Protein dose requirements to maximize skeletal muscle protein synthesis after repeated bouts of resistance exercise in young trained women

Studies examining the effect of protein (PRO) feeding on post resistance exercise (RE) muscle protein synthesis (MPS) have primarily been performed in men, and little evidence is available regarding the quantity of PRO required to maximally stimulate MPS in trained women following repeated bouts of RE. We therefore quantified acute (4 h and 8 h) and extended (24 h) effects of two bouts of resistance exercise, alongside protein-feeding, in women, and the PRO requirement to maximize MPS. Twenty-four RE trained women (26.6 ± 0.7 years, mean ± SEM) performed two bouts of whole-body RE (3 × 8 repetitions/maneuver at 75% 1-repetition maximum) 4 h apart, with post-exercise ingestion of 15 g, 30 g, or 60 g whey PRO (n = 8/group). Saliva, venous blood, and a vastus lateralis muscle biopsy were taken at 0 h, 4 h, 8 h, and 24 h post-exercise. Plasma leucine and branched chain amino acids were quantified using gas chromatography mass spectrometry (GC-MS) after ingestion of D2 O. Fifteen grams PRO did not alter plasma leucine concentration or myofibrillar synthetic rate (MyoFSR). Thirty and sixty grams PRO increased plasma leucine concentration above baseline (105.5 ± 5.3 μM; 120.2 ± 7.4 μM, respectively) at 4 h (151.5 ± 8.2 μM, p < 0.01; 224.8 ± 16.0 μM, p < 0.001, respectively) and 8 h (176.0 ± 7.3 μM, p < 0.001; 281.7 ± 21.6 μM, p < 0.001, respectively). Ingestion of 30 g PRO increased MyoFSR above baseline (0.068 ± 0.005%/h) from 0 to 4 h (0.140 ± 0.021%/h, p < 0.05), 0 to 8 h (0.121 ± 0.012%/h, p < 0.001), and 0 to 24 h (0.099 ± 0.011%/h, p < 0.01). Ingestion of 60 g PRO increased MyoFSR above baseline (0.063 ± 0.003%/h) from 0 to 4 h (0.109 ± 0.011%/h, p < 0.01), 0 to 8 h (0.093 ± 0.008%/h, p < 0.01), and 0 to 24 h (0.086 ± 0.006%/h, p < 0.01). Post-exercise ingestion of 30 g or 60 g PRO, but not 15 g, acutely increased MyoFSR following two consecutive bouts of RE and extended the anabolic window over 24 h. There was no difference between the 30 g and 60 g responses.

Integrating women into combat roles: comparing the UK Armed Forces and Israeli Defense Forces to understand where lessons can be learnt

In October 2018, women became eligible to serve in all roles in the UK Armed Forces. The Israeli Defense Forces (IDF) have employed women in limited ground close combat (GCC) roles since 1995. Integration of women into some IDF combat units has improved our understanding of injury risk for servicewomen. While the research findings from physiological studies on women in IDF GCC roles helped inform the integration of women into UK GCC roles, the applicability of the data is limited by the differences between Israeli and UK approaches to recruitment, training and operational deployability of servicewomen. Women in IDF combat roles do, therefore, not provide a good model on the health and performance implications for women in UK Armed Forces combat roles. Further original research to better understand and develop mitigations against any health risks facing UK servicewomen in GCC roles is warranted.

Effect of sex and combat employment on musculoskeletal injuries and medical downgrading in trained military personnel: an observational cohort study

INTRODUCTION

Following the opening of all combat roles to women across the UK Armed Forces, there is a requirement to understand the risk of injury to these female personnel. Women injure at a higher rate than men during basic military training, but fewer data are published from individuals who have passed military training.

METHODS

A bespoke survey was designed to investigate differences in injury prevalence and medical downgrading between sexes and career employment groups (ie, job roles) in the UK Armed Forces.

RESULTS

Questionnaire data were evaluated from 847 service personnel (87% men) employed in combat roles (Royal Marines, Infantry, Royal Armoured Corps, Royal Air Force Regiment (all men)) and non-combat roles (Royal Regiment of Artillery, Corps of Royal Engineers, Royal Logistic Corps and Combat Service Support Corps who were attached to one of the participating units (men and women)). Women reported more total (OR 1.64 (95% CI: 1.03 to 2.59), p=0.035), lower limb (OR 1.92 (95% CI: 1.23 to 2.98), p=0.004) and hip (OR 2.99 (95% CI: 1.59 to 5.62), p<0.001) musculoskeletal injuries in the previous 12 months than men, but there were no sex differences in the prevalence of current or career medical downgrading due to musculoskeletal injury (both p>0.05). There were no differences in 12-month musculoskeletal injury prevalence between men in combat roles and men in non-combat roles (all p>0.05), but men in non-combat roles were more likely to be currently medically downgraded (OR 1.88 (95% CI: 1.27 to 2.78), p=0.001) and medically downgraded during their career (OR 1.49 (95% CI: 1.11 to 2.00), p=0.008) due to musculoskeletal injury than men in combat roles. More time in service and quicker 1.5-mile run times were associated with increased prevalence of total musculoskeletal injuries, and female sex was a predictor of hip injury.

CONCLUSIONS

Although women are at greater risk of injury than men, we have no evidence that combat employment is more injurious than non-combat employment. The prevention of hip injuries should form a specific focus of mitigation efforts for women.

Role of sex and stature on the biomechanics of normal and loaded walking: implications for injury risk in the military

Load carriage and marching 'in-step' are routine military activities associated with lower limb injury risk in service personnel. The fixed pace and stride length of marching typically vary from the preferred walking gait and may result in overstriding. Overstriding increases ground reaction forces and muscle forces. Women are more likely to overstride than men due to their shorter stature. These biomechanical responses to overstriding may be most pronounced when marching close to the preferred walk-to-run transition speed. Load carriage also affects walking gait and increases ground reaction forces, joint moments and the demands on the muscles. Few studies have examined the effects of sex and stature on the biomechanics of marching and load carriage; this evidence is required to inform injury prevention strategies, particularly with the full integration of women in some defence forces. This narrative review explores the effects of sex and stature on the biomechanics of unloaded and loaded marching at a fixed pace and evaluates the implications for injury risk. The knowledge gaps in the literature, and distinct lack of studies on women, are highlighted, and areas that need more research to support evidence-based injury prevention measures, especially for women in arduous military roles, are identified.

Hormonal contraceptive prescriptions in the UK Armed Forces

INTRODUCTION

Thirty four per cent of women use hormonal contraceptives in the UK and the contraceptive pill is the most common method. There are no comparable data in the UK Armed Forces, but servicewomen are often required to complete physically arduous job roles in combat zones and may be more likely to take contraceptives to control or stop menstrual bleeding than the general population. We explored the prevalence of hormonal contraceptive prescriptions in the UK Armed Forces.

METHODS

The study used defence medical records (Defence Medical Information Capability Programme) to identify hormonal contraceptive prescriptions for all serving regular UK servicewomen (n=15 738) as of 1 September 2017.

RESULTS

Thirty one per cent of servicewomen (Royal Navy, 28%; British Army, 30%; Royal Air Force, 34%) had a current prescription for a hormonal contraceptive. Non-officer ranks were more likely to have a prescription for a hormonal contraceptive (32%) than officers (27%) (p<0.01). The contraceptive pill was more commonly prescribed (68%) than long-acting reversible contraceptive methods (32%) (contraceptive injection, 11%; contraceptive implant, 11%; intrauterine device, 10%).

CONCLUSION

Prescription data suggest that the prevalence of hormonal contraceptive use in UK servicewomen is comparable with the general UK population. These findings suggest that military service does not influence prevalence or choice of hormonal contraceptives.

Hormonal contraceptive use, bone density and biochemical markers of bone metabolism in British Army recruits

INTRODUCTION

Hormonal contraceptive use might impair bone health and increase the risk of stress fracture by decreasing endogenous oestrogen production, a central regulator of bone metabolism. This cross-sectional study investigated bone density and biochemical markers of bone metabolism in women taking hormonal contraceptives on entry to basic military training.

METHODS

Forty-five female British Army recruits had biochemical markers of bone metabolism, areal bone mineral density (aBMD) and tibial speed of sound (tSOS) measured at the start of basic military training. Participants were compared by their method of hormonal contraception: no hormonal contraception (NONE), combined contraceptive pill (CP) or depot-medroxyprogesterone acetate (DMPA) (20±2.8 years, 1.64±0.63 m, 61.7±6.2 kg).

RESULTS

aBMD was not different between groups (p≥0.204), but tSOS was higher in NONE (3%, p=0.014) when compared with DMPA users. Beta C-terminal telopeptide was higher in NONE (45%, p=0.037) and DMPA users (90%, p=0.003) compared with CP users. Procollagen type 1 N-terminal propeptide was higher in DMPA users compared with NONE (43%, p=0.045) and CP users (127%, p=0.001), and higher in NONE compared with CP users (59%, p=0.014). Bone alkaline phosphatase was higher in DMPA users compared with CP users (56%, p=0.044).

CONCLUSIONS

DMPA use was associated with increased bone turnover and decreased cortical bone integrity of the tibia. Lower cortical bone integrity in DMPA users was possibly mediated by increased intracortical remodelling, but trabecular bone was not affected by contraceptive use.

Positive adaptation of HPA axis function in women during 44 weeks of infantry-based military training

BACKGROUND

Basic military training (BMT) is a useful model of prolonged exposure to multiple stressors. 8-12 week BMT is associated with perturbations in the hypothalamic-pituitary-adrenal (HPA) axis which could predispose recruits to injury and psychological strain. However, characterisations of HPA axis adaptations during BMT have not been comprehensive and most studies included few if any women.

METHODS

We studied women undertaking an arduous, 44-week BMT programme in the UK. Anxiety, depression and resilience questionnaires, average hair cortisol concentration (HCC), morning and evening saliva cortisol and morning plasma cortisol were assessed at regular intervals throughout. A 1-h dynamic cortisol response to 1 μg adrenocorticotrophic hormone-1-24 was performed during weeks 1 and 29.

RESULTS

Fifty-three women (aged 24 ± 2.5 years) completed the study. Questionnaires demonstrated increased depression and reduced resilience during training (F 6.93 and F 7.24, respectively, both p < 0.001). HCC increased from 3 months before training to the final 3 months of training (median (IQR) 9.63 (5.38, 16.26) versus 11.56 (6.2, 22.45) pg/mg, p = 0.003). Morning saliva cortisol increased during the first 7 weeks of training (0.44 ± 0.23 versus 0.59 ± 0.24 μg/dl p < 0.001) and decreased thereafter, with no difference between the first and final weeks (0.44 ± 0.23 versus 0.38 ± 0.21 μg/dl, p = 0.2). Evening saliva cortisol did not change. Fasting cortisol decreased during training (beginning, mid and end-training concentrations: 701 ± 134, 671 ± 158 and 561 ± 177 nmol/l, respectively, p < 0.001). Afternoon basal cortisol increased during training while there was a trend towards increased peak stimulated cortisol (177 ± 92 versus 259 ± 13 nmol/l, p = 0.003, and 589 ± 164 versus 656 ± 135, p = 0.058, respectively).

DISCUSSION

These results suggest a normal stress response in early training was followed quickly by habituation, despite psychological and physical stress evidenced by questionnaire scores and HCC, respectively. There was no evidence of HPA axis maladaptation. These observations are reassuring for women undertaking arduous employment.

Cardiorespiratory coordination reveals training-specific physiological adaptations

PURPOSE

To compare the effects of high-intensity interval training (HIIT) and moderate-intensity training (CONT), matched for total work, on cardiorespiratory coordination and aerobic fitness.

METHODS

This is a two-arm parallel group single-blind randomised study. Twenty adults were assigned to 6 weeks of HIIT or volume-matched CONT. Participants completed a progressive maximal cycling test before and after the training period. Principal component (PC) analysis was performed on the series of cardiorespiratory variables to evaluate dimensionality of cardiorespiratory coordination, before and after lactate turnpoint. PC₁ eigenvalues were compared.

RESULTS

Both HIIT and CONT improved aerobic fitness (main effects of time, p < 0.001, [Formula: see text] ≥ 0.580), with no differences between groups. CONT decreased the number of PCs from two to one at intensities both below and above the lactate turnpoint; PC₁ eigenvalues increased after CONT both below (Z = 2.08; p = 0.04; d = 0.94) and above the lactate turnpoint (Z = 2.10; p = 0.04; d = 1.37). HIIT decreased the number of PCs from two to one after the lactate turnpoint only; PC₁ eigenvalues increased after HIIT above the lactate turnpoint (Z = 2.31; p = 0.02; d = 0.42).

CONCLUSIONS

Although CONT and HIIT improved aerobic fitness to a similar extent, there were different patterns of change for cardiorespiratory coordination. These changes appear training-intensity specific and could be sensitive to investigate the individual response to endurance training.

Protein fixation and antigen retrieval: chemical studies

Abstract Fixation with formaldehyde is the first process to which most biopsy and necropsy specimens are exposed prior to dehydration and embedding in paraffin wax. Tissue specimens that have been fixed in formaldehyde have architectural characteristics that are familiar to virtually every pathologist and these facilitate routine diagnosis. Nevertheless, formaldehyde fixation has some deleterious effects including reduction in immunoreactivity and degradation of nucleic acids. Development of methods to counteract these deleterious effects requires an understanding of the chemical events that occur during tissue fixation and subsequent tissue processing. This short review illustrates some of the chemical consequences of formaldehyde fixation and ethanol dehydration. It also provides some insight into the molecular events accompanying heat-induced antigen retrieval.

Effects of anesthetic and nonanesthetic steroids on dipalmitoylphosphatidylcholine liposomes: a calorimetric and Raman spectroscopic investigation

The effects of anesthetic and nonanesthetic steroids on dipalmitoylphosphatidylcholine liposomes were studied by use of high sensitivity scanning calorimetry and Raman spectroscopy. Calorimetric measurements indicated that both anesthetic and nonanesthetic steroids depressed and broadened the gel to liquid-crystalline phase transition. There was no correlation between the perturbations by the steroids on the primary gel to liquid-crystalline phase transition temperature and anesthetic potency. The magnitudes of the steroid-induced transition broadening and lowering of the pretransition temperature, however, correlated well with anesthetic potency. This effect appeared to arise from the projection from the plane of the D ring of substituents at the C(17) position of the steroid nucleus. Raman spectroscopic measurements demonstrated that the steroid molecule is localized within the acyl region of the bilayer and that effects of the steroid do not extend to either the head-group or interface regions of the lamellae. The data are consistent with unitary hypotheses relating general anesthesia to lipid perturbations. For model systems, perturbations to the subtle structural and dynamical properties of the bilayer pretransition may provide a more sensitive marker than the main phase transition in assessing the significance of lipid mediation in inducing anesthetic action.

Hemochromatosis (HFE) gene sequence analysis of formalin-fixed, paraffin-embedded liver biopsy specimens

BACKGROUND

Hereditary hemochromatosis (HH) is a common disease predominantly characterized by mutations of the HFE gene.

METHODS AND RESULTS

We investigated the utility of HFE gene sequence analysis in the diagnosis of HH in 61 prospectively accrued formalin-fixed, paraffin-embedded liver biopsy specimens with clinical or histologic features suggestive of HH. Mutations in codons 63 or 282 of the HFE gene were identified by direct sequencing; in 21 of these samples, quantitative hepatic iron testing was also performed. Changes characteristic of HH were present in 16 (26%) of the cases, and 54% of the cases showed HFE gene mutations. The most common alteration was homozygous mutation of codon 282 (11 cases, 18%), followed by the combined 63 + 282 heterozygous mutation (3 cases, 5%). Two cases (3%) showed biallelic mutation of codon 63. The other 28 cases (46%) showed no sequence abnormalities. Weak iron staining did not exclude HH; intense staining did not reliably predict HH.

CONCLUSION

When HH is clinically and/or histologically suspected, HFE gene sequencing of formalin-fixed, paraffin-embedded liver biopsy specimens is a rapid and cost-effective approach to genotypic diagnosis of HH.

Mitotic counting in surgical pathology: sampling bias, heterogeneity and statistical uncertainty

Mitotic counting in surgical pathology: sampling bias, heterogeneity and statistical uncertainty Although several articles on the methodological aspects of mitotic counting have been published, the effects of macroscopic sampling and tumour heterogeneity have not been discussed in any detail. In this review the essential elements for a standardized mitotic counting protocol are described, including microscopic calibration, specific morphological criteria, macroscopic selection, counting procedure, effect of biological variation, threshold, and the setting of an area of uncertainty ('grey area'). We propose that the use of a standard area for mitotic quantification and of a grey area in mitotic counting protocols will facilitate the application of mitotic counting in diagnostic and prognostic pathology.

Pleomorphic (giant and/or spindle cell) carcinoma of lung shows a high percentage of variant CYP1A12

BACKGROUND

Pleomorphic carcinoma (PC) of the lung is an aggressive epithelial neoplasm composed of giant and/or spindle tumor cells and associated with short survival. Most patients are cigarette smokers. The tumor susceptibility gene P-450 1A1 (CYP1A1) is involved in the activation of polycyclic aromatic hydrocarbons, including benzo[a]pyrene, producing DNA-damaging epoxides that lead to G:C-->T:A point mutations. Isoleucine (Ile)-valine (Val) and Val-Val genotypes of the CYP1A1 exon 7 polymorphism are associated with an increased risk for lung cancer in certain populations.

METHODS AND RESULTS

We sought to determine whether 25 archival, formalin-fixed, paraffin-embedded PC samples had a modified CYP1A1 gene profile at exon 7 using allele-specific PCR amplification. KRAS mutation status was available for all samples. Previous investigations have shown 0.88 Ile-Ile, 0.12 Ile-Val, and rarely, Val-Val as normal baseline population frequencies. Conversely, the markedly different PC CYP1A1 population frequencies were more likely to have the heterozygote variant alleles: 0.24 (six cases, Ile-Ile) and 0.76 (19 cases, Ile-Val; P <.001). CYP1A1 genotypes were found to be similar in both tumor and nontumor samples in a given case. All KRAS-mutated cases were Ile-Val heterozygotes.

CONCLUSION

The increased propensity for the variant CYP1A1 allele may be the contributing factor to PC pathogenesis and may also result from KRAS mutations in these tumors.

Gastrointestinal stromal tumor workshop

Gastrointestinal stromal tumor (GIST) has emerged in the past year as a prototypical neoplasm that responds to therapy directed against a single target molecule-the KIT receptor tyrosine kinase protein. Although GIST seldom responds to conventional chemotherapeutic agents, early experience with the tyrosine kinase inhibitor, STI-571 (Gleevec; Novartis, Basel, Switzerland), has been extremely encouraging. Early results have appeared in a recent case report in the New England Journal of Medicine (April 5, 2001),(1) and in early clinical trials from the United States and Europe that were reported at the plenary session of the American Society of Clinical Oncology in San Francisco on May 14, 2001. STI-571 is one of the earliest examples of a nontoxic chemotherapeutic agent (an agent whose anti-cancer activity is not predicated on a cytotoxic mechanism). STI-571 has already shown clinical value in BCR-ABL-positive leukemias. Early clinical results in GIST are so encouraging that oncologists may soon be wrestling with the opportunity of referring every patient with malignant GIST into clinical trials with STI-571. To ensure appropriate treatment, pathologists need to understand the biology and treatment of this tumor and to have standard methods and criteria for providing diagnosis (GIST or not GIST) and consistent prognostic classification (high risk of metastasis or low risk of metastasis).

Apoptosis, bcl-2 expression, and p53 expression in gastrointestinal stromal/smooth muscle tumors

The authors investigated the relations between outcome and apoptosis, immunohistochemical demonstration of bcl-2 protein, and immunohistochemical staining for p53 protein in patients with gastrointestinal stromal/smooth muscle tumors (GIST). Patients whose tumors demonstrated cellular apoptosis using the terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate-biotin nick end labeling (TUNEL) assay had an improved survival over those whose tumors did not improve. In contrast, patients whose tumors demonstrated staining for bcl-2 protein had a decreased survival compared with those whose tumors did not demonstrate bcl-2. There was no relation between p53 immunoreactivity and survival. These results suggest that inhibition of apoptosis may be associated with malignant behavior in patients with gastrointestinal stromal/smooth muscle tumors.

Standardization in immunohistochemistry

Over the last few years, the role of immunohistochemical analysis has been changing from that of an ancillary diagnostic technique to that of a stand-alone diagnostic method, the results of which determine treatment approach. With this change comes a need for increasing standardization of both preanalytical and analytical methods, so that results emanating from different laboratories are directly comparable. These efforts have been aided to some degree by the development of automated staining systems and by the increased use of test kits, but interlaboratory reproducibility for immunohistochemical methods is still far lower than that of most clinical analytical measurements. In this article, the author presents some approaches to further reduce intra- and interlaboratory variation in the performance of immunohistochemical assays, focusing attention on guidelines recently published by NCCLS.

Fine needle aspiration of gastrointestinal stromal tumors

OBJECTIVE

Gastrointestinal stromal tumors (GISTs) are uncommon mesenchymal tumors of the gastrointestinal tract. Fine needle aspiration (FNA) is one option for diagnosing GISTs before surgery. This study was designed to evaluate the clinical utility of FNA in the diagnosis of GISTs.

STUDY DESIGN

FNAs from 19 GISTs originating in the stomach, small bowel and colon obtained from 1988 to 1998 were studied. Immunocytochemistry was performed on 12 cases. The GISTs were classified as benign, borderline and malignant, according to location, size, mitotic activity and clinical outcome.

RESULTS

Benign (three) and borderline (five) GISTs were all spindle cell type; malignant GISTs included five spindle cell type and six epithelioid type. Most smears contained abundant cellular material. Benign and borderline GISTs of spindle cell type tended to have cells arranged in tightly cohesive clusters, while malignant GISTs were more likely to exhibit loosely cohesive groups with many single cells, occasional nuclear pleomorphism, hyperchromasia and irregular nuclear contours. Epithelioid-type GISTs mimicked adenocarcinoma. Mitoses were seldom observed in either type. CD117 (KIT protein product) was demonstrated by immunocytochemistry in 9 cases, CD34 in 11, desmin in 3, S-100 protein in 2 and smooth muscle actin in 6 cases.

CONCLUSION

FNA can be used to diagnose GISTs as spindle cell and epithelioid types, but cytomorphology alone cannot be used to assess malignant potential. Immunocytochemical staining for CD117 is helpful in confirming the diagnosis. Care must be taken to differentiate epithelioid-type GISTs from adenocarcinoma.

Chromosome identification using hidden Markov models: comparison with neural networks, singular value decomposition, principal components analysis, and Fisher discriminant analysis

The analysis of G-banded chromosomes remains the most important tool available to the clinical cytogeneticist. The analysis is laborious when performed manually, and the utility of automated chromosome identification algorithms has been limited by the fact that classification accuracy of these methods seldom exceeds about 80% in routine practice. In this study, we use four new approaches to automated chromosome identification--singular value decomposition (SVD), principal components analysis (PCA), Fisher discriminant analysis (FDA), and hidden Markov models (HMM)--to classify three well-known chromosome data sets (Philadelphia, Edinburgh, and Copenhagen), comparing these approaches with the use of neural networks (NN). We show that the HMM is a particularly robust approach to identification that attains classification accuracies of up to 97% for normal chromosomes and retains classification accuracies of up to 95% when chromosome telomeres are truncated or small portions of the chromosome are inverted. This represents a substantial improvement of the classification accuracy for normal chromosomes, and a doubling in classification accuracy for truncated chromosomes and those with inversions, as compared with NN-based methods. HMMs thus appear to be a promising approach for the automated identification of both normal and abnormal G-banded chromosomes.

Analysis of KIT mutation and protein expression in fine needle aspirates of gastrointestinal stromal/smooth muscle tumors

OBJECTIVE

To determine if sequencing the KIT gene could facilitate more definitive FNA diagnosis.

STUDY DESIGN

Sixteen cases of gastrointestinal stromal/smooth muscle tumor (GIST) in which fine needle aspiration (FNA) was performed (mean age, 67; M/F = 12/4) were studied. DNA was extracted from cytologic preparations from all patients (15 cell blocks, 1 alcohol-fixed smear) and seven subsequent resection specimens. DNA was amplified by polymerase chain reaction, using primers designed to amplify a segment of the KIT gene exon 11 and sequenced on an ABI Prism 377 DNA sequence analyzer (Applied Biosystems, Indianapolis, Indiana, U.S.A.). Immunocytochemical staining for CD 117 (the KIT gene product) was performed on sections from 12 cell blocks and 7 surgical resections.

RESULTS

In-frame deletion of exon 11 was detected in eight cases (7 monoalleic, 1 bialleic); a point mutation was found in one case. Mutation was found only in histologically malignant (6 of 10 cases) and borderline GISTs (3 of 4 cases). No mutation was identified in benign tumors. In three cases, scant cellularity or blood precluded sequencing. CD 117 was expressed in 12 of 15 cases.

CONCLUSION

Immunocytochemical staining for CD 117 is useful in confirming a cytologic diagnosis of GIST but does not facilitate diagnosis of malignancy. FNA biopsy specimens are suitable for KIT gene sequencing; detection of a KIT mutation favors a malignant diagnosis, though absence of mutation does not preclude malignancy.

A comparison of cervical pathology between United States Air Force women who did and did not serve in the Persian Gulf War

PURPOSE

The purpose of this study was to look objectively at cervical cytological differences between women Gulf War female veterans (GWFV) and Gulf War-era active duty females not deployed to the Gulf (NDF) during Operation Desert Shield/Desert Storm using Pap smear results.

METHODS

A cohort of 6715 active duty Air Force women who also served on active duty between August 7, 1990-March 1, 1991 provided at least one Pap smear as part of routine medical care during 1994. Of these, 1446 were identified as GWFV and 5269 were identified as NDF. Diagnoses were compared using Chi-square tests with Yate's continuity correction.

RESULTS

There were no differences between the two groups, overall, in the diagnosis of other than within normal limits (OTWNL), the diagnoses of significant disease or in Bethesda system diagnoses in each of the three years for which comparisons were made. GWFV diagnosed in the 26-30 age group were significantly more likely to have a diagnosis of OTWNL than were NDF in the same age group in 1994. There were no differences between the two groups in any other age category.

CONCLUSIONS

The data provide little support for the hypothesis that a difference exists between GWFV and NDF with respect to abnormal cervical cytology.

Telecytologic diagnosis of breast fine needle aspiration biopsies. Intraobserver concordance

OBJECTIVE

To determine the intraobserver concordance between telecytologic and glass slide diagnosis of breast fine needle aspirates.

STUDY DESIGN

Twenty-five cases, originally received in consultation, were each examined by three cytopathologists. An average of seven compressed digital images per case were presented, together with a brief clinical history, using the http protocol and an internet browser.

RESULTS

Agreement between the telecytologic and glass slide diagnosis ranged from 80% to 96%. Nevertheless, two cases that had been unequivocally diagnosed as malignant based upon video images were considered to be benign by the same pathologist when reviewing the glass slides. Both diagnostic confidence and self-concordance were higher for one pathologist having significant previous video microscopy experience.

CONCLUSION

Although intraobserver concordance between telecytologic and glass slide diagnoses of breast fine needle aspirates is high, refinement of existing criteria for diagnosis of malignancy, taking account of the particular limitations associated with telecytologic diagnosis, may be prudent prior to widespread use of telecytology for fine needle aspiration evaluation.

Cluster of uterine mullerian adenosarcoma in the Washington, DC metropolitan area with high incidence of sarcomatous overgrowth

Mullerian adenosarcoma is an uncommon variant of uterine sarcoma. Twelve uterine adenosarcomas were diagnosed during a 42-month period at the Washington Hospital Center in Washington, DC. Based on estimated incidence data derived from the US Department of Defense beneficiary population, an estimated relative risk of 15.4 (95% confidence interval, 7.7-31.0) was calculated, indicating a significantly increased incidence of adenosarcoma in the population studied (p<0.0000001). Among 10 patients who underwent hysterectomy, six (60%) of their tumors had sarcomatous overgrowth. In comparison with the previously reported proportion of adenosarcomas with sarcomatous overgrowth, approximately 16%, the proportion with sarcomatous overgrowth was significantly higher than expected (p<0.01). Mullerian adenosarcoma with sarcomatous overgrowth was first described in 1989 and suggests that the cluster of adenosarcomas reported herein may be due in part to the current classification of some uterine tumors as adenosarcoma with sarcomatous overgrowth that previously would have been classified as other types of uterine sarcoma. Nonetheless, even after reviewing and updating the classification of all sarcomas diagnosed at the Washington Hospital Center from 1985 to 1998, the ratio of adenosarcomas to uterine adenocarcinomas during the 1994-1998 period was 4.7 times (p<0.005) that of the 1985-1993 period, suggesting a more modest but real increase in the occurrence of this tumor. Correct classification of mullerian adenosarcomas with sarcomatous overgrowth is important because the limited available data suggest that the prognosis is notably worse than that for adenosarcomas without sarcomatous overgrowth.

Advanced laboratory techniques at the Armed Forces Institute of Pathology applicable to diagnosis and research in dermatology

The Armed Forces Institute of Pathology (AFIP) is well known for providing expert pathology in many specialties and educational courses for civilian and military personnel. Some of the departments at the AFIP have also developed expertise in various advanced laboratory techniques for diagnosis and research that are applicable to dermatology and are not available at most medical centers.

Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site

Although the significance of various prognostic factors, such as tumor size and mitotic index (MI), has been well established for smooth-muscle tumors of the stomach, the significance of these factors in other sites is less well defined. We studied 1004 patients with gastrointestinal smooth-muscle tumors for whom vital status could be determined. The average MI and tumor size varied significantly among the five major sites examined: esophagus (53 cases), stomach (524 cases), small bowel 252 cases), colon/rectum (108 cases), and omentum/mesentery/peritoneum (67 cases). There was a significant difference in site-specific survival (p = 0.001), with 10-year survival varying between 50% and 70%. Multivariate analysis demonstrated tumor location (p = 0.0320), size (p = 0.0003), MI (p < 0.0001), and patient age (p < 0.0001) to each carry independent prognostic value. The significance of MI was highly site dependent. Separation of survival curves for the stomach, using a threshold for analysis of either 5 or 10 mitotic figures/50 high-power fields, was very good. In contrast, small-bowel tumors showed little separation between survival curves, regardless of whether a threshold of 1, 5, or 10 mitotic figures MF/50 high-power fields was used to distinguish groups. In no site were tumor size and MI alone sufficient to provide an accurate long-term prediction of prognosis. Although tumor location, size, MI, and age have independent value in predicting the prognosis of patients with gastrointestinal smooth-muscle tumors, better methods are still required to accurately predict clinical course.

KIT mutation portends poor prognosis in gastrointestinal stromal/smooth muscle tumors

Gastrointestinal stromal/smooth muscle tumors (GISTs) are uncommon neoplasms for which current criteria for the diagnosis of malignancy (location, size, and mitotic index) do not always reliably predict patient outcome. Recently, mutation of KIT oncogene exon 11 has been observed in some of these tumors, but the relationship between mutation and clinical outcome has not yet been determined. DNA was obtained from the formalin-fixed, paraffin-embedded tissue of 35 gastric GISTs. A segment of exon 11 was amplified by PCR and sequenced on an ABI 377 sequencer. The relationship between the presence or absence of mutation, tumor size, and mitotic index was investigated using correlation analysis, and the relationship between mutation and outcome was investigated using Kaplan-Meier plots, the Cox-Mantel statistic, and the Cox regression model. Exon 11 deletion mutations were identified in 10 cases, and point mutations were identified in an additional 3 cases; 22 cases demonstrated no KIT mutations. KIT mutation was associated with decreased survival (p = 0.001), with fewer than 30% of patients surviving more than 3 years, compared with over 65% survival for patients whose tumors did not bear the mutation. KIT mutation did not correlate with either the mitotic index or the tumor size. In conclusion, KIT mutation is associated with poor prognosis in patients with gastrointestinal stromal tumors. Whether the KIT mutation will prove to be an independent prognostic factor awaits the completion of larger studies.

Loss of heterozygosity on chromosome 11p15 during histological progression in microdissected ductal carcinoma of the breast

Microdissection of histologically identifiable components from formalin-fixed, paraffin-embedded tissue sections allows molecular genetic analyses to be correlated directly with pathological findings. In this study, we have characterized loss of heterozygosity (LOH) at chromosome 11p15 at different stages of progression in microdissected tumor components from 115 ductal carcinomas of the breast. Microdissected foci of intraductal, infiltrating, and metastatic tumors were analyzed to determine the stage of progression at which LOH at 11p15 occurs. LOH was detected in 43 (37%) of 115 cases. Foci of intraductal carcinoma could be microdissected from 85 cases, of which 30 (35%) showed LOH at some stage of progression. LOH was detected in the intraductal component in 26 of these 30 cases. Interstitial deletions were characterized by using a panel of 10 highly polymorphic markers. The smallest region of overlap (SRO) for LOH at 11p15 was bounded by the markers D11S4046 and D11S1758. LOH at 11p15.5 showed no correlation with estrogen receptor status, the presence of positive lymph nodes, tumor size, histological grade, or long-term survival. We conclude that 11p15 LOH usually occurs early in breast cancer development but less frequently does not develop until the infiltrating or metastatic stages of tumor progression.

PAPNET-assisted rescreening of cervical smears: cost and accuracy compared with a 100% manual rescreening strategy

CONTEXT

The Food and Drug Administration has recently approved several devices that use computerized image analysis to rescreen Papanicolaou (Pap) smears that have already been examined by cytotechnologists. Physicians and laboratories must decide whether the utility of these devices justifies the cost.

OBJECTIVE

To determine the effectiveness and cost of PAPNET-assisted rescreening in identifying cervical abnormalities not identified by manual rescreening.

DESIGN

PAPNET-assisted rescreening of 5478 Pap smears obtained in 1994 and 1995 previously identified as "within normal limits" or "benign changes" on both initial and random screening.

PATIENTS

Female service members and dependents aged 12 to 88 years.

SETTING

Air Force clinics in the United States and Japan.

INTERVENTION

Rescreening of Pap smears by PAPNET, followed by reevaluation of abnormal smears by the consensus panel, consisting of 3 cytotechnologists and 3 pathologists.

MAIN OUTCOME MEASURES

Proportion of Pap smears initially screened as normal identified as abnormal by both PAPNET and consensus panel; costs of rescreening.

RESULTS

PAPNET screening identified 1614 (29%) slides requiring additional microscopic review. On further review, 448 (8% of total) had possibly abnormal cells. Ultimately, 11 of these cases were reviewed by the consensus panel for potentially atypical cells. Of these 11 cases, 5 were reclassified as atypical squamous cells of undetermined significance (ASCUS) and 1 as atypical glandular cells of undetermined significance (AGUS). No additional squamous intraepithelial neoplasia (SIL) was identified in these smears; the patient with a diagnosis of AGUS on rescreening was diagnosed as having a low-grade SIL (LSIL) on follow-up. Costs were $5825 to $33781 for each additional ASCUS or AGUS diagnosis. A cost of $17475 to $101343 is expected for each case of LSIL identified by PAPNET-assisted rescreening and not by traditional manual rescreening.

CONCLUSIONS

PAPNET-assisted rescreening identified a few more cases of ASCUS than did manual rescreening, but at a relatively high cost. The costs of rescreening should be carefully compared with the expected efficacy in reducing cervical cancer mortality.

Flow cytometry in diagnostic cytology

Flow cytometry (FCM) is a useful adjunct to cytologic examination, because the quantitative biochemical information it provides complements the morphologic information gained during visual examination. It aids in the interpretation of bladder washings, and is particularly useful for the assessment of lymphoid lesions, whether they originate from fine-needle aspiration, cerebrospinal fluid, or effusions. Optimal use of FCM frequently requires assessment of more than one parameter; simultaneous use of cell differentiation markers and nuclear DNA quantitation is often significantly more useful than either alone. Despite the utility of FCM, however, the potential for future development appears to be limited. Improvements in image cytometry allow reasonable assessment of ploidy and S-fraction to be made from specimens prepared on glass slides. Multiparameter measurements may also be accomplished with imaging techniques, which allow the further advantage of visual identification of cells with equivocal morphologic changes. The development of artificial intelligence methods for use with imaging technology has also significantly exceeded that of FCM. Finally, image cytometry is often more useful for samples with few cells. Other challenges are posed by immunocytochemical methods which compete with flow cytometry as tools for assessment of proliferation. Given the relatively high cost of FCM instrumentation, survival of FCM as an ancillary technique in cytopathology will require further technical refinements to offset the advantages currently associated with image cytometry and immunocytochemistry.

Packing characteristics of two-component bilayers composed of ester- and ether-linked phospholipids

The miscibility properties of ether- and ester-linked phospholipids in two-component, fully hydrated bilayers have been studied by differential scanning calorimetry (DSC) and Raman spectroscopy. Mixtures of 1,2-di-O-hexadecyl-rac-glycero-3-phosphocholine (DHPC) with 1,2-dipalmitoyl-sn-glycero-3-phosphoethanolamine (DHPE) and of 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) with 1,2-di-O-hexadecyl-sn-glycero-3-phosphoethanolamine (DHPE) have been investigated. The phase diagram for the DPPC/DHPE mixtures indicates that these two phospholipids are miscible in all proportions in the nonrippled bilayer gel phase. In contrast, the DHPC/DPPE mixtures display two regions of gel phase immiscibility between 10 and 30 mol% DPPE. Raman spectroscopic measurements of DHPC/DPPE mixtures in the C-H stretching mode region suggest that this immiscibility arises from the formation of DHPC-rich interdigitated gel phase domains with strong lateral chain packing interactions at temperatures below 27 degrees C. However, in the absence of interdigitation, our findings, and those of others, lead to the conclusion that the miscibility properties of mixtures of ether- and ester-linked phospholipids are determined by the nature of the phospholipid headgroups and are independent of the character of the hydrocarbon chain linkages. Thus it seems unlikely that the ether linkage has any significant effect on the miscibility properties of phospholipids in biological membranes.

MDM2 amplification, P53 mutation, and accumulation of the P53 gene product in malignant fibrous histiocytoma

Fifty-two cases of malignant fibrous histiocytoma (MFH) were evaluated for amplification of the MDM2 gene, mutation of the P53 gene, accumulation of the P53 gene product, and their relation to disease-free and overall survival. All tests were carried out on formalin-fixed, paraffin-embedded tissue samples. Amplification of the MDM2 gene was detected in 15 of 52 cases (29%). Six of 52 cases (12%) demonstrated abnormalities of the P53 gene. Sequence analysis detected point mutations in four cases and a 1-base pair deletion in one case, whereas differential polymerase chain reaction (dPCR) indicated that the P53 gene had been entirely deleted in one case. Eight of 52 cases (15%) demonstrated staining for the P53 protein in >10% of tumor cells. The presence of MDM2 amplification did not have a significant effect on either disease-free or overall survival. Patients with accumulation of the P53 gene product did not differ in disease-free or overall survival from patients without P53 accumulation. Survival also was not significantly different in patients with genetic aberration in P53. However, when the patients were stratified by histologic grade, the results indicated that patients with alterations in the P53 gene may have shorter overall survival.

Can you count on the mitotic index?

The mitotic index (MI) is the most commonly use quantitative measure in anatomic pathology but has been widely criticized for supposed "irreproducibility." In this article, the authors show that mitotic figure (MF) counts may be described by a Poisson distribution, give confidence intervals for the MI, and show that the supposed irreproducibility is largely a consequence of the counting techniques. They also show how to obtain the MI to a predetermined level of precision and present an analysis of why mitotic figure counting works, when properly used, despite the inherently low precision of the estimates that are usually obtained.

Lamellar-phase polymorphism in interdigitated bilayer assemblies

Bilayers composed of 1-octadecanoyl-2-decanoyl-sn-glycero-3-phosphocholine (C(18)C(10)PC) adopt a mixed-interdigitated gel-phase packing where the short chains of the C(18)C(10)PC molecules pack end-to-end while their long chains span the entire hydrocarbon width of the bilayer. Calorimetric cooling scans of freshly prepared hand-shaken bilayer suspensions of C(18)C(10)PC exhibit a single exothermic phase transition at 14.6 degrees C, whereas suspensions incubated at temperatures below 2 degrees C for several days exhibit an additional phase-transition exotherm at 17.9 degrees C. Calorimetric and electron microscopic evidence is presented that low-temperature incubation of C(18)C(10)PC bilayer suspensions composed of liposomes of heterogeneous size leads to the conversion of those liposomes in the suspension below about 0.2 microns in diameter into planar lamellar sheets. These lamellar sheets are the origin of the phase-transition exotherm at 17.9 degrees C, whereas the phase-transition exotherm at 14.6 degrees C arises from the liposomes in the suspension. We also show that phosphatidylcholine bilayer suspensions, induced to interdigitate by ethanol, exhibit a similar thermotropic behavior. The implication of these findings for the reversibility of interdigitated gel to liquid-crystalline phase transitions and the role of phospholipid molecular geometry in the formation of interdigitated bilayers are addressed.

Use of semiquantitative PCR to assess onset and treatment of Pneumocystis carinii infection in rat model

The use of semiquantitative PCR (SQPCR) to assess Pneumocystis carinii pneumonia (PCP) infection and its response to treatment was studied with rats. Groups of eight rats were immunosuppressed with steroids for 3 to 12 weeks. Untreated controls were maintained for the same periods. Three groups of rats were treated with pentamidine, three groups were treated with trimethoprim-sulfamethoxazole, and three groups of rats were tapered from steroids. At various times during suppression, rats from the different groups were sacrificed. At necropsy, lungs were lavaged to obtain bronchoalveolar fluids and then homogenized. Bronchoalveolar fluids and homogenates were assayed by cyst counting and SQPCR. An increase in the SQPCR signal was seen throughout immunosuppression, with a slow decrease upon the withdrawal of steroids and a faster decrease with drug treatment. SQPCR results with lung homogenates and bronchoalveolar fluids strongly correlated with each other and with cyst counts. These results warrant investigation of SQPCR for assessing treatment results of human P. carinii pneumonia infection.

Proliferating-cell nuclear antigen immunocytochemistry in the evaluation of gastrointestinal smooth-muscle tumors

Current methods do not provide a way always to distinguish benign from malignant gastrointestinal smooth-muscle tumors. We compared immunocytochemical assessment of proliferating-cell nuclear antigen expression with flow cytometry and mitotic figure-counting as a prognostic marker in 85 gastrointestinal smooth-muscle tumors. Although proliferating-cell nuclear antigen expression was associated with poor prognosis in univariate statistical analysis, it was not significant in multivariate proportional hazards models that included either the mitotic index or aneuploidy of the flow-cytometric G2M peak. We conclude that proliferating cell nuclear antigen assessment is not warranted in the routine evaluation of gastrointestinal smooth-muscle tumors.

Use of remote video microscopy (telepathology) as an adjunct to neurosurgical frozen section consultation

We investigated the use of remote video microscopy (telepathology) to assist in the diagnosis of 52 neurosurgical frozen section cases. The TelMed system (Discovery Medical Systems, Overland Park, KS), in which the referring pathologist selects appropriate fields for transmission to the consultant, was used for the study. There was a high degree of concordance between the diagnosis rendered on the basis of transmitted video images and that rendered on the basis of direct evaluation of frozen sections; however, in seven cases there was substantial disagreement. Remote evaluation was associated with a more rapid consultation from the standpoint of the consultant, who spent approximately 2 minutes less per case when using remote microscopy; this was achieved at the expense of considerably greater effort on the part of the referring pathologist, who spent approximately 16 minutes per case selecting an average of 4.5 images for transmission to the consultant. The use of remote video microscopy for pathology consultation is associated with a complex series of tradeoffs involving cost, information loss, and timeliness of consultation.

Predicting prognosis of gastrointestinal smooth muscle tumors. Role of clinical and histologic evaluation, flow cytometry, and image cytometry

Both flow cytometry (FCM) and morphometry have been proposed as techniques for predicting the prognosis of gastrointestinal (GI) smooth muscle tumors (SMTs). In particular, DNA aneuploidy by FCM has been associated with high histologic grade and shortened survival, whereas the DNA index determined by image cytometry has been proposed as a criterion for the diagnosis of malignancy. To further define the potential roles of these two techniques, we performed a variety of morphometric and FCM measurements on paraffin blocks from 122 patients with GI SMTs, with a median follow-up period of 6 years, together with assessments of tumor size and mitotic activity. None of the morphometric measurements (nuclear perimeter, area, form factor, longest diameter, average ferret diameter, equivalent diameter, and DNA index) was a significant prognostic factor when analyzed using a univariate Cox model. In contrast, the flow cytometric mean channel number, the fraction of cells in G2M, aneuploidy of the G0/G1 peak, aneuploidy of the G2M peak, tumor size, and mitotic activity index were statistically significant in univariate models, together with the patient age and sex, and whether or not the patient presented with metastases. In a multivariate model, > 10 mitotic figures per 50 high-power fields and metastases indicated a poor prognosis. If metastasis was not allowed to enter the model, the mitotic index and aneuploidy of the G2M peak portended a poor prognosis.

Immunocytochemistry in the differential diagnosis of effusions: use of logistic regression to select a panel of antibodies to distinguish adenocarcinomas from mesothelial proliferations

Many studies have shown immunohistochemistry to be beneficial in discriminating between adenocarcinoma and mesothelial reactions in effusions. Although many of these studies suggest using a panel of antibodies, none of them used statistical methods to optimize their choice of assays. In the current study, stepwise logistic regression was applied to our data to select an appropriate panel of antibodies to differentiate between adenocarcinoma and all types of mesothelial proliferations. One hundred effusions (64 cases of adenocarcinoma, 27 cases of benign mesothelial proliferations, and 9 cases of malignant mesothelial proliferations) were analyzed for their reactivity with anti-EMA, anti-MFG, anti-CEA, Leu-M1, B72.3, and the newly described epithelial membrane marker BER-EP4. An abbreviated panel consisting of anti-CEA, EMA, and B72.3 was shown to be sufficient in over 95% of our cases to accurately characterize a given effusion. When all three assays are negative, a diagnosis of adenocarcinoma is extremely unlikely, while when two or three of the assays are positive a diagnosis of adenocarcinoma is almost certain. The use of stepwise logistic regression has proven useful in the design of antibody panels as an adjunct to the differential diagnosis of effusions and may be applicable to the selection of panels in other diagnostic problems.

Determination of B-cell clonality in paraffin-embedded lymph nodes using the polymerase chain reaction

Formalin-fixed, paraffin-embedded tissue from B-cell malignant lymphomas (26), reactive lymphadenopathies (8), non-B-cell malignancies (5), and atypical lymphoproliferative lesions (7) were analyzed for clonal immunoglobulin heavy chain gene rearrangement by the polymerase chain reaction (PCR), using consensus primers for the variable and joining regions of the gene. By employing a high-resolution gel electrophoresis technique, we were able to demonstrate one or two dominant bands, indicating a clonal population, in 15 of the 23 cases (65%) of B-cell lymphoma in which amplification occurred. Six of six reactive lymph nodes in which amplification occurred produced a multi-banded pattern indicative of a polyclonal population. This improved PCR technique allows a clearer distinction between clonal and polyclonal patterns than other previously proposed methods. It also works well in paraffin-embedded tissue and may therefore be a useful adjunct to the diagnostic armamentarium applied to archival material.