Multiple imputation for the Cox proportional hazards model with missing covariates

STUDY OBJECTIVES: To examine equity in the health care system with regard to cancer patient care by estimating the level of systematic regional variation in cancer survival in the Nordic countries. Specifically, those cancer sites which exhibit high levels of systematic regional variation in survival and hence inequity were identified. Estimating the reduction in cancer deaths which could be achieved by eliminating this variation so that everyone receives effective care will provide a readily interpretable measure of the amount of systematic regional variation. A comprehensive analysis of regional variation in survival has not previously been conducted so appropriate statistical methodology must be developed. SETTING AND PARTICIPANTS: All those aged 0-90 years who had been diagnosed with at least one of 12 common malignant neoplasms between 1977 and 1992 in Denmark, Finland, Norway, and Sweden. DESIGN: A separate analysis was conducted for each country. Regression models for the relative survival ratio were used to estimate the relative risk of excess mortality attributable to cancer in each region after correcting for age and sex. An estimate of the amount of systematic regional variation in survival was obtained by subtracting the estimated expected random variation from the observed regional variation. An estimate was then made of the potential reduction in the number of cancer deaths for 2008-12 if regional variation in survival were eliminated so that everyone received the same level of effective care. MAIN RESULTS: Between 2008 and 2012, an estimated 2.5% of deaths from cancers in the 12 sites studied could be prevented by eliminating regional variation in survival. The percentage of potentially avoidable deaths did not depend on country or sex but it did depend on cancer site. There was no relationship between the level of regional variation in a given country and the level of survival. The cancer sites for which the greatest percentage savings could be achieved were melanoma (11%) and cervix uteri (6%). The sites for which the highest number of deaths could be prevented were prostate, colon, melanoma, and breast. CONCLUSIONS: This methodology showed a small amount of systematic regional variation in cancer survival in the Nordic countries. The cancer sites with high levels of regional variation identified are potential targets for cancer control programmes.     

Adolescents'' description and management of pregnancy and preterm labor

Xenopus laevis larvae with an elevated expression of c-src were generated by mating a transgenic X. laevis male frog carrying proviral Rous sarcoma virus (RSV) long terminal repeat (LTR) and most of the pol gene sequences in its sperm DNA and a normal X. laevis female frog. Offspring (15-20%) with a higher dosage of c-Src, detected in disorganized myotomal musculature and in cerebral and spinal neuronal cells by immunohistochemical analysis, developed abnormally, with edemas (in most cases), head deformities, and eye and axial system defects. In the remaining embryos, a small increase in c-src expression seemed to be compatible with normal embryogenesis. The dosage of c-Src correlated with the dosage of RSV LTR integrated in frog DNA as revealed by Southern and polymerase chain reaction (PCR) analyses. Authenticity of the integrated RSV LTR including enhancer sequence was proved by sequencing. Probing of total RNA from aberrant larvae demonstrated several times higher dosage of c-src mRNA in their tissues than in control tadpoles. We hypothesize that the integrated RSV regulatory sequences can stimulate the expression of c-src proto-oncogene of X. laevis above a threshold that interferes with the early developmental program of frog embryos.     

Epipubic bones in eutherian mammals from the late Cretaceous of Mongolia

An important transformation in the evolution of mammals was the loss of the epipubic bones. These are elements projecting anteriorly from the pelvic girdle into the abdominal region in a variety of Mesozoic mammals, related tritylodonts, marsupials and monotremes but not in living eutherian (placental) mammals. Here we describe a new eutherian from the Late Cretaceous period of Mongolia, and report the first record of epipubic bones in two distinct eutherian lineages. The presence of epipubic bones and other primitive features suggests that these groups occupy a basal position in the Eutheria. It has been argued that the epipubic bones support the pouch in living mammals, but epipubic bones have since been related to locomotion and suspension of the litter mass of several attached, lactating offspring. The loss of the epipubic bones in eutherians can be related to the evolution of prolonged gestation, which would not require prolonged external attachment of altricial young. Thus the occurrence of epipubic bones in two Cretaceous eutherians suggests that the dramatic modifications connected with typical placental reproduction may have been later events in the evolution of the Eutheria.     

Athletics and osteoarthritis

Athletes, and an increasing number of middle aged and older people who want to participate in athletics, may question whether regular vigorous physical activity increases their risk of developing osteoarthritis. To answer this, the clinical syndrome of osteoarthritis must be distinguished from periarticular soft tissue pain associated with activity and from the development of osteophytes. Sports that subject joints to repetitive high levels of impact and torsional loading increase the risk of articular cartilage degeneration and the resulting clinical syndrome of osteoarthritis. However, moderate habitual exercise does not increase the risk of osteoarthritis; selected sports improve strength and mobility in older people and people with mild and moderate osteoarthritis. People with abnormal joint anatomy or alignment, previous significant joint injury or surgery, joint instability, above-average body weight, disturbances of joint or muscle innervation or inadequate muscle strength probably have increased risk of osteoarthritis. These people and those with early osteoarthritis can benefit from regular physical activity, but they should have a careful evaluation of their joint structure and function before participation. They should consider measures that decrease the intensity and frequency of impact and torsional loading of joints, including use of sports equipment that decreases joint impact loading, maintaining or improving muscle strength, tone, and general conditioning so that muscle contractions help protect joints from injury and high impact, and decreasing body weight.     

Tumor dormancy and cell signaling. V. Regrowth of the BCL1 tumor after dormancy is established

The majority of BALB/c mice immunized with the BCL1 lymphoma-derived idiotype (Id+) IgM and subsequently challenged with BCL1 tumor cells develop a state of tumor dormancy. The vast majority of dormant lymphoma cells are in cell cycle arrest, but there are also residual replicating cells. In the present studies, we attempted to define features of both the dormant lymphoma cells and the host that lead to escape from dormancy. Escape from dormancy occurs at a steady rate over a 2-year period, suggesting that it is a stochastic process. We found that, in the majority of mice, escape was due to the emergence of genetic variants that were no longer susceptible to the anti-Id-mediated induction of dormancy. Ten percent of these variants were Id-; the remainder were Id+ but could grow in the presence of anti-Id antibodies, suggesting that there were mutations in molecules involved in one or more mIg-mediated negative-signaling pathways. In two of five such escapees, alterations in either Syk, HS1, and/or Lyn were observed. In a small percentage of mice, a low titer of circulating anti-Id antibody before tumor challenge correlated with a subsequent, more rapid loss of dormancy.     

Paroxysmal atrial tachycardia with second-degree atrioventricular block

Paroxysmal atrial tachycardia with atrioventricular block usually indicates potentially dangerous overdigitalization, and serious heart disease is almost universally present. In this report, we describe a patient with a structurally normal heart who manifested spontaneously intra-atrial reentrant tachycardia with Wenckebach atrioventricular block in the absence of medications. In this patient, the longest atrial paced cycle length that induced atrioventricular nodal block was 390 ms, and the atrial cycle length during tachycardia ranged from 360 to 400 ms. The electrophysiologic study in our patient demonstrated that second-degree atrioventricular block during atrial tachycardia may occur in patients without structural heart diseases or taking any medication.     

Regulation of progesterone receptor messenger ribonucleic acid in the rat medial preoptic nucleus by estrogenic and antiestrogenic compounds: an in situ hybridization study

Progesterone receptor (PR) messenger RNA (mRNA) is concentrated in neurons of the preoptic area and other regions of the rat hypothalamus where it is colocalized with the estrogen receptor and regulated by changes in the steroid hormonal milieu. To date, little is known about the regulation of PR mRNA by estrogens and whether antiestrogenic compounds are capable of modulating its expression. The present studies used in situ hybridization to ascertain the time course of PR mRNA regulation in the medial preoptic nucleus by 17beta-estradiol, determine the effective dose required to elicit a response, and compare the efficacy of 17beta-estradiol with a variety of estrogenic or antiestrogenic compounds. The first series of studies revealed that the treatment of ovariectomized rats with 17beta-estradiol resulted in an increase in PR expression within 2 h, after which it remained elevated until 10 h postinjection and then returned to baseline levels. When ovariectomized rats were injected with 25-1000 ng/kg of 17beta-estradiol and euthanized 6 h later, a dose-dependent increase in the level of PR mRNA was observed, with a maximal response at 1000 ng/kg and an EC50 of 93.5 ng/kg. Subsequent studies evaluated the efficacy of a variety of estrogenic and antiestrogenic compounds in the rat preoptic nucleus. 17Beta-estradiol, diethylstilbestrol, and 17alpha-estradiol all significantly increased the level of PR mRNA, although the degree of induction varied with each compound. The injection of tamoxifen, raloxifene, toremifene, droloxifene, clomiphene, GW 5638, or ICI 182,780 had no significant estrogenic effect on PR gene expression at the dose evaluated. In contrast, when tamoxifen or raloxifene, but not ICI 182,780, was administered in the antagonist mode, a significant dose-related decrease in the estradiol-induced level of PR mRNA was seen in the preoptic area. The results of these studies clearly demonstrate that PR mRNA expression in the rat preoptic area is rapidly stimulated by a small dose of 17beta-estradiol. Moreover, the present report has also shown that the estrogenic nature of compounds such as tamoxifen, raloxifene, toremifene, droloxifene, clomiphene, and GW 5638 cannot be predicted by their activity in peripheral tissues. Together, the results of these studies provide important information about the central activity of estrogens and provide evidence for their tissue-specifc actions in the rat.     

Pharmacokinetic features, immunogenicity, and toxicity of B43(anti-CD19)-pokeweed antiviral protein immunotoxin in cynomolgus monkeys

Withdrawal responses to mechanical and thermal stimuli applied to the plantar surface of the hindpaw were measured before and after bone damage. In separate groups of rats the bone was injured by scraping the periosteum of the tibia, drilling a hole through the tibia, aspirating bone marrow, or drilling a hole through the calcaneus. Scraping the periosteum did not alter withdrawal responses to the mechanical stimuli, or evoke nocifensive behavior. In contrast, secondary mechanical hyperalgesia and allodynia, and cold allodynia were observed after a hole was drilled through the tibia or calcaneus and after aspiration of bone marrow. The secondary hyperalgesia peaked at 2 h after injury. Drilling a hole through the calcaneus permitted primary hyperalgesia to be easily quantified. Primary hyperalgesia lasted up to 24 h after injury. Nocifensive behavior characterized by a lifting and guarding of the damaged limb was also observed after a hole was drilled through the tibia or calcaneus. Drilling a hole through the tibia or calcaneus should be a useful experimental model for investigating the mechanisms underlying bone pain.     

Selective modification of insulin action in adipose tissue by hyperthyroidism

Adipose-tissue lipolysis (assessed from glycerol release) and glucose uptake were examined in parametrial and mesenteric adipocytes prepared from control or hyperthyroid rats in relation to changes in insulin sensitivity. Basal rates of lipolysis did not differ significantly between adipose-tissue depots. Lipolysis was maximally stimulated by noradrenaline at 1 microM, half-maximal anti-lipolytic effects of insulin were observed at approximately 11 microU/ ml insulin, and half-maximal stimulation of glucose uptake was observed at approximately 16 microU/ml insulin in adipocytes from both depots. Wortmannin caused a dose-dependent inhibition of the anti-lipolytic effect of insulin (150 microU/ml) on noradrenaline-stimulated lipolysis. Half-maximal effects of wortmannin were observed at 20-40 nM. The p70S6K inhibitor rapamycin and the mitogen-activated protein kinase kinase inhibitor PD098059 had no effects on noradrenaline-stimulated lipolysis. Hyperthyroidism increased basal rates of lipolysis and the maximal response of lipolysis to noradrenaline stimulation (3.1-fold, P < 0.001 and 2.1-fold, P < 0.05 respectively) in parametrial adipocytes. Hyperthyroidism markedly blunted the sensitivity of noradrenaline-stimulated lipolysis to half-maximal suppression by insulin in both parametrial and mesenteric adipocyte depots, and noradrenaline-stimulated lipolysis at a maximal insulin concentration remained significantly higher in adipocytes prepared from hyperthyroid rats compared with controls. Hyperthyroidism had no effect on basal and little effect on insulin-stimulated glucose uptake. Tri-iodothyronine administered at a low dose selectively influenced the anti-lipolytic action of insulin in parametrial adipocytes, and led to significantly less marked elevation in plasma non-esterified fatty acid concentrations in vivo. The results demonstrate a selective effect of hyperthyroidism to impair insulin's anti-lipolytic action, and are consistent with the operation of different downstream signalling mechanisms for the effects of insulin on adipocyte glucose transport and lipolysis.