractures due to bone fragility, with important sequelae in terms of disability and mortality. It has been already demonstrated that the information about bone mass density (BMD) alone is not sufficient to predict the risk of fragility fractures, since several fractures occur in patients with normal BMD [1].

The Fragility Score is a parameter that allows to estimate skeletal fragility thanks to a trans-abdominal ultrasound scan performed with Radiofrequency Echographic Multi Spectrometry (REMS) technology. It is calculated by comparing the results of the spectral analysis of the patient’s raw ultrasound signals with reference models representative of fragile and non-fragile bones [2]. It is a dimensionless parameter, which can vary from 0 to 100, in proportion to the degree of fragility, independently from BMD.

Objectives:

This study aims to evaluate the effectiveness of Fragility Score, measured during a bone densitometry exam performed with REMS technology at lumbar spine, in identifying patients at risk of incident osteoporotic fractures at a follow-up period of 5 years.

Methods:

Caucasian women with age between 30 and 90 were scanned with spinal REMS and DXA. The incidence of osteoporotic fractures was assessed during a follow-up period of 5 years. The ability of the Fragility Score to discriminate between patients with and without incident fragility fractures was subsequently evaluated and compared with the discriminatory ability of the T-score calculated with DXA and with REMS.

Results:

Overall, 533 women (median age: 60 years; interquartile range [IQR]: 54-66 years) completed the follow-up (median 42 months; IQR: 35-56 months), during which 73 patients had sustained an incident fracture.

Both median REMS and DXA measured T-score values were significantly lower in fractured patients than for non-fractured ones, conversely, REMS Fragility Score was significantly higher (Table 1).

Table 1.

Analysis of T-score values calculated with REMS and DXA and Fragility Score calculated with REMS. Median values and interquartile ranges (IQR) are reported. The p-value is derived from the Mann-Whitney test.

Patients without incident fragility fracturePatients with incident fragility fracturep-valueT-score DXA[median (IQR)]-1.9 (-2.7 to -1.0)-2.6 (-3.3 to -1.7)0.0001T-score REMS[median (IQR)]-2.0 (-2.8 to -1.1)-2.7 (-3.5 to -1.9)<0.0001Fragility Score[median (IQR)]29.9 (25.7 to 36.2)53.0 (34.2 to 62.5)<0.0001

By evaluating the capability to discriminate patients with/without fragility fractures, the Fragility Score obtained a value of the ROC area under the curve (AUC) of 0.80, higher than the AUC of the REMS T-score (0.66) and of the T-score DXA (0.64), and the difference was statistically significant (Figure 1).

Figure 1.

ROC curve comparison of Fragility Score, REMS and DXA T-score values in the classification of patients with incident fragility fractures.

Furthermore, the correlation between the Fragility Score and the T-score values was low, with Pearson correlation coefficient r=-0.19 between Fragility Score and DXA T-score and -0.18 between the Fragility Score and the REMS T-score.

Conclusion:

The Fragility Score was found to be an effective tool for the prediction of fracture risk in a population of Caucasian women, with performances superior to those of the T-score values. Therefore, this tool presents a high potential as an effective diagnostic tool for the early identification and subsequent early treatment of bone fragility.

References:

[1]Diez Perez A et al. Aging Clin Exp Res 2019; 31(10):1375-1389.

[2]Pisani P et al. Measurement 2017; 101:243–249.

Disclosure of Interests:

None declared

Automatic measurement of head-perineum distance during intrapartum ultrasound: description of the technique and preliminary results

OBJECTIVES

To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth.

METHODS

HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard.

RESULTS

A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (r²=0.98) and low residual errors: RMSE = 2.01 mm (4.9%) were found.

CONCLUSION

The automatic algorithm for the assessment of the HPD represents a reliable technique.

SAT0461 SHORT-TERM MONITORING OF DENOSUMAB EFFECT IN BREAST CANCER PATIENTS RECEIVING AROMATASE INHIBITORS USING REMS TECHNOLOGY ON LUMBAR SPINE

Background:

Aromatase inhibitor (AI) therapy in women with estrogen receptor-positive (ER+) breast cancer (BC) causes accelerated bone loss and increased risk of osteoporosis and fractures as side effects. Denosumab (i.e. 60 mg twice a year) is a viable therapy against bone resorption, but the short-term monitoring of bone mineral density (BMD) change with time is still an unmet clinical need, since the current techniques (including dual-energy X-ray absorptiometry, DXA) require 1-2 years between two consecutive measurements [1]. Radiofrequency Echographic Multi Spectrometry (REMS), with high performance in terms of precision and repeatability [2], might be used in this setting of patients for short-term monitoring of bone health-related parameters.

Objectives:

The objective is the short-term monitoring of the effect of AIs with/without denosumab on bone health in BC patients using REMS and DXA scans at lumbar spine.

Methods:

Post-menopausal ER+ BC patients treated with adjuvant AIs were recruited. Two subgroups were identified, whether receiving also 60 mg of denosumab therapy every 6 months or not (named Group A and Group B, respectively). All patients underwent baseline DXA and REMS lumbar spine scans at time T0, previous to the first AI therapy, and after 12 months (time T1). REMS scan only was repeated also at 18 months (T2), since a 6-month interval between two consecutive scans is not recommended for DXA. The bone mineral density (BMD) was measured with both techniques.

Results:

Overall, 254 ER+ BC patients were enrolled (127 per group). The effect of denosumab on BMD is reported in Table. The BMD values obtained by DXA and REMS were not significantly different at T0 and T1, whereas the difference between Group A and B at T1 was statistically significant (p<0.001) both for REMS and DXA. At T2, REMS confirmed the increasing trend of BMD for Group A and the decreasing one for Group B, and the difference between groups was statistically significant (p<0.001). For each time point and each group, there were not statistically significant differences between DXA and REMS.

Conclusion:

Several studies have shown the effect of denosumab on BMD over a period not less than 2 years from the start of treatment. This study showed the feasibility of short-term follow-up using REMS lumbar spine scans at 6-month time steps.

References:

[1]Diez-Perez A et al, Aging Clin Exp Res 2019;31(10):1375–89

[2]Di Paola M et al, Osteoporos Int 2018;30:391–402

Table 1.

BMD values, expressed as g/cm2, measured by DXA and REMS for Group A (patients receiving AIs only) and Group B (patients receiving AIs and denosumab) at baseline (T0), 12 months (T1) and 18 months (T2) from the start of therapy. Results are presented as median values with 25thand 75thpercentiles. P-values are obtained with a Mann-Whitney test.

DXAREMSScan timeGroup AGroup BpGroup AGroup BpT00.840 (0.719-0.959)0.867 (0.723-0.958)0.990.833 (0.708-0.949)0.855 (0.714-0.973)0.77T10.823 (0.702-0.944)0.889 (0.749-0.990)0.0030.819 (0.691-0.927)0.887 (0.740-1.018)<0.001T2---0.801 (0.679-0.909)0.899 (0.754-1.020)<0.001

Note:The authorsD. Ciardo, M. Ciccarese, F. Conversano, M. Di Paola, R. Forcignanò, A. Grimaldi, F.A. Lombardi, M. Muratore and P. Pisaniare listed in alphabetical order

Disclosure of Interests:

None declared

AB1082 INFLUENCE OF THE VARIATION OF THE OPERATOR, PATIENT POSITION AND DEVICE ON THE MEASUREMENT PERFORMANCE OF RADIOFREQUENCY ECHOGRAPHIC MULTI SPECTROMETRY (REMS)

Background:

The monitoring of bone mineral density (BMD) is a key aspect for patients undergoing pharmacological treatments that might cause BMD changes at non-physiological rates. At present, the short-term follow-up of patients under treatment in terms of BMD change with time remains an unmet clinical need, since the current techniques, including the gold standard dual X-ray absorptiometry (DXA), require at least 1 year between two consecutive measurements [1]. Therefore, an effective strategy for the assessment of BMD should guarantee high accuracy, precision and repeatability of the measurements.

Objectives:

The aim is to assess the influence of the variation 1) in patient position, 2) operator (both intra- and inter-) and 3) device on the REMS performance at lumbar spine and femoral neck.

Methods:

210 women were enrolled, divided in 7 groups of 30-patient each for the assessment of the parameters of interest, i.e. inter-device, intra- and inter-operator repeatability for lumbar spine scans and inter-patient position, inter-device, intra- and inter-operator repeatability for femoral neck scans.

All patients underwent 2 REMS scans at lumbar spine or femoral neck, performed by the same operator or by 2 different operators or by the same operator using 2 different devices or in different patient position (i.e. supine without constraints or with a constrained 25°-rotation of the leg). The percentage coefficient of variation (CV%) with 95% confidence interval and least significant change for a 95% confidence level (LSC) have been calculated.

Results:

For lumbar spine, intra-operator repeatability resulted in CV%=0.37% (95%CI: 0.26%-0.48%), with LSC=1.02%, inter-operator repeatability resulted in CV%=0.55% (95% CI: 0.42%-0.68%), with LSC=1.52%, inter-device repeatability resulted in CV%=0.53% (95% CI: 0.40%-0.66%), with LSC=1.47%.

For femoral neck, intra-operator repeatability resulted in CV%=0.33% (95%CI: 0.23%-0.43%), with LSC=0.91%, inter-operator repeatability resulted in CV%=0.47% (95% CI: 0.35%-0.59%), with LSC=1.30%, inter-device repeatability resulted in CV%=0.42% (95% CI: 0.30%-0.51%), with LSC=1.16%, inter-patient position repeatability resulted in CV%=0.24% (95% CI: 0.18%-0.30%), with LSC=0.66%.

Conclusion:

REMS densitometry is highly precise for both anatomical sites, showing high performance in repeatability. These results suggest that REMS might be a suitable technology for short-term monitoring. Moreover, thanks to its ionizing radiation-free approach, it might be applied for population mass investigations and prevention programs also in paediatric patients and pregnant women.

References:

Note:Carla Caffarelli, Giovanni Adami§, Giovanni Arioli§, Gerolamo Bianchi§, Maria Luisa Brandi§, Sergio Casciaro§, Luisella Cianferotti§, Delia Ciardo§, Francesco Conversano§, Davide Gatti§, Giuseppe Girasole§, Monica Manfredini§, Maurizio Muratore§, Paola Pisani§, Eugenio Quarta§, Laura Quarta§, Stefano Gonnelli

§Equal contributors listed in alphabetical order

Disclosure of Interests:

Carla Caffarelli: None declared, Giovanni Adami: None declared, Giovanni Arioli *: None declared, Gerolamo Bianchi Grant/research support from: Celgene, Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB, Maria Luisa Brandi: None declared, Sergio Casciaro: None declared, Luisella Cianferotti: None declared, Delia Ciardo: None declared, Francesco Conversano: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Giuseppe Girasole: None declared, Monica Manfedini: None declared, Maurizio Muratore: None declared, Paola Pisani: None declared, Eugenio Quarta: None declared, Laura Quarta: None declared, Stefano Gonnelli: None declared

SUN-LB74 Radiofrequency Echographic Multi-Spectrometry (REMS) for the Assessment of Bone Strength and Fracture Risk Prediction

Introduction Fragility bone fractures impact patient’s quality of life and worldwide healthcare systems: accurate technologies and device are required in order to early diagnose and monitor the effect of osteoporosis on a mass-population basis. Several studied have analysed the pros and cons of the numerous technologies available nowadays for the diagnosis and monitoring of bone health, highlighting the need of further tools able to better define and estimate bone strength and to predict the risk of fracture [1].

Objectives The aim is to assess the state of the art about Radiofrequency Echographic Multi-Spectrometry (REMS).

Methods A review of the available literature was performed, considering full papers, reviews and abstracts on REMS published before January 31^th 2020.

Results REMS has been recently presented by an ESCEO consensus paper as a valuable technology for osteoporosis diagnosis and fracture risk estimation [1]. It is based on the automatic processing of the raw unfiltered signals obtained with an ultrasound scan, thus overcoming the main drawback of dual-energy X-ray absorptiometry (DXA) and computed tomography (CT)-based technologies [2]. Moreover, REMS scans are performed at axial skeleton reference sites, i.e. lumbar spine [3] and femoral neck [4], differently from quantitative ultrasound (QUS) technology, which is usually applied to peripheral sites [3]. Clinical performance has been confirmed by a multicentre clinical trial enrolling over 1900 Caucasian women, demonstrating a high correlation between bone mineral density (BMD) estimated by REMS and DXA. In addition, high performance in terms of precision and intra- and inter-operator repeatability of REMS have been assessed [6]. Prospective studies have demonstrated the predictive ability of incident fragility fractures [7] and the high concordance with DXA in terms of measured BMD in patients with rheumatoid arthritis and pre/post-menopause [8, 9].

Conclusions REMS is an innovative approach for the early diagnosis, short-term monitoring of osteoporosis and risk fracture prediction. The available data envisaged for further applications in paediatric patients, pregnant women and patients at risk of secondary osteoporosis (e.g., diabetic, nephropathic, oncological patients). The EchoS system, a device implementing the REMS technology, has recently received the approval from the U.S. Food and Drug Administration (FDA).

References 1. Diez-Perez et al. Aging Clin Exp Res 2019;31(10):1375–89 2. Iwaszkiewicz & Leszczyński. Forum Reumatol 2019;5(2):81–8 3. Hans & Baim. J Clin Densitom 2017;20(3):322-3 4. Conversano et al. Ultrasound Med Biol 2015;41:281–300 5. Casciaro et al. Ultrasound Med Biol 2016;42:1337–56 6. Di Paola et al. Osteoporos Int 2018;30:391–402 7. Adami et al. Ann Rheum Dis, vol.78, supp.2, 2019, p.A928 8. Bojincă et al. Exp Ther Med 2019;18(3):1661-68 9. Kirilova et al. Clin Cases Miner Bone Metab 2019; 16(1):14-17

Radiofrequency echographic multispectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck

An innovative, non-ionizing technique to diagnose osteoporosis on lumbar spine and femoral neck was evaluated through a multicenter study involving 1914 women. The proposed method showed significant agreement with reference gold standard method and, therefore, a potential for early osteoporosis diagnoses and possibly improved patient management.

INTRODUCTION

To assess precision (i.e., short term intra-operator precision) and diagnostic accuracy of an innovative non-ionizing technique, REMS (Radiofrequency Echographic Multi Spectrometry), in comparison with the clinical gold standard reference DXA (dual X-ray absorptiometry), through an observational multicenter clinical study.

METHODS

In a multicenter cross-sectional observational study, a total of 1914 postmenopausal women (51-70 years) underwent spinal (n = 1553) and/or femoral (n = 1637) DXA, according to their medical prescription, and echographic scan of the same anatomical sites performed with the REMS approach. All the medical reports (DXA and REMS) were carefully checked to identify possible errors that could have caused inaccurate measurements: erroneous REMS reports were excluded, whereas erroneous DXA reports were re-analyzed where possible and otherwise excluded before assessing REMS accuracy. REMS precision was independently assessed.

RESULTS

In the spinal group, quality assessment on medical reports produced the exclusion of 280 patients because of REMS errors and 78 patients because of DXA errors, whereas 296 DXA reports were re-analyzed and corrected. Analogously, in the femoral group there were 205 exclusions for REMS errors, 59 exclusions for DXA errors, and 217 re-analyzed DXA reports. In the resulting dataset (n = 1195 for spine, n = 1373 for femur) REMS outcome showed a good agreement with DXA: the average difference in bone mineral density (BMD, bias ± 2SD) was -0.004 ± 0.088 g/cm² for spine and - 0.006 ± 0.076 g/cm² for femur. Linear regression showed also that the two methods were well correlated: standard error of the estimate (SEE) was 5.3% for spine and 5.8% for femur. REMS precision, expressed as RMS-CV, was 0.38% for spine and 0.32% for femur.

CONCLUSIONS

The REMS approach can be used for non-ionizing osteoporosis diagnosis directly on lumbar spine and femoral neck with a good level of accuracy and precision. However, a more rigorous operator training is needed to limit the erroneous acquisitions and to ensure the full clinical practicability.

Dietary Habits, Internal Migration and Social Class in a Sample of a Northern Italian Population

The study of migrants has generated interesting hypotheses on the etiology of different types of cancer. In particular, it has been suggested that both colon and breast cancer could be related to living conditions, including diet, in the country of immigration. Considerable internal migration occurred in Italy in the sixties. We studied a random sample of 1,400 subjects living in the city of Torino and the province of Varese. They were interviewed with a detailed questionnaire about their dietary habits, and the consumption of several nutrients was considered according to the area of birth and social class. The hypothesis we tested was whether, after controlling for social class, there were different dietary habits among the migrants and the native population, and whether such differences could help in the formulation of etiologic hypotheses on cancer. We found that the intake of saturated fatty acids and cholesterol was lower among the migrants from the south, whereas they consumed higher levels of vegetables than people born in the north. The different intake of saturated fatty acids and cholesterol seemed to be attributable mainly to the consumption of butter, for which the south/north ratio was as low as 0.47 in men and 0.56 in women. Important gradients by social class were also suggested for several nutrients.

Emerging and re-emerging infectious disease in otorhinolaryngology

SUMMARY

Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Method for the Study of Regional Myocardial Perfusion in Patients with Atherosclerotic Coronary Artery Disease

In patients with ischemic heart disease the evaluation of regional myocardial perfusion by 133Xenon intra-coronary injection using a gamma camera computer system allows the detection of regional alterations of myocardial perfusion. While at rest a minority of the patients studied shows large alterations, during pacing induced angina a severe reduction of regional myocardial perfusion can be evidenced both in initial distribution scintigrams, when the injection is performed during angina, and on the washout curves when angina is induced immediately after the injection, during the course of the washout.

The surgical approach to nodule Thyr 3-4 after the 2.2014 NCCN and 2015 ATA guidelines

BACKGROUND

The incidence of palpables thyroid nodules in general population is 5% and the prevalence of non -palpable nodules is higher (35-60%) in the endemic goiter area. In the last years the new guidelines and new classification related to thyroid nodule have changed the indication to treat it.

MATERIAL AND METHOD

We analyzed the patients treated from January 2013 to June 2016 for Thyr 3 and Thyr 4 thyroid nodule sec. Bethesda system. We have divided in I and II period related to the 2.2014 and 2015 ATA guidelines and we have evaluated the indication to treat, the type of surgical procedure, the incidence of thyroid carcinoma and the adverse events.

RESULTS

We selected from 909 cases, 252 cases surgically treated with preoperative diagnosis of Thyr 3(80 cases) and Thyr 4(172 cases); carcinoma was found in 21/80 (26.2%) and in 62/172 (26.05%). The period was divided from January 2013 to December 2014 and from January 2015 to june 2016 (first and second period). In II period we found carcinoma in 8/40 Thyr3 and in 26/88 Thyr 4. The incidence of lobectomy in II period was higher than I period (p < 0.0001) sec.guidelines indications. No difference in adverse events. The number of cancer is lower in patients treated with lobectomy than those who underwent total thyroidectomy (12,5%vs 21,8% in Thyr 3; 15,3% vs 32% in Thyr 4).

CONCLUSIONS

The indications to treat related to Thyr 3 and Thyr4 are changed in the two periods. The number of cancer is lower in patients treated with lobectomy. The new guidelines have changed the surgical approach to thyroid nodule.

Automatic ultrasound technique to measure angle of progression during labor

OBJECTIVE

To evaluate the accuracy and reliability of an automatic ultrasound technique for assessment of the angle of progression (AoP) during labor.

METHODS

Thirty-nine pregnant women in the second stage of labor, with fetus in cephalic presentation, underwent conventional labor management with additional translabial sonographic examination. AoP was measured in a total of 95 acquisition sessions, both automatically by an innovative algorithm and manually by an experienced sonographer, who was blinded to the algorithm outcome. The results obtained from the manual measurement were used as the reference against which the performance of the algorithm was assessed. In order to overcome the common difficulties encountered when visualizing by sonography the pubic symphysis, the AoP was measured by considering as the symphysis landmark its centroid rather than its distal point, thereby assuring high measurement reliability and reproducibility, while maintaining objectivity and accuracy in the evaluation of progression of labor.

RESULTS

There was a strong and statistically significant correlation between AoP values measured by the algorithm and the reference values (r = 0.99, P < 0.001). The high accuracy provided by the automatic method was also highlighted by the corresponding high values of the coefficient of determination (r²  = 0.98) and the low residual errors (root mean square error = 2°27' (2.1%)). The global agreement between the two methods, assessed through Bland-Altman analysis, resulted in a negligible mean difference of 1°1' (limits of agreement, 4°29').

CONCLUSIONS

The proposed automatic algorithm is a reliable technique for measurement of the AoP. Its (relative) operator-independence has the potential to reduce human errors and speed up ultrasound acquisition time, which should facilitate management of women during labor. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

An Advanced Quantitative Echosound Methodology for Femoral Neck Densitometry

The aim of this paper was to investigate the clinical feasibility and the accuracy in femoral neck densitometry of the Osteoporosis Score (O.S.), an ultrasound (US) parameter for osteoporosis diagnosis that has been recently introduced for lumbar spine applications. A total of 377 female patients (aged 61-70 y) underwent both a femoral dual X-ray absorptiometry (DXA) and an echographic scan of the proximal femur. Recruited patients were sub-divided into a reference database used for ultrasound spectral model construction and a study population for repeatability assessments and accuracy evaluations. Echographic images and radiofrequency signals were analyzed through a fully automatic algorithm that performed a series of combined spectral and statistical analyses, providing as a final output the O.S. value of the femoral neck. Assuming DXA as a gold standard reference, the accuracy of O.S.-based diagnoses resulted 94.7%, with k = 0.898 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral density and corresponding DXA values, with r(2) up to 0.79 and root mean square error = 5.9-7.4%. The reported accuracy levels, combined with the proven ease of use and very good measurement repeatability, provide the adopted method with a potential for clinical routine application in osteoporosis diagnosis.

Automatic Echographic Detection of Halloysite Clay Nanotubes in a Low Concentration Range

Aim of this work was to investigate the automatic echographic detection of an experimental drug delivery agent, halloysite clay nanotubes (HNTs), by employing an innovative method based on advanced spectral analysis of the corresponding "raw" radiofrequency backscatter signals. Different HNT concentrations in a low range (5.5-66 × 1010 part/mL, equivalent to 0.25-3.00 mg/mL) were dispersed in custom-designed tissue-mimicking phantoms and imaged through a clinically-available echographic device at a conventional ultrasound diagnostic frequency (10 MHz). The most effective response (sensitivity = 60%, specificity = 95%), was found at a concentration of 33 × 1010 part/mL (1.5 mg/mL), representing a kind of best compromise between the need of enough particles to introduce detectable spectral modifications in the backscattered signal and the necessity to avoid the losses of spectral peculiarity associated to higher HNT concentrations. Based on theoretical considerations and quantitative comparisons with literature-available results, this concentration could also represent an optimal concentration level for the automatic echographic detection of different solid nanoparticles when employing a similar ultrasound frequency. Future dedicated studies will assess the actual clinical usefulness of the proposed approach and the potential of HNTs for effective theranostic applications.

Major osteoporotic fragility fractures: Risk factor updates and societal impact

Osteoporosis is a silent disease without any evidence of disease until a fracture occurs. Approximately 200 million people in the world are affected by osteoporosis and 8.9 million fractures occur each year worldwide. Fractures of the hip are a major public health burden, by means of both social cost and health condition of the elderly because these fractures are one of the main causes of morbidity, impairment, decreased quality of life and mortality in women and men. The aim of this review is to analyze the most important factors related to the enormous impact of osteoporotic fractures on population. Among the most common risk factors, low body mass index; history of fragility fracture, environmental risk, early menopause, smoking, lack of vitamin D, endocrine disorders (for example insulin-dependent diabetes mellitus), use of glucocorticoids, excessive alcohol intake, immobility and others represented the main clinical risk factors associated with augmented risk of fragility fracture. The increasing trend of osteoporosis is accompanied by an underutilization of the available preventive strategies and only a small number of patients at high fracture risk are recognized and successively referred for therapy. This report provides analytic evidences to assess the best practices in osteoporosis management and indications for the adoption of a correct healthcare strategy to significantly reduce the osteoporosis burden. Early diagnosis is the key to resize the impact of osteoporosis on healthcare system. In this context, attention must be focused on the identification of high fracture risk among osteoporotic patients. It is necessary to increase national awareness campaigns across countries in order to reduce the osteoporotic fractures incidence.

New perspectives in echographic diagnosis of osteoporosis on hip and spine

Currently, the accepted "gold standard" method for bone mineral density (BMD) measurement and osteoporosis diagnosis is dual-energy X-ray absorptiometry (DXA). However, actual DXA effectiveness is limited by several factors, including intrinsic accuracy uncertainties and possible errors in patient positioning and/or post-acquisition data analysis. DXA employment is also restricted by the typical issues related to ionizing radiation employment (high costs, need of dedicated structures and certified operators, unsuitability for population screenings). The only commercially-available alternative to DXA is represented by "quantitative ultrasound" (QUS) approaches, which are radiation-free, cheaper and portable, but they cannot be applied on the reference anatomical sites (lumbar spine and proximal femur). Therefore, their documented clinical usefulness is restricted to calcaneal applications on elderly patients (aged over 65 y), in combination with clinical risk factors and only for the identification of healthy subjects at low fracture risk. Literature-reported studies performed some QUS measurements on proximal femur, but their clinical translation is mostly hindered by intrinsic factors (e.g., device bulkiness). An innovative ultrasound methodology has been recently introduced, which performs a combined analysis of B-mode images and corresponding "raw" radiofrequency signals acquired during an echographic scan of the target reference anatomical site, providing two novel parameters: Osteoporosis Score and Fragility Score, indicative of BMD level and bone strength, respectively. This article will provide a brief review of the available systems for osteoporosis diagnosis in clinical routine contexts, followed by a synthesis of the most promising research results on the latest ultrasound developments for early osteoporosis diagnosis and fracture prevention.

A novel ultrasound methodology for estimating spine mineral density

We investigated the possible clinical feasibility and accuracy of an innovative ultrasound (US) method for diagnosis of osteoporosis of the spine. A total of 342 female patients (aged 51-60 y) underwent spinal dual X-ray absorptiometry and abdominal echographic scanning of the lumbar spine. Recruited patients were subdivided into a reference database used for US spectral model construction and a study population for repeatability and accuracy evaluation. US images and radiofrequency signals were analyzed via a new fully automatic algorithm that performed a series of spectral and statistical analyses, providing a novel diagnostic parameter called the osteoporosis score (O.S.). If dual X-ray absorptiometry is assumed to be the gold standard reference, the accuracy of O.S.-based diagnoses was 91.1%, with k = 0.859 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral densities and corresponding dual X-ray absorptiometry values, with r(2) values up to 0.73 and a root mean square error of 6.3%-9.3%. The results obtained suggest that the proposed method has the potential for future routine application in US-based diagnosis of osteoporosis.

Are we changing our inclusion criteria for the minimally invasive videoassisted thyroidectomy?

AIM

The first cases treated with Minimally Invasive videoassisted thyroidectomy (MIVAT) were characterized by inclusion and exclusion criteria that are changing with the experience.

MATERIALS AND METHODS

We have analyzed the patients treated from july 2005 to december 2010 with MIVAT All these cases were treated in accord with Miccoli's technique with a minicervicotomy of 1.5-2 cm above the sternal notch. We have divided the cases on the surgical period highlighting changing in the inclusion criteria and the adverse events (0-211 cases; 212-300 cases). All the cases treated were followed up at days 7 (ambulatory visit) and days 30-12 months (ambulatory visit or telephone contatct). The patients classified in the II° period were chracterized by the exclusion of the clinical thyroiditis. We have related these cases with the cases treated with conventional thyroidectomy(CT).

RESULTS

No differences in postoperative pain,nerve palsy and hypocalcemia in MIVAT group and CT group. We have registered a postoperative pain at 24 hours lower in MIVAT group. The percentage of transitory nerve palsy in the MIVAT group in the first period was 2,84 % versus 1,12 % in the second period.

CONCLUSION

MIVAT technique is safe and reproducible, with an excellent cosmetic results. In our experience MIVAT remains the better surgical options for the patients that meet the inclusion criteria.These cases are 15% of patients treated with thyroidectomy in our Endocrine surgery Unit.

Screening and early diagnosis of osteoporosis through X-ray and ultrasound based techniques

Effective prevention and management of osteoporosis would require suitable methods for population screenings and early diagnosis. Current clinically-available diagnostic methods are mainly based on the use of either X-rays or ultrasound (US). All X-ray based methods provide a measure of bone mineral density (BMD), but it has been demonstrated that other structural aspects of the bone are important in determining fracture risk, such as mechanical features and elastic properties, which cannot be assessed using densitometric techniques. Among the most commonly used techniques, dual X-ray absorptiometry (DXA) is considered the current “gold standard” for osteoporosis diagnosis and fracture risk prediction. Unfortunately, as other X-ray based techniques, DXA has specific limitations (e.g., use of ionizing radiation, large size of the equipment, high costs, limited availability) that hinder its application for population screenings and primary care diagnosis. This has resulted in an increasing interest in developing reliable pre-screening tools for osteoporosis such as quantitative ultrasound (QUS) scanners, which do not involve ionizing radiation exposure and represent a cheaper solution exploiting portable and widely available devices. Furthermore, the usefulness of QUS techniques in fracture risk prediction has been proven and, with the last developments, they are also becoming a more and more reliable approach for assessing bone quality. However, the US assessment of osteoporosis is currently used only as a pre-screening tool, requiring a subsequent diagnosis confirmation by means of a DXA evaluation. Here we illustrate the state of art in the early diagnosis of this “silent disease” and show up recent advances for its prevention and improved management through early diagnosis.

Sonographic markers for early diagnosis of fetal malformations

Fetal malformations are very frequent in industrialized countries. Although advanced maternal age may affect pregnancy outcome adversely, 80%-90% of fetal malformations occur in the absence of a specific risk factor for parents. The only effective approach for prenatal screening is currently represented by an ultrasound scan. However, ultrasound methods present two important limitations: the substantial absence of quantitative parameters and the dependence on the sonographer experience. In recent years, together with the improvement in transducer technology, quantitative and objective sonographic markers highly predictive of fetal malformations have been developed. These markers can be detected at early gestation (11-14 wk) and generally are not pathological in themselves but have an increased incidence in abnormal fetuses. Thus, prenatal ultrasonography during the second trimester of gestation provides a “genetic sonogram”, including, for instance, nuchal translucency, short humeral length, echogenic bowel, echogenic intracardiac focus and choroid plexus cyst, that is used to identify morphological features of fetal Down’s syndrome with a potential sensitivity of more than 90%. Other specific and sensitive markers can be seen in the case of cardiac defects and skeletal anomalies. In the future, sonographic markers could limit even more the use of invasive and dangerous techniques of prenatal diagnosis (amniocentesis, etc.).

Use of oxidized and regenerated cellulose in thyroid surgery: a prospective analysis as cause of postoperative hypocalcemia on 485 patients consecutively treated

AIM

The intraoperative hemorrage determines an higher risk of parathyroid glands lesions, and laryngeal nerve injuries. We have examined if the use of oxidized and regenerated cellulose could be a cause of postoperative hypocalcemia because of the compression on the parathyroid glands or for tissue adhesions

METHODS

From June 2009 to December 2010 we have examined 485 patients consecutively treated with total thyroidectomy. The cases examined were divided in two groups on the use of ionized cellulose (group A and B). 24 hours after surgical procedure, all patients were submitted to serum calcium evaluation. The data were analyzed with χ2 test and t-student test; P<0.05 was statistically significant.

RESULTS

We have selected 372 cases out of 485 examined. We have registered after 10 hours from surgical procedure a case of hemorrhage with reintervention in group B (no use of cellulose). The cost of ionized cellulose is € 46; we have used this device in 212 cases on 372 patients undergone to total thyroidectomy, with a cost of € 9 752. The mean value of the serum calcium was statistically different between pre- and postoperative evaluation in all cases (P<0.0001) divided both on gender and on the use of hemostatic devices.

CONCLUSION

In our experience, there isn't a statistically significant difference on incidence of postoperative hypocalcemia, related to use of ionized and regenerated cellulose on mean surgical time in all patients either treated with traditional surgery or with video-assisted procedure.

The cancer burden and cancer control in developing countries

Substantial changes in large parts of the developing world have materialised in the last three decades. These are extremely diverse countries with respect to culture, societal values and political arrangements, but sharing one feature--prevalent poverty and limited resources to protect the health of individuals. The control of emerging chronic diseases in low-resource countries is a formidable challenge. For this reason any intervention should be kept logistically simple and incorporated into a general plan aiming at building gradually the infrastructure that is necessary to bring care to the population at large. The present contribution summarizes some of the priorities in cancer prevention in developing countries and the underlying evidence base, and addresses some of the challenges.

Marriage and parenthood among childhood cancer survivors: a report from the Italian AIEOP Off-Therapy Registry

BACKGROUND

The aim of this study was to describe the patterns of marriage and parenthood in a cohort of childhood cancer survivors included in the Off-Therapy Registry maintained by the Italian Association of Pediatric Hematology and Oncology.

DESIGN AND METHODS

We analyzed a cohort of 6,044 patients diagnosed with cancer between 1960 and 1998, while aged 0 to 14 years and who were 18 years old or older by December 2003. They were followed up through the regional vital statistics registers until death or the end of follow up (October 30, 2006), whichever occurred first, and their marital status and date of birth of their children were recorded. The cumulative probabilities of being married and having a first child were computed by gender and compared by tumor type within the cohort. Marriage and fertility rates (the latter defined as the number of live births per woman-year) were compared with those of the Italian population of the same age, gender, area of residence and calendar period by means of the observed to expected (O/E) ratios.

RESULTS

During the follow-up period, 4,633 (77%) subjects had not married. The marriage O/E ratios were 0.56 (95% CI: 0.51-0.61) and 0.70 (95% CI: 0.65-0.76) among men and women, respectively. Overall, 263 men had 367 liveborn children, and 473 women had 697 liveborn children. The female fertility O/E ratio was 0.57 (95% CI: 0.53-0.62) overall, and 1.08 (95% CI: 0.99-1.17) when analyses were restricted to married/cohabiting women

CONCLUSIONS

Childhood cancer survivors are less likely to marry and to have children than the general population, confirming the life-long impact of their previous disease on their social behavior and choices. The inclusion of counseling in the strategies of management and long-term surveillance of childhood cancer patients could be beneficial to survivors as they approach adulthood.

The role of parents, friends and teachers in adolescents' cigarette smoking and tombak dipping in Sudan

OBJECTIVE

To assess the influence of smoking and tombak (local smokeless tobacco) dipping by parents, teachers and friends on cigarette smoking and tombak dipping by school-going Sudanese adolescents.

METHODS

This was a school-based cross-sectional survey was conducted in 2005-2006. Logistic regression was used for the analysis. A total of 4277 Sudanese school-going adolescents (aged 11-17 years) from 23 schools who completed an anonymous self-administered questionnaire on the use of tobacco products. Main outcome measures were self-reported tobacco use during the previous month defined current tobacco use. Ever smoking, tombak dipping and other tobacco products were also considered as outcomes.

RESULTS

After adjusting for sex, age and school grade, adolescents' smoking habits were strongly associated with the habit in their parents and friends and, more weakly, with tombak dipping by teachers. When adjusted for each other, the association with smoking in friends was unaffected and remained significant (prevalence OR (POR) of having ever smoked was 1.94, 95% CI 1.64 to 2.29; OR of being current smoker was 3.77, 95% CI 2.80 to 5.07). Tobacco smoking in friends was positively associated with adolescents ever tombak dipping (POR 1.81, 95% CI 1.41 to 2.33) and current dipping (OR 3.33, 95% CI 2.20 to 5.05). The association with parental habits was reduced but still significantly elevated. Tombak dipping by teachers was only associated with adolescents ever tobacco smoking.

CONCLUSIONS

Tobacco use by parents, teachers and friends was associated with adolescents' tobacco habits. The influence of friends was the strongest. In developing programmes against adolescents' tobacco habits, there is need to target the influence of these 'significant others'. Sudan needs to develop and implement comprehensive anti-smoking and anti-tombak dipping legislation to reduce the growing prevalence of such habits.

Risk factors for breast cancer among Filipino women in Manila

Age-adjusted incidence rates of breast cancer vary greatly worldwide with highest rates found in the typically 'westernised' countries of North America and Europe. Much lower rates are observed in Asian and African populations but an exception to this has been reported for the Manila Cancer Registry in the Philippines. The reason for this high rate is unknown but may be associated with the change in lifestyle that has occurred in urban Manila since the 1960s. In 1995, a randomised controlled trial was set up in Manila to evaluate the feasibility of a screening intervention by clinical breast examination as an alternative to mammography. The cohort of 151,168 women was followed-up to 2001 for cancer incidence and a nested case-control study carried out. This aimed to evaluate the increase in breast cancer risk associated with known risk factors. Increased risks were seen for a high level of education (OR = 1.9 95%CI 1.1-3.3 for education stopped at > or =13 versus <13 years), nulliparity (OR = 5.0 95% CI 2.5-10.0 for nulliparity versus five or more children), and late age at first birth (OR = 3.3 95% CI 1.3-8.3 for age > or =30 versus <20 years). We found no association with excess body weight, height, use of exogenous hormones or alcohol consumption. From this study, the recognised "classical" risk factors do not fully explain the high breast cancer incidence in Metro Manila, especially when compared to other urban Asian populations. We conclude that it is too simplistic to ascribe the high risk to 'westernisation'.

Breast cancer mortality trends in the WEST compared to the EAST: lives gained, lives lost

Abstract #6082

INTRODUCTION: Breast Cancer (BrCa) Mortality trends between 1950 – 2005 were reviewed between the Western (WEST) and Eastern Asian (EAST) countries, with the objective to gain understanding between therapeutic and diagnostic interventions and underlying epidemiology factors determining BrCa outcomes.&#x2028; METHODOLOGY: We compared BrCa mortality trends in the WEST (Canada, UK, USA) and in the EAST (Japan and China-Shanghai). Data were obtained from WHO - IARC, Lyon (Canada, USA, UK, Japan); and from the Shanghai Cancer Registry (China-Shanghai). We analyzed age-standardized annual mortality rates per 100,000 / population (as per 1960 world standard population). Mortality trends were expressed relative to the baseline (year 1950 for all, year 1973 for China-Sha).&#x2028; RESULTS: The baseline mortality rates were: 22.5 for Canada; 23.5 for UK; 21.6 for USA, 4.1 for Japan; and 7.3 for China-Shanghai.&#x2028; &#x2028; CONCLUSION. These data confirm a substantial mortality reduction in the WEST evident after the 1980's - 1990's, likely reflecting the interaction of diagnostic and therapeutic interventions (mammography, education, systemic / locoregional therapies, etc). The different timing and extent of mortality reduction in the WEST probably reflect different degree of implementation of the interactive factors.&#x2028; On the other hand, mortality is increasing in the EAST, in parallel with the “westernization” of those regions (industrialization, diet, etc, Ref. [NEJM; 2008:358;3)]. For the EAST, our data also support a correlation between the timing / extent of the “westernization” and mortality trend dynamics (i.e. mortality increase in Japan 20 years earlier than China).

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6082.

Epidemiology and clinicopathology of breast cancer in metro Manila and Rizal Province, Philippines

The breast cancer incidence in the Philippines is among the highest in Asia. Age-standardized incidence rates (ASR) in Metro Manila and Rizal Province derived from the Philippine Cancer Society-Manila Cancer Registry and the Department of Health-Rizal Cancer Registry showed increase from 1980 to 2002, and were significantly higher in 7 cities in Metro Manila and significantly lower in 14 cities/municipalities mostly in Rizal Province. The AJCC Clinical Stage did not change from 1993 to 2002 among incident cases, the average distribution being: I= 5%, IIA= 20%, IIB= 18%, IIIA= 9%, IIIB= 10%, IV= 11%, Unknown= 28%. The International Agency for Research on Cancer attempted to run a randomized screening trial in 1995-1997 in the Philippines based on clinical breast examination by trained nurses and midwives. Unfortunately, even after home visits by a team equipped to perform needle biopsy, only 35% of screen-positive cases eventually had a diagnostic test. The estimated prevalence of BRCA mutations among unselected patients in the Philippine General Hospital (PGH) in 1998 was 5.1%, with a prevalence of 4.1% for BRCA2 mutations alone. There is a continuing effort at improving IHC hormone receptor testing at PGH, particularly on early fixation in buffered formalin. It was observed that hormone receptor-positive proportions tended to be higher in core needle biopsy specimens (72%) compared to mastectomy specimens (65%). During the years 1991, 1994 and 1997, 97% of incident cases of early breast cancer underwent modified radical mastectomy, 18% had postoperative radiotherapy, 51% had adjuvant hormone treatment and 47% received adjuvant chemotherapy. Survival of incident cases in 1993 to 2002 was compared to that of Filipino-Americans and Caucasians in the SEER 13 database. The age-adjusted 5-year relative survival, using period analysis, of Metro Manila residents, Filipino-Americans and Caucasians were 58.6%, 89.6% and 88.3% respectively.

Hyper-insulinaemia and cancer, meta-analyses of epidemiological studies

BACKGROUND

A substantial body of evidence links sex hormones, diet, excess body weight and physical activity to the risk of developing cancer at several sites common in affluent countries. The hypothesis that high circulating levels of insulin could be the underlying factor increasing cancer risk has been proposed. Epidemiological studies on markers of hyper-insulinaemia and cancer are reviewed and summarized.

METHODS

Studies of cancers of the colon and rectum, pancreas, breast, and endometrium examining the association with blood levels of C-peptide, insulin, glucose, glycated haemoglobin (HbA1c) were searched in PubMed. Multivariate, adjusted relative risks (RR) and their 95% confidence intervals were abstracted and summarized by meta-analyses.

RESULTS

Most of the studies identified were cohorts that relied on measurements obtained at baseline or assessed in blood stored at low temperature several years before the onset of cancer. The meta-analyses showed excess risks of colorectal and pancreatic cancers associated with higher levels of circulating C-peptide/insulin and with markers of glycaemia. Significant heterogeneity was found among four epidemiological studies of endometrial cancer and C-peptide giving a summary RR compatible with no association. Overall breast cancer risk was significantly higher in the upper categories of C-peptide/insulin, however, the excess derived entirely from retrospective studies.

CONCLUSION

Current evidence suggests that subjects who develop colorectal and pancreatic cancers have increased pre-diagnostic blood levels of insulin and glucose.

The molecular causes of low ATM protein expression in breast carcinoma; promoter methylation and levels of the catalytic subunit of DNA-dependent protein kinase

AIMS

To investigate whether aberrant methylation of the ATM promoter or loss of the catalytic subunit of DNA-dependent protein kinase (DNA-PKcs) may be the underlying causes of reduced ATM protein levels often seen in breast tumours.

METHODS AND RESULTS

Methylation-specific polymerase chain reaction was used to determine the ATM promoter status and DNA-PKcs levels were measured by immunohistochemistry. None of the 74 invasive carcinomas (ICs) studied showed ATM promoter hypermethylation, whereas promoter methylation of CDKN2A/p16 (1.8%) and GSTP1 (15.8%) was detected. Of 92 ICs examined, 68 had reduced DNA-PKcs levels, supporting previous findings that alterations in double-strand break repair are associated with breast cancer pathogenesis. Although no association was found between the DNA-PKcs and ATM scores for the series of 92 tissues and 22/24 tissues with normal DNA-PKcs had reduced ATM, 29 tumours showed low expression of both DNA-PKcs and ATM compared with normal tissues.

CONCLUSIONS

No evidence was found that the reduction in ATM protein levels seen in breast carcinoma is the result of epigenetic silencing. However, cross-regulation between DNA-PKcs and ATM may be a possible cause in a subset of tumours and warrants further investigation.

The XRCC1 -77T->C variant: haplotypes, breast cancer risk, response to radiotherapy and the cellular response to DNA damage

X-ray repair cross-complementing 1 (XRCC1) is required for single-strand break repair in human cells and several polymorphisms in this gene have been implicated in cancer risk and clinical prognostic factors. We examined the frequency of the 5'-untranslated region (5'-UTR) variant -77T-->C (rs 3213235) in 247 French breast cancer (BC) patients, 66 of whom were adverse radiotherapy responders, and 380 controls and determined the haplotypes based on this and the previously genotyped variants Arg194Trp, Arg280His and Arg399Gln. The -77T-->C variant alone showed no significant association with BC risk or therapeutic radiation sensitivity. The H5 haplotype (variant allele codon 280, wild-type allele other positions) was associated with increased BC risk [odds ratio (OR), 1.90; 95% confidence interval (CI), 1.12-3.23] and the H3 haplotype (wild-type allele all four positions) was inversely associated with therapeutic radiation sensitivity compared with the reference group (H1 haplotype, -77C, wild-type allele codons 194, 280, 399) (OR, 0.39; 95% CI, 0.16-0.92). However given that the global tests for association were not significant these results should be interpreted carefully. Lymphoblastoid cell lines heterozygous for the H1/H3 haplotypes had a significantly higher cell survival (P=0.04) after exposure to ionising radiation (IR) than those with the H1/H1 haplotypes, in agreement with the association study. However no haplotype-specific differences in XRCC1 expression or cell cycle progression were noted in the 24 h following IR exposure. These results suggest that the -77T-->C genotype or another variant in linkage disequilibrium influences the cellular response to DNA damage, although the underlying molecular mechanisms remain to be established.