Considering the Role of Adaptive Evolution in Models of the Ocean and Climate System.

Numerical models have been highly successful in simulating global carbon and nutrient cycles in today's ocean, together with observed spatial and temporal patterns of chlorophyll and plankton biomass at the surface. With this success has come some confidence in projecting the century-scale response to continuing anthropogenic warming. There is also increasing interest in using such models to understand the role of plankton ecosystems in past oceans. However, today's marine environment is the product of billions of years of continual evolution-a process that continues today. In this paper, we address the questions of whether an assumption of species invariance is sufficient, and if not, under what circumstances current model projections might break down. To do this, we first identify the key timescales and questions asked of models. We then review how current marine ecosystem models work and what alternative approaches are available to account for evolution. We argue that for timescales of climate change overlapping with evolutionary timescales, accounting for evolution may to lead to very different projected outcomes regarding the timescales of ecosystem response and associated global biogeochemical cycling. This is particularly the case for past extinction events but may also be true in the future, depending on the eventual degree of anthropogenic disruption. The discipline of building new numerical models that incorporate evolution is also hugely beneficial in itself, as it forces us to question what we know about adaptive evolution, irrespective of its quantitative role in any specific event or environmental changes.

cpDNA-RFLP in Ceramium (Rhodophyta): intraspecific polymorphism and species-level phylogeny.

Restriction fragment length polymorphism (RFLP) analysis of chloroplast (cp) DNA is a powerful tool for the study of microevolutionary processes in land plants, yet has not previously been applied to seaweed populations. We used cpDNA-RFLP, detected on Southern blots using labeled total plastid DNA, to search for intraspecific and intrapopulational cpDNA RFLP polymorphism in two species of the common red algal genus Ceramium in Ireland and Britain. In C. botryocarpum one polymorphism was detected in one individual among 18 from two populations. Twenty-six individuals of C. virgatum from five populations at three locations exhibited a total of four haplotypes. One was frequent (80.8% of individuals); the others were rare (7.7, 7.7, and 4.2%) and were private to particular populations. Polymorphism was observed in two populations. The corrected mean was 2.26 ± 0.36 haplotypes per population, which was within the typical range determined for higher plants using similar techniques. The spatial distribution of haplotypes was heterogeneous, with highly significant population differentiation (P = 0.00018; Fisher's exact test). Intraspecific polymorphism in C. virgatum had no impact on species-level phylogenetic reconstruction. This is the first unequivocal report of both intraspecific and intrapopulational cpDNA-RFLP polymorphism in algae.

How gastroenterologists screen for colonic cancer in ulcerative colitis: an analysis of performance.

BACKGROUND: The aim of this study was to assess the colorectal cancer surveillance practices of British gastroenterologists for patients with ulcerative colitis. METHODS: A questionnaire that investigated aspects of surveillance in patients with ulcerative colitis was mailed to all consultant gastroenterologists in the U.K. (n = 413). RESULTS: Three hundred forty-one questionnaires were returned (response rate 83%). Ninety-four percent of consultants practice cancer surveillance in ulcerative colitis, with 35% maintaining a registry of patients in surveillance programs. All gastroenterologists perform surveillance in patients with pancolitis, 24% in those with left-sided colitis and 2% in patients with proctitis. The mean duration of disease before surveillance is commenced is 9.2 years for pancolitis and 12.4 years for left-sided colitis (p < 0.0001). Only 4% of gastroenterologists routinely offer patients with disease of more than 10 years' duration a prophylactic colectomy. Colonoscopies are conducted by an accredited gastroenterologist in 65% of cases and biopsies are reviewed by specialists in gastrointestinal pathology in 45%. When histology reveals low-grade dysplasia only 4% advise colectomy and when high-grade dysplasia is found 53% recommend colectomy. Sixteen percent of gastroenterologists were unaware of the significance of a dysplasia associated lesion or mass. CONCLUSION: The majority of gastroenterologists practice surveillance on a disorganized basis. There is inconsistency in the management of patients with dysplasia and education of gastroenterologists is needed.

Local recurrence in the conservatively treated breast cancer patient: a correlation with age and family history.

BACKGROUND: The purpose of this study was to evaluate the relationships among young age at diagnosis, family history status, and local recurrence in breast cancer patients treated with lumpectomy and radiation therapy. METHODS: Between January 1970 and December 1990, 984 early-stage breast cancer patients were treated with conservative surgery and radiation therapy at Yale-New Haven Hospital. All patient data, including demographics, staging information, treatment, and outcome variables were entered into a computerized database. The current study focused on the relationships between young age, family history, and local relapse. A group of 52 patients who experienced a local recurrence in the conservatively treated breast and 52 matched control patients who had not experienced a local recurrence were asked to participate in a study to determine whether local recurrence was associated with family history. Detailed family history interviews were conducted, and pedigrees were analyzed by a genetic counselor who was blind to the clinical history of the patients. RESULTS: As of September 1997, with a median follow-up of 12.3 years for the 984 patients in the database, the overall actuarial 10-year survival is 73%, and the 10-year distant metastasis-free survival is 78%. Of the 984 patients, 112 have experienced a local relapse in the conservatively treated breast, resulting in a 10-year actuarial breast relapse rate of 15%. The 10-year survival after breast relapse is 69%. Patient age tested as a continuous variable correlated strongly with ipsilateral breast tumor relapse. Using age 40 as a cutpoint, patients aged 40 years or less had a significantly higher local relapse rate than patients older than 40 years (P < 0.001). Although the relationship between local relapse and young age was strong, no association was found between family history and local relapse in the detailed family history study. CONCLUSIONS: Young age at diagnosis was a significant prognostic factor for local relapse. In a detailed family history study using a case-control design, no significant differences in family history status were found between patients who had experienced a local relapse and patients who had not.

Breast reconstruction in previously irradiated patients using tissue expanders and implants: a potentially unfavorable result.

There exists a paucity of definitive information on the suitability of implant reconstructions in previously irradiated breast cancer patients. This controversial topic prompted a review of our prosthetic reconstructions in this select group of patients. A retrospective study of patients treated between 1976 and 1993 with lumpectomy and radiation therapy for early breast cancer revealed 67 patients with local recurrences. Nine of these patients (10 breasts) underwent a two-stage prosthetic reconstruction following a salvage mastectomy. The average age was 47.9 years. The mean dose of irradiation was 6,070 cGy. The average interval from radiation therapy to placement of a tissue expander was 4.6 years. In one patient (10%) the tissue expander extruded. The average follow-up for 8 patients (9 breasts) who underwent exchange to a permanent prosthesis was 5.1 years. In four reconstructions (40%) there was an uneventful postoperative course. Two cases (20%) were difficult to expand and the final result lacked projection. One patient (10%) developed an infection requiring removal of the permanent prosthesis. Two patients (20%) developed Baker class III or IV capsular contractures. Overall, in our group of 10 implant reconstructions, 60% of the patients resulted in either a complication or an unfavorable result.

The impact of genetic screening on surgical decision-making in breast cancer.

For centuries, clinicians have recognized that a segment of their patient population is at increased risk to develop breast cancer based on their family history of the disease. Due to the absence of molecular information, it was not uncommon for women and their surgeons to make decisions regarding management of prophylactic surgery based solely on their family history, without specific information about the patient's personal risk to develop the disease. It has been only within the past 7 years that linkage for the breast cancer (BRCA) susceptibility genes has been established, and within the past 3 years that the genes have been cloned. Although clinical testing for the BRCA genes has been available for less than 2 years, it is already apparent that the implications for surgeons and their patients are significant.

Vertical mammaplasty: technique and complications.

Vertical mammaplasty is among a group of mammaplasty procedures designed to minimize the extent of skin excision, and thus the potential for aesthetically unpleasing scars. However, these less traditional techniques have not enjoyed the same usage as classic inverted-mammaplasties, and thus the accumulated experience in these techniques is less. Vertical mammaplasty can yield excellent results when applied appropriately, but the learning curve can be significant. Details of operative technique are presented along with potential compfications, with the objective of maximizing the safety and outcome of vertical mammaplasty.

Timing, magnitude, and utility of surgical delay in the TRAM flap: II. Clinical studies.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was performed in 15 patients 1 week after a preliminary delay procedure. The indications for surgical delay were obesity, smoking, prior radiation therapy, a requirement for large volumes of transmidline tissue, or combinations of these risk factors. The delay procedure consisted of outpatient ligation of the deep and superficial inferior epigastric vessels. Prior to and 1 week following the delay procedure, noninvasive Doppler examinations of the superior epigastric vessels were performed. Following the delay procedure, the diameter of the superior epigastric artery increased from 1.3 +/- 0.2 to 1.8 +/- 0.3 mm (p < 0.001) and the calculated superior epigastric artery flow increased from 7.25 +/- 0.8 to 18.2 +/- 2.7 ml/min (p < 0.001). Breast reconstruction in these high-risk patients was successful without major ischemic complications, but a tendency toward unreliability of zone IV was noted. This clinical observation is consistent with the findings in our animal studies (part I). The preliminary delay procedure was well tolerated with minimal morbidity. We feel that a preliminary delay procedure is a very useful option for breast reconstruction patients at high risk for TRAM flap vascular compromise.

Surgical delay in TRAM flap breast reconstruction: a comparison of 7- and 14-day delay periods.

Thirty-one transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstructions were performed after a delay period either of 1 week (group I, N = 15) or 2 weeks (group II, N = 16). The preliminary delay procedure consisted of bilateral deep inferior epigastric and superficial inferior epigastric artery and vein ligation. In group I the diameter and flow in the superior epigastric artery increased from baseline values of 1.3 +/- 0.3 mm and 7.25 +/- 0.8 ml per minute to 1.8 +/- 0.3 mm and 18.2 +/- 2.7 ml per minute at 1 week. In group II the diameter and flow in the superior epigastric artery increased from baseline values of 1.2 +/- 0.3 mm and 5.85 +/- 1.5 ml per minute to 1.7 +/- 0.4 mm and 23.4 +/- 6.2 ml per minute at 2 weeks. The differences between 1 and 2 weeks were not statistically significant. The complication rate in either group was similar. We conclude that a preliminary delay procedure is highly effective at augmenting TRAM flap vascularity and may be implemented between 1 and 2 weeks prior to TRAM flap breast reconstruction in high-risk patients.

Three-dimensional reconstruction of melanotic neuroectodermal tumor of infancy involving the occipital bone and dura.

A rare case of melanotic neuroectodermal tumor of infancy involving the right occipital bone in an 11-month-old infant is described. The bone tumor and its dural extension were surgically removed. Three-dimensional reconstruction of the tumor and brain from neuroimaging data added worthwhile information for preoperative planning. Microscopic examination revealed melanotic and neuroblastic tissue in a fibrillary matrix involving the expanded bone and superficial dura. A focal osteoblastic cranial mass in an infant should alert the clinician to consider this tumor.

Meningococcal disease in Los Angeles County, California, and among men in the county jails.

BACKGROUND: From January through March 1993, there were 54 cases of meningococcal disease in Los Angeles County, California, of which 9 occurred among men incarcerated in the county's jail system, which was 40 percent above capacity at the time. Several of the 45 patients from the community had had contact with men recently released from a county jail. METHODS: We interviewed patients from the community (n=42) and neighborhood controls matched with the patients for age, race, and ethnic group (n=84) about potential exposures. We collected and cultured pharyngeal swabs for Neisseria meningitidis from men entering the central jail (n=162), men leaving the central jail (n=379), members of the jail staff (n=121), and patients at a community health center (n=214). Meningococcal isolates were identified by serotyping and multilocus enzyme electrophoresis. RESULTS: The presence of community-acquired meningococcal disease was strongly associated with exposure to a person who had been in or worked at one of the county jails (multivariate matched odds ratio, 18.5; 95 percent confidence interval, 3.8 to 90.8; P<0.001). Pharyngeal carriage of meningococcus was significantly more frequent among men released from jail (19 percent) or entering jail (17 percent) than among workers at the jails (3 percent) or community residents seen at the clinic (1 percent). Among men entering jail, those who had previously been incarcerated were more often carriers than those who had not (21 percent vs. 7 percent, P=0.03). Of the isolates from nine community residents with serogroup C meningococcal disease, eight were the same strain as that isolated from the eight inmates with serogroup C disease. CONCLUSIONS: In this outbreak of meningococcal disease in Los Angeles County, nearly half of community residents with the disease had contact with persons who had been in a county jail. The high rates of carriage among recidivists and released inmates suggests that the men became meningococcal carriers while in jail.

Optical breast lesion localization fiber: preclinical testing of a new device.

Preclinical testing was performed of an optical breast lesion localization fiber to guide surgical excision. The prototype device comprised dual 0.010- inch (0.254-mm)-diameter hooks attached to the tip of a 1,000-microns (0.03937-inch)-diameter optical fiber, which allowed retention in soft tissue after passage through a 17-gauge extra-thin-wall needle. The proximal end of the optical fiber was attached to a 15-mW, 635-nm diode laser, with a thumbscrew connector. The tip of the optical fiber was visible through several centimeters of breast tissue in two human mastectomy specimens, which facilitated determination of the location of the hooks. The optical localization fiber may allow lesions to be approached at surgery by many different paths. Clinical tests are indicated to further evaluate this device.

The continuing increase in adenocarcinoma of the uterine cervix: a birth cohort phenomenon.

BACKGROUND: Adenocarcinoma of the uterine cervix has been reported to be increasing among young white women and earlier studies suggest a birth cohort pattern for the observed increase. No study, however, has examined the time trends of adenocarcinoma of the cervix by birth cohort. METHODS: Using Surveillance, Epidemiology, and End Results (SEER) data through 1990, the current study is designed to examine the time trends of invasive adenocarcinoma by birth cohort. An age-period-cohort model was fitted to the annual-age-specific rates to identify the components of birth cohort and time period as determinants of the observed time trends. RESULTS: The results from this study clearly show that invasive adenocarcinoma of the uterine cervix has been increasing in both whites and blacks, but the increase is statistically significant only among whites, reaching 4.2 percent per year for those born since 1935. The results also show that the recent increase in invasive adenocarcinoma started among those born around the mid 1920s, and a strong birth cohort effect is largely responsible for the observed increase. CONCLUSION: Invasive adenocarcinoma of the uterine cervix is increasing among recent birth cohorts. Analytical epidemiological studies are urgently needed to explore the risk factors responsible for the increase. The time trends for adenocarcinoma of the cervix should also be carefully monitored in the coming years.

Continuing increase in incidence of germ-cell testis cancer in young adults: experience from Connecticut, USA, 1935-1992.

The current study is designed to examine long-term trends by histologic types of testis cancer in Connecticut. A regression model was used to identify age, period, or cohort as determinants of the time-trend on histologic types of testis cancer. The results from this descriptive epidemiologic study show that the overall age-adjusted incidence rate of testis cancer has increased 3.5-fold in Connecticut during the past nearly 60 years of cancer registration. The rates for seminoma and non-seminoma have been increasing since the mid-1950s and increase in a similar manner for those aged 15 to 49. The largest increase was observed in the age groups 20 to 44 for seminoma and 15 to 34 for non-seminoma. The observed increase was limited to whites. The results from age-period-cohort modeling suggest that the observed increase in seminoma before 1950s could be largely attributable to a period effect, while the increase for cohorts born after about 1910 both for seminoma and for non-seminoma are mainly explained by a strong birth-cohort effect. Therefore, the observed increase in germ-cell testis cancer in this population is likely to continue in the coming years. Thus far, the proposed hypotheses, such as exposure to DES in utero, earlier lifetime exposure to viruses, trauma or unusual amounts of heat to the testis, cannot adequately explain the observed incidence patterns of testis cancer. Analytical epidemiologic studies with large sample size are urgently needed to examine the risk factors responsible for the increase.

Time trend in pancreatic cancer incidence in Connecticut, 1935-1990.

A total of 13,246 incident pancreatic cancer cases, reported to the Connecticut Tumor Registry between 1935 and 1990, were included in our study. Results indicate that the overall age-adjusted incidence rate of pancreatic cancer increased between 1935 and 1964 in males, and leveled off thereafter. Since 1975, the incidence rate has in fact been decreasing, from 12.04/100,000 in 1975-79 to 10.44/100,000 in 1985-90. In females, the overall age-adjusted incidence rate also increased between 1935 and 1974. Since then, however, it has remained relatively stable. Age-specific incidence rates also show no signs of an increase in rate from any age group, or from either sex for recent birth cohorts. There is also no clear increase in the incidence of pancreatic cancer in any of the ethnic/gender categories since the early 1970s. Age-period-cohort modeling shows that the increasing birth cohort trend peaked among those born around 1920-1925 and, for recent birth cohort, a slightly decreasing trend was observed in both males and females. Our study reveals no signs of an increase in the immediate future in pancreatic cancer incidence rate in any of the sex, ethnic and age groups in Connecticut.

Indications for the surgical management of central nervous system blastomycosis.

BACKGROUND: Blastomycotic infections of the central nervous system (CNS) occur infrequently. The medical literature concerning blastomycosis of the CNS contains little information regarding indications for surgery. METHODS: We report five cases of CNS blastomycosis that required surgery: four intracranial and one intraspinal. One patient had a prior diagnosis of sarcoidosis, whereas none of the others had been diagnosed with any other systemic illness. The patients were evaluated with plain x rays as well as with computed tomography or magnetic resonance imaging. RESULTS: Four of these patients had extradural abscesses that required surgical drainage as well as debridement of granulomatous tissue and infected bone. The remaining patient had an intracerebellar abscess. Postoperatively, three patients were treated with amphotericin B, one with amphotericin B and ketoconazole, and one with an experimental protocol of fluconazole alone. All of the patients recovered without sequelae of seizures, recurrence of disease, or reaction to pharmacotherapy, although one patient had transient renal insufficiency due to amphotericin B. CONCLUSIONS: Our experience with CNS blastomycosis managed surgically is reported. We propose three general surgical indications for these patients: mass lesions, diagnostic biopsy, and osteomyelitis refractory to pharmacotherapy.

Severe cervical kyphotic deformities in patients with plexiform neurofibromas: case report.

Two patients with cervical plexiform neurofibromas are presented. Each of these patients had severe cervical kyphosis and has undergone anterior decompression, anterior reconstruction, and posterior stabilization. We discuss the surgical management of cervical kyphotic deformities associated with plexiform neurofibromas and review the factors associated with bony changes in neurofibromatosis.

Time trend and the age-period-cohort effect on the incidence of histologic types of lung cancer in Connecticut, 1960-1989.

BACKGROUND: Recent epidemiologic studies have suggested changing patterns of lung cancer incidence by histologic type. The observed time trends have been attributed to a change in the rate of cigarette smoking, changes in exposure to new environmental carcinogens, and changes in the criteria for the histopathologic diagnosis of lung cancer. The current study was designed to examine the incidence patterns of lung cancer by histologic type in Connecticut and to use this information to project the future trend of the disease in this population. METHODS: This study was based on all the lung cancer cases reported to the Connecticut Tumor Registry between 1960 and 1989. On the basis of this data set, crude and age-adjusted incidence rates of lung cancer were calculated by histologic type for each sex. The age-specific incidence rates are presented by calendar year and cohort year of birth. A regression model was used to identify birth cohort, period, and age as determinants of the observed time trends. RESULTS: For the overall age-adjusted incidence rates, squamous cell carcinoma and small cell carcinoma have stabilized in men, whereas they are still increasing in women. The incidence of adenocarcinoma has been increasing in both men and women, but there has been a much sharper incidence among females since the mid-1970s. An examination of age-specific incidence rates by birth cohort and the results from age-period-cohort modeling indicate that incidences of all three major histologic types of lung cancer in the recent birth cohorts either have started decreasing (squamous cell carcinoma) or shown a clear reduction in the rate of increase (adenocarcinoma and small cell carcinoma). This study, however, did not indicate an increase of bronchoalveolar lung carcinoma, which was reported by other clinically based studies. CONCLUSION: While the overall age-adjusted incidence rates showed different incidence patterns for different histologic types of lung cancer, a decreasing or stabilized rate for all three major histologic types of lung cancer was observed in recent birth cohorts in both males and females. The observed incidence pattern is consistent with smoking trends over time including changes in smoking prevalence and the consumption of low tar and filter cigarettes. It is expected that if the current trend in tobacco smoking continues and if there are no major changes in other risk factors for lung cancer, a forthcoming stabilization or decrease in the rate of lung cancer incidence for all major histologic types (including adenocarcinoma) in both sexes in Connecticut could be anticipated.

Hiccups and brainstem compression.

A 70-year-old man presented with a 12-year history of intractable hiccups. Magnetic resonance imaging and cerebral angiography revealed dolichoectasia of the right vertebral artery with compression of the brainstem at the pontomedullary level.