Pteropox infection in a juvenile grey-headed flying fox (Pteropus poliocephalus)

A juvenile grey-headed flying fox (GHFF) (Pteropus poliocephalus) presented to the Australia Zoo Wildlife Hospital after a wildlife carer found the animal hanging on the outside of an aviary. On presentation, the animal was emaciated and moribund with disseminated, multifocal, depigmented and proliferative lesions on the wing membranes and skin of the neck. Histopathology revealed multiple, well-circumscribed proliferative epidermal lesions with intracytoplasmic inclusion bodies. A poxvirus was identified via transmission electron microscopy and next-generation sequencing (NGS). Analysis of sequences obtained demonstrated 99% nucleotide identity to Pteropox virus strain Australia (GenBank KU980965). To the authors' knowledge, this paper describes the first case of Pteropox virus infection in a GHFF.

Reducing radiation exposure and cancer risk for children with scoliosis: EOS the new gold standard

PURPOSE

Children are exposed to significant radiation doses during the investigation and treatment phases of scoliosis. EOS is a new form of low-dose radiation scan which also yields great image quality. However, currently its use is discouraged in the UK due to higher costs. We aimed to quantify the additional radiation dose and cancer risk.

METHODS

We retrospectively reviewed all paediatric cases who received both standing whole spine roentgenograms and EOS scans as part of their investigations for scoliosis during a six-month period. We compared the radiation doses between the two modalities and estimated the additional mean lifetime cancer risk per study.

RESULTS

We identified 206 children (mean age 14.4) who met the criteria of having both scans. Dose area products (dGycm2) were converted to estimated effective doses (mSv). The total mean doses were 0.68 mSv (PA 0.49 + Lat 0.19) for plain films, and 0.13 mSv (PA 0.08 + Lat 0.04) for EOS scans (p < 0.001). Additional lifetime cancer risk of a plain film was 543% greater than EOS for both sexes (1/10727 versus 1/5827 in males, 1/34483 versus 1/6350 in females).

CONCLUSION

There is approximately 5.4-fold increase in risk of cancer for both boys and girls with roentgenograms over EOS, with girls being the most impacted. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in children. In our opinion, EOS dual planar scanning is the new gold standard when X-ray of the whole spine is required.

LEVEL OF EVIDENCE

III.

Chemotherapy May Obviate Prophylactic Femoral Nail Surgery for Multiple Myeloma Patients With High Mirels' Score Lesions and Impending Pathological Hip Fracture

Bone involvement presents in >80% of patients with multiple myeloma. This causes lytic lesions for which prophylactic surgery is indicated to prevent pathological fractures if the lesion is graded ≥9/12 on Mirels' score. Although successful, these surgeries have risks and extended recovery periods. We present a case indicating myeloma chemotherapy may obviate prophylactic femoral nailing for high Mirels' score lesions in the femoral head with impending pathological hip fracture. A 72-year-old woman presented in December 2017 with back pain. A plain X-ray indicated degenerative anterolisthesis in her lumbosacral spine. Serum analysis revealed abnormal protein, globulin, alkaline phosphatase, and albumin levels while protein electrophoresis and serum immunofixation revealed raised immunoglobulin A (IgA) kappa paraprotein and kappa serum free light chains, respectively. Whole-body CT scans showed widespread lytic bone lesions and bone marrow biopsy confirmed infiltration by plasma cells. She was diagnosed with International Staging System (ISS) stage 3 multiple myeloma, which was successfully treated with bortezomib, thalidomide and dexamethasone with regular bisphosphonates that year. She presented again to the hospital in June 2020 with acute back and pelvic pain; Her paraprotein and serum-free light chains had increased significantly from her previous clinic appointment, indicating serological progression. MRI showed a relapse of the myeloma deposits in her right femoral head and spine. The deposit in her femoral head was graded 10/12 on Mirels' score, which indicated prophylactic femoral nailing. Instead, the patient was treated with daratumumab, bortezomib, and dexamethasone with escalation to monthly zoledronic acid infusions, as it was thought surgery would provide limited cytoreductive effect, preventing chemotherapy for six weeks post-surgery, potentiating pathological hip fracture and disease progression at other sites. This resulted in a complete response, thus reducing the deposits such that the femoral lesion was graded <8 on Mirels' score, improved her pain, and restored her ability to traverse stairs. She remains in complete response with ongoing daratumumab and denosumab maintenance treatment as of December 2022. Chemotherapy and bisphosphonates substantially reduced the myeloma deposit in the femoral head such that indications of prophylactic surgery were eliminated according to Mirels' score recommendations. This reduced the risk of pathological hip fracture whilst eliminating surgical complications. Further research should be conducted into the safety and efficacy of this treatment regimen in patients with high Mirels' score lesions. With this knowledge, consideration can be taken as to whether prophylactic femoral nailing is necessary given strong indications.

Thoracolumbar spine trauma: a guide for the FRCS examination

Thoracolumbar spine injuries are commonly seen in trauma settings and have a high risk of causing serious morbidity. There can be controversy when it comes to classifying thoracolumbar injuries within the spinal community, but there remains a need to classify, evaluate and manage thoracolumbar fractures. This article aims to provide a guide on classification of thoracolumbar spine injuries using the AO Spine Thoracolumbar Injury Classification System (AO TLICS).

Re-activation of HIF signalling pathway in the epicardium improves heart regeneration after myocardial infarction

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

In mouse, cardiac regenerative capacity is maintained for the first week after birth but lost thereafter. Reactivation of this process holds great therapeutic potential, however, the molecular pathways that might be targeted to extend neonatal regeneration remain elusive. Here, we explore a role for hypoxia inducible factor (HIF) family of transcription factors on the regulation of epicardial activity which is essential for cardiac response to injury.

Purpose

HIF signalling might be involved in the quiescence of the epicardium observed in the first week of life. Thus, HIF stabilisation may induce epicardial re-activation and extend the 7-day regenerative window in a neonate mouse model of myocardial infarction (MI).

Methods

We analysed epicardial expression of HIF signalling during embryonic development, and in a regenerative post-natal day 1 (P1) versus non-regenerative (P7) mouse model by single cell RNA-sequencing. Next, we established in vitro epicardial explants to confirm the role of HIF signalling in epicardial activation, and finally we induced MI by permanent ligation of the proximal left anterior descending (LAD) coronary artery in P7 mice to test weather HIF signalling re-activation improved heart regeneration in a non-regenerative model.

Results

Expression of both HIF-1α and HIF-2α is very pronounced at early stages of heart development and gradually decreases throughout gestation. The epicardium preferentially expresses HIF-1α by embryonic day (E) 16.5. Postnatally, GO term analysis showed an enrichment of hypoxia-related pathways in P1 compared to P7 hearts, largely in the epicardial cell population. Accordingly, expression of Phd2, encoding for the main suppressor of HIF signalling, was enriched in P7 derived epicardial cells. Notably, the increase in Phd2 levels coincided with a clear reduction in the expression of Wilms’ tumour 1 (Wt1) in P7 versus P1 hearts, a key player in the epicardial activation. In vitro studies on epicardial explants confirmed regulation of WT1 expression and migration capacity following genetical and pharmacological modulation of HIF signalling. Finally, in vivo targeting of PHD enzymes through pharmacological inhibition with clinically approved drugs in a neonatal mouse model of MI led to prolonged epicardial activation, increased vascularisation, augmented infarct resolution and preserved cardiac function up to 3 weeks after injury.

Conclusions

Together, these findings show that modulation of HIF signalling can regulate epicardial activity and improve heart regeneration capacity beyond the 7-day regenerative window and may represent a viable therapeutic strategy for treating ischaemic heart disease.

Surgeon-Directed Neuromonitoring in Adolescent Spinal Deformity Surgery Safely Assesses Neurological Function

Background

Spinal deformity correction is associated with the risk of intra-operative neurological injury. Surgeon-directed monitoring (SDM) of transcranial motor-evoked potentials (TcMEP) is an option to monitor intra-operative spinal cord function. We report a retrospective analysis of a prospective database to assess the safety of this technique in spinal deformity correction in adolescent patients.

Methods

Surgeon-directed neuro-monitoring was utilised in 142 consecutive deformity correction surgeries (2012-2017). Surgeons were responsible for electrode placement, intra-operative stimulation, and interpretation of TcMEP data. If waveform disappearance occurred in the lower limb (LL), the surgeon would re-stimulate after excluding technical or anaesthetic factors. Failure to return normal waveforms led to maneuver reversal and reducing distractive force and ensuring subsequent return to baseline. Wake up test and ankle clonus followed by staging surgery was considered if the LL waveforms failed to return indicating potential motor injury.

Results

Of 142 patients, three cases (2.11%) had a complete visual loss of LL signals that did not resolve with anaesthetic stabilisation, leading to reversed surgical manoeuvre and staged surgery. No cases with permanent neurological dysfunction were recorded. This outcome supports surgeon-directed monitoring as a safe monitoring option, as an alternative to neurophysiologist-led monitoring. It also provides evidence in support of the waveform disappearance criteria as a safe TcMEP warning criterion with a 100% negative predictive value.

Conclusions

Where there is a lack of availability of trained neurophysiologists, surgeon-directed neuro-monitoring is a safe and reliable method of preventing intra-operative neurological injury amongst adolescent patients undergoing deformity correction.

Germline ATM variants predispose to melanoma: a joint analysis across the GenoMEL and MelaNostrum consortia

PURPOSE

Ataxia-Telangiectasia Mutated (ATM) has been implicated in the risk of several cancers, but establishing a causal relationship is often challenging. Although ATM single-nucleotide polymorphisms have been linked to melanoma, few functional alleles have been identified. Therefore, ATM impact on melanoma predisposition is unclear.

METHODS

From 22 American, Australian, and European sites, we collected 2,104 familial, multiple primary (MPM), and sporadic melanoma cases who underwent ATM genotyping via panel, exome, or genome sequencing, and compared the allele frequency (AF) of selected ATM variants classified as loss-of-function (LOF) and variants of uncertain significance (VUS) between this cohort and the gnomAD non-Finnish European (NFE) data set.

RESULTS

LOF variants were more represented in our study cohort than in gnomAD NFE, both in all (AF = 0.005 and 0.002, OR = 2.6, 95% CI = 1.56-4.11, p < 0.01), and familial + MPM cases (AF = 0.0054 and 0.002, OR = 2.97, p < 0.01). Similarly, VUS were enriched in all (AF = 0.046 and 0.033, OR = 1.41, 95% CI = 1.6-5.09, p < 0.01) and familial + MPM cases (AF = 0.053 and 0.033, OR = 1.63, p < 0.01). In a case-control comparison of two centers that provided 1,446 controls, LOF and VUS were enriched in familial + MPM cases (p = 0.027, p = 0.018).

CONCLUSION

This study, describing the largest multicenter melanoma cohort investigated for ATM germline variants, supports the role of ATM as a melanoma predisposition gene, with LOF variants suggesting a moderate-risk.

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.

Is the AO spine thoracolumbar injury classification system reliable and practical? a systematic review

Controversy surrounding the classification of thoracolumbar injuries has given rise to various classification systems over the years, including the most recent AOSpine Thoracolumbar Injury Classification System (ATLICS). This systematic review aims to provide an up-to-date evaluation of the literature, including assessment of a further three studies not analysed in previous reviews. In doing so, this is the first systematic review to include the reliability among non-spine subspecialty professionals and to document the wide variety between reliability across studies, particularly with regard to sub-type classification. Relevant studies were found via a systematic search of PubMed, EBESCO, Cochrane and Web of Science. Data extraction and quality assessment were conducted in line with Cochrane Collaboration guidelines. Twelve articles assessing the reliability of ATLICS were included in this review. The overall inter-observer reliability varied from fair to substantial, but the three additional studies in this review, compared to previous reviews, presented on average only fair reliability. The greatest variation of results was seen in A1 and B3 subtypes. Least reliably classified on average was A4 subtype. This systematic review concludes that ATLICS is reliable for the majority of injuries, but the variability within subtypes suggests the need for further research in assessing the needs of users in order to increase familiarity with ATLICS or perhaps the necessity to include more subtype-specific criteria into the system. Further research is also recommended on the reliability of modifiers, neurological classification and the application of ATLICS in a paediatric context.

Tranexamic acid use in a patient with sickle cell disease undergoing posterior scoliosis correction surgery: safely mitigating bleeding and vaso-occlusive crises

A 15-year-old female with 2-year post-menarchal adolescent idiopathic scoliosis and sickle cell disease (SCD) underwent posterior scoliosis correction surgery. SCD is associated with higher rates of surgical complications, and these patients require careful management to prevent vaso-occlusive sickle cell crises (VOSCC); scoliosis correction surgery can be associated with high morbidity and mortality, including significant blood loss. Multiple techniques were employed to successfully prevent VOSCC in this patient including a preoperative transfusion, meticulous haemostasis at osteotomy sites, not performing a costoplasty despite presence of a rib hump, maintenance of intraoperative mean arterial pressure below 70 mmHg, aggressive postoperative hydration and the use of intraoperative tranexamic acid (TXA). This is the first reported case of the use of TXA in a patient with SCD and scoliosis correction surgery. A satisfactory correction was achieved with a longer than average inpatient stay due to non-sickle cell pain and protracted wound ooze.

Abstract LB-274: Primary tumor gene expression signature predicts long-term outcomes in primary melanoma: A prospective multicenter study

Purpose: Adjuvant therapies prolong survival in patients with stage III melanoma. However, biomarkers are needed to stratify patients with primary melanoma at highest risk for metastases which could help minimize exposure to potentially irreversible toxicities and allow for rational clinical trial designs in the adjuvant setting.

Methods: We analyzed data from 194 RNA-sequenced primary cutaneous melanomas from patients with stage IIB-IIIC disease recruited to the multicenter AVAST-M phase III randomized trial. By undertaking covariate-corrected differential expression between patients experiencing distant metastasis (n=89) versus no-metastases (n=105), we identified metastasis-associated genes of which 121 were externally validated and made up our predictive signature, “Cam_121”. Several machine learning classification models were trained using nested leave-one-out cross validation (LOOCV) to test the signature's capacity to predict metastases. Univariate and multivariate Cox proportional hazard regression survival analyses were performed. The signatures' predictive accuracy was further externally validated in an independent population-controlled cohort study measuring melanoma-specific survival (Leeds Melanoma Cohort, n=687).

Results: The signature distinguished patients with distant recurrence from those without across multiple machine learning models (sensitivity=0.64, specificity=0.79, accuracy=0.72, kappa=0.43) and performed significantly better than any of the models trained with the clinical covariates alone (pAccuracy =4.92x10-3), as well as those trained with predictive signatures selected from two published datasets (Decision-Dx MelanomaTM and Leeds Melanoma Cohort 150 genes). The signature also correlated with progression-free survival (PFS), overall survival (OS) and melanoma-specific survival (MSS) while retaining its predictive accuracy following multivariate correction (PFS: HR=0.49 (0.35-0.69), p=2.8x10-5, OS: HR=0.6 (0.42-0.86), p=0.005 and MSS: HR=0.57, p=8x10-5). Importantly, we found that the median signature expression score positively correlated with measures of immune cell infiltration, with a lower score representing a poorer tumor lymphocytic infiltration and worse long-term prognosis.

Conclusions: We have identified Cam_121 a primary melanoma expression signature that outperforms currently available predictive signatures. The signature confirms (using unbiased approaches) the central prognostic importance of immune cell infiltration in long-term patient outcomes and could help identify primary melanoma patients at highest risk of metastases and poor survival who might benefit most from adjuvant therapies.

Citation Format: Manik Garg, Dominique-Laurent Courturier, Nuno A. Fonseca, Matthew Wongchenko, Yibing Yan, Jeremie Nsengimana, Tim Bishop, Julia Newton-Bishop, Mark Middleton, Pippa Corrie, David J. Adams, Alvis Brazma, Roy Rabbie. Primary tumor gene expression signature predicts long-term outcomes in primary melanoma: A prospective multicenter study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-274.

1104 Increasing Accessibility of Nightmare Treatment Via Mobile Health

Introduction

Nightmares have been tied to a myriad of adverse mental health outcomes and are known to persist after treatment of other concerns such as posttraumatic stress, depression, and anxiety. When reaching clinical levels, nightmare disorder is known to effect 2-6% of the general population, Although many treatments exist for nightmare disorder and posttraumatic nightmares, Imagery Rehearsal Therapy has consistently been cited as the first line treatment. Mobile health (mHealth) technology has emerged as a viable platform from which to deliver sleep medicine interventions.

Methods

We assessed the efficacy of an Imagery Rehearsal Therapy-based mobile application (Dream EZ) developed by the National Center for Telehealth and Technology. College students (n = 99) were recruited in a two-part online study and randomized to the treatment condition or waitlist control. Repeated measures analysis of variance were used to assess the efficacy of smartphone-based mHealth application treatment (Dream EZ) in reduction of psychological symptoms (nightmare distress, PTSD symptoms, and suicide risk) as compared to waitlist control.

Results

Findings support the use of Dream EZ for nightmares distress reduction (main effect: p =.004, d = .57; interaction: p =.049, d = .41). Results regarding effectiveness of Dream EZ in relation to reduction of PTSD symptoms (main effect: p = .415, d = .17; interaction: p =.262, d = .23) showed no significant interactions between PTSD symptoms and treatment group assignment. In relation to changes in suicidality (main effect: p =.007, d = .57; interaction: p =.758, d = .07), findings were nonsignificant.

Conclusion

Use of nightmare-focused treatment through a mHealth smartphone application may be a viable avenue for promoting management of nightmare distress in college students. These findings present an opportunity to explore further options for increasing accessibility of sleep-focused treatment options in a challenging and fast-paced population.

Support

No support to disclose.

Predicting the periodic risk of anthrax in livestock in Victoria, Australia, using meteorological data

Cases of anthrax in livestock are infrequently and irregularly reported in the state of Victoria, Australia; however, their impact on individual livestock, farming communities and the government agencies tasked with containing these outbreaks is high. This infrequency has been anecdotally associated with differences in annual and local weather patterns. In this study, we used historical anthrax cases and meteorological data from weather stations throughout Victoria to train a generalized linear mixed effects model to predict the daily odds of a case of anthrax occurring in each shire in the coming 30 days. Meteorological variables were transformed to deviations from the mean values for temperature or cumulative values for rainfall in the shire across all years. Shire was incorporated as a random effect to account for meteorological variation between shires. The model incorporated a post hoc weighting for the frequency of historic cases within each shire and the spatial contribution of each shire to the recently redefined Australian Anthrax Belt. Our model reveals that anthrax cases were associated with drier summer conditions (OR 0.96 (95% CI 0.95-0.97) and OR 0.98 (95% CI 0.97-0.99) for every mm increase in rainfall during September and December, respectively) and cooler than average spring (OR 0.20 (95% CI 0.11-0.52) for every °C increase in minimum daily temperature during November and warmer than average summer temperatures (OR 1.45 (95% CI 1.29-1.61) for every °C increase in maximum daily temperature during January. Cases were also preceded by a 40-day period of cooler, drier temperatures (OR 0.5 (95% CI 0.27-0.74) for every °C increase in maximum daily temperature and OR 0.96 (95% CI 0.95-0.97) for every mm increase in rainfall followed by a warmer than average minimum (or nightly) temperature 10 days immediately before the case (OR 1.46 (95% CI 1.35-1.58) for every °C increase in maximum daily temperature). These coefficients of this training model were then applied daily to meteorological data for each shire, and output of these models was presented as a choropleth and timeline plot in a Shiny web application. The application builds on previous spatial modelling and provides Victorian agencies with a tool to engage at-risk farmers and guide discussions towards anthrax control. This application can contribute to the wider rejuvenation of anthrax knowledge and control in Victoria and corroborates the anecdote that increased odds of disease can be linked to meteorological events.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

An assessment of the distance between the phrenic nerve and major intrathoracic structures

Background

There is a lack of consensus in the literature regarding phrenic nerve proximity to thoracic structures at the level of the diaphragm. This study was undertaken to provide thoracic surgeons data on phrenic nerve location in order to reduce iatrogenic injury during invasive surgery.

Methods

Bilateral thoracic dissection was performed on 43 embalmed human cadavers (25 males; 18 females) and data was obtained from 33 left and 40 right phrenic nerves. The site of phrenic nerve penetration into the diaphragm was identified. Calipers were used to measure the distance from each phrenic nerve to the: inferior vena cava (IVC), descending aorta, esophagus, lateral thoracic wall and anterior thoracic wall.

Results

Mean thoracic diameter of male cadavers was significantly greater than that of female cadavers (P value <0.0001). There was no statistically significant difference between the distances from each phrenic nerve to visceral structures between males and females, except regarding the distance from the right phrenic nerve to the anterior thoracic wall where males exhibited significantly greater distances (P value =0.0234).

Conclusions

This study provides important data on phrenic nerve proximity to intrathoracic structures in an effort to help reduce iatrogenic injury during procedures within the thoracic cavity. Although males had a significantly larger thoracic diameter than females, the only statistically significant difference showed that the right phrenic nerve is deeper in the thoracic cavity in males. As this nerve passes closer to visceral structures it may be more susceptible to damage from pathology in surrounding vessels. This may explain the increased incidence of right phrenic nerve damage due to aortic aneurysm in males reported in the literature.

Associations between maternal physical activity in early and late pregnancy and offspring birth size: remote federated individual level meta-analysis from eight cohort studies

OBJECTIVE

Evidence on the impact of leisure time physical activity (LTPA) in pregnancy on birth size is inconsistent. We aimed to examine the association between LTPA during early and late pregnancy and newborn anthropometric outcomes.

DESIGN

Individual level meta-analysis, which reduces heterogeneity across studies.

SETTING

A consortium of eight population-based studies (seven European and one US) comprising 72 694 participants.

METHODS

Generalised linear models with consistent inclusion of confounders (gestational age, sex, parity, maternal age, education, ethnicity, BMI, smoking, and alcohol intake) were used to test associations between self-reported LTPA at either early (8-18 weeks gestation) or late pregnancy (30+ weeks) and the outcomes. Results were pooled using random effects meta-analyses.

MAIN OUTCOME MEASURES

Birth weight, large-for-gestational age (LGA), macrosomia, small-for-gestational age (SGA), % body fat, and ponderal index at birth.

RESULTS

Late, but not early, gestation maternal moderate to vigorous physical activity (MVPA), vigorous activity, and LTPA energy expenditure were modestly inversely associated with BW, LGA, macrosomia, and ponderal index, without heterogeneity (all: I2  = 0%). For each extra hour/week of MVPA, RR for LGA and macrosomia were 0.97 (95% CI: 0.96, 0.98) and 0.96 (95% CI: 0.94, 0.98), respectively. Associations were only modestly reduced after additional adjustments for maternal BMI and gestational diabetes. No measure of LTPA was associated with risk for SGA.

CONCLUSIONS

Physical activity in late, but not early, pregnancy is consistently associated with modestly lower risk of LGA and macrosomia, but not SGA.

TWEETABLE ABSTRACT

In an individual participant meta-analysis, late pregnancy moderate to vigorous physical activity modestly reduced birth size outcomes.

Abstract 228: Association analysis across different populations identifies 26 new cutaneous melanoma risk loci

Heritability of cutaneous melanoma is among the highest across cancer types and is mostly determined by common, noncoding genetic variants. Previous genome-wide association studies (GWAS), mostly including subjects from Australia and Northern European countries, had identified twenty genetic loci associated with melanoma risk. To characterize the genetic landscape of cutaneous melanoma across different populations, we conducted a new association study in Southern European countries including 6,043 melanoma cases and 10,383 controls from the MelaNostrum Consortium. Moreover, we largely expanded the analyses of melanoma cases and controls from other populations, for a total of 27,450 histologically confirmed melanoma cases and 49,888 controls from Northern Europe, Southern Europe, USA and Australia. Imputation was done using the Haplotype Reference Consortium as a reference panel. We assessed the association between cutaneous melanoma risk and single-nucleotide polymorphisms (SNPs) adjusting for country and ancestry-informative principal components. We identified 26 new genetic loci associated with melanoma risk achieving genome-wide significance. The pigmentation pathway, with TYRP1 and MITF, and the telomere-related pathway with RTEL1, TERC, and POT1 among the candidate genes, continued to show an important role for melanoma susceptibility. Additional candidate pathways emerged, including signaling (with GPRC5A and DOCK8), cell-cell junction (with CDH1), immune-related functions (with DCST2, involved in antigen processing), transcriptional regulation (with FOXD3, which represses MITF expression), or tumor-suppressor genes (TP53). Adding genotype data from 6,130 self-reported melanoma cases in a sensitivity analysis identified eight additional novel genetic loci involved in the HLA region, signaling transduction and transcription factor functions. A combined analysis of the melanoma GWAS with the GWAS of pigmentation characteristics from the UK Biobank including 500,000 UK persons, and with a GWAS of nevus density including over 52,000 persons, revealed substantial overlap across phenotypes. Although the effect size of the SNPs on melanoma risk was consistent across populations, substantial differences in minor allele frequency (MAF) were observed in pigmentation-related genes between Northern and Southern European populations; for example, MC1R, SLC45A2, and ASIP SNP MAF was 8.2, 3.1 and 14.2 in Northern and 2.6, 8.8, and 5.5 in Southern European subjects, respectively. Additional analyses based on melanoma histologic subtypes and body site distribution are ongoing. These results provide further insight into genetic susceptibility to cutaneous melanoma and provide the opportunity for genetic risk scores in risk-prediction models for early detection and targeted prevention of the disease.

Citation Format: Cristina Pellegrini, Matthew Law, Mark Iles, Mitch Machiela, Alex Stratigos, Tongwu Zhang, Kevin Brown, Julia Newton-Bishop, Nick Hayward, Nick Martin, Alisa Goldstein, Rose Yang, Stephen Chanock, Florence Demenais, Susana Puig, Eduardo Nagore, Jianxin Shi, Tim Bishop, Stuart McGregor, Maria Teresa Landi, GenoMEL Consortium, MelaNostrum Consortium. Association analysis across different populations identifies 26 new cutaneous melanoma risk loci [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 228.

Abstract 5204: MYC expression and smoking as drivers of failure of immune response to melanoma

There is good evidence that an immune response to melanoma predicts better survival. We report a bioinformatic study designed to identify immune subgroups of primary melanomas in order to better understand the biology of immune cell/tumor interaction, and to identify candidate predictive biomarkers for immunotherapy.

We applied an approach described by Angelova et al. to the inference of tumor immune cell infiltrates using differential expression of signature genes, in 703 primary melanoma transcriptomes from the Leeds Melanoma Cohort (LMC). Consensus clustering of immune cell scores identified 3 subgroups in LMC and replication was sought in The Cancer Genome Atlas (TCGA) data set, (primarily metastatic samples). We then used the whole transcriptomic data to explore associated biological pathways: a protein-protein interaction network analysis of genes was performed in Cytoscape plugin Reactome FIVIZ. Nodal genes were identified and the cellular origin of the gene expression signature further explored using immunohistochemistry (IHC) and in patient-derived melanoma cell culture transcriptomes. Clinicopathological and environmental factors, and immune cell scores associated with survival within immune subgroups, were then analysed using a multivariate Cox proportional hazard model.

We identified three subgroups with transcriptomic patterns indicative of: low, intermediate and high immune cell infiltration. The groups were concordant with histological evidence of tumor infiltrating lymphocytes. Genes enriched in the low, compared with the high immune group, were in cell cycle, metabolic and Beta-catenin pathways. MYC was the nodal (the most influential) gene of the protein-protein interaction network in this group. In the high immune group, genes were enriched in immune pathways, including antigen processing and presentation, with the nodal gene - NFKB1. Based on the literature and our results, we hypothesised that MYC downregulates HLA-class I, hence we tested MYC correlations in the melanoma cell line transcriptomes (in which immune cells were absent). Indeed, MYC was negatively correlated with many HLA class I genes, with HLA-B having the strongest result: R=-0.57. IHC of primary tumors showed tumor nuclear expression of MYC. Reported smoking independently predicted a worse outcome for patients classified as the high immune group (HR=3.52, P=0.008). The transcriptomic analysis showed that smoking correlated with an increased Th2 cell score (P=0.03) and reduced NK56 bright score (P=0.01) in that group.

We report evidence that MYC plays an important role in immune evasion in primary melanoma. The transcriptomic data support in vitro findings that MYC downregulates HLA class I expression. Furthermore, we present important results that smoking status modifies immune response in melanoma and is an independent risk factor for melanoma death. We hypothesise that smoking may impact on immunotherapy efficacy.

Citation Format: Joanna Pozniak, Jeremie Nsengimana, Jon Laye, Sally O'Shea, Sabrina Schindler, Mitch Levesque, Tim Bishop, Julia Newton-Bishop. MYC expression and smoking as drivers of failure of immune response to melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5204.

Pedicle distraction increases intervertebral and spinal canal area in a cadaver and bone model

INTRODUCTION

Lumbar spinal stenosis is degenerative narrowing of the spinal canal and/or intervertebral foramen causing compression of the spinal cord and nerve roots. Traditional decompression techniques can often cause significant trauma and vertebral instability. This paper evaluates a method of increasing pedicle length to decompress the spinal and intervertebral foramen, which could be done minimally invasive.

METHODS

Three Sawbone (Sawbones Europe, Sweden) and 1 cadaveric lumbar spine underwent bilateral pedicle distraction at L4. A pedicle channel was drilled between the superior articular process and transverse process into the vertebral body. The pedicles underwent osteotomy at the midpoint. Screws were inserted bilaterally and fixated distraction of 0 mm, 2 mm, 4 mm and 6 mm. CT images were taken at each level of distraction. Foramen area was measured in the sagittal plane at L3/4. Spinal canal area was measured at L4 in the axial images. The cadaver was used to evaluate safety of osteotomy and soft tissue interactions preventing distraction. Statistical analysis was by student paired t-test and Pearson rank test.

RESULTS

Increasing distraction led to greater Spinal canal area. From 4.27 cm² to 5.72 cm² (p = 0.002) with 6 mm distraction. A Maximal increase of 34.1%. Vertebral foramen area also increased with increasing pedicle distraction. From 2.43 cm² to 3.22 cm² (p = 0.022) with 6 mm distraction. A maximal increase of 32.3%. The cadaver spinal canal increased in area by 21.7%. The vertebral foramen increased in area by 36.2% (left) and 22.6% (right).

DISCUSSION

For each increase in pedicle distraction the area of the spinal and vertebral foramen increases. Pedicle distraction could potentially be used to alleviate spinal stenosis and root impingement. A potential osteotomy plane could be at the midpoint of the pedicle with minimal risk to nerve roots and soft tissue restrictions to prevent distraction.

Feasibility of a text-based smoking cessation intervention in rural older adults

Text-based interventions are effective for smoking cessation, but have not been tested in rural older adults. The purpose of this study was to compare the feasibility, acceptability and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) program to a non-SGR text messaging support condition among rural older adults. Adults over 60 years were randomized to either: (i) the SGR program (n = 20), a text-based program to reduce smoking over 4-weeks plus text-based support messages; or (ii) control (n = 20), receipt of text-based support messages only. Participants completed surveys at baseline and end of program to assess feasibility and acceptability of the intervention, and biochemically validated 7-day point prevalence cessation was assessed at end of treatment. Most participants (81%) reported reading all the messages they received. Participants found both interventions useful in quitting smoking (SGR = 57%, Control = 63%) and would recommend it to a friend (SGR = 72%, Control = 79%). Although not statically significant, the SGR group had a higher rate of biochemically validated cessation (SGR = 15%, Control = 5%, Cohen d = 0.67). Among those still smoking, the median percent reduction in cigarettes was 33.3% for both groups. Text-based cessation interventions are feasible, acceptable and can be easily disseminated to rural older adult tobacco users.

Sagnac Interferometry with a Single Atomic Clock

The Sagnac effect enables interferometric measurements of rotation with high precision. Using matter waves instead of light promises resolution enhancement by orders of magnitude that scales with particle mass. So far, the paradigm for matter wave Sagnac interferometry relies on de Broglie waves and thus on free propagation of atoms either in free fall or within waveguides. However, the Sagnac effect can be expressed as a proper time difference experienced by two observers moving in opposite directions along closed paths and has indeed been measured with atomic clocks flown around Earth. Inspired by this, we investigate an interferometer comprised of a single atomic clock. The Sagnac effect manifests as a phase shift between trapped atoms in different internal states after transportation along closed paths in opposite directions, without any free propagation. With analytic models, we quantify limitations of the scheme arising from atomic dynamics and finite temperature. Furthermore, we suggest an implementation with previously demonstrated technology.

A multi-country Salmonella Enteritidis phage type 14b outbreak associated with eggs from a German producer: ‘near real-time’ application of whole genome sequencing and food chain investigations, United Kingdom, May to September 2014

Binary file ES_Abstracts_Final_ECDC.txt matches

Missed orthopaedic injuries in adult trauma patients at a major trauma centre

Introduction

Despite advances in trauma care, missed injury remains a significant cause of morbidity and mortality in trauma worldwide. In England, few have published their missed injury rates and there are no recent data for London. In 2010 London trauma networks were restructured and the impact on missed injury rates is not known. This study aimed to determine the incidence of missed orthopaedic injury for adult trauma patients at St George’s Hospital, London, and to analyse missed injuries and comment on risk factors.

Method

Trauma patients were recorded prospectively at the daily trauma meeting from July to September 2012. The researcher attended clinical activities and reviewed the patient notes and radiology reports daily whilst each patient was an inpatient until discharge. Missed injuries were defined as fractures or dislocations discovered more than 12 h after arrival in the emergency department. The notes for missed injury patients were reviewed again at six months. Missed injury details were recorded/analysed.

Results

Three hundred and forty three adult trauma patients were referred to trauma and orthopaedics in the three-month study period; 5 (1.5%) had a missed injury and 148 (43.1%) had an ISS>15. All missed injuries occurred in these major trauma patients, giving an incidence of 5/148 (3.4%). Four were extremity injuries and one was cervical. All missed injury patients had a GCS of 15/15, were admitted outside normal working hours, were direct admissions and had whole-body CT.

Conclusions

At 3.4% our missed injury incidence is comparable to those published from similar major trauma centres. This provides recent London data following the restructuring of trauma networks.

The clinicopathological and gene expression patterns associated with ulceration of primary melanoma

Ulceration of primary melanomas is associated with poor prognosis yet is reported to predict benefit from adjuvant interferon. To better understand the biological processes involved, clinicopathological factors associated with ulceration were determined in 1804 patients. From this cohort, 348 primary tumor blocks were sampled to generate gene expression data using a 502-gene cancer panel and 195 blocks were used for immunohistochemistry to detect macrophage infiltration and vessel density. Gene expression results were validated using a whole genome array in two independent sample sets. Ulceration of primary melanomas was associated with more proliferative tumors, tumor vessel invasion, and increased microvessel density. Infiltration of tumors with greater number of macrophages and gene expression pathways associated with wound healing and up-regulation of pro-inflammatory cytokines suggests that ulceration is associated with tumor-related inflammation. The relative benefit from interferon reported in patients with ulcerated tumors may reflect modification of signaling pathways involved in inflammation.

Abstract 3140: Using formalin-fixed paraffin-embedded melanoma tumors for the detection of copy number variation by next generation sequencing

DNA copy number variation (CNV) has been identified in many cancers. Recent studies have shown that CNV data, in combination with other high-throughput techniques, can provide novel biological insight to tumor biology. Although a number of CNV whole-genome studies have been performed on melanoma using cell lines and frozen tumors, very few have used formalin fixed paraffin embedded (FFPE)-derived material. Melanoma tumors are small and rarely frozen, which means that FFPE tumor blocks would be a very valuable source of genomic material to be used for CNV analysis if the methodologies were adequately developed. It has been shown that reliable next generation sequencing data can be produced from FFPE-derived DNA in lung cancers (Wood et al., 2010). Here, we report a study showing that DNA from FFPE melanoma tumor blocks can be used for CNV detection on a next generation sequencing platform. DNA from 20 FFPE melanoma samples was used to prepare genomic libraries, which were sequenced on the Illumina GAIIx instrument. Successful library preparation occurred at DNA levels of at least 30ng, while current protocols generally suggest 50ng with high quality material and 1μg generally. The use of SPRIworks (Beckman Coulter) and Bravo (Agilent) robots was compared with the manual method for library preparation with input DNA mass of 30-150ng. Libraries prepared manually were always of better quality and yield. We also investigated means of improving library preparation. Melanin co-purifies with DNA and inhibits downstream reactions, and indeed lower coverage was seen in our samples if they were heavily pigmented. To overcome the adverse effects of melanin, 10 DNA samples (5 pairs) were used for library preparation with and without bovine serum albumin (BSA). BSA has been shown to bind to melanin, and as a result the melanin does not inhibit the DNA polymerase reaction. All 5 libraries with BSA were of higher quality and yield when compared to those prepared without BSA. All comparisons were made after running the libraries on an Agilent DNA chip.

Currently available data from the GAIIx were used to develop the analysis pipeline. The first 10 samples were multiplexed together and run twice, while the remaining 10 were multiplexed at 5 samples per lane and run once. The average coverage obtained was 0.10x with a range of 0.03x-0.11x. We observed a strong effect on mapping quality based upon the end-cycle quality scores, leading us to adopt an aggressive data trimming procedure. More samples from the Leeds Melanoma Cohort will soon be prepared and sequenced on the Illumina HiSeq2000 instrument. We aim to identify if tumors with driver BRAF mutations have different genomic signatures when compared to those with NRAS mutations. Finally, genomic data will be combined with clinical data and we will check for the prognostic significance of CNV changes identified in our samples.

Citation Format: Anastasia Filia, Alastair Droop, Mark Harland, Tim Bishop, Julia Newton-Bishop. Using formalin-fixed paraffin-embedded melanoma tumors for the detection of copy number variation by next generation sequencing. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3140. doi:10.1158/1538-7445.AM2013-3140

Serum vitamin D levels, VDR, and survival from melanoma

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Background: Vitamin D has pleiotropic effects, which may moderate the interaction between patients and their tumors. Two studies were carried out to test the hypothesis that higher vitamin D levels reduce the risk of relapse from melanoma. Methods: A pilot retrospective case-control study in 271 melanoma patients suggested that vitamin D may protect against recurrence of melanoma. We then tested these findings in a survival analysis in a cohort of 872 cases recruited to the Leeds Melanoma Cohort (median follow up of 4.7 years). Results: Pilot study Results suggested that taking vitamin D reduced the risk of relapse from melanoma (OR 0.6, 95% CI: 0.4, 1.1). Non-relapsers had higher mean 25-dihydroxyvitamin D3 levels than relapsers (49 nmol/L compared with 46, p=0.3). Cohort study Higher 25-dihydroxyvitamin D3 levels were associated with lower Breslow thickness at diagnosis and were independently protective of relapse and death: hazard ratio (HR) for relapse free survival (RFS) 0.76, 95% CI: (0.64, 0.96), for a 20nmol/L increase in serum level. There was evidence of interaction between the vitamin D receptor (VDR) BsmI genotype and serum 25-dihydroxyvitamin D3 levels on RFS. Conclusions: The pilot study provided preliminary evidence for a role for vitamin D in outcome from melanoma. The cohort study provided further evidence that higher 25-dihydroxyvitamin D3 levels, at diagnosis, were associated both with thinner tumors and better survival, independent of Breslow thickness, from melanoma. Melanoma patients should avoid vitamin D deficiency. Further studies are needed to establish optimal serum levels for melanoma patients.

No significant financial relationships to disclose.

Characterisation of ultraviolet-B-induced inflammation as a model of hyperalgesia in the rat

In humans, the acute inflammatory reaction caused by ultraviolet (UV) radiation is well studied and the sensory changes that are found have been used as a model of cutaneous hyperalgesia. Similar paradigms are now emerging as rodent models of inflammatory pain. Using a narrowband UVB source, we irradiated the plantar surface of rat hind paws. This produced the classical feature of inflammation, erythema, and a significant dose-dependent reduction in both thermal and mechanical paw withdrawal thresholds. These sensory changes peaked 48h after irradiation. At this time there is a graded facilitation of noxious heat evoked (but not basal) c-fos-like immunoreactivity in the L4/5 segments of the spinal cord. We also studied the effects of established analgesic compounds on the UVB-induced hyperalgesia. Systemic as well as topical application of ibuprofen significantly reduced both thermal and mechanical hyperalgesia. Systemic morphine produced a dose-dependent and naloxone sensitive reversal of sensory changes. Similarly, the peripherally restricted opioid loperamide also had a dose-dependent anti-hyperalgesic effect, again reversed by naloxone methiodide. Sequestration of NGF, starting at the time of UVB irradiation, significantly reduced sensory changes. We conclude that UVB inflammation produces a dose-dependent hyperalgesic state sensitive to established analgesics. This suggests that UVB inflammation in the rat may represent a useful translational tool in the study of pain and the testing of analgesic agents.

A combined genomewide linkage scan of 1,233 families for prostate cancer-susceptibility genes conducted by the international consortium for prostate cancer genetics

Evidence of the existence of major prostate cancer (PC)-susceptibility genes has been provided by multiple segregation analyses. Although genomewide screens have been performed in over a dozen independent studies, few chromosomal regions have been consistently identified as regions of interest. One of the major difficulties is genetic heterogeneity, possibly due to multiple, incompletely penetrant PC-susceptibility genes. In this study, we explored two approaches to overcome this difficulty, in an analysis of a large number of families with PC in the International Consortium for Prostate Cancer Genetics (ICPCG). One approach was to combine linkage data from a total of 1,233 families to increase the statistical power for detecting linkage. Using parametric (dominant and recessive) and nonparametric analyses, we identified five regions with "suggestive" linkage (LOD score >1.86): 5q12, 8p21, 15q11, 17q21, and 22q12. The second approach was to focus on subsets of families that are more likely to segregate highly penetrant mutations, including families with large numbers of affected individuals or early age at diagnosis. Stronger evidence of linkage in several regions was identified, including a "significant" linkage at 22q12, with a LOD score of 3.57, and five suggestive linkages (1q25, 8q13, 13q14, 16p13, and 17q21) in 269 families with at least five affected members. In addition, four additional suggestive linkages (3p24, 5q35, 11q22, and Xq12) were found in 606 families with mean age at diagnosis of < or = 65 years. Although it is difficult to determine the true statistical significance of these findings, a conservative interpretation of these results would be that if major PC-susceptibility genes do exist, they are most likely located in the regions generating suggestive or significant linkage signals in this large study.

Comparative molecular pathology of sporadic hyperplastic polyps and neoplastic lesions from the same individual

AIM

The biology of colorectal hyperplastic polyps is of considerable relevance, because recent evidence suggests that under certain circumstances hyperplastic polyps may be precursors of neoplasms. The aim of this study was to assess and compare the clinical and molecular characteristics of hyperplastic polyps and neoplastic lesions removed from patients without the hyperplastic polyposis syndrome.

METHODS

One hundred and twenty six patients were identified through a series of genetic epidemiological studies. Each patient had at least one neoplastic lesion and one hyperplastic polyp; there was a total of 147 hyperplastic polyps. All lesions were evaluated for K-ras mutations, loss of heterozygosity (LOH) of the adenomatous polyposis coli (APC) gene, and microsatellite instability.

RESULTS

K-ras mutation was detected in 15 (10%) hyperplastic polyps, all from the rectosigmoid colon. No hyperplastic polyp had APC LOH or microsatellite instability. Patients with adenomas or carcinomas showing K-ras mutations were not more likely to have hyperplastic polyps with K-ras mutations. The average number of adenomas did not differ between those patients with hyperplastic polyps with K-ras mutations and those without K-ras mutations. There was no association between the hyperplastic polyp and the adenoma regarding the colon segments from which the two lesions were removed.

CONCLUSIONS

The sporadic hyperplastic polyp is a lesion with limited molecular change and no relation to patients' neoplastic lesions.

Premature coronary artery disease shows no evidence of linkage to loci encoding for tissue inhibitors of matrix metalloproteinases

Tissue inhibitors of metalloproteinases (TIMP1, TIMP2, TIMP3) are naturally occurring inhibitors of matrix metalloproteinases (MMPs). It has been proposed that MMPs have a role in weakening the fibrous cap and subsequent plaque rupture. We hypothesized that TIMP polymorphisms could predispose to premature coronary artery disease. As a first step, we examined the relevant loci using a linkage approach. Sibling pairs recruited for the British Heart Foundation (BHF) Family Heart Study with premature coronary artery disease were examined. Two to three microsatellite markers were examined per TIMP gene. These markers were either intragenic or very close to the locus encoding for the gene. Products were analyzed by capillary gel electrophoresis. Single and multipoint linkage analysis based on the likelihood ratio test was performed using SPLINK and Mapmaker/Sibs software; 417 families were genotyped consisting of 385 sibling pairs, 27 trios, and five sets of four siblings. We were unable to detect linkage of premature coronary artery disease to loci encoding for TIMP1-3. Polymorphisms of the tissue inhibitors of MMP genes do not predispose to premature coronary artery disease in an epidemiologically significant way.

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

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

Structure and function of mitochondria in hepatopancreas cells from metabolically depressed snails

Mitochondria in cells isolated from the hepatopancreas of aestivating land snails (Helix aspersa) consume oxygen at 30% of the active control rate. The aim of this study was to investigate whether the lower respiration rate is caused by a decrease in the density of mitochondria or by intrinsic changes in the mitochondria. Mitochondria occupied 2% of cellular volume, and the mitochondrial inner membrane surface density was 17 microm(-1), in cells from active snails. These values were not different in cells from aestivating snails. The mitochondrial protein and mitochondrial phospholipid contents of cells were also similar. There was little difference in the phospholipid fatty acyl composition of mitochondria isolated from metabolically depressed or active snails, except for arachidonic acid, which was 18% higher in mitochondria from aestivating snails. However, the activities of citrate synthase and cytochrome c oxidase in mitochondria isolated from aestivating snails were 68% and 63% of control, respectively. Thus the lower mitochondrial respiration rate in hepatopancreas cells from aestivating snails was not caused by differences in mitochondrial volume or surface density but was associated with intrinsic changes in the mitochondria.

Processes contributing to metabolic depression in hepatopancreas cells from the snail Helix aspersa

Cells isolated from the hepatopancreas of the land snail Helix aspersa strongly depress respiration both immediately in response to lowered P(O2) (oxygen conformation) and, in the longer term, during aestivation. These phenomena were analysed by dividing cellular respiration into non-mitochondrial and mitochondrial respiration using the mitochondrial poisons myxothiazol, antimycin and azide. Non-mitochondrial respiration accounted for a surprisingly large proportion, 65+/−5 %, of cellular respiration in control cells at 70 % air saturation. Non-mitochondrial respiration decreased substantially as oxygen tension was lowered, but mitochondrial respiration did not, and the oxygen-conforming behaviour of the cells was due entirely to the oxygen-dependence of non-mitochondrial oxygen consumption. Non-mitochondrial respiration was still responsible for 45+/−2 % of cellular respiration at physiological oxygen tension. Mitochondrial respiration was further subdivided into respiration used to drive ATP turnover and respiration used to drive futile proton cycling across the mitochondrial inner membrane using the ATP synthase inhibitor oligomycin. At physiological oxygen tensions, 34+/−5 % of cellular respiration was used to drive ATP turnover and 22+/−4 % was used to drive proton cycling, echoing the metabolic inefficiency previously observed in liver cells from mammals, reptiles and amphibians. The respiration rate of hepatopancreas cells from aestivating snails was only 37 % of the control value. This was caused by proportional decreases in non-mitochondrial and mitochondrial respiration and in respiration to drive ATP turnover and to drive proton cycling. Thus, the fraction of cellular respiration devoted to different processes remained constant and the cellular energy balance was preserved in the hypometabolic state.

Haplotype analysis of two recurrent CDKN2A mutations in 10 melanoma families: evidence for common founders and independent mutations

Germ-line mutations in CDKN2A have been shown to predispose to cutaneous malignant melanoma. We have identified 2 new melanoma kindreds which carry a duplication of a 24bp repeat present in the 5' region of CDKN2A previously identified in melanoma families from Australia and the United States. This mutation has now been reported in 5 melanoma families from 3 continents: Europe, North America, and Australasia. The M53I mutation in exon 2 of CDKN2A has also been documented in 5 melanoma families from Australia and North America. The aim of this study was to determine whether the occurrence of the mutations in these families from geographically diverse populations represented mutation hotspots within CDKN2A or were due to common ancestors. Haplotypes of 11 microsatellite markers flanking CDKN2A were constructed in 5 families carrying the M53I mutation and 5 families carrying the 24bp duplication. There were some differences in the segregating haplotypes due primarily to recombinations and mutations within the short tandem-repeat markers; however, the data provide evidence to indicate that there were at least 3 independent 24bp duplication events and possibly only 1 original M53I mutation. This is the first study to date which indicates common founders in melanoma families from different continents.

Intrinsic metabolic depression in cells isolated from the hepatopancreas of estivating snails

Many animals across the phylogenetic scale are routinely capable of depressing their metabolic rate to 5-15% of that at rest, remaining in this state sometimes for years. However, despite its widespread occurrence, the biochemical processes associated with metabolic depression remain obscure. We demonstrate here the development of an isolated cell model for the study of metabolic depression. The isolated cells from the hepatopancreas (digestive gland) of the land snail (Helix aspersa) are oxygen conformers; i.e., their rate of respiration depends on pO(2). Cells isolated from estivating snails show a stable metabolic depression to 30% of control (despite the long and invasive process of cell isolation) when metabolic rate at the physiological pH and pO(2) of the hemolymph of estivating snails is compared with metabolic rate at the physiological pH and pO(2) of the hemolymph of control snails. When the extrinsic effects of pH and pO(2) are excluded, the intrinsic metabolic depression of the cells from estivating snails is still to below 50% of control snails. The in vitro effect of pO(2) on metabolic rate is independent of pH and state (awake or estivating), but the effects of pH and state significantly interact. This suggests that pH and state change affect metabolic depression by similar mechanisms but that the metabolic depression by hypoxia involves a separate mechanism.

Haplotype and phenotype analysis of nine recurrent BRCA2 mutations in 111 families: results of an international study

Several BRCA2 mutations are found to occur in geographically diverse breast and ovarian cancer families. To investigate both mutation origin and mutation-specific phenotypes due to BRCA2, we constructed a haplotype of 10 polymorphic short tandem-repeat (STR) markers flanking the BRCA2 locus, in a set of 111 breast or breast/ovarian cancer families selected for having one of nine recurrent BRCA2 mutations. Six of the individual mutations are estimated to have arisen 400-2,000 years ago. In particular, the 6174delT mutation, found in approximately 1% of individuals of Ashkenazi Jewish ancestry, was estimated to have arisen 29 generations ago (1-LOD support interval 22-38). This is substantially more recent than the estimated age of the BRCA1 185delAG mutation (46 generations), derived from our analogous study of BRCA1 mutations. In general, there was no evidence of multiple origins of identical BRCA2 mutations. Our study data were consistent with the previous report of a higher incidence of ovarian cancer in families with mutations in a 3.3-kb region of exon 11 (the ovarian cancer cluster region [OCCR]) (P=.10); but that higher incidence was not statistically significant. There was significant evidence that age at diagnosis of breast cancer varied by mutation (P<.001), although only 8% of the variance in age at diagnosis could be explained by the specific mutation, and there was no evidence of family-specific effects. When the age at diagnosis of the breast cancer cases was examined by OCCR, cases associated with mutations in the OCCR had a significantly older mean age at diagnosis than was seen in those outside this region (48 years vs. 42 years; P=.0005).

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

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

Haplotype and phenotype analysis of six recurrent BRCA1 mutations in 61 families: results of an international study

Several BRCA1 mutations have now been found to occur in geographically diverse breast and ovarian cancer families. To investigate mutation origin and mutation-specific phenotypes due to BRCA1, we constructed a haplotype of nine polymorphic markers within or immediately flanking the BRCA1 locus in a set of 61 breast/ovarian cancer families selected for having one of six recurrent BRCA1 mutations. Tests of both mutations and family-specific differences in age at diagnosis were not significant. A comparison of the six mutations in the relative proportions of cases of breast and ovarian cancer was suggestive of an effect (P = .069), with 57% of women presumed affected because of the 1294 del 40 BRCA1 mutation having ovarian cancer, compared with 14% of affected women with the splice-site mutation in intron 5 of BRCA1. For the BRCA1 mutations studied here, the individual mutations are estimated to have arisen 9-170 generations ago. In general, a high degree of haplotype conservation across the region was observed, with haplotype differences most often due to mutations in the short-tandem-repeat markers, although some likely instances of recombination also were observed. For several of the instances, there was evidence for multiple, independent, BRCA1 mutational events.