How much of the deprivation gap in cancer survival can be explained by variation in stage at diagnosis: an example from breast cancer in the East of England.

Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.

Should relative survival be used with lung cancer data?

BACKGROUND: Under certain assumptions, relative survival is a measure of net survival based on estimating the excess mortality in a study population when compared with the general population. Background mortality estimates are usually taken from national life tables that are broken down by age, sex and calendar year. A fundamental assumption of relative survival methods is that if a patient did not have the disease of interest then their probability of survival would be comparable to that of the general population. It is argued, as most lung cancer patients are smokers and therefore carry a higher risk of smoking-related mortalities, that they are not comparable to a population where the majority are likely to be non-smokers. METHODS: We use data from the Finnish Cancer Registry to assess the impact that the non-comparability assumption has on the estimates of relative survival through the use of a sensitivity analysis. RESULTS: Under realistic estimates of increased all-cause mortality for smokers compared with non-smokers, the bias in the estimates of relative survival caused by the non-comparability assumption is negligible. CONCLUSION: Although the assumption of comparability underlying the relative survival method may not be reasonable, it does not have a concerning impact on the estimates of relative survival, as most lung cancer patients die within the first 2 years following diagnosis. This should serve to reassure critics of the use of relative survival when applied to lung cancer data.

Sustainable aquaculture through the One Health lens.

Aquaculture is predicted to supply the majority of aquatic dietary protein by 2050. For aquaculture to deliver significantly enhanced volumes of food in a sustainable manner, appropriate account needs to be taken of its impacts on environmental integrity, farmed organism health and welfare, and human health. Here, we explore increased aquaculture production through the One Health lens and define a set of success metrics - underpinned by evidence, policy and legislation - that must be embedded into aquaculture sustainability. We provide a framework for defining, monitoring and averting potential negative impacts of enhanced production - and consider interactions with land-based food systems. These metrics will inform national and international science and policy strategies to support improved aquatic food system design.

Farm characteristics and farmer perceptions associated with bovine tuberculosis incidents in areas of emerging endemic spread.

While much is known about the risk factors for bovine tuberculosis (bTB) in herds located in high incidence areas, the drivers of bTB spread in areas of emerging endemicity are less well established. Epidemiological analysis and intensive social research identified natural and social risk factors that may prevent or encourage the spread of disease. These were investigated using a case-control study design to survey farmers in areas defined as recently having become endemic for bTB (from or after 2006). Telephone surveys were conducted for 113 farms with a recent history of a bTB incident where their officially tuberculosis free status had been withdrawn (OTFW) (cases) and 224 controls with no history of a bTB incident, matched on location, production type and the rate of endemic bTB spread. Farmers were questioned about a range of farm management strategies, farm characteristics, herd health, wildlife and biosecurity measures with a focus on farmer attitudes and behaviours such as farmers' perception of endemicity and feelings of control, openness and social cohesion. Data generated in the telephone surveys was supplemented with existing herd-level data and analysed using conditional logistic regression. Overall, herd size (OR 1.07), purchasing an animal at a cattle market compared to purchasing outside of markets (OR 2.6), the number of contiguous bTB incidents (2.30) and the number of inconclusive reactors detected in the 2 years prior to the case incident (OR 1.95) significantly increased the odds of a bTB incident. Beef herds using a field parcel more than 3.2km away from the main farm and dairy herds reporting Johne's disease in the previous 12 months were 3.0 and 4.7 times more likely to have a recent history of a bTB incident, respectively. Beef herds reporting maize growing near, but not on, their farm were less likely to be case herds. Operating a closed farm in the two years prior to the case breakdown did not reduce the odds of a bTB incident. Farmers that had recently experienced a bTB incident were more likely to have implemented badger biosecurity in the previous year, but no more likely than control farms to have implemented cattle biosecurity. Case farmers felt significantly less likely to be influenced by government, vets or other farmers compared to those with no history of bTB. This suggests that alternative methods of engaging with farmers who have recently had a breakdown may need to be developed.

Farming on the edge: farmer attitudes to bovine tuberculosis in newly endemic areas.

Defra's recent strategy to eradicate bovine tuberculosis (bTB) establishes three spatial zones: high-risk areas (HRAs) and low-risk areas, and an area referred to as 'the edge', which marks the areas where infection is spreading outwards from the HRA. Little is known about farmers in the edge area, their attitudes towards bTB and their farming practices. This paper examines farmers' practices and attitudes towards bTB in standardised epidemiologically defined areas. A survey was developed to collect data on farmer attitudes, behaviours, practices and environmental conditions as part of an interdisciplinary analysis of bTB risk factors. Survey items were developed from a literature review and focus groups with vets and farmers in different locations within the edge area. A case-control sampling framework was adopted with farms sampled from areas identified as recently endemic for bTB. 347 farmers participated in the survey including 117 with bTB, representing a 70per cent response rate. Results show that farmers believe they are unable to do anything about bTB but are keen for the government intervention to help control the spread of bTB.

The pig analogue of CD59 protects transgenic mouse hearts from injury by human complement.

BACKGROUND: It has been proposed that hyperacute rejection (HAR) of pig-to-primate vascularized xenografts is due in large part to ineffective regulation of recipient complement by pig complement regulatory proteins (CRPs), and indeed transgenic expression of human CRPs in pigs can prevent hyperacute rejection. However, at least one pig CRP (CD59) efficiently regulates human complement in vitro, suggesting that it is the level of expression of a particular CRP(s) rather than cross-species incompatibility that explains the HAR of porcine xenografts. We investigated the relative effectiveness of transgenically expressed pig and human CD59 in providing protection of mouse hearts from human complement in an ex vivo setting. METHODS: Transgenic mice expressing pig CD59 or human CD59 under the control of the human ICAM-2 promoter, which restricts expression in tissues to vascular endothelium, were used. Hearts from mice expressing similar levels of pig CD59 or human CD59 were perfused ex vivo with 10% human plasma and heart function was monitored for 60 min. Sections of perfused hearts were examined for deposition of the membrane attack complex (MAC). RESULTS: Control nontransgenic hearts (n=5) were rapidly affected by the addition of human plasma, with mean function falling to less than 10% of the initial level within 15 min. In contrast, hearts expressing either pig CD59 (n=6) or human CD59 (n=8) were protected from plasma-induced injury, maintaining 31 and 35% function, respectively, after 60 min of perfusion. MAC deposition was markedly reduced in both pig CD59 and human CD59 transgenic hearts compared to nontransgenic control hearts. CONCLUSIONS: When highly expressed on endothelium in transgenic mice, pig CD59 provided equivalent protection to human CD59 in a model of human complement-mediated xenograft rejection. Thus supranormal expression of endogenous porcine CRPs may be a feasible alternative to the expression of human CRPs in preventing HAR of pig-to-primate xenografts.

Incidence and associations of single umbilical artery in prenatally diagnosed malformed, midtrimester fetuses: a review of 62 cases.

The absence of one umbilical artery (SUA) is the most common malformation of the umbilical cord. It may accompany other abnormalities or occur as an isolated defect. We examined 885 fetuses, terminated following the prenatal diagnosis of serious or lethal malformations between April 1977 and March 1989, for the presence of SUA. We found 62 cases of SUA. This represents an incidence of 7.01% (62/885). The most common abnormalities found in association with SUA were: (1) multiple malformations (8/11 cases, SUA incidence = 72.7%), (2) ADAM complex (7/14 cases, SUA incidence = 50.%), (3) multicystic renal dysplasia (5/20 cases, SUA incidence = 25.%), and (4) Potter sequence (5/21 cases, SUA incidence = 23.8%). These associations have not been documented previously. In 6 fetuses the Meckel syndrome was diagnosed, and SUA was present in 2 of these. Therefore, SUA may represent an additional anomaly in Meckel syndrome that has not been reported previously.

Cellular distribution of androgen receptors in the liver.

In order to determine the cellular distribution of androgen receptors (AR) in normal liver and to examine whether phenotypic changes occur in a variety of non-neoplastic liver diseases, cryostat sections of explanted livers removed from 52 consecutive patients undergoing orthotopic transplantation were immunostained using an anti-androgen receptor monoclonal antibody. In histologically normal liver, AR was immunolocalised to the nuclei of hepatocytes. The proportion of positive hepatocytes varied from about 50% to greater than 90%. Staining, of variable intensity, was restricted to parenchymal cells with no evidence of zonal heterogeneity with respect to labelling intensity. In tissue from patients with biliary cirrhoses and in some cases of alcoholic cirrhosis, labelling for AR was observed in areas of ductular metaplasia but not in areas of "typical" ductular reaction (ductular proliferation). Otherwise, no consistent abnormalities in immunolabelling were seen in any of the diseased livers.

Ploidy analysis on Wilms' tumour touch imprints using ethidium bromide and automated image analysis integrated confocal laser scanning microscopy.

Although image analysis (IA) is increasingly being used to quantitate nuclear DNA, comparative data between fluorescence methods of IA and flow cytometry (FCM) is limited. In this study fluorescence IA was compared with FCM data in a series of Wilms' tumour touch preparations. Airdried touch imprints that had previously been Giemsa stained were restained with ethidium bromide. Confocal fluorescence images were obtained with a confocal laser scanning microscope and assessed by a fully automated IA package. Data was collected from 400 nuclei per imprint. The resulting DNA histograms were analysed and ploidy status and DNA indices determined using standard criteria. Results were compared with those derived from FCM analysis of nuclear suspensions. Ten of twelve tumours were concordant by both techniques. However in two cases assessed as diploid by FCM, IA identified aneuploidy. Excellent correlation between DNA indices as assessed by both techniques was observed (r = 0.987). In the three cases for which both unstained and Giemsa stained touch imprints were available for IA, the histogram configurations did not differ significantly. Fluorescence IA is an accurate and sensitive technique for DNA quantitation, which appears at least comparable to FCM assessment and which has a number of important advantages.

"Medullary ray glomerular counting" as a method of assessment of human nephrogenesis.

Renal weight (left-right combined), as a parameter of renal development, is required to be less than half the normal value for age for a statistically confident diagnosis of hypoplasia. "Medullary ray glomerular counting" (MRGC), counting cortical glomerular generations, has been proposed as a simple technique of possibly greater sensitivity. Recent development of the Disector method for the unbiased stereological estimation of total glomerular number has provided a, hitherto unavailable, "golden standard" with which to determine the diagnostic potential of MRCG. Both "true" (actual number of generations seen) and "assumed" (a subjective "guess" of the total number of generations) MRGC counts were determined in 11 pairs of kidneys from spontaneously aborted, normally developed, non-malformed fetuses (gestational age: 15-40 weeks). Each kidney was randomly analysed blind and on two separate occasions by two paediatric pathologists using a written protocol. Results were compared with unbiased stereological estimates of glomerular number. Intra- and inter-observer and intra- and inter-(left-right)renal reproducibility were analysed. In conclusion, MRGC, using "real" counts, is a highly reproducible parameter of renal development from 15-36 weeks' gestation. Sensitivity for detection of both hypoplasia and maturation delay increase with gestational age and generally exceeds that of renal weight.

Helium-oxygen therapy in the emergency department.

Helium is an inert gas with unique physical properties that allow it to be used for various respiratory emergencies. Because of its low specific gravity and low viscosity, the passage of helium through the respiratory tract is smoother, more laminar, and less turbulent than either air or oxygen. These properties have prompted the use of helium and oxygen in patients with airway obstructions due to tumor, foreign body, edema, or bronchoconstriction. Helium-oxygen has been used to facilitate bronchoscopy through small diameter endotracheal tubes and to increase the effectiveness of high-frequency jet ventilation. Helium has been successful in the treatment of spinal cord decompression sickness seen in divers. Helium-oxygen mixtures are commercially available and may be useful in the emergency department to treat patients with airway obstruction. This article reviews literature concerning the use of helium-oxygen gas mixtures in the emergency department. Additional research conducted in the future may further define the use of this unique gas mixture in the emergency department.

Identification of mutations in rat CD59 that increase the complement regulatory activity.

Formation of the membrane attack complex (MAC) of complement on host cells is inhibited by the glycosylphosphatidylinositol- (GPI-) anchored glycoprotein CD59. Published data on the active site of human CD59 are confusing. To clarify these data, we set out to elucidate the active site of a nonprimate CD59 molecule by site-directed mutagenesis. We also undertook to investigate a region of potential species selectivity, and to this end rat CD59 was chosen for all mutations. Our investigations confirmed the proposal that the active site of CD59 is the major hydrophobic groove, with mutations Y36A, W40A, and L54A ablating complement inhibitory function of CD59. Other mutations reducing the function of rat CD59 were I56E, D24A, and D24R. Importantly, mutations at one residue increased the function of rat CD59. The K48E mutation significantly increased function against human rat or rabbit serum, whereas the K48A mutation increased function against human serum alone. A similar mutation in human CD59 (N48E) had no effect on activity against human or rat serum but completely abolished all activity against rabbit serum. These findings suggest that the alpha-helix of human CD59, adjacent to the hydrophobic groove, influences the interaction between human CD59 and rabbit C8, C9, or both.

Molecular cloning, expression and characterization of the rat analogue of human membrane cofactor protein (MCP/CD46).

In humans, host cells are protected from homologous complement by membrane proteins encoded in the regulators of complement activation (RCA) gene cluster. These include complement receptor 1 (CR1), decay-accelerating factor (DAF, CD55) and membrane cofactor protein (MCP, CD46). In mouse and rat a single membrane inhibitor, Crry, appeared to perform the functions of both DAF and MCP and was proposed to be the functional analogue of both. Recently, however, murine homologues of DAF and MCP have been identified, prompting a search for the rat counterparts. We have described the identification of rat DAF and here describe the cloning of rat MCP from cDNA and genomic libraries, using a probe based on the mouse MCP cDNA sequence. The domain structure for rat MCP was identical to that of mouse MCP with four short consensus repeats (SCRs) followed by a STP domain, transmembrane segment and cytoplasmic tail. Overall identity of rat and mouse MCP was 77% at the amino acid level and 88% at the nucleotide level. Northern blot analysis from a range of tissues indicated that high-level expression was limited to the testis, although expression in other tissues was detected using reverse transcription-polymerase chain reaction. Rat MCP mRNA localized to Sertoli cells and spermatogonia in seminiferous tubules by in situ hybridization, but was absent in mature sperm. In cofactor assays utilizing human factor I, a recombinant soluble form of rat MCP catalysed cleavage of human C3ma.

Attitudes of junior medical staff to requesting permission for autopsy.

The attitudes of junior medical staff in a university teaching hospital to requesting postmortem examination were assessed. Following completion of 100 death certificates, autopsy was sought in only 28 cases (and refused in 18). The majority of staff were unaware of the reported benefits of autopsy, despite their inclusion in the local medical handbook and had received no training in how to seek permission for a necropsy. Formal education programmes have been shown to improve hospital autopsy rates and the results of this study suggest that these would be welcomed by junior medical staff.

Fetal pathology in intrauterine death due to parvovirus B19 infection.

OBJECTIVES: To study the pathological features of fetuses dying because of parvovirus B19 infection, with particular reference to the presence of hydrops; to assess the usefulness of immunochemistry as a screening method for the detection of parvovirus infection at post-mortem examination. DESIGN: Review of clinical, sonographic, serological and pathological data; immunohistochemical staining of post-mortem tissue. SAMPLE: Cases of intrauterine fetal death occurring during the 18-month period January 1993 to June 1994 inclusive, referred for post-mortem examination to the Pathology Department, Royal Victoria Infirmary, Newcastle upon Tyne. RESULTS: Eleven cases of fetal death due to parvovirus infection were identified. Seven fetuses were less than 18-week size. Three fetuses showed conspicuous hydropic change. One of the 11 cases was detected for the first time by retrospective immunochemical screening. Of cases originating from the Newcastle district, parvovirus infection was responsible for about 10% of all non-malformed fetal deaths occurring between 10 and 24 weeks of gestation referred for pathological examination. CONCLUSIONS: During the period of study, parvovirus infection was a relatively common cause of mid-trimester fetal death. Many fetuses dying because of this infection are not noticeably hydropic, and the possibility of parvovirus infection should be considered in any case of intrauterine fetal death. Immunochemistry can be used to confirm the histopathological diagnosis, and may be of particular help where there is advanced autolysis; immunohistochemical screening may detect occasional cases not initially identified by examination of routinely stained tissue sections.

Molecular cloning and functional characterization of the rat analogue of human decay-accelerating factor (CD55).

We report here the cloning of cDNAs encoding two forms of the rat analogue of human decay-accelerating factor (DAF; CD55). Screening of a rat kidney cDNA library using a mouse DAF probe identified a partial cDNA encoding the 3' end of rat DAF. The 5' end of the cDNA was cloned using the rapid amplification of cDNA ends (RACE) technique. A second form of rat DAF was identified using 3'RACE. Cloning and sequencing of full length cDNAs for both forms showed that they were identical up to nucleotide 1143 except for a 51-bp insert in the ST-rich region of the second form. After nucleotide 1143, the two sequences diverged; the cDNA cloned from the library encoded a unique 112-amino acid "tail," whereas the second form, identified by 3'RACE, encoded an 18-amino acid hydrophobic stretch, which was predicted to be a glycosylphosphatidylinositol (GPI) anchor addition signal. Expression in the NIH-3T3 mouse fibroblast cell line confirmed that the short tail did encode a GPI-addition signal, whereas the longer tail caused the protein to be secreted. Northern blot analysis identified two distinct transcripts for the GPI form, as well as a variability in expression levels of the different transcripts in the panel of tissues screened. Southern blot analysis showed that both the GPI and secreted forms of rat DAF were expressed in a wide range of tissues. The GPI-linked form of rat DAF stably expressed in a murine fibroblast cell line reduced C3 deposition and conferred protection from lysis by rat serum.

Transience of cervical HPV infection in sexually active, young women with normal cervicovaginal cytology.

Human papillomavirus DNA was detected in cervical specimens from 366 sexually active young women with cytomorphologically normal cervices using the polymerase chain reaction. In 93% (25/27) of initially infected women, the same viral type was not detected upon re-examination four menstrual cycles later. These results suggest that the majority of HPV infections in young women are transient.

Molecular cloning and functional characterization of the pig analogue of CD59: relevance to xenotransplantation.

In this work, we report the cloning of the cDNA for the porcine analogue of human CD59. Degenerate primers, derived from the N-terminal sequence of pig erythrocyte CD59, were used to obtain the corresponding cDNA sequence. From this sequence, gene-specific primers were designed and used to amplify the 3' and 5' ends of the cDNA using the rapid amplification of cDNA ends (RACE) method. The complete 768-bp cDNA so obtained consisted of a 84-bp 5' untranslated region, a 26-amino-acid NH2-signal peptide, a 98-amino-acid coding region, including putative N-glycosylation sites and a glycosylphosphatidylinositol-anchoring signal, and a 312-bp 3' untranslated region. The mature protein sequence was 48% identical to human CD59 at the amino acid level. Northern blot analysis revealed several distinct CD59 transcripts, and a variability in expression levels of the different transcripts in the panel of tissues screened. Stable expression of pig CD59 in a CD59-negative human cell line conferred protection against lysis by complement from pig and several other species. Separate expression of pig and human CD59 at similar levels in the same cell line allowed a direct functional comparison between these two analogues. Pig CD59 and human CD59 showed similar activity in inhibiting lysis by complement from all species tested; in particular, expressed pig CD59 efficiently inhibited lysis by human complement. The relevance of these data to current work in the engineering of pig organs for xenotransplantation is discussed.

An assessment of volume-weighted mean nuclear volume estimates as a prognostic index for neuroblastoma.

This study evaluates an objective, unbiased, stereologic parameter (volume-weighted mean nuclear volume vV) as a prognostic indicator for survival of neuroblastoma in comparison with three histopathologic grading systems. In this retrospective study 24 consecutive, nonselected patients from the registry of Royal Liverpool Children's Hospital, Alder Hey, England were analyzed. Only primary lesions obtained before chemotherapy were used. Follow-up time in surviving patients (n = 10) was 4.5 to 20 years. All lesions were regraded blind and twice by two pathologists. vV was estimated on routinely processed, hematoxylin and eosin-stained, 5-microns sections, requiring on average less than 20 min per patient. Results show an absolute cut-off point for survival at vV = 270 microns 3. No patient with vV less than this value is alive at present (n = 7). In addition, actuarial survival curves for nonsurvivors show a bimodal pattern of survival time, separating patients with vV greater than (n = 7) and less than (n = 7) 270 microns 3. In comparison with the same analysis for the results of regrading by means of the Hughes or Beckwith system, results of vV estimation were superior. In comparison with the Shimada system the results confirmed the strong dichotomy for survivors and nonsurvivors, although with more overlap. vV has the advantage of predicting length of survival in nonsurvivors. The combination of Shimada grading and vV measurement, on the basis of the material studied, seems to offer useful prediction of biologic behavior. vV was always estimated on the small cell population, reducing the problems of biopsy representability.