Cost-effectiveness of HPV-based cervical screening based on first year results in the Netherlands: a modelling study.

OBJECTIVE: We aim to compare the cost-effectiveness of the old cytology programme with the new high-risk human papillomavirus (hrHPV) screening programme, using performance indicators from the new Dutch hrHPV screening programme. DESIGN: Model-based cost-effectiveness analysis. SETTING: The Netherlands. POPULATION: Dutch 30-year-old unvaccinated females followed up lifelong. METHODS: We updated the microsimulation screening analysis (MISCAN) model using the most recent epidemiological and screening data from the Netherlands. We simulated both screening programmes, using the screening behaviour and costs observed in each programme. Sensitivity analyses were performed on screening behaviour, utility losses and discount rates. MAIN OUTCOME MEASURES: Cervical cancer incidence and mortality rates, number of screening tests and repeat tests, colposcopy referrals by lesion grade, costs from a societal perspective, quality-adjusted life years (QALYs) gained and cost-effectiveness. RESULTS: The new Dutch cervical cancer screening programme decreased the cervical cancer mortality by 4% and the incidence by 1% compared with the old programme. Colposcopy referrals of women without cervical intra-epithelial neoplasia grade 2 or worse, increased by 172%, but 13% more QALYs were still achieved. Total costs were reduced by 21%, mainly due to fewer screening tests. Per QALY gained, the hrHPV programme cost 46% less (€12,225) than the cytology programme (€22,678), and hrHPV-based screening remained more cost-effective in all sensitivity analyses. CONCLUSIONS: The hrHPV-based screening programme was found to be more effective and cost-effective than the cytology programme. Alternatives for the current triage strategy should be considered to lower the number of unnecessary referrals. TWEETABLE ABSTRACT: First results after implementation confirm that HPV screening is more cost-effective than cytology screening.

Long-term radiographic appearance of a bioabsorbable biocomposite tibial tuberosity advancement cage implant.

OBJECTIVE: To report the radiographic appearance of a bioabsorbable biocomposite tibial tuberosity advancement cage at least 1 year after implantation. Design Retrospective case series. METHODS: Medical records (February 2014-March 2015) of dogs receiving a biocomposite tibial tuberosity advancement cage were reviewed. Cases were selected if they had undergone surgery at least 1 year before the selection, no additional surgeries were performed, and no known surgical site infection had occurred. Medical record information assessed included signalment, body weight (kg), affected stifle joint (left or right), date of original surgery and the size of biocomposite cage used (9 or 12 mm). Radiographs were evaluated by two blinded radiologists who calculated percentages of osteolucency present in five zones around the cage and assigned a numerical score based on these calculations. Variables were evaluated statistically for effect on lucency percentage and numerical score. RESULTS: Fifty dogs were included. Zone 5 (caudoproximal area) was found to have the lowest lucency percentage and score and zone 3 (distal area) had the highest lucency percentage and score. Twelve-millimetre cages were significantly associated with a higher lucency numerical score than 9 mm cages. CONCLUSION: A biocomposite tibial tuberosity advancement cage was found to have variable amounts of radiographically apparent osseous integration at least 1 year after implantation.

[Housing Project 'Living Independently with Intensive Support (WmI)': The Scientific Evaluation]. / Modellprojekt "Wohnen mit Intensivbetreuung (WmI)": Die wissenschaftliche Evaluation.

BACKGROUND: In Germany, people with multiple severe disabilities caused by brain injuries, are predominantly cared for in permanent residential living facilities. In 2009 the Fürst Donnersmarck Foundation (FDSt) launched a new housing project - supported living accommodations (SLA) - for this group of people. Residents from a permanent residential living facility (Fürst Donnersmarck House, FDH) are offered the opportunity to move into 2 newly built SLA with a 24/7 individual support of a social pedagogic staffs as well as nursing care. The aim of the study is to compare the changes of residents' social and health related outcomes in the SLA group as compared to the group remaining in stationary care. METHODS: In a prospective longitudinal study (2009-2011) residents of the FDH are surveyed using standardized self- and proxy-rating instruments. Times of measurement are shortly before moving into the SLA (baseline, t1) and at follow-up after 6, 12 and 18 months after relocation (t2-t4). Additionally to residents' socio-demographic data, health outcomes including ADL functioning (EBI), quality of life (WHOQoL-Bref, EQ-5D), need of assistance (HMB-W), social inclusion/perceived disability (WHODAS II), anxiety and depression (HADS) and social contacts were evaluated. RESULTS: 40 residents could be included into the study, 29 of them moved into 2 SLA. The underlying neurological causes of the handicap were mainly sequelae of acuired damage of the central nervous system during adult age. Residents are on average 46.2 years old and predominantly male (65%). During the study the perceived dis-ability (WHODAS II) increased statistically significant but we could not show differences between groups (p > 0.05). Changes in functional and cognitive everyday abilities, fear, depression and quality of life (WHOQoL-Bref, EQ-5D) could not be shown (p > 0.05). The perceived sense of -mastery (Pearlin Mastery Scale) increased statistically significant and showed more positive developments by tendency in SLA. Everyday activities in SLA increased to a large extent. CONCLUSION: Some positive but no overall effects of moving into SLA can be shown. It is remarkable that the serious changes of living conditions do not lead to less QoL or more anxiety in this vulnerable group of people but resulted in increasing external contacts and greater mobility. Social pedagogic support offers the residents the chance to bear a more self-determined life and to participate actively in new social networks.

The effect of screw angulation and insertion torque on the push-out strength of polyaxial locking screws and the single cycle to failure in bending of polyaxial locking plates.

OBJECTIVE: To evaluate the mechanical properties of the Polyaxial Advanced Locking System (PAX) in screw push-out and four-point bending. MATERIALS AND METHODS: Screw push-out: PAX locking screws were applied to first generation PAX plates at three different insertion angles with two different insertion torques. A load was applied parallel to the screw axis, and screw push-out force was measured. Four-point bending: PAX plates were applied to a bone model and a fracture gap was simulated. Bending stiffness, bending strength, and bending structural stiffness were evaluated and compared to published data. RESULTS: Screw push-out forces were significantly higher at 0 and 5 degree insertion angles when compared with an insertion angle of 10 degrees. An insertion torque of 3.5 Nm also produced significantly higher push-out forces compared to 2.5 Nm. Four-point bending: Qualitative comparison of the data gained in this study with previously published data suggests that the PAX system bending stiffness and bending structural stiffness seems to be higher than that of other veterinary orthopaedic implants, but the bending strength was similar. CLINICAL RELEVANCE: The PAX locking system offers the benefit of polyaxial screw insertion while maintaining comparable biomechanical properties to other currently available orthopaedic implants.

In vitro mechanical evaluation and comparison of two crimping devices for securing monofilament nylon and multifilament polyethylene for use in extracapsular stabilization of the canine stifle.

OBJECTIVE: To compare the tensile strength and stiffness of non-absorbable suture loops created with two types of crimping devices. METHODS: Loops of monofilament nylon leader line (MN) of 18 kg, 36 kg, and 45 kg multifilament polyethylene (MP) with a crimp and MP with a crimp and knot were mechanically tested to failure in quasistatic tensile loading after being created with either a wave pattern crimp device or three applications of a single crimp device. Each testing group consisted of five samples. Tensile loading to failure at a rate of 9.5 mm/s was used. Failure was defined as a sudden drop in the recorded force. RESULTS: All suture materials failed by breaking near the crimp tube with both crimp devices, with exception of the MP without knot, which slipped through the crimp tube using both devices. Sutures secured with the wave pattern crimping device were significantly stronger with a higher load yield, maximum load, displacement yield, failure displacement, and maximum displacement than the single crimp device. Loops of MP suture crimped by either device plus the addition of a surgeon's knot resulted in a significantly stronger construct than unknotted crimped MP constructs. Crimped MP combined with knot were significantly stiffer, but not stronger, than crimped 45 kg MN. CLINICAL SIGNIFICANCE: Performing extra- capsular repair for ruptured cranial cruciate ligaments with the wave pattern crimp system may result in lower failure rates due to the construct being significantly stronger than the single crimp system.

The role of fibroblast Tiam1 in tumor cell invasion and metastasis.

The co-evolution of tumors and their microenvironment involves bidirectional communication between tumor cells and tumor-associated stroma. Various cell types are present in tumor-associated stroma, of which fibroblasts are the most abundant. The Rac exchange factor Tiam1 is implicated in multiple signaling pathways in epithelial tumor cells and lack of Tiam1 in tumor cells retards tumor growth in Tiam1 knockout mouse models. Conversely, tumors arising in Tiam1 knockout mice have increased invasiveness. We have investigated the role of Tiam1 in tumor-associated fibroblasts as a modulator of tumor cell invasion and metastasis, using retroviral delivery of short hairpin RNA to suppress Tiam1 levels in three different experimental models. In spheroid co-culture of mammary epithelial cells and fibroblasts, Tiam1 silencing in fibroblasts led to increased epithelial cell outgrowth into matrix. In tissue-engineered human skin, Tiam1 silencing in dermal fibroblasts led to increased invasiveness of epidermal keratinocytes with pre-malignant features. In a model of human breast cancer in mice, co-implantation of mammary fibroblasts inhibited tumor invasion and metastasis, which was reversed by Tiam1 silencing in co-injected fibroblasts. These results suggest that stromal Tiam1 may have a role in modulating the effects of the tumor microenvironment on malignant cell invasion and metastasis. This suggests a set of pathways for further investigation, with implications for future therapeutic targets.

Analysis of normal epithelial cell specific-1 (NES1)/kallikrein 10 mRNA expression by in situ hybridization, a novel marker for breast cancer.

PURPOSE: Normal epithelial cell specific-1 (NES1)/kallikrein 10 gene is expressed in normal mammary and prostate epithelial cells, but the expression of NES1 mRNA and protein is markedly reduced in established breast and prostate cancer cell lines although the NES1 gene is intact. Here, we wished to assess whether NES1 expression is down-regulated in primary breast cancers. EXPERIMENTAL DESIGN: We developed and used an in situ hybridization technique with an antisense NES1 probe to detect NES1 mRNA in sections of normal breast specimens, typical and atypical ductal hyperplasia, ductal carcinoma in situ, and infiltrating ductal carcinoma. RESULTS: All of the 30 normal breast specimens showed high NES1 expression. Notably, 18 (75%) of 24 typical and atypical breast hyperplasia specimens showed high NES1 expression, with weak-to-moderate expression in 6 (25%). Significantly, 13 (46%) of 28 ductal carcinoma in situ specimens lacked NES1 expression, and the remaining 15 (54%) showed weak-to-moderate expression. Finally, 29 of 30 (97%) infiltrating ductal carcinoma grades I-III samples lacked NES1 mRNA, with weak expression in the remaining one sample. CONCLUSIONS: Our results demonstrate that NES1 mRNA is expressed in normal breast tissue and benign lesions, with loss of NES1 expression during tumor progression. We suggest that NES1 expression may serve as a molecular tool in the study of breast cancer progression. Studies with larger series of specimens should help assess whether NES1 expression can be a diagnostic and/or prognostic marker in breast and other cancers.

Development of spontaneous mammary tumors in BALB/c p53 heterozygous mice. A model for Li-Fraumeni syndrome.

Breast cancer is the most frequent tumor type among women in the United States and in individuals with Li-Fraumeni syndrome. The p53 tumor suppressor gene is altered in a large proportion of both spontaneous breast malignancies and Li-Fraumeni breast cancers. This suggests that loss of p53 can accelerate breast tumorigenesis, yet p53-deficient mice rarely develop mammary tumors. To evaluate the effect of p53 loss on mammary tumor formation, the p53(null) allele was back-crossed onto the BALB/c genetic background. Median survival was 15.4 weeks for BALB/c-p53(-/-) mice compared to 54 weeks for BALB/c-p53(+/-) mice. Sarcomas and lymphomas were the most frequent tumor types in BALB/c-p53(-/-) mice, whereas 55% of the female BALB/c-p53(+/-) mice developed mammary carcinomas. The mammary tumors were highly aneuploid, frequently lost the remaining wild-type p53 allele, but rarely lost BRCA1. Although mammary tumors were rarely detected in BALB/c-p53(-/-) female mice, when glands from BALB/c-p53(-/-) mice were transplanted into wild-type BALB/c hosts, 75% developed mammary tumors. The high rate of mammary tumor development in the BALB/c background, but not C57Bl/6 or 129/Sv, suggests a genetic predisposition toward mammary tumorigenesis. Therefore, the BALB/c-p53(+/-) mice provide a unique model for the study of breast cancer in Li-Fraumeni syndrome. These results demonstrate the critical role that the p53 tumor suppressor gene plays in preventing tumorigenesis in the mammary gland.

Cytoplasmic sequestration and functional repression of p53 in the mammary epithelium is reversed by hormonal treatment.

Proper function of the p53 tumor suppressor gene is critical for inhibiting tumor development in a broad spectrum of tissues. Although the mammary gland is highly susceptible to tumor formation, the functional status of p53 in the normal tissue had not been investigated. Therefore, expression, localization, and activity of p53 were examined in normal mammary tissues. High levels of p53 protein were found expressed in the cytoplasm of the ductal epithelium of the quiescent mammary gland. Ionizing radiation failed to recruit p53 to the nucleus, and p53-dependent responses were minimal. However, transient hormonal stimulation resulted in nuclear accumulation of p53, an induction of p21/WAF1, and a 5-fold increase in apoptosis after ionizing radiation. Therefore, the functional state of wild-type p53 in the mammary epithelium can be regulated by hormonal stimuli.

Regulation of p53 and its targets during involution of the mammary gland.

Post-lactational involution of the mammary gland provides a system in which to study the expression and function of genes that regulate apoptosis in the context of a normal tissue. The functions of the p53 tumor suppressor gene have been extensively studied as a mediator of apoptosis in response to DNA damage, but its regulation in normal physiologic processes has been poorly characterized. Expression of p53 mRNA was shown to be among the first genes to be induced in mammary tissue following weaning of neonates. Although involution proceeds in the absence of a functional p53 gene, it is delayed compared to normal individuals. Therefore, involution can be viewed as biphasic with initial responses being sensitive to p53, whereas secondary responses being p53-independent. These observations can be exploited to determine the subset of genes that are p53-responsive and that mediate the effects of p53 in normal mammary tissue.

Expression of MDM2 during mammary tumorigenesis.

The MDM2 oncoprotein encodes a 90 kDa nuclear phosphoprotein capable of abrogating the growth suppressive functions of p53 and pRb tumor suppressor proteins by direct interaction. Alternative splicing of MDM2 protein coding sequences has been documented during tumor progression in human ovarian and bladder carcinomas. The aim of this study was to determine whether alternative splicing of MDM2 occurs during breast tumorigenesis in mice and humans and whether protein coding sequences were affected. Specimens representing normal and malignant breast tissues from the murine D2 mammary tumor model system and human breast carcinomas were examined. Three distinct mdm2 mRNA transcripts of 3.3, 1.6 and 1.5 kb were detected in normal and malignant murine mammary tissues by Northern blot analysis using a full-length mdm2 cDNA probe. Additional Northern blot analysis using a probe derived from exon 12 of murine mdm2 demonstrated that the 1.5 and 1.6 kb transcripts lack sequences encoding the C-terminus of the protein. No evidence of internal deletions of protein coding sequences of mdm2 was detected in any of the normal mammary tissues or D2 murine mammary tumors examined by reverse transcription PCR (RT-PCR). Three distinct MDM2 transcripts of 6.7, 4.7 and 1.9 kb were detected in malignant human breast tissue by Northern blot analysis using a cDNA probe specific for the complete open reading frame of human MDM2. However, a cDNA probe specific for the last exon of human MDM2 hybridized only to the 6.7 and 4.7 kb transcripts, demonstrating that the 1.9 kb transcript lacked protein coding sequences contained in exon 12. Similarly, no internal deletions were detected in a panel of malignant human breast tissues using RT-PCR and analogous primers within human MDM2. Therefore, breast tumors differ from other solid tumors reported previously in that no internal deletions of MDM2 protein coding sequences were observed. However, the data document the presence of multiple MDM2 mRNA transcripts in both normal and malignant breast tissues. A subset of MDM2 transcripts were shown to lack the last exon which contains sequences coding for the RING and zinc fingers and domains which are targets for caspase-3 mediated proteolytic degradation and are required to target p53 for proteosomal degradation.

Delayed involution of the mammary epithelium in BALB/c-p53null mice.

In mammals, weaning of neonates and subsequent milk stasis initiates removal of the secretory epithelium of the mammary gland by apoptosis. The p53 tumor suppressor gene is induced rapidly following weaning of neonates, but its role in the process of involution has not been defined. Therefore, experiments were performed to identify the cell types in which the p53 gene is expressed during involution and determine the consequences of its absence in BALB/c-p53null mice. Both p53 mRNA and protein were detected in the mammary epithelium within 48 h following weaning and resulted in an eightfold increase in levels of p21WAF1 mRNA. Induction of p21WAF1 mRNA was absent in BALB/c-p53null mice, and therefore, was shown to be p53-dependent. The BALB/c-p53null mice exhibited delayed involution of the mammary epithelium, as measured by 60% greater epithelial area compared to BALB/c-p53(wt) mice through 5 days post-weaning. The delay was transient with no differences being apparent at 7 days post-weaning. Expression of the stromal protease stromelysin-1 was unaffected by the absence of p53 suggesting that stromal responses were intact. These data demonstrate that p53 participates in the first stage of involution initiated by the epithelium itself, but does not affect the second phase during which stromal proteases are induced.

A five-year experience with fragile X testing. Setting laboratory standards of practice and a cost-effective protocol.

During the years 1990-1994, our center tested 652 patients, with a broad range of referral indications, for fragile X syndrome using either cytogenetic analysis alone (Protocol 1) or more recently, a combination of DNA analysis and routine karyotyping (protocol 2). The overall positive rate for fragile X was 3.1% with an incidence of other chromosomal abnormalities (OCAs) of 3.2%. Breakdown of cases using each testing protocol along with percent positives is: [table: see text] Use of Protocol 2 yielded only definitive fragile X results, while more than half of the "positives" using Protocol 1 were equivocal. Historically this has been problematic for both the laboratory and physician since interpretation is often dependent on an equally equivocal clinical picture. Protocol 2 eliminates these diagnostic dilemmas without compromising detection of other chromosomal abnormalities, the incidence of which appears to be unaffected by testing method used. The overall incidence of OCA of 3.2% underscores the value of routine karyotyping in this referral group and likely reflects the phenotypic variability of fragile X and its clinical overlap with other chromosomal abnormalities. We believe that a fragile X testing protocol combining routine karyotyping with definitive molecular technology represents the most cost-effective diagnostic approach to this clinically challenging patient population.

Continuing role of a frozen-tissue bank in molecular pathology.

The growth of molecular diagnostics and its application in various clinical laboratories have made it necessary to standardize the methods used to freeze and store tissues used in molecular testing. It may now be advantageous to preserve fresh tissues and other specimen types in a central frozen-tissue bank so that sample preparation and storage conditions are appropriate for molecular applications and so that the specimen inventory can be efficiently managed. The pathology laboratory is a logical site for the facility because the professional and technical expertise available is focused on the complex scientific and regulatory aspects of laboratory medicine. Organizationally, the tissue-bank program should be overseen by a surgical pathologist to integrate it into routine surgical pathology activities. A member of the laboratory technical staff can serve as the tissue-bank coordinator with responsibility for systematic storage and retrieval of specimens and routine maintenance of equipment and supplies. To facilitate the tissue-freezing procedure and efficient storage of multiple types of specimens, 2.0 ml cryogenic vials are used as the uniform storage container. All specimens are stored at -140 to -150 degrees C in the vapor phase of liquid nitrogen. The specimen inventory data are maintained with a computerized program specifically designed to manage complex specimen storage. A frozen-tissue bank is easily implemented in a pathology laboratory and is a valuable institutional asset for diagnostic and research purposes.

The role of androgen receptor gene mutations in male breast carcinoma.

Certain germline mutations (607Arg-Gln, 608Arg-Lys) in the androgen receptor gene have been associated with the occurrence of breast cancer in males suffering from partial androgen insensitivity. To assess whether somatic mutations in this gene could be detected in breast carcinoma, archival tumor tissue of males without clinical evidence of androgen insensitivity was screened for point mutations in the androgen receptor gene. DNA was retrieved by chloroform-phenol extraction from formalin-fixed, paraffin-embedded tissues. Exons 2-8 of the androgen receptor gene, encoding the DNA- and hormone-binding regions of the receptor, were amplified by polymerase chain reaction and subjected to nonisotopic single strand conformation assay (SSCA) to screen for point mutations. In the tumor DNA, no variations suggestive of mutations were encountered on SSCA. However, in a control patient with partial androgen insensitivity and predominantly female phenotype, the germline mutation 607Arg-Gln was identified in blood leukocyte DNA. Our results indicate that somatic mutations of the androgen receptor are not required for the development of male breast cancer. This, however, does not exclude an increased risk of breast carcinoma in patients with androgen insensitivity.

Ring chromosomes in dermatofibrosarcoma protuberans are composed of interspersed sequences from chromosomes 17 and 22.

Ring chromosomes are found in most dermatofibrosarcoma protuberans (DFSPs), and recent reports demonstrate that portions of the DFSP ring chromosomes derive from chromosome 17. In this study we characterized ring chromosomes in three DFSPs using a combined approach of karyotyping, chromosome painting, and comparative genomic hybridization. Chromosome painting demonstrated that the ring chromosomes in each DFSP were composed of discontinuous, interwoven sequences from chromosomes 17 and 22. Amplification of chromosomes 17 and 22 sequences was confirmed in each of these cases by comparative genomic hybridization, and over-representation of chromosomes 17 and 22 sequences was also demonstrated by comparative genomic hybridization in 1 of 2 cytogenetically unremarkable DFSPs. We conclude that amplification of chromosomes 17 and 22 sequences, in ring form, is a characteristic aberration in DFSP.

Communication and control: parent, child, and health care professional interactions during painful procedures.

Through use of a qualitative ethological approach, observations of 17 children who were undergoing 44 painful procedures during cancer diagnosis or treatment were videotaped and analyzed. The children, aged 4 to 18 years, were part of a larger study testing the effectiveness of nonpharmacologic pain management techniques. Analysis of the videotaped observations revealed that several distinct patterns of conversation between caregivers, parents, and children varied greatly among situations. Both child-centered and nonchild-centered communications were demonstrated. During periods of quiet, nonchild-centered behaviors increased. As a child's distress increased, parents actively changed behaviors to redirect verbal support back to the child and to the pain control interventions. Nurses' encouraging parents to be actively involved and physically close during painful treatments may results in less distress and discomfort for the child. In addition, health care professionals need to be aware of the various patterns of child-parent-caregiver interactions and the need to stay focused on the child during painful procedures to enhance the child's ability to cope.

Specimen storage and the use of a relational database.

Advances in genetic research make laboratory specimens a valuable source of DNA. Regulations call for quick turnaround time in locating stored specimens. Personal computers and database software make it possible to store, locate, and inventory samples efficiently and assist in research work and cooperation between laboratory sites.