Cell-cycle-phase progression analysis identifies unique phenotypes of major prognostic and predictive significance in breast cancer.

Multiparameter analysis of core regulatory proteins involved in G1-S and G2-M cell-cycle transitions provides a powerful biomarker readout for assessment of the cell-cycle state. We have applied this algorithm to breast cancer to investigate how the cell cycle impacts on disease progression. Protein expression profiles of key constituents of the DNA replication licensing pathway (Mcm2, geminin) and mitotic machinery (Plk1, Aurora A and the Aurora substrate histone H3S10ph) were generated for a cohort of 182 patients and linked to clinicopathological parameters. Arrested differentiation and genomic instability were associated with an increased engagement of cells into the cell division cycle (P<0.0001). Three unique cell-cycle phenotypes were identified: (1) well-differentiated tumours composed predominantly of Mcm2-negative cells, indicative of an out-of-cycle state (18% of cases); (2) high Mcm2-expressing tumours but with low geminin, Aurora A, Plk1 and H3S10ph levels (S-G2-M progression markers), indicative of a G1-delayed/arrested state (24% cases); and (3) high Mcm2-expressing tumours and also expressing high levels of the S-G2-M progression markers, indicative of accelerated cell-cycle progression (58% of cases). The active cell-cycle progression phenotype had a higher risk of relapse when compared with out-of-cycle and G1-delayed/arrested phenotypes (HR=3.90 (1.81-8.40, P<0.001)), and was associated with Her-2 and triple negative subtypes (P<0.001). It is of note that high-grade tumours with the G1-delayed/arrested phenotype showed an identical low risk of relapse compared with well-differentiated out-of-cycle tumours (HR=1.00 (0.22-4.46), P=0.99). Our biomarker algorithm provides novel insights into the cell-cycle state of dynamic tumour cell populations in vivo. This information is of major prognostic significance and may impact on individualised therapeutic decisions. Patients with an accelerated phenotype are more likely to derive benefit from S- and M-phase-directed chemotherapeutic agents.

Spontaneous spinal infections in older people.

Back pain is common in the elderly. Spinal infection is a rare, but possibly increasing, cause. We describe a retrospective case note review of 41 patients aged 65 years and over with spontaneous spinal infections over a 6-year period. The incidence was 9.8/100,000/year. Staphylococcus aureus was the most common isolate. The mean time from symptom onset to diagnosis was 34 days. Most patients presented with back pain and elevated CRP. Differentiation between discitis and other spinal infections does not appear to be important, as clinical characteristics and outcomes are similar.

Use of luteinising-hormone-releasing hormone agonists as adjuvant treatment in premenopausal patients with hormone-receptor-positive breast cancer: a meta-analysis of individual patient data from randomised adjuvant trials.

BACKGROUND: Several trials have been done to assess treatment of premenopausal breast cancer with luteinising-hormone-releasing hormone (LHRH) agonists, but results have been inconclusive, especially for patients with hormone-receptor-positive cancer. METHODS: We collected individual patients' data from published trials and did analyses focused on women with tumours positive for oestrogen receptor, progesterone receptor, or both. The main endpoints were recurrence and death after recurrence. FINDINGS: We obtained data for 11 906 premenopausal women with early breast cancer randomised in 16 trials. When used as the only systemic adjuvant treatment, LHRH agonists did not significantly reduce recurrence (28.4% relative reduction, 95% CI consistent with 50.5% reduction to 3.5% increase, p=0.08) or death after recurrence (17.8%, 52.8% reduction to 42.9% increase, p=0.49) in hormone-receptor-positive cancers. Addition of LHRH agonists to tamoxifen, chemotherapy, or both reduced recurrence by 12.7% (2.4-21.9, p=0.02); and death after recurrence by 15.1% (1.8-26.7, p=0.03). LHRH agonists showed similar efficacy to chemotherapy (recurrence 3.9% increase, 7.7% reduction to 17.0% increase; death after recurrence 6.7% reduction, 20.7% reduction to 9.6% increase; both not significant). No trials had assessed an LHRH agonist versus chemotherapy with tamoxifen in both arms. LHRH agonists were ineffective in hormone-receptor-negative tumours. INTERPRETATION: LHRH agonists provide an additional class of agents for treatment of premenopausal women with hormone-receptor-positive breast cancer. Optimum duration of use is unknown.

Evaluation of strategies to improve nutrition in people with dementia in an assessment unit.

OBJECTIVES: To evaluate strategies designed to improve nutrition in elderly hospitalised patients with dementia. DESIGN: Observation phase followed by sequential interventions. SETTING: A Short stay assessment unit. PARTICIPANTS: Hospital Inpatients with a variety of conditions causing dementia. INTERVENTIONS: Phase 1: Observation. Phase 2: Encouraging dietary, 'Grazing'. Phase 3: Using volunteers to feed patients. Phase 4: Improving dining room ambience by playing soothing music. MEASUREMENTS: Body Mass Index (BMI), mid arm circumference, mini nutrition index and caloric intake by plate waste measurement. RESULTS: BMI fell in the Observation phase 0.6 +/- 0.68 kg/m2 (p < 0.001), but increased in each of the Intervention phases. Phase2 0.3 +/- 0.86 kg/m2 (p < 0.04), Phase 3 0.37 +/- 0.4 kg/m2 (p < 0.04), Phase 4 0.39 +/- 0.7 kg/m2 (p < 0.007). Caloric intake increased in the intervention phases. CONCLUSIONS: Simple, inexpensive and easy to implement strategies can improve nutrition in hospital inpatients with dementia.

The risk of recurrent stroke after intracerebral haemorrhage.

BACKGROUND AND AIM: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. PATIENTS AND METHODS: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. RESULTS: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type. CONCLUSION: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Adjuvant goserelin in pre-menopausal patients with early breast cancer: Results from the ZIPP study.

The Zoladex In Pre-menopausal Patients (ZIPP) study was designed to determine whether addition of goserelin ('Zoladex') and/or tamoxifen to adjuvant therapy (radiotherapy and/or chemotherapy), provided benefit to pre- or peri-menopausal women with operable, early breast cancer. A combined analysis of four randomised trials using a core protocol was performed. Patients (n = 2710) were randomised into a 2 x 2 factorial trial based on goserelin and tamoxifen (n = 1800) or randomised to receive goserelin or not (n = 910; some received elective tamoxifen) for 2 years. The analysis presented here compares women who did (n = 1354) or did not (n = 1356) receive goserelin. After a median follow-up of 5.5 years, goserelin provided a significant benefit for event-free survival (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.69, 0.92; P = 0.002) and overall survival (HR 0.81; 95% CI 0.67, 0.99; P = 0.038). Goserelin was well tolerated. These data show that the addition of goserelin to standard adjuvant therapy is more effective than standard therapy alone in pre-menopausal women with early breast cancer.

Trends in endocrine therapy and chemotherapy for early breast cancer: a focus on the premenopausal patient.

PURPOSE: The majority of breast cancers are diagnosed at an early stage, and treatment is focused on cure and prolonging disease-free survival. Local therapy (surgery and/or radiation treatment) is standard, along with systemic adjuvant therapy that may effectively prevent or delay relapse and death in early-stage disease. In premenopausal women, adjuvant therapeutic approaches include combination cytotoxic chemotherapy and endocrine therapy. Cyclophosphamide, methotrexate and 5-fluorouracil (CMF) was the established chemotherapy regimen; however, newer regimens have more recently been introduced that may offer some benefit over CMF including anthracycline-containing regimens [e.g. cyclophosphamide, epirubicin and 5-fluorouracil (CEF)], and taxane-containing regimens. For women with oestrogen receptor (ER)-positive disease, a second option is endocrine therapy that aims to suppress mitogenic oestrogen signalling. Until recently, 5 years of tamoxifen was regarded as the standard adjuvant endocrine treatment in ER-positive disease. Ovarian ablation is also effective in premenopausal women, and can be achieved by surgery, radiotherapy, or via the use of a luteinising hormone-releasing hormone analogue such as goserelin. Combining tamoxifen and goserelin treatment provides more effective oestrogen blockade than either drug alone. However, as the third-generation aromatase inhibitors (AIs) have demonstrated improved efficacy over tamoxifen in postmenopausal women with early and advanced disease, combination treatment with goserelin plus an AI may provide optimal oestrogen blockade in premenopausal patients. CONCLUSIONS: This review assesses the relative merits of chemotherapeutic and endocrine approaches for the treatment of early breast cancer, and summarises relevant ongoing clinical trials, with an emphasis on the premenopausal setting.

Breast-conserving surgery with intra-operative radiotherapy: the right approach for the 21st century?

Wide local excision followed by external beam radiation therapy (EBRT) to the whole breast has become the standard of care for most patients with localised 'early' breast cancer in the UK, Europe, and the USA. Local relapse rates are low, and overall survival figures have improved during the past decade, with the advent of more effective systemic endocrine- and chemo-therapy. A policy of EBRT for every patient undergoing breast conserving surgery (BCS) is however associated with a number of practical difficulties, acute radiation side effects and longer term toxicity, all of which detract from the obvious benefits of EBRT. In addition, with a disease as common as early breast cancer and a treatment programme typically requiring sophisticated radiation planning and many fractions of treatment, the policy of BCS plus EBRT has enormous resource implications within departments of oncology, greatly contributing to lengthy pre-treatment delays. For all these reasons, we and others have developed an increasing interest in techniques of partial breast irradiation, with an emphasis in our own Department on the emerging technique of intra-operative radiotherapy (IORT), which we initially employed as a boost to the tumour bed for use in conjunction with EBRT to the whole breast. To test the possibility of replacing the whole of the EBRT 3-6 week programme by a single application of IORT at the time of surgery, we and others have commenced a large scale prospectively randomised clinical trail in selected patients. Nine international centres are currently participating, and 350 patients have now been randomised to receive either IORT as part of the initial surgical excision or conventional EBRT with a pragmatic dose policy according to the preference of the contributing centre. The majority of patients undergoing IORT receive this at the time of initial surgery but it is also permissible within the trial programme to randomise suitable patients after the excised specimen has been histologically examined, thus avoiding any unsuitable patients - for example, those with a lobular carcinoma. These patients will be stratified and assessed separately from the 'pre-pathology' group, whose surgery and IORT is completed within a single session; if the latter patients are found to have unfavourable histology we have the facility, within the trial, to add EBRT. The trial is ongoing and our early experience has been encouraging. We have also recently assessed the long term local failure rate in patients offered IORT as a tumour bed boost, in conjunction with conventional EBRT. This methodology will also be the subject of a future randomised clinical trial.

Hippocampal theta: a sensory-inhibition theory of function.

The most prominent electrical signal which can be recorded from the hippocampus is called theta rhythm. Over the past 30 years there have been numerous attempts to relate this waveform to behavior. Theta has been associated with arousal, learning memory, attention, and most recently motor movement. While the relationship between one type of theta and certain kinds of movement is well established, a second type of theta shows no such relationship. In the present paper it is argued that the most parsimonious hypothesis relating theta to behavior is not the motor programming theory but a sensory-inhibition model. In this model theta is regarded as representative of general inhibition of systems not being used during motor behavior or alert immobility.

Effect of low dose infusions of ile-atrial natriuretic peptide in healthy elderly males: evidence for a postreceptor defect.

Low dose infusions of atrial natriuretic peptide (ANP) have significant biological effects in young adults. In view of the accumulating evidence of age-related changes in ANP physiology, we investigated the effects of a 2-h low dose infusion of ile12-ANP (1.5 pmol/kg/min) in eight healthy, supine, normotensive elderly men in a single blind, random order, placebo-controlled study. Calculated MCR of ANP was 3.3 +/- 0.4 L/min, disappearance half-life 4.1 +/- 0.4 min, and volume of distribution 21 +/- 4 L. The ile-ANP infusions induced the expected significant (3-fold) increases in plasma ANP immunoreactivity in association with enhancement of both plasma and urine cyclic guanosine monophosphate. Despite this, there were no measurable natriuretic effects or changes in blood pressure, and the activities of the renin-angiotensin-aldosterone and sympathetic nervous systems were unchanged. These findings suggest an abnormality in the post-cyclic guanosine monophosphate effector of ANP among elderly normotensive men.

Epidermal growth factor receptor and other oncogenes as prognostic markers.

Analysis of epidermal growth factor receptor (EGFr) and estrogen receptor (ER) was performed on tumor samples from 231 patients with operable breast cancer followed for up to 6 years after surgery. The median duration of follow-up in patients still alive at the time of analysis was 45 months. Thirty-five percent of patients (82) had tumors greater than 10 fmol/mg of 125I-EGF binding (EGFr+) and 47% (109) had cystolic ER concentration greater than 5 fmol/mg (ER+), with a marked inverse relationship between EGFr and ER (P less than .00001). EGFr was second only to axillary-node status as a prognostic marker for all patients in terms of both relapse-free and overall survival in univariate analysis (P less than .001, log-rank EGFr + v EGFr-). For patients with histologically negative axillary nodes, EGFr was superior to ER in predicting relapse and survival (P less than .01 and P less than .005, respectively, compared to P less than .1 and P less than .1, log-rank). In a multivariate (Cox model) analysis, only EGFr--out of EGFr, ER, size, and grade--was predictive for either relapse-free or overall survival for patients with node-negative disease (P = .052 and P = .026, respectively). One hundred eighty-seven case patients in the series were assessed for neu expression immunochemically, and 31 were positive. There was a highly significant increased risk of relapse and death in the positive group. In patients with otherwise good prognostic markers (ER+, node-negative, well-differentiated tumors), neu expression predicted for significantly worsened overall survival.(ABSTRACT TRUNCATED AT 250 WORDS)

The response to treatment of subclinical thiamine deficiency in the elderly.

The significance of subclinical thiamine deficiency in the elderly was determined by assessing response to thiamine supplementation in a randomized double-blind, placebo-controlled trial. Thirty-five of 222 people aged > or = 65 y had two concentrations of erythrocyte thiamine pyrophosphate (TPP) < 140 nmol/L 3 mo apart and 41 other people had the first, but not the second, TPP concentration below this value. Both groups were randomly assigned in a double-blind trial to oral thiamine (10 mg/d) or a placebo. All subjects randomly assigned to receive thiamine showed increases in TPP concentrations compared with control subjects. Only the subjects with persistently low TPP concentrations showed subjective benefits from treatment with improvements in quality of life (measured on a visual analogue scale; P = 0.02) and decreases in systolic blood pressure (P = 0.05) and weight (P < 0.01) when compared with subjects given placebo. There was a trend toward benefits in sleep and energy (P = 0.07). We conclude that a low TPP concentration on two occasions is a better predictor of response to treatment than an isolated measurement. Quality of life was enhanced by providing thiamine supplements. Blood pressure and weight were lower after thiamine supplementation.

Effect of raloxifene on breast cancer cell Ki67 and apoptosis: a double-blind, placebo-controlled, randomized clinical trial in postmenopausal patients.

PURPOSE: Raloxifene is a selective estrogen receptor (ER) modulator approved for prevention and treatment of postmenopausal osteoporosis. This is an exploratory study of raloxifene in primary breast cancer patients. EXPERIMENTAL DESIGN: Postmenopausal women (50-80 years of age), with histological or cytological diagnosis of stage I or II primary breast cancer, were randomly assigned to 14 days of placebo, 60 mg/day raloxifene, or 300 mg twice daily (600 mg/day) of raloxifene. A core biopsy of the primary tumor was obtained before therapy, and a representative sample of the excised tumor was obtained from the operative specimen after treatment. Paired baseline and endpoint biopsies from each patient were analyzed for Ki67, apoptosis, and estrogen and progesterone receptors. Treatment group differences in efficacy measurements were primarily evaluated for baseline-to-endpoint change and percentage change using a one-way ANOVA with treatment as the fixed effect. RESULTS: Of 167 enrolled patients, 143 had evaluable efficacy data. Most breast cancer cases were invasive (98.6%), stage I (76.6%), and ER-positive (83.2%). In patients with ER-positive tumors, Ki67 increased 7% from baseline on placebo and decreased by 21% on 60 mg/day raloxifene (P = 0.015 versus placebo) and by 14% on 600 mg/day raloxifene (P = 0.064 versus placebo). Raloxifene did not affect apoptosis. ER decreased significantly with 60 mg/day or 600 mg/day raloxifene compared with placebo (P < 0.01 for each comparison). Raloxifene had no statistically significant effects on Ki67 among patients with ER-negative tumors. There were no treatment differences in adverse events. CONCLUSION: In this exploratory trial, 60 mg/day raloxifene showed a significant antiproliferative effect in ER-positive breast cancer, demonstrated by the decrease in Ki67, with no effect in ER-negative cancer. This provides support for raloxifene having a breast cancer preventive effect in postmenopausal women.

A census-based comparison of centenarians in New Zealand with those in the United States.

OBJECTIVE: To describe the characteristics of New Zealand's centenarians, as given in the 1991 census, and to compare these characteristics with those of centenarians from the United States. DESIGN: A census-based descriptive study. SETTING: The complete national population as defined by the 1991 New Zealand census. RESULTS: In 1991, there were 246 female and 51 male centenarians in New Zealand. Fifty-one percent of the men and 29% of the women lived at home; 16% lived at home with someone else (55% with children). People who were widowed were more likely to be living in a residential institution (69%) than people who were married (40%). Forty-three percent of men and 39% of women earned less than NZ$10,000 per year. Most had no formal educational qualification. Fourteen percent of men and 35% of women living at home did housework in the previous week. Compared with the United States, there are fewer New Zealand centenarians per number of population. People of European race were overrepresented in the New Zealand centenarian population, whereas African Americans were overrepresented in the United States centenarian population. CONCLUSIONS: Our data have shown the heterogeneity associated with extreme ageing and can be used as a basis for comparison with other countries.

A community study of vitamin B12 and folate levels in the elderly.

OBJECTIVE: To measure the prevalence of low serum vitamin B12, folate, and red cell folate levels and their relationship with other nutritional indices. DESIGN: Prospective survey of elderly subjects using radioisotope dilution assays. SETTING: Primary care medical center, Christchurch, New Zealand. PATIENTS: 257 elderly subjects (age 65 years and over), residing in their own homes or in residential homes, were randomly selected. Of these, 204 (79%) participated. The study population was comparable to the elderly population of New Zealand. MAIN OUTCOME MEASURES: Vitamin B12, serum, and red cell folate levels. RESULTS: The prevalence rates for low levels of serum vitamin B12, folate, and red cell folate were 7.3%, 1%, and 3.3%, respectively. The elderly cohort had lower vitamin B12 (P less than 0.001) but higher serum and red cell folate levels (P less than 0.001) than our normal reference range (age 18-65 years). Red blood cell folate levels showed positive correlations with nutritional indices and mental test scores. No correlations were found between vitamin B12 levels and diet or other nutritional indices. CONCLUSIONS: Low folate levels in older people living at home are infrequent findings. In contrast low vitamin B12 levels are more common. Poor diet and undernutrition may contribute to low folate levels, but these factors are less important for the low B12 levels found.

Modality specific type 2 theta production in the immobile rat.

The purpose of the present study was to compare the relative effectiveness of stimulation of different sensory modalities in eliciting Type 2 theta in the rat in the presence or absence of a ferret. Visual, auditory, and tactile stimuli were presented to rats in both conditions. Tactile stimulation produced more movement than either visual or auditory stimuli when the ferret was present. In both conditions, however, more Type 2 theta was observed in response to tactile or visual stimulation than to auditory stimulation. In the arousal condition, stimulation of tactile and auditory modalities resulted in significant increases in the amount of Type 2 theta produced. Input to the visual modality produced high levels of Type 2 theta production in both low- and high-arousal conditions. It is argued that Type 2 theta is not necessarily a precursor to movement but rather sensory processing while in a high state of arousal.

Macrophage infiltration of breast tumours: a prospective study.

In 50 cases of infiltrating breast cancer investigated in a prospective study the number of macrophages within each tumour was assessed. The macrophages were identified by their cytoplasmic acid phosphatase activity. The number of lymphocytes and plasma cells within the tumours were graded by a scoring technique. Significantly fewer cases with metastases were found among those with high macrophage and plasma cell scores. There was no correlation between lymphoreticular infiltration and the degree of tumour differentiation, but in cases without metastases the lymphoreticular infiltration between tumour cells was nearly always only slight when the macrophage score was low.

Evolution of afterdischarge and seizure characteristics during electrical kindling of the guinea-pig.

Interspecies comparisons may help us understand the mechanisms which underlie brain plasticity. In this study, we examined the electrical kindling phenomenon in the amygdala, piriform and perirhinal regions of the guinea-pig. The changes in afterdischarge (AD) characteristics and behavioural seizures were assessed under different stimulation intervals and parameters as well as under reduced inhibitory neurotransmitter systems. We report that the guinea-pigs displayed a number of similarities with other species, such as the progressive increases in AD characteristics and seizure behaviours, but also a number of differences, such as the behavioural manifestations of the seizures, failing to reach a fully generalized tonic-clonic seizure and an apparent insensitivity to both low-frequency stimulation and reduced GABA and catecholamine levels.

Anatomical correlates of rhythmical slow wave activity (theta) in the hippocampal formation of the cat.

The topography of spontaneous and hypothalamically induced hippocampal rhythmical slow wave activity (theta) was studied acutely in cats anesthetized with urethane. Tracking and depth profile analysis using microelectrodes showed two amplitude maxima of theta activity approximately 180 degrees out of phase separated by a null zone. One amplitude peak was located in stratum oriens of CA1 (maximum amplitude 1.2 mV) and the other peak in stratum moleculare of the fascia dentata (maximum amplitude 1.9 mV). The null zone was localized to stratum radiatum, just ventral to the CA1 pyramidal cells. The two 'generator' hypothesis of theta activity was discussed in relation to similar findings for other species. Pharmacological results were interpreted as supporting the view that there is an ascending cholinergic input mediating theta in the urethanized cat.