Tumor microenvironment, which is largely affected by inflammatory cells, is a crucial participant in the neoplastic process through promotion of cell proliferation, survival and migration. We measured the effects of polymorphonuclear neutrophil (PMN) conditioned medium alone, and supplemented with serine proteinase inhibitor α-1 antitrypsin (AAT) or its C-terminal fragment (C-36 peptide), on cultured lung cancer cells.3H]-thymidine incorporation, Matrigel invasion and ELISA methods, respectively.Lung cancer HCC cells were grown in a regular medium or in a PMN-conditioned medium in the presence or absence of AAT (0.5 mg/ml) or its C-36 peptide (0.06 mg/ml) for 24 h. Cell proliferation, invasiveness and release of IL-8 and VEGF were analyzed by [Cells exposed to PMN-conditioned medium show decreased proliferation and IL-8 release by 3.9-fold, p < 0.001 and 1.3-fold, p < 0.05, respectively, and increased invasiveness by 2-fold (p < 0.001) compared to non-treated controls. In the presence of AAT, PMN-conditioned medium loses its effects on cell proliferation, invasiveness and IL-8 release, whereas VEGF is up-regulated by 3.7-fold (p < 0.001) compared to controls. Similarly, C-36 peptide abolishes the effects of PMN-conditioned medium on cell invasiveness, but does not alter its effects on cell proliferation, IL-8 and VEGF release. Direct HCC cell exposure to AAT enhances VEGF, but inhibits IL-8 release by 1.7-fold (p < 0.001) and 1.4-fold (p < 0.01) respectively, and reduces proliferation 2.5-fold (p < 0.01). In contrast, C-36 peptide alone did not affect these parameters, but inhibited cell invasiveness by 51.4% (p < 0.001), when compared with non-treated controls.Our data provide evidence that neutrophil derived factors decrease lung cancer HCC cell proliferation and IL-8 release, but increase cell invasiveness. These effects were found to be modulated by exogenously present serine proteinase inhibitor, AAT, and its C-terminal fragment, which points to a complexity of the relationships between tumor cell biological activities and local microenvironment. The relationship between inflammation, innate immunity and cancer is widely accepted. Early in the neoplastic process, inflammatory cells and their released molecular species influence the growth, migration and differentiation of all cell types in the tumor microenvironment, whereas later in the tumorigenic process neoplastic cells also divert inflammatory mechanisms, such as metalloproteinase production, and chemokine/cytokine functions to favour tumor spread and metastasis -3. Humanin vitro [in vivo [in vitro [in vivo. Together these findings prompted us to design an experimental model in vitro that would allow us to evaluate how neutrophil-derived products themselves and in combination with exogenously added native AAT or its C-36 peptide influence lung cancer HCC cell growth, invasion and metastatic properties.A large number of studies support the notion that proteases play an important role in the progression of malignant tumors. Therefore, the expression of proteinase inhibitors is considered to be an antimalignant event . Alpha-1in vitro . Moreove[in vivo . Our in [in vivo . Recentlin vitro , which w3H]-thymidine incorporation assay  compared to control cells cultured in a regular medium. Thus, our data show that both PMN-conditioned medium and AAT loose their inhibitory effects on cancer cell proliferation when used in combination. Under the same experimental conditions, the C-36 peptide of AAT added either directly to HCC cells or as a supplement with PMN-conditioned medium did not exert any significant effects on HCC cell proliferation relative to controls  or its C-36 peptide (0.06 mg/ml) on lung cancer HCC cell proliferation, we measured DNA biosynthesis using a [say Fig. . HCC cel, p < 0.0 comparedTo characterize lung cancer cell properties after their exposure to PMN-conditioned medium with and without added AAT or its C-36 peptide, we performed cell invasiveness assays. As illustrated in Fig. in vivo [Vascular endothelial growth factor (VEGF) and chemokine IL-8 are factors produced by tumor cells as well as by neutrophils -34, and in vivo . We analNeutrophil degranulation results in a large release of proteases, and to verify this we monitored proteolytic activity in PMN-conditioned medium by zymography, an electrophoretic technique used for the qualitative evaluation of proteases. As illustrated in Fig. Cell culture supernatants collected from HCC cells cultured in a regular medium or in PMN-conditioned medium with and without addition of AAT were analysed for AAT by 7.5% SDS-PAGE followed by immunoblotting using polyclonal antibody against human AAT. As shown in Fig. Local and systemic inflammatory mediators derived by tumor-associated PMN and tumor cells are suggested to play a role in the development of lung tumors ,37. Diffin vitro.PMN, the most abundant circulating blood leukocytes, are potent effectors of inflammation and release a wide profile of serine and metalloproteinases . InfiltrWe found that PMN-conditioned medium expresses multiple effects on lung cancer HCC cell functional activities (decreases in cell proliferation and IL-8 release and stimulation of cell invasion through the ECM membrane), but has no significant effects on VEGF release. These dual neutrophil activities toward cancer cells have been described by other investigators. It has been suggested that through the release of cytokines, chlorinated oxidants and defensins, neutrophils may cause direct tumor killing ,48 whilein vitro model, AAT added to degranulated PMN-conditioned medium occurs in a complexed form. Thus, the modulating effects of AAT on PMN-medium activities toward HCC cancer cells can be attributed to AAT alone, but also to its interaction(s) with components of the medium. Verification of the effects of AAT on separate components released by degranulated PMN needs further investigations.The major function of AAT is to inhibit neutrophil derived serine proteases, particularly neutrophil elastase . A localin vitro and in animal models, in vivo [It is important to point out that AAT alone as well as in combination with PMN-conditioned medium induced VEGF release from HCC cells. VEGF is one of the most potent angiogenic molecules, regulating both angiogenesis and vascular permeability, and hence promotes tumor progression and development in NSCLC . Many co in vivo . Therefo in vivo . Yavelow in vivo  and AAT  in vivo . However in vivo -59. Togein vitro suggests that the chemokine IL-8 promotes rapid release of all neutrophil granular stores after cell exposure to cytoskeleton-disrupting agents [During tumor progression, inflammatory cells produce large amounts of IL-8, an autocrine growth factor ,60. Leveg agents . In the in vitro and in vivo [AAT is the main inhibitor of neutrophil elastase and proteinase 3  and it h in vivo ,30. We f in vivo . InteresOur data show that AAT in various molecular forms expresses differential effects on lung tumour cell responses and provide an experimental evidence for complexity in the interactions of neutrophil-released molecular species and lung cancer cells.Native, purified human plasma AAT was purchased from the Clinical Chemistry Department . The quality of AAT preparations was confirmed by 7.5% SDS-PAGE and determination of anti-elastase activity as described by Gaillard et al. . SynthetNeutrophils were isolated from the peripheral blood of healthy donors using Polymorphprep™ (Axis-Shield PoC AS, Oslo, Norway) according to the manufacturers recommendations. Neutrophils were harvested as the lower cellular band above the red cell pellet. Residual erythrocytes were removed by a hypotonic lysis using ice cold 0.2% NaCl (w/v) for 30 s, followed addition of an equal volume of 1.6% NaCl to restore isotonicity. The neutrophil purity was typically 90% as determined by an AC900EO AutoCounter (Swelab Instruments, Sweden) and cell viability exceeded 95% according to trypan blue staining.6 cells/ml) according to Videm and Strand [g for 10 min at 4°C. Supernatants were collected and analyzed for the cytokine release and enzyme activity.PMN-conditioned medium was prepared by degranulating neutrophils (5 × 10d Strand . Briefly2, in 125-cm2 flasks in RPMI-1640 medium, supplemented with 10% FBS, 100 IU/ml penicillin, and 100 μg/ml streptomycin. Medium was changed every 2–3 days. Prior to experiments HCC cells were seeded into 12-wells plates at a density of 3 × 105 cells/ml, and cultured until confluent. After, cells were washed and a serum-free medium containing test substances was added for 24 h. Two sets of experiments were designed: the first, in which HCC cells were exposed to native AAT (0.5 mg/ml) or C-36 peptide (0.06 mg/ml) in a RPMI-1640 and the second, in which the cells were cultured in PMN-conditioned medium alone or supplemented with native AAT or C-36 peptide.Human non-small cell lung carcinoma (HCC) cells were established from the lung of 54-year old women with non-small cell lung the adenocarcinoma type (DSMC No. ACC 534). The cells were routinely grown at 37°C in a humid air containing 5% CO3H] Thymidine was then added (0.2 μCi/ml) for a further 4 h at 37°C. The medium was then aspirated, the cells were washed twice with 0.5 M NaCl and incubated for 5 min with 5% trichloroacetic acid. The cells were then washed with distilled water, dissolved in 1 ml 0.5 M NaOH, neutralised with 200 μl HCl and radioactivity determined in a β-counter . Protein concentration in cell lysates was determined by the Lowry method using HSA as a standard.HCC cells were incubated with test substances for 20 h. [6 cells/ml alone or together with test substances. Each suspension was added to the upper chamber of an ECM Invasion system. Medium containing 10% of fetal bovine serum (FBS), serving as a chemoattractant, was added to the lower chamber. The chambers were incubated at 37°C in 5% CO2 for 24 h. Invasive cells were stained and counted using microscope (Olympus BX41, PC program Olympus MicroImage) at a 100 × magnification. The number of cells per field, from 10 randomly selected fields, are presented.Cell invasion assay was performed in an invasion chamber, a 24-well tissue culture plate with 12 inserts. The inserts contain an 8 μm pore size polycarbonate filters over which is placed a thin layer of ECMatrix™. HCC cells were suspended in a serum free medium containing 1 × 10HCC cells were cultured alone or stimulated with test substances for 24 h. Cell free supernatants were then analysed by zymography using 10% and 12% Tris-Glycine gels containing 0.1% gelatin or β-casein, respectively (NOVEX, Invitrogen Life Technologies, UK). Briefly, supernatants were diluted in a sample buffer and separated by electrophoresis at 125 V for 90 min. The gels were then renatured and developed over night in a developing buffer (NOVEX, Invitrogen Life Technologies, UK) at 37°C. After washing, the gels were stained with Coomassie Blue R-250. Proteases that can utilize casein or gelatine as a substrate showed up as clear zones in the gels.HCC cell supernatants were analysed for the VEGF and IL-8 levels by using commercially available quantitative ELISA kits (R&D systems, Minneapolis, USA) according to manufacturers instructions. The lowest detectable concentration for VEGF and IL-8 was 15.6 pg/ml and 10 pg/ml, respectively.HCC cells supernatants were analysed by 10% SDS-PAGE gels and when transferred to a polivinylidene fluoride (PVDF) membrane (Millipore, Millipore Corporation, Bedford, MA 01730) using a semi-dry immunoblot transfer system. The blot was visualised using polyclonal rabbit antibody to human AAT (1:500) (DAKO, A/S, Denmark), secondary horseradish peroxidase-conjugated swine anti-rabbit antibody (1:800) (DAKO, A/S, Denmark) and peroxidase substrate, DAB (3,3-diaminobenzidine tetrahydrochloride) (Sigma, USA).The differences in the means of experimental results were analysed for their statistical significance with the one-way ANOVA combined with a multiple-comparisons procedure (Scheffe multiple range test), with an overall significance level of α = 0.05. Statistical Package (SPSS for Windows, release 11.0) was used for the statistical calculations.AAT – alpha1-antitrypsin; C-36 – C-terminal fragment of AAT; FBS – fetal bovine serum; NSCLC – non small-cell lung cancer; MMPs – matrix metalloproteinases; MT-MMP – membrane type matrix metalloproteinase; PBS – phosphate buffered saline; PMN – polymorphonuclear neutrophil; VEGF – vascular endothelial growth factor.Inga Zelvyte – AB, Tim Stevens – JY, Ulla Westin – JY, Sabina Janciauskiene ES, FG


Adult T-cell leukemia (ATL) was first reported as a distinct clinical entity in 1977 in Japan. The predominant physical findings are skin lesions, lymphadenopathy and hepatosplenomegaly. The ATL cells are of mature T-helper phenotype and have a characteristic appearance with indented nuclei. There is striking frequent hypercalcemia with increased numbers of osteoclasts. Central to the identification of the disease is a striking geographic clustering in southwestern Japan and the isolation of human T-cell lymphotropic virus type-1 (HTLV-1) from the cell lines of patients. Worldwide epidemiological studies have been made through international collaborations. Several diseases were found to be related to HTLV-1 infection. Moreover, it was noted that an immunodeficiency state may be induced by HTLV-1 infection. In Japan, HTLV-1 carriers have been estimated to be 1.2 million, and more than 700 cases of ATL have been diagnosed each year. Adult T-cell leukemia (ATL) was described as a distinct clinical entity in 1977 in Kyoto, Japan . The illIt was around the 1973 that we came to recognize the existence of ATL, previously an unknown disease. I would like to give a retrospective view concerning the background of our studies on ATL.Many clinicians in Japan probably feel that the descriptions of diseases in the literature from abroad differ from the features of the diseases observed in their practices in Japan. We can mention many examples in the field of hematology. One of these is that the incidence of chronic lymphocytic leukemia is quite low, being only 2% of all hematological malignancies. What differs is not only the incidence but also the detailed symptoms and signs of diseases. This vague feeling that an autochthonous pathology exists in Japan may be considered as key factor in the background of our study of ATL.The second major factor is the recent progress made in basic immunology. Having an interest in immunoglobulin abnormalities, I studied multiple myeloma and related diseases in the days when even the word 'immunoglobulin' was not yet in use. The central theme of immunology at that time was to identify the structure of antibodies. Immunology has advanced rapidly, and myeloma was defined as a B-cell malignancy. Therefore, it was quite natural to enlarge the objectives of our clinical studies to all lymphoproliferative diseases.At this stage of our research in Kyoto, joint studies with young researchers were initiated. This was the third and most important element of the background of our ATL study. I became acquainted with Drs. Takashi Uchiyama and Junji Yodoi, who are currently both working in Kyoto, during their postgraduate training. Dr. Yodoi prepared an antiserum against human thymocytes and invited us to direct our attention to T-cells.In the course of examining patients with various lymphoproliferative disorders, we arrived at the conclusion that ATL was a disease which had not been described anywhere before. It was recognized that T-cell malignancy had a relatively high incidence among Japanese adults and that most of the patients with this disease were from Kyushu. This discovery was made from our bedside observations rather than from laboratory work. Thereafter, Dr. Uchiyama went to the National Cancer Institute, Bethesda to work with Dr. Thomas A. Waldmann and raised a monoclonal antibody, called 'Tac' antibody, which later played an important role in our ATL studies. Dr. Yodoi has developed a new field of research by identifying a novel cytokine, ATL-derived factor (ADF), which has proved to be important in redox regulation. At the end of 1981, I moved from Kyoto to Kumamoto, which is located in the middle of Kyushu. Our studies advanced remarkably there, due mainly to the efforts of excellent young co-workers including Drs. Kazunari Yamaguchi, Toshio Hattori, and Masao Matsuoka, who are now independently working in Tokyo, Sendai and Kyoto, respectively.th International Congress of Hematology in Kyoto, it was stated that 'attempt to elucidate leukemogenesis in this disease should be directed towards exploring the genetic background and a possible viral involvement'. HTLV (human T-cell leukemia virus), the pathogen of ATL, was first reported by Dr. Robert C. Gallo and his co-workers in Bethesda in 1980 and 1981. They isolated HTLV from cultured cells taken from a patient with an aggressive variant of mycosis fungoides and another with Sezary syndrome. Although both patients were said to have cutaneous T-cell lymphoma, they had some unusual features which, in retrospect, linked them to the clinical entity now called ATL.This discovery of ATL ushered in some dramatic developments in oncology, virology and, unexpectedly, neurology and other fields of medicine. When we reported a series of 13 patients with ATL in 1976 on the occasion of the 16In Japan, co-culturing of ATL cells with umbilical cord lymphocytes was first done successfully by Dr. Isao Miyoshi's group in Okayama, who obtained the cell line MT-1. Dr. Yorio Hinuma and his co-workers in Kyoto demonstrated that ATL patients have antibodies against presumed viral antigens on MT-1 cells by indirect immunofluorescence method. Subsequently, a retrovirus was isolated and called ATLV (adult T-cell leukemia virus). Since Dr. Mitsuaki Yoshida and his group in Tokyo showed that HTLV and ATLV are, in fact, identical, the term HTLV-1 (human T-cell lymphotropic virus type 1) has been commonly used.Furthermore, the following observations have been successively reported to support the etiologic association of HTLV-1.1. All patients with ATL have antibodies against HTLV-1.2. The areas of high incidence of ATL patients correspond closely with those of high incidence of HTLV-1 carriers.in vitro.3. HTLV-1 immortalizes human T cells 4. Monoclonal integration of HTLV-1 proviral DNA was demonstrated in ATL cells.Thus, HTLV-1 is the first retrovirus directly associated with human malignancy.The diagnostic criteria for HTLV-1 associated ATL have been defined as follows:1. Presence of morphologically proven lymphoid malignancy with T-cell surface antigens .2. Presence of antibodies to HTLV-1 in the sera.3. Demonstration of monoclonal integration of HTLV-1 provirus by Southern blot method.Virological study led us to classify the patients with ATL into four clinical subtypes according to the clinical features: acute, chronic, smoldering, and lymphoma. The acute type is the prototypic ATL in which patients exhibit increased number of ATL cells, frequent skin lesions, systemic lymphadenopathy, and hepatosplenomegaly. Most of these patients are resistant to chemotherapy and have a poor prognosis. In chronic ATL, white blood cell count is mildly increased, and skin lesions, lymphadenopathy, and hepatosplenomegaly are sometimes exhibited. In the past, chronic ATL was thought to be 'chronic T-lymphocytic leukemia'. Smoldering ATL is characterized by the presence of a few ATL cells in the peripheral blood over a period of years. Frequent symptoms are skin or pulmonary lesions. Chronic and smoldering ATL often progress to acute ATL after a long period (crisis). Lymphoma-type ATL is characterized by prominent systemic lymphadenopathy, with few abnormal cells in the peripheral blood. This type has been diagnosed as nonleukemic malignant lymphoma. Later, the Lymphoma Study Group in Japan proposed a practical diagnostic criteria for classifying ATL into these four subtypes.HTLV-1 is endemic in southwestern Japan, especially Kyushu and Okinawa, in the Caribbean Islands, and in Central Africa. It has been revealed that there are HTLV-1 carriers in South America, Papua New Guinea, the Solomon Islands, South China, and other isolated populations in the world, including Ainus in Hokkaido and Aborigines in Australia. These epidemiological studies have been promoted by international collaborations, to which Drs. William A. Blattner in Bethesda, Guy de The in Paris, Kazuo Tajima in Nagoya, Shunro Sonoda in Kagoshima, and many other epidemiologists have made important contributions. Dr. Daniel Catovsky and his colleagues in London delineated the clinical features of ATL patients originating in the Caribbean islands.On the other hand, several diseases have been found to be related to HTLV-1 infection. Drs. Antoinne Gessain and Guy de The first reported the association of tropical spastic paraparesis (TSP) and HTLV-1, and Dr. Mitsuhiro Osame and his co-workers in Kagoshima studied features of HTLV-1-associated myelopathy (HAM/TSP) in detail. HTLV-1 uveitis was subsequently described by a study group of ophthalmologists in Kyushu. HTLV-1 may also be associated with bronchopneumonitis, arthritis, polymyositis and other inflammatory conditions. Moreover, it was noted that an immunodeficiency state may be induced by HTLV-1 infection.In Japan, HTLV-1 carriers have been estimated to be 1.2 million, and more than 700 cases of ATL have been diagnosed each year. Majority of HTLV-1 transmission occurs via one of three routes, all of which require the passage of virus-infected cells. HTLV-1 carrier mothers transmit the virus to newborns mainly through breast milk. Dr. Shigeo Hino and his group in Nagasaki conducted intensive fieldwork regarding the mother-to-infant infection. Carrier mothers in Japan have been instructed to refrain from breastfeeding or modify the feeding procedures to prevent HTLV-1 infection. There is convincing evidence that HTLV-1 can be transmitted from individual to individual by sexual contact, especially males to females, and also through blood transfusions. All blood donated at the Red Cross Blood Centers in Japan has been subjected to HTLV-1 antibody testing beginning in November 1986.Treatment of ATL is the most difficult task. Dr. Masanori Shimoyama in Tokyo has organized a multicenter study group for the chemotherapy of ATL. Many other trials have been reported: deoxycoformycin, α-interferon combined with azidothymidine, and so on. The use of humanized monoclonal antibodies against the interleukin-2 receptor has been championed by Dr. Waldmann's group. More recently, successful allogeneic bone marrow transplantation for patients with ATL has been reported from many institutions.th International Conference of Human Retrovirology held in Kumamoto on May 11–13, 1992.Before my retirement from Kumamoto University in 1996, I edited a book titled "Adult T-cell Leukaemia" . Many ofA companion article by Robert C. Gallo recollects the events surrounding the discovery of the first human retrovirus, HTLV-I .


The incidence of breast cancer in young women (age < 35) is low. The biology of the disease in this age group is poorly understood, and there are conflicting data regarding the prognosis for these women compared to older patients.We retrospectively analyzed 2040 consecutive primary invasive breast cancer patients who underwent surgical procedures at our institution between 1990 and 1999. The younger age group was defined as patients aged <35 years at the time of diagnosis. The clinicopathological characteristics and treatment outcomes were compared between younger and older age groups.A total of 256 (12.5%) patients were aged <35. There was a significantly higher incidence of nuclear grade 3 and medullary histological-type tumors in younger patients compared to older patients. Axillary lymph node status, T stage, histological grade, c-erbB2 expression and estrogen receptor status did not differ significantly between the two age groups. Younger patients had a greater probability of recurrence and death at all time periods. Although there was no significant difference in disease-free survival between the two age groups in lymph node-negative patients, the younger group showed worse prognosis among lymph node-positive patients (p < 0.001). In multivariate analysis, young age remained a significant predictor of recurrence (p = 0.010).Young age (<35) is an independent risk factor for relapse in operable breast cancer patients. Breast cancer is relatively rare in women less than 35 years of age, with this group accounting for less than 4% of the total number of breast cancer cases diagnosed in Western countries ,2. DespiIt remains controversial whether young age at diagnosis is an adverse prognostic factor in primary breast cancer. While some studies have found that younger patients have worse clinical outcomes than older patients -7, otherBreast cancer is the most frequent cancer in Korean women and its incidence is increasing . Breast The aim of the present study was to retrospectively investigate clinicopathological characteristics and prognosis in a large, ethnically homogeneous group of young breast cancer patients (less than 35 years old) treated with the same strategy at a single institution.A retrospective review was performed of the medical records of all consecutive primary invasive breast cancer patients (not including phyllodes tumor) undergoing curative surgery in the Department of Surgery, Seoul National University Hospital between January 1990 and December 1999. Patients with distant metastasis detected at the time of surgery or within 4 months of surgery were excluded. Those patients whose surgical margins were positive for malignancy were also excluded. Patients' records were reviewed for the following: age of onset, family history of breast cancer in 1st or 2nd degree relatives, histological type of cancer, tumor size in pathology reviews, axillary lymph node status, histological grade (HG: Scarff-Bloom-Richardson classification), nuclear grade (NG: Black's nuclear grade), type of surgical procedure and adjuvant therapy administered. Disease was staged according to the American Joint Committee of Cancer (AJCC) system . The 'yo2 test (Pearson statistic) was used to determine the differences in clinicopathological features between the two groups of patients. The follow-up duration was calculated from the date of diagnosis until the date of death or last contact. The disease-free survival was the time between diagnosis and confirmation of disease recurrence. The overall survival was the time between diagnosis and death as a result of any cause, regardless of recurrence events. Survival estimates were computed using the Kaplan-Meier method [The χr method  and the r method . Multivar method . All stast or 2nd degree relatives, T stage, histological grade, c-erbB2 expression, nor ER or PR status were different between the two groups  were aged <35 at the time of diagnosis. The median follow-up was 74 months. Histology showed the incidence of medullary carcinoma was significantly higher than ductal carcinoma in the younger group (p = 0.018). There was a significantly higher incidence of nuclear grade 3 in the younger group than in the older group (p = 0.015). Axillary lymph node status, the most prominent prognostic factor in breast cancer, was not significantly different between the two age groups. Also, neither the family history of breast cancer in 12.5% wereThe proportion of breast-conserving surgery compared to mastectomy was similar in both groups. Axillary lymph node dissection, at least to the first Berg level , was perp < 0.001). At 5 years, the actuarial recurrence rate for patients <35 years old was 30.4% as compared with 18.7% for older patients. This difference persisted at 10 years, at which time the actuarial recurrence rates were 40.1% and 28.6%, respectively. Overall survival among younger patients was significantly worse than for older patients . The 5-year survival rate was 80.0% for patients aged <35 years as compared with 88.5% for older patients. Stratified analysis according to axillary lymph node status was performed for disease-free survival. In lymph node-negative patients there was no significant difference in disease-free survival between the two age groups . However, in lymph node-positive patients, disease-free survival was significantly worse in younger patients .Younger patients had a worse disease free survival (greater probability of recurrence) at all time periods . However, young age was not a significant independent predictor of overall survival in the same Cox model . Because hormone therapy was done more frequently in older patients than young age group  remained a significant predictor of recurrence when entered into a model containing all potential demographic, pathologic and immunohistochemical variables (Table 5 years rOur results showed that operable young breast cancer patients (<35 years old) have a worse prognosis than older patients in terms of both overall survival and recurrence. The difference in disease-free survival was clear in patients with axillary lymph node metastasis, but was not observed in lymph node-negative patients. Even after controlling for differences in distribution of potential prognostic factors, young age remained a significant predictor of recurrence.The present findings support previous reports showing that women diagnosed with breast cancer at a younger age have a poorer prognosis compared with their older counterparts -7. HowevTo our knowledge, the present study is the largest to directly compare the prognosis of younger (<35) breast cancer patients with that of their older counterparts. Moreover, the data in this study were generated from patients of the same ethnicity undergoing treatment at a single institution under the same contemporary strategy of surgery and adjuvant therapy over a relatively short time period (10 years). In addition, this study included a multivariate analysis of the difference in distribution of potential prognostic markers between the two age groups.The biomarker results in the present study are different to those reported for other populations, including ethnically-related Asian patients. In a study of 1052 Chinese breast cancer patients in Hong Kong, 53% and 61.6% of pre- and postmenopausal women were ER-positive, respectively, and 51.5% and 46.2% were PR-positive, respectively . Those fAlthough not a major focus of this study, we found PR and c-erbB2 expression were significant independent predictors of disease recurrence. Currently, the role of PR status as a prognostic factor is not clear, with some evidence to suggest it is useful ,27 and oThe St. Gallen Consensus Conferences in 1998 and 2001 concluded that age under 35 was a high risk factor for relapse in node-negative breast cancer patients ,33. KromIt has been suggested that younger women with breast cancer have a poorer prognosis because they present with later stage disease due to either physician or patient delay in diagnosis. However, in this study, no significant difference was found between the two age groups in terms of tumor size or lymph node status. Moreover, multivariate analysis indicated that young age is an independent negative prognostic factor. This issue of delayed diagnosis is not conclusive now and should be elucidated further in subsequent studies.p = 0.008). Although we did not have full information on each patient's menopausal status at the time of diagnosis, this result suggests that patients under 35 years have even worse prognosis than relatively "less young age" premenopausal patients.One possible limitation of this study is that the control group was heterogeneous and contained a mixture of premenopausal and postmenopausal patients. Adami et al. showed complex pattern of survival as a function of age at diagnosis of breast cancer . Howeverst degree relatives. We found four BRCA2 and one BRCA1 mutations that are thought to be disease-causing (data not shown). Only one of these 5 patients was less than 35 years old at the time of cancer development. It is known that young breast cancer patients are more likely to have an inherited form of the disease [Up to 15–30% of women aged less than 35 years diagnosed with breast cancer are likely to have germ-line BRCA1 or BRCA2 mutations . Althoug disease . However disease .Although most current breast cancer investigators agree that young age is an adverse prognostic factor for breast cancer, there have been few studies designed to elucidate the molecular or genetic differences associated with young age breast cancer. Recent CGH (Comparative Genomic Hybridization) analysis suggested that alterations in specific regions on chromosomes might be responsible for the poor outcome of early onset breast cancer . Future These results show that operable young breast cancer patients (<35 years old) have a worse prognosis than older patients in terms of both overall survival and recurrence. Even after controlling for differences in distribution of potential prognostic factors, young age is an independent predictor of recurrence. The underlying biology of young age breast cancer needs to be elucidated and development of tailored treatment for this patient population is crucial.The author(s) declare that they have no competing interests.WH selected cases, reviewed medical records, analyze data, and drafted the manuscript. SWK participated in the data collection and input. IAP carried out the pathological diagnosis and immunohistochemistry. DK performed the statistical analysis. SWK, YKY, SKO, KJC, and DYN conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Health food stores have long hawked fish oil capsules as a cure-all for everything from migraines to heart disease. And though such claims are often weak on scientific evidence, fish oil, it turns out, is no snake oil. A recent review of scientific studies concludes that omega-3 fatty acids can indeed protect against heart disease, and the American Heart Association now recommends fish oil capsules for patients with coronary heart disease.Fatty acids come in hundreds of varieties, distinguished primarily by their structure, which in turn determines their physiological role. Unlike proteins or genes—which are polymers made up of amino acids and nucleotides, respectively—fatty acids are a large group of compounds containing long chains of carbon and hydrogen atoms with a carboxylate group (acid) attached at the end. It is this asymmetrical chemical configuration that gives fatty acids their unique properties. Fatty acid diversity comes from variations in the length of the carbon chain and in the number of double bonds between carbons. Fatty acids with one or more double bonds are called unsaturated fatty acids.PLoS Biology, Marina Kniazeva et al. explore the origin and function of mmBCFAs in the worm Caenorhabditis elegans and find that these relatively obscure fatty acids play a crucial role in growth and development.Fatty acids play an essential role in metabolism, providing the cell with a concentrated source of energy, and form the structural foundation of the cell membrane, where they are most conspicuous and perhaps best understood. Long-chain (unbranched) fatty acids, which run ten to 22 carbons long, are the most common fatty acids in animal cells and the most studied. One much less understood class of fatty acids—the monomethyl branched-chain fatty acids (mmBCFAs)—has been found in organisms from bacteria to humans, but its role remains obscure. In this issue of elo-5 and elo-6.mmBCFAs are abundant in diverse genera of bacteria, which use a supply of branched-chain amino acids and enzymes to assemble the fatty acid chains. mmBCFA biosynthesis has been characterized in bacteria, but not in eukaryotes.  Here, Kniazeva et al. identified worm genes that are homologous to the gene that codes for an enzyme called elongase in another eukaryote, yeast. Elongases are enzymes that extend the length of fatty acid chains by two carbons. To see what kind of fatty acid molecules the homologous worm genes were synthesizing, the authors used a technique called RNA interference (RNAi) to “silence” the genes' expression in the worms. Surprisingly, two of the eight inhibited genes had a specific effect on branched-chain fatty acid levels: elo-5 function had deleterious effects on the growth and development of the worms. The progeny of worms treated as embryos with RNAi for elo-5 stopped growing at the first larval stage, while the progeny of worms treated at later stages developed to adulthood but got progressively sicker and showed reproductive problems. These defects were corrected when the researchers fed the mmBCFAs directly to the worms, indicating that these mmBCFAs are essential for normal larval growth and development.Inhibiting Given the widespread distribution of mmBCFAs in organisms as diverse as bacteria and humans, it's perhaps not too surprising that they regulate essential physiological functions during animal development. It's still not clear, however, what all the components of the fatty acid manufacturing machinery are or how an organism monitors production levels. And though it's still an open question as to how these ubiquitous molecules function in mammals, the fact that they have been conserved throughout evolution underscores their importance—and suggests they may play a similar role.


Concerns regarding the privacy of health information are escalating owing both to the growing use of information technology to store and exchange data and to the increasing demand on the part of patients to control the use of their medical records. The objective of this study was to evaluate the Health Care Information Directive (HCID), a recently-developed patient decision aid that aims to delineate the level of health information an individual is willing to share.We convened a series of four focus group meetings with several communities in a large Canadian city. A total of 28 men and women participated, representing health care consumer advocates, urban professionals, senior citizens, and immigrants who speak English as a second language. Data were analysed using qualitative methods.Participants lacked substantial knowledge regarding the fate and uses of personal health information. They expressed mistrust concerning how their information will be used and protected. Several suggestions were made towards customizing the use of data according to specific needs rather than broad and full access to their charts. Furthermore, despite concern regarding the implementation of a tool like the HCID, participants were hopeful that a refined instrument could contribute to the improved regulation of health information.This study indicated poor knowledge concerning the uses of personal health information, distrust concerning security provisions, and cautious support for a patient decision aid such as the HCID to improve control over health data. The det century -6.prima facie obligation for the protection of such intimate and privileged information [Health information is valuable for numerous purposes, first and foremost for patient care, but also for secondary uses including hospital administration and health services research ,8. Such ormation ,8. Scienormation -12. Yet,ormation -15; howeormation .Internationally, legal initiatives have proposed solutions to the dilemma posed by health information. In Europe and North America, such initiatives have led to restrictive legislation that, according to some commentators, may endanger public health goods ,16,17. AIn 2001, Upshur and Goel first proposed the Health Care Information Directive (HCID), a patient decision aid analogous to an advance directive in end-of-life care [In the original proposal, it was stated that pilot testing of the tool, and revision on the basis of such testing, is required . In ordeThe study was set in Toronto, Canada, a large, culturally-diverse urban centre. In order to sample multiple views and perspectives, a series of focus group meetings was convened with the following four groups: senior citizens, urban professionals, immigrants with English as a second language, and consumer advocates. The latter group was comprised of volunteer members of a well-known national consumer advocacy association for which health care is an issue of primary interest and activity. We opted to employ focus group methodology as opposed to individual interviews or a questionnaire survey in order to capitalize on the effects of group interaction. These particular communities or target groups were selected in order to maximize the variability within our sample on important demographic characteristics such as age, gender, occupation, education, and native language, etc. . Potential participants were recruited using various methods: the seniors were recruited through a local community centre offering programs for senior citizens; participants in the immigrant/ESL group were recruited through an immigrants group at another community centre; the urban professionals were recruited by way of posters and fliers distributed at a number of hospitals and university sites; and the advocates were recruited through a national consumer advocacy association. In all cases, initial contact with potential participants was made either by telephone or e-mail and then followed up with formal letters of invitation describing the project. The focus group meetings were held in a convenient location for the participants and lasted for up to two hours.We developed a topic guide for the focus group meetings in order to address the main issues related to the feasibility of the HCID (see Appendix 1). The topic guide was developed according to the principles of formative evaluation  . Focus gTwo of the authors (GCD and CST) moderated the four focus group meetings, which lasted 90 minutes on average. A total of 28 participants took part  independently read each of the transcripts and identified passages of text relating to each of the various key issues from the topic guide (e.g., content, utility, benefits, etc.) which, for the purposes of coding and analysis, served as the macro-codes. Following this step, lists of themes were constructed and then compared. The transcripts were then independently coded according to an agreed-upon coding scheme. Tests for inter-coder reliability indicated a high level of agreement among the two coders; instances of disagreement were resolved through a process of discussion and negotiation. To strengthen the validity of the findings, the analytic processes of coding and interpretation were reviewed by the senior author (REGU). The results of our analysis are reported according to five key themes: participant knowledge and understanding of health information and its uses; control of access to health data; mistrust of data security provisions; need and utility for a tool such as the HCID; and, finally, perceived implementation barriers. Consenus statements reported below are not a reflection of any explicit consensus development techniques, but rather are summary statements of the research team's observation and interpretation of the focus group discussions. For each quotation, a specific code is provided to identify the speaker as a participant in one of the four focus groups .The majority of participants possessed extremely limited knowledge of how their PHI is collected, used, and disclosed. Many confessed to having given little or no thought to the issues involved in the health privacy debate. This was particularly true for recent immigrants: "I think the truth is that I don't know. I've never thought of that before, who has my information."(IM-1). The level of understanding was low among participants in other groups as well, as a number of comments betrayed basic misperceptions of how PHI is currently managed within the Canadian health care system:"It [personal health information] goes in the computer and then it's available to every medical professional in Ontario." (SC-3)"Health providers have access to your file, to your information... but everybody in the financial department, too, because they have to bill OHIP [Ontario Health Insurance Program] so they have to know everything about you." (IM-2)One participant perceptively noted that the general population has limited knowledge of the issue of health privacy:"That's another thing. What do people know about what they can get access to, what they can ask for, and what they can expect? I think the majority of the population have no idea of what they can ask for and expect to get." (CA-4)Participants' accounts clearly suggested an absence of patient control over the collection, use, and disclosure of PHI. No participants recalled having ever been consulted about how their information was to be used. A great deal of concern was voiced about the extent to which health data appears to be freely accessible to a wide variety of users: "Lawyers, psychologists, social workers, researchers, pharmaceutical companies. Where does it stop?" (UP-4). In the course of describing how they feel about the issue of health privacy, participants repeatedly used terms such as "scary" and "horrifying":"I'm scared to guess who has [access to my health information]. It looks so easy for a lot of people to have access. That's the scary part of it. Maybe your employer can have access to your files, too. I don't know, that's just a guess." (IM-6)The majority of participants expressed concern that their PHI is not adequately safe-guarded and that the implementation of a tool such as the Health Care Information Directive would not result in significantly enhanced privacy or increased security. There was a widespread view that too much data is currently made available when only specific details are required. Doubts were raised about how consent for one specific use only would be managed:"What's going to prevent any leaking from one of these [uses] into the others? ... It just seems to me that if there's information on-line, things are going to be compromised. You know, people make a living doing that stuff. The more they find out about you, the more you can be exploited. It's that simple. These systems, they're not secure yet, and I don't know if they can ever be secure." (UP-3)Health privacy concerns related to the security of electronic databases and the Internet were shared by others:"We've all heard stories where there's been stolen identities. How difficult is it for the victim to get his or her own identity back? Same idea. Where does it end? Where does it stop? Who's got what information? How am I going to protect myself?" (UP-6)Participants suggested a number of other mechanisms that could work in conjunction with the HCID to enhance security and facilitate individual control over PHI. One such mechanism would be an online real-time audit system in which the details of all accesses to an individual's PHI are recorded and made available to those wishing to track access to their PHI over time. Also, the idea of a health data ombud was raised in several groups and received a great deal of support.Issues related to trust were raised in each of the four groups. Participants of all ages and socioeconomic status expressed feelings of mistrust in relation to the protection of their privacy and the security of their PHI. A great many participants spoke of how their past experiences with the health care system have fostered significant mistrust and suspicion where their right to privacy is concerned. These accounts revealed a growing distress that large corporations have too much access to and influence on government programs, especially in contrast to the access and influence accorded to patients:"What about the rights of the patient? Let's say I'm the patient. What kind of power do I have? Let's say this [the HCID] was created next year. What power does the patient have to make sure any of this is happening? To me, a pharmaceutical company is way more powerful than the patient." (CA-2)Others were even more sceptical, questioning the trustworthiness of the basic tenets of the model upon which the HCID is based:"By filling this out, I'm buying into the concept of sharing information, but I don't have any faith that it can be kept private.... It will spill, it will bleed, it will flow. So I'm distrustful of the whole thing. This just sets up more spilling and more flowing. If I fill out a form like this, then I'm validating the process, which I don't really trust." (UP-8)While the majority were sceptical that the HCID would prevent all breaches of privacy, there was a general consensus that it would serve to enhance significantly the security of health data. One participant noted that the proposed decision aid may also serve a useful purpose as "a sort of consciousness raising" tool. Other impressions varied from "it has some potential" to "it is a great step forward." Reactions were mixed in response to the question of whether the HCID will be successful in empowering individuals and increasing the amount of control over PHI:"I'm very dubious as to whether this matrix will be useful because of the difficulty people will have filling it out. In spite of that, I think the idea has merit and principle. There's merit in what you're trying to do, but I don't think that this is going to succeed." (CA-5)"I guess the reality is our information will be shared, so we might as well get on the bandwagon with regulating it and controlling it... You can't stop it from being shared, so maybe you can influence how it will be shared." (UP-2)Despite the weaknesses and limitations of the present version of the directive, one participant neatly summarized the view of the majority of participants regarding the utility of the HCID or some such tool: "Not having it allows total absence of control, therefore it is a necessary evil." (CA-4).Participants provided numerous suggestions regarding the formatting of the HCID in order to facilitate implementation. Ideas ranged from simplifying the language and providing definitions of technical terms to modifying the layout and shading those areas where there is no discretion (i.e., for physician payment):"Maybe you've got too many columns.... Well, maybe you're trying to do too many different things at once." (CA-4)"This is too busy, it's too much. If I'm sick, I friggin' don't want to be bothered with it.... Look at this. English is my first language. How would somebody whose mother tongue is something other than English? It's too complicated." (SC-1)"I think people tend to say 'no' for things that are not clear. I would say 'yes' if I knew what it means exactly, but I don't know, so I don't want to take a chance." (IM-1)To address the complexity issue, suggestions were made concerning the need to provide a customer service representative either in a health clinic or via a toll-free helpline for assistance with completing the HCID.Across the four groups, there was great variability in the preferred mode of implementation. The preference among participants in the health advocates and urban professional groups was for an on-line implementation format. In contrast, the majority of the senior citizens and immigrants preferred other options, the former favouring a postal format and the latter the primary care setting. As one senior citizen remarked: "I prefer the doctor's office. I wouldn't fill it and send it back through the mail, no." (SC-3)British Medical Journal suggested that perhaps patients should be asked whether certain items of their medical chart should only be shared with specified individuals or organizations or only for pre-determined purposes [A recent editorial in the purposes . This paStudy participants lacked substantial knowledge regarding the fate and uses of PHI within a publicly-funded health care system. Participants expressed mistrust concerning how their PHI is used and safe-guarded. Several suggestions were made towards customizing the use of data according to specific needs rather than broad and full access to their charts. Furthermore, concerns were expressed regarding the implementation of a tool such as the HCID. Nevertheless, there was hope that a refined instrument could contribute to improved data management and regulation and enhanced privacy protection.Although this study reports on a small sample from a single large urban centre, the focus group participants were drawn from various different niches of Canadian society. This sampling strategy allowed us to explore a broad range of experiences and perspectives; however, further testing and evaluation are required. Ultimately, it will be necessary to evaluate the tool using a representative sample of patients who complete the HCID in a 'live' test of its feasibility.Our findings underscore the difficulties involved in accessing health care data for research and other secondary purposes. Participants acknowledge the myriad benefits derived from the use of health data; however, distrust, lack of respect, and insufficient patient control of the process threaten to undermine these very benefits. This finding has been previously reported by Willison and associates in Canada  and by RParticipants appreciated the benefits accorded by a tool such as the HCID. As opposed to forms of blanket consent or other opt in/opt out models, the possibility of exerting greater control over one's PHI was attractive. The participants provided concrete suggestions for improving the format and content of the HCID. It is evident that any method to enhance control of health information via explicit consent requires description of the various forms the data may take, the specific purposes for which the data would be used, and the various channels of the health care system through which the data might flow. To our knowledge, such detailed data flowmaps for PHI do not exist in Canada, although they have been laid out in Great Britain . A modelAn intriguing finding was the appeal of an online data audit system. Possessing the ability to monitor who has accessed their PHI and for what purposes raises the possibility of additional strategies that could empower individuals to control the fate of their health information. This finding has also been verified by Pyper and colleagues  and was Finally, there is a distinction to be made between using the HCID to enforce the will of the patient versus its use as a documentation tool. Our vision is that the HCID will, ultimately, serve both of these important functions; further follow-up evaluation of a revised model of the HCID using a larger sample (comprised of patients as well as providers) is needed to address this distinction. As with any patient decision aid or empowerment tool, documenting the preference of the patient is only meaningful and useful to the extent that the documented preferences are known and ultimately acted upon by those providing care. We believe the present data illustrate the critical problem of mistrust that currently exists. Indeed, this is one of the greatest challenges to be overcome in the continuing development and validation of this tool.This study indicated poor knowledge concerning the uses of health data, distrust concerning current security provisions, and qualified support for a tool such as the HCID to improve patient control over health information. On the basis of this evaluation, the HCID will be revised significantly, including the addition of an educational component, and then submitted to further evaluation. The creation of data flowmaps and the exploration of audit functions and governance structures are strongly recommended as avenues for future research.None declared.CST participated in the collection, analysis, and interpretation of the data and is the primary author of the paper. GCD recruited the participants, moderated the focus group meetings, participated in the data analysis, and contributed to the editing and revising of the paper. REGU initiated and designed the study, participated as a reliability check in the process of data analysis, and contributed to the editing and revising of the paper. As principal investigator, he will act as guarantor. All authors have read and approved the final version of the paper.1. What is your understanding of the term 'personal health information'?2. Who do you believe has access to your personal health information?3. Do you believe that consent should be required to access your personal health information?1. What is your first impression of the Health Care Information Directive?2. Is it clear?3. Is it self-explanatory?1. How useful do you believe the Health Care Information Directive would be in practice?2. Is it user-friendly?3. What kind of changes would you suggest?1. How feasible is the application of the Health Care Information Directive?2. Who should present it to the patient?3. When should it be presented to the patient?1. What are the potential gains of the Health Care Information Directive?2. What are the potential harms?3. Does it adequately protect privacy and confidentiality?The pre-publication history for this paper can be accessed here:


Mycobacterium tuberculosis causes tuberculosis (TB) in people, and related species that infect other animals are used as model systems for the study of TB. Much progress has been made in identifying the armaments (or virulence factors) of the bacteria. But the interplay, or chess match, between the bacterium and the animal it infects is much less clear. One of the host's first moves against the mycobacterium is the formation of a granuloma. Granulomas are tightly aggregated structures that consist of macrophages—one of the first lines of defense of the immune system—within which the infecting bacterium grows. Besides these and related cells that are present at the site of infection, additional macrophages and other immune cells are recruited in the formation of the granuloma. Although granulomas are required for the elimination of the infection, Lalita Ramakrishnan and colleagues have now shown that the bacteria have a game plan of their own.Fighting an infection might seem to be a battle between David and Goliath, given the relative sizes of bacterial infectious agents and the animals they infect. But on closer examination it is more often a chess match between two skilled opponents who have the uncanny ability to anticipate each other's moves. M. marinum. This enables the researchers to watch cells as they are recruited into the granuloma.One problem in understanding the interaction between the mycobacterium and the host has been that it occurs deep in the lung of the infected animal, which makes it difficult to analyze how each of the animal or bacterial factors affect the strategic interplay between the host and pathogen. To overcome this limitation, Ramakrishnan and colleagues used zebrafish embryos, which are transparent and can be infected by a relative of the TB pathogen, M. bovis that is used as an attenuated TB vaccine. But the precise role of RD1 in infection remains obscure.Some of the virulence factors of mycobacteria are encoded in an area of the genome called the RD1 locus. In a mouse model, a strain of the bacteria missing RD1 causes far less pathology than a strain with the full complement of genes. The RD1 locus is also absent in the bacterial strain M. marinum and a strain with an RD1 deletion, Ramakrishnan and colleagues have observed that RD1 is actually required for granuloma formation but isn't needed for the bacteria to infect macrophages. What's more, macrophages that are infected with mycobacteria that contain RD1 produce a signal that further recruits macrophages to granulomas. This might seem an odd virulence strategy, as macrophages are required for mycobacterial elimination. But in this ongoing chess match, the virulent mycobacterium exploits the host's defense—granuloma formation—by providing additional macrophages for the bacteria to infect.By visualizing in zebrafish infections of a virulent strain of The end game of the chess match remains unclear. While granulomas are required for protection against mycobacteria, they are not completely effective. Thus, these bacteria have developed a strategy to recruit the normally defensive cells of the host to their advantage, but it remains to be shown what tips the balance between the macrophages' ability to clear the infection and their unwitting participation in the development of TB.


The objective of our study was to investigate the use of the interrupter technique as a method to measure the response to provocation and to compare it with the conventional PD100Rint, EI) as well as by percent dose response ratio (DRR).We studied 170 normal subjects, 100 male and 70 female (mean ± SD age, 38 ± 8.5 and 35 ± 7.5 years, respectively), non-smoking from healthy families. These subjects had no respiratory symptoms, rhinitis or atopic history. A dosimetric cumulative inhalation of methacholine was used and the response was measured by the dose which increases baseline end interruption resistance by 100% (PD20FEV1 (r = 0.76, p < 0.005), with relatively narrow limits of agreement at -1.39 μmol and 1.27 μmol methacholine, respectively, but the interrupter methodology proved more sensitive than FEV1 in terms of reactivity (DRR).BHR at a cut-off level of 0.8 mg methacholine exhibited 31 (18%) of the subjects (specificity 81.2%), 21 male and 10 female, while 3% showed a response in the asthmatic range. The method was reproducible and showed good correlation with PDInterrupter methodology is clinically useful and may be used to evaluate bronchial responsiveness in normal subjects and in situations when forced expirations cannot be performed. In addition, a deep inspiration, as it is required during an FEViculties  and henciculties .The interrupter method has been shown to be a simple and non-invasive technique of measuring airway mechanics in children or patients with limited co-operation . It is aAn official statement by the ATS (American Thoracic Society) on methacholine provocation indicated that the interrupter method may be useful in testing patients who cannot perform acceptable spirometry manoeuvres but its use should be restricted to laboratories with expertise in their application and interpretation . Further20FEV1 method, and therefore clinically useful.We hypothesized that, since normals present with lower levels of airway obstruction during challenge, the interrupter technique in this case might be suitable and comparable with the reference PDThe study was conducted in a tertiary referral centre for respiratory disease and 198 subjects were initially enrolled. All subjects were healthy with a negative history and physical examination, normal blood counts, chemistries, chest radiography and spirometry.One individual from this sample reacted to the diluent control solution (0.6%), defined as a resistance difference of > 30% baseline  and was Routine spirometry was performed according to standardized guidelines . InterruThe airflow interruptions were performed using the Bronchoscreen system (Jaeger, Würzburg, Germany) , a compu1 had fallen = 20% compared with FEV1 after an initial saline inhalation. The bronchial aerosol provocation system (APS Jaeger, Wurzburg, Germany) was used in this procedure. The nebulizer was calibrated to draw 5 μL of solution per automatic actuation lasting 0.6 seconds. The 100 μL of aerosol bolus had a mass median aerodynamic diameter of 1.9 μm with 80% of the droplets being less than 5.5 μm at a set pressure of 1.6 bar (22.8 psi). The subjects inhaled methacholine by slow inspiratory capacity manoeuvres guided by the green colour of light emission diodes (so that inspiratory flow was <0.5l/s) and the response was assessed 1 min after each inhaled dose.Bronchial responsiveness was measured by a rapid methacholine provocation dosimetric test, as previously described by our group with the same apparatus but using histamine instead . Briefly100Rint, EI), calculated by interpolation from the last two points of the cumulative semilogarithmic dose-response diagram, and 2) the percent slope (dose-response ratio-DRR) of a line extending from the origin to the last point of the curve (DRR) [100 Rint, EI >4 mg. The DRR data were analyzed from the whole sample. The 10 day reproducibility of the PD100Rint, EI was investigated by randomly asking 39 subjects to come again after one week for a second examination. During the second visit we compared Rint, EI with FEV1 as measurements of response to provocation, the latter determined 30 s after the assessment of Rint, EI [1 variation within ± 5% were received and the highest value was used for calculating the dose producing a 20% fall in FEV1 (PD20FEV1).Data was assessed by using two different estimates: 1) provocation dose which increases Rint, EI by 100% (PDve (DRR) . PlateauRint, EI . At leas2 test, were used for statistical analysis. The relative duplicate error was used to assess test-retest reproducibility of the PD100Rint, EI , defined as a standard deviation of the differences divided by the v2 after log transformation (approximates coefficient of variation)[20FEV1 was defined and calculated according to Bland and Altman [Regression analysis and correlation, Shapiro-Wilk test for normality and the non-parametric Mann-Whitney-U-/Wilcoxon Rank Sum test with normal approximation and the xariation). Agreemed Altman . Normal d Altman .1 and maximal expiratory flow when 50% of the forced vital capacity (FVC) remains to be exhaled (Vmax50), were higher in males by 16.3%, 14, 7% and 2.5% than in females. While Rint, EI was higher in females, possibly reflecting smaller airway size, but these differences were not statistically significant. The distribution of PD100Rint, EI is shown in Figure Subjects' anthropometric data and baseline spirometry are shown in Table 2 = 1.48, p = 0.22, odds = 1.79). Furthermore, 5 of these 31 subjects  were found to show moderate bronchial hyperesponsiveness (PD100Rint, EI < 0.4 mg or < 1.66 μmol methacholine), as frequently found in current symptomatic asthmatics [100Rint, EI to baseline post-saline Rint, EI and the respective DRR. Subjects with negative reactions (> 8.8 μmol) showed DRRs that were ten times lesser compared to those with BHR (mean ± SD = 67.52 ± 10.66 vs 690 ± 390, p < 0.001). Plateau response was exhibited by 66 (38%) of the subjects,  without gender related statistical difference (x2 = 0.81, p= 0.36). They had DRRs that were 2.5 times smaller compared to the subjects with normal but measurable reactions (30.1 ± 9.8 vs. 75.0 ± 49.9, p = 0.024).Twenty one males and ten females (18%) of our subjects exhibited bronchial hyperesponsiveness. These values were normally distributed (W = 0.93, p = 0.12), with no gender related difference (xthmatics . No corr100Rint, EI and PD20FEV1 (r = 0.76, 95% CI 0.53-0.88) with relatively narrow limits of agreement .PD100Rint, EI was found reproducible with a duplicate error of 8.3% or 0.65 doubling doses (within 140 μg). A close correlation was found between PD100Rint, EI, is comparable to the conventional PD20FEV1 method for evaluation of BHR in a large sample of normal subjects. We have also found that this technique has a specificity of 81.2% for normal subjects and its dose response ratio is 7-fold more sensitive than the conventional FEV1 method. It is known that specific airway conductance is four times more sensitive than FEV1 as a measure of response to provocation but the use of a body plethysmograph makes assessment of bronchial challenge expensive and time consuming. The present methodology is particularly useful in children and in the elderly, since it is non-invasive, sensitive to changes in airway calibre and requires no subject co-operation. The opening interrupter technique offers the additional advantage of simplicity and ease of application, being particularly useful in subjects unable to perform forced manoeuvres.In this study we have shown that the interrupter technique, and specifically PD30Rint, EI), so we assessed the PD100Rint, EI threshold, which is above the 95 % confidence interval at one tail direction (1.96SD) observed in our normal sample at baseline  has been reported (17), data on agreement are presented for the first time in this study.The Rint, EI was measured during expiration above forced residual capacity (FRC), because resistance hardly changes above this level and since subjects performed relaxed tidal flow maoeuvres, measurements were not affected by variations in breathing. Furthermore, we did not correct Rint, EI by lung volumes because the variability formed in the FRC can reduce the benefit of standardization of Rint, EI and the correlation between respiratory resistance and FRC is not significant over the limited FRC range of healthy subjects . Problem100Rint, EI methacholine, which defines severe and moderate hyperresponsiveness compatible with asthma [20FEV1 as well as to 2.5%, which represents the proportion of subjects beyond the 2 SD of the mean on one side of a normal distribution. If the PD100Rint, EI threshold is set at 0,8 mg methacholine [1) showed that 50% of normals had no calculable PC20FEV1.If a cut-off value is set at 0,4 mg PDh asthma  then 3% h asthma  working acholine , which iacholine . In contacholine . A plateacholine , using aIn this study, by direct comparison of two methods, one involving a deep inhalation, the relative effects of maximal expiratory manoeuvres on airway calibre can be indirectly assessed. The data in Table 1 and airway conductance in a large sample of subjects but not all were normals. It is known that in bronchial challenge the dose-response curve is expressed mainly by the threshold dose indicating hyperresponsiveness and the rate and magnitude of the response (hyperreactivity, DRR). The less reactive DRRs of the FEV1 method lend support to the perturbed actomyosin equilibrium hypothesis recently described, in that with stretching there is a decrease in myosin duty cycle and the magnitude of the contractile response becomes functionally disengaged from the level of the contractile stimulus [Recently, Sundblad et al  reportedstimulus . Furthemstimulus . The fac6 FEV1. The limits of agreement between PD100Rint, EI and the classical PD20FEV1 were found relatively small at -1.39 μmol and 1.27 μmol respectively. This implies that this method may be used as an alternative to FEV1 during provocation, as it is simple and easy to perform and requires no patient co-operation.No correlation was found in this study between BHR and baseline airway calibre, although Malo et al. found a Gender differences in BHR were explored because of the smaller lung size in women. Our data are in agreement with recent studies  that in In summary, the interrupter technique as an index of response to provocation has been shown to be useful to assess bronchial responsiveness in normal subjects, when maximal efforts cannot be performed. We recommend threshold doses of 100% baseline, because they show reliable agreement with the classical PD20FEV1 method.1:Forced Expiratory Volume in 1 sec, FVC:Forced Vital Capacity, FRC:Functional Residual Capacity, PA:Alveolar Pressure, Pao: airway opening Pressure, PC20FEV1:Provocative Concentration causing a 20% fall in FEV1, PC30Rint, EI:Provocative Concentration causing a 30% increase in Rint, EI, PD100Rint, EI: Provocation dose which increases Rint, EI by 100%, PD20FEV1:Provocation Dose producing a 20% fall in FEV1, Rint, EI:Interrupter Resistance at End Interruption, VC:Vital Capacity,ATS:American Thoracic Society, BHR:Bronchial Hyperresponsiveness, DRR:Dose Response Ratio, FEVThe authors declare that they have no competing interests.PP, IK, AT, SA, DB were involved with the study conception. PP, AT, SA performed the interrupter technique and collected the data. PP did the statistical analysis. PP, AT, DB prepared the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The typical symptoms of coronary heart disease (CHD), chest pain and breathlessness, are well-known. They are considered quite dramatic, and can thus be fairly reliably mapped by a survey. However, people might have other clearly unpleasant symptoms impairing quality of life. The aim of this study is to evaluate the appearance of these complaints of working-aged people with self-reported CHD.The study consists of a postal questionnaire of randomly selected Finns in age groups 30–34, 40–44 and 50–54, a response rate of 39% (N = 15,477). The subjects were asked whether or not a doctor had told them that they had angina pectoris or had had myocardial infarction. Four randomly selected age and sex matched controls were chosen for every patient. The occurrence of self-reported dyspnoea, chest pain during anger or other kind of emotion, palpitation and perspiration without physical exercise, irregular heartbeats, flushing, trembling of hands and voice, jerking of muscles, depression and day-time sleepiness were examined. Odds ratios (OR) with 95% confidence intervals (CI), between occurrence of symptoms and CHD with and without heart infarction, were computed by multivariate logistic regression analysis.The sample eventually comprised 319 CHD patients. Dyspnoea, chest pain during anger or other kind of emotion, palpitation, perspiration without physical exercise, irregular heartbeats daily or almost daily, trembling of hands and voice, and jerking of muscles occurred statistically significantly more frequently among CHD patients than among controls. The CHD patients also reported more depressive mood according to Beck's inventory scores and poorer sleep and more frequent day-time sleepiness than controls. In the multivariate logistic regression analysis chest pain during anger or other kind of emotion (ORs 4.12 and 3.61) and dyspnoea (ORs 2.33 and 3.81) were the symptoms most associated with CHD.Working-aged people with self-reported coronary heart disease evince a number of symptoms limiting the quality of their every day life. This aspect should be paid attention to when evaluating functional capacity of these patients. In Finland, as in most industrialised countries mortality from cardiovascular diseases has shown decreasing trends since around 1970 . The MinThe typical symptoms of coronary heart disease (CHD), chest pain and breathlessness, are well-known. They are considered quite dramatic, and thus can be fairly reliably mapped by a survey . HoweverThe diagnosis of CHD is usually based on medical examinations or register data and not on what people by themselves experience. However, people act and use health services according to what they experience to suffer from and what they experience to limit their ability to work. Since CHD patients have many other symptoms than the traditional and well-known, it is important to know what the spectrum of symptoms and complaints among working-aged people with self-reported coronary heart disease is in relation to functional capacity.The Health and Social Support study (HeSSup) is a prospective etiological follow-up study on the psychosocial health of the Finnish working-aged population. The HeSSup population consisted of a random sample of 39,563 individuals drawn from the Finnish Population Register in three age groups: 30–34, 40–44, and 50–54. The survey was carried out by postal questionnaire. Forms were returned by 15,477 individuals (approximately 5,000 in each age group), a response rate of 38.9% (37.6% in 30–34, 37.9% in 40–44, and 41.1% in 50–54).The sample was subjected to a thorough analysis of non-response . The anaThe subjects were asked whether or not a doctor had told them that they had angina pectoris or had had myocardial infarction. The perceived state of health was determined according to Likert's five-step scale (good, quite good, fair, rather poor and poor). In order to avoid small frequencies in the analyses this was modified to a three-step scale (good, fair, poor).The appearance of dyspnoea was categorised into four degrees of difficulty according to a widely used cardiovascular survey method . PersonsParticipants were also asked whether or not they had experienced daily or weekly chest pain during anger or other kind of emotion, palpitation and perspiration without physical exercise, flushing, trembling of hands and voice, and jerking of muscles. Irregular heartbeats daily or weekly were asked, too. Depression was estimated by Beck's  depressiIn interpretation of results the coronary heart disease (CHD) patients were divided into two groups. The first comprised coronary patients not having had heart infarction (angina pectoris group) and the second patients having had heart infarction (infarction group). In order to have the best available comparison groups, four randomly selected age and sex matched controls for comparison were selected for every patient. Thus there were altogether 740 controls for the angina pectoris group and 536 controls for the infarction group. Stroke was ruled out in the control groups, but otherwise there were no differences between the CHD groups and their respective controls.The associations, odds ratio (OR) with 95% confidence intervals (CI), between symptoms and coronary heart disease with and without heart infarction, were computed by multivariate logistic regression analysis. The analyses were made using the SAS System for Windows, release 8.2/2000.The data comprised 319 patients: 185 coronary heart disease patients who had not experienced heart infarction (55.1% were men) and 134 patients who had (78.4% were men) Table .State of health was perceived as good or quite good by 37.3% in the angina group and by 24.6% in the infarction group. The corresponding figures in the control groups were 76.0% and 67.4%, the differences being statistically significant (p < 0.001). State of health was perceived as poor or rather poor by 28.1% in the angina group and by 32.8% in the infarction group.At least mild breathlessness occurred in two thirds of the angina group and three fourths of the infarction group Table . DifficuIn the multivariate logistic regression analysis chest pain during anger or other kind of emotion and dyspnoea were the symptoms most associated with CHD Table . IrregulThe principal finding in this study was that many working-aged coronary heart disease patients experience unpleasant symptoms such as dyspnoea, chest pain during anger or emotion, irregular heart beats, perspiration without physical exercise, and jerking of muscles. In addition, the frequency of most of the self-reported symptoms among the study population is higher also in respect of those symptoms, which would not be expected at least among those CHD patients whose disease is in good balance. Working-aged CHD patients may be regarded as a special group compared with the main part of CHD patients who are already by age entitled to a pension. It is likely that working-aged CHD patients have experienced the most widespread and intense exposure to risk factors, which thus has caused them this disease among the first ones within their age group. As working-aged they are wished, however, to return back to normal life and work as soon as possible. According to our study they still have a lot of symptoms concerning their every day life, which harm their recovery and rehabilitation. It is also noteworthy that many of the working aged CHD patients are still in working life. Although chest pain and dyspnoea do not prevent them to work at customer service, many of the symptoms such as trembling of hands interfere their normal jobs while appearing mostly in rest. Trembling of hands and voice are also very irritating symptoms, and they may be considered shaming. Thus they may interfere social life and reduce the quality of life.The study material may be considered representative of the Finnish working-aged population, although the response rate was only 39%. Careful non-response analysis indicated that respondents and non-respondents were comparable in respect of the most important demographic variables . It is pOur method to determine the existence of CHD is based on the patients' report on whether a doctor had told them that they suffered from this particular disease. Thus, we cannot know for sure the accuracy of the information reported. Nowadays, CHD is rare among young people ,2. In ouThere are validated instruments, such as the generic The Short Form 36 Health Survey  (SF-36),The occurrence of dyspnoea and chest pain even during anger or other kind of emotion may be considered a finding that was expected. In an American study on the care of coronary heart patients at the emergency department the most frequently reported symptom was chest pain (70% among men and 71% among women) and dyspnoea (30% men and 29% among women) . The typIt was suggested as far back as 1987 that palpitations are not an independent risk factor for increased cardiac morbidity or mortality . Our finThe high occurrence of trembling of hands and voice, and jerking of muscles may be considered an unexpected finding. Most CHD patients use beta-blocking medicines, which in addition to protecting the heart muscle also reduce the adrenergic stimulation and thus relief the symptom of trembling.Concerning depression our findings support those of previous studies. One out of four of symptomatic coronary heart disease patients have namely been found to have a probable depressive disorder, but none of them had previously been identified as suffering from depression or been treated for this reason . In primIt was also of noteworthy that daytime sleepiness was connected with coronary heart disease. A cross-sectional study of 5,419 Finnish adult men found a higher prevalence of diagnosed myocardial infarction among those who slept more than nine hours, whilst those sleeping less than six hours per night had more symptomatic coronary disease . In a SwFrom previous research we know that despite having survived a life-threatening clinical event, CHD patients appear to have continued adverse behaviours such as smoking, being obese and having frequent hangovers more than the control population . The folAccording to the present findings many working-aged people with self-reported coronary heart disease perceive their state of health as poor or rather poor. They suffer from a wide range of symptoms limiting their every day life. It is noteworthy that many of these symptoms are not only irritating, but constitute a threat to health. The health related quality of life is poor among working-aged coronary heart disease patients.The author(s) declare that they have no competing interests.MPTS drafted the manuscript; SBS participated in drafting of the manuscript; MJK participated in the design of the study and the statistical analyses; LHS participated in the statistical analyses; KJM conceived of the study, and participated in its design and co-ordination. All authors have read and approved the final manuscript.


Past estimates have put the prevalence of schistosomiasis between 40% and 50% in the Malawi population overall based on studies undertaken ten years or more ago. More recent surveys in known high risk areas find similar levels. However control measures, changing ecology and migration may have led to changes in the prevalence of schistosomiasis in different parts of Malawi. A national schistosomiasis and soil-transmitted helminth (STH) survey was undertaken to measure the distribution, prevalence and intensity of infection in November 2002.Schistosoma haematobium.A school was selected randomly from a random sample of 30 Traditional Authorities stratified by six distinct ecological zones, and 1,664 year 3 pupils (9–10 year olds) were questioned about recent illnesses and "red urine". Samples of urine and faeces were examined for the presence of eggs using the standard Kato-Katz technique for soil-transmitted helminths and intestinal schistosomiasis and urine samples using the filtration technique for Schistosoma mansoni is 0.4% (95% CI 0–1.3%), S. haematobium 6.9% (95% CI 1.9 – 11.9%), hookworm 1.3% (95% CI 0.4–2.3%), Ascariasis 0.5% (95% CI 0.1–1.0%) and trichuriasis 0% in year 3 pupils . Intensity of infection is low for all infections except for 2.5% who have high intensity S. haematobium infection. The "red urine" question is 67% sensitive and 80% specific for positive S. haematobium microscopy.The prevalence of The reduction in prevalences may be real as a result of recent control measures, or false if historical results were based on surveys of high risk populations. Another explanation is that this survey used an unrepresentative sample of schools. Detailed analysis suggests this is unlikely.Recommendations include the use of a 30% positive threshold for the "red urine" screening question to be used in schoolchildren in high prevalence areas.This survey, based on a national probability sample excluding the northern region lakeside area, finds much lower overall prevalence and intensity of schistosomiasis and STHs than previous estimates based on selected surveys. Disease control featuring chemotherapy may be having a profound effect. The localised nature of the distribution of the infections means that control programmes may work best if undertaken at district level or below. "Red urine" questionnaire surveys may help identify hot spots. Chronic infections with soil-transmitted helminths and schistosomiasis are common in Malaŵi and cause considerable morbidity . The MinS. mansoni and S. haematobium were detected in 27% and 20% of schoolchildren respectively [S. haematobium [All water bodies in Malawi are considered to be potential transmission sites for schistosomiasis . The mosectively . A survematobium . This leIn Malawi there is little contemporary information available on helminth infection. Furthermore, fragmented control measures, changing ecology   survey was undertaken to measure the distribution, prevalence and intensity of infection in November 2002. Results from the survey are reported in this paper.Methods follow recent WHO advice to allow comparison with other international studies . This inSeven areas  represent the seven distinct ecology and soil conditions in Malaŵi figure :-Northern Region highland (23)Northern Region lakesideCentral Region highland (62)Central Region lakeside (17)Southern Region highland (51)Southern Region lakeside (31)Urban (3)The northern region lakeside had recently been surveyed by the Karonga Prevention Study . To savePrimary-school children were chosen as the target population. There are several reasons for conducting the survey in this age group. Children consistently have the highest prevalence and transmission of schistosomiasis and soil-transmitted nematodes (except hookworm); treatment via schools on a national scale is feasible  . Stool samples were stored in a cool box during transfer to the laboratory, and then kept at 4°C until processed within 24 hrs of collection.S. mansoni more than 400 epg were defined as high intensity. Urine samples were tested using the filtration technique for S. haematobium. Infection with S. haematobium was classified as high intensity if at least 50 eggs per 10 ml of urine were detected or there was visible haematuria [Stool samples were tested for the presence of eggs using the standard Kato-Katz technique  for soilematuria .S. haematobium infection in schools was investigated using Pearson product moment correlation coefficient (SPSS).Data were double entered into EpiInfo and then exported into STATA v7 for initial analysis. SPSS was used for chi squared, paired-t and McNemar tests. EpiInfo 2002 was used to calculate adjusted prevalence rates for ecological zones and national prevalence. The prevalences and 95% confidence intervals were computed incorporating the stratification by ecological zones. Sampling weights were computed as the product of the number of TA's in an ecological zone times the number of schools in the selected TA. For the urban zone, weights were adjusted for the fact that there were only three TA's and two schools were selected from two of them . The relationship between the prevalence and intensity of A total of 1,664 children were surveyed. Between 36 and 71 children were included from each school. There were 1,662 completed questionnaires, 1,546 stool samples and 1,638 urine specimens collected. Just over half (50.7%) of the sample was female. The mean age (for 1,658 children where age was recorded) was 10.7 years [range 6–17 years]. The mean age of boys was 10.9 years and of girls 10.5 years.S. haematobium detected by urine microscopy, of which 45 had high intensity infection. The prevalence in schools ranged between 0 (11 schools) and 43.1% (a school in the southern lowlands). Twenty one children from eight different schools had visible haematuria. Only 8 children from 2 different schools had S. mansoni detected by stool microscopy and none were high intensity infections.A total of 140 children from 19 different schools had S. mansoni was found to be 0.4%. The national prevalence of S. haematobium was found to be 6.9% (95% CI 1.9–11.9%) .as Table . The higS. haematobium based on ecology and known previous prevalence and compared our survey results with these expectations. Of the 12 expected high prevalence schools seven were found to be high and 5 unexpectedly low. Of the 18 expected low prevalence schools 12 were found to be low and 6 unexpectedly high. Unexpected results were found in the expected low prevalence as much as in the expected high prevalence schools using the McNemar test for symmetry actual (p = 0.29).To assess the sampling method used to select schools we classified the selected schools into high and low expected prevalence of We also compared the historical results for Malawi districts compiled by the London School of Hygiene and Tropical Medicine for the Schistosomiasis Control Initiative in 2001  with our results. Prevalence has fallen overall by 24% . A formal paired t-test finds this reduction is true for low as well as high prevalence schools .There was also a low prevalence of STHs in all areas, though urban areas had the highest rates for any STH (6.6%) and hookworm was most prevalent in the Northern Highland area (2.6%). There were no STHs detected in the Central lakeshore schools.S. haematobium  found in the Southern Lowlands zone the positive predictive value is 49% and the negative predictive value is 89%.Total number of respondents was 1,662 Table . It is pum Table . The senS. haematobium and 6%–42% in the case of S. mansoni. The school located closest to rice fields had a high prevalence of schistosomiasis. In another recent survey carried out at the Cape McClear peninsula in the Southern Lake zone results showed markedly different S. haematobium and S. mansoni prevalence amongst adjacent villages situated on the lake shore and inland .The overall prevalence of schistosomiasis is well below expectations. Based on previous studies in Malawi the overall prevalence of schistosomiasis was thought to be between 40% and 50% in the population. Of course these were surveys of selected populations, perhaps undertaken in the season of high transmission. Certainly the disease is localised in Malawi. In the study conducted in the northern lakeshore area in 2000 by Randall et al , schoolcS. haematobium and 0.4% for S. mansoni. The finding highlights two important features of schistosomiasis in Malawi. Firstly, these infections are highly localised and secondly they are not common in general. As expected higher prevalence rates are found in the Southern lake/lowlands zone. S. mansoni does not seem to be a generalised problem in any particular ecological area in the country.Our survey, representative of all schoolchildren in the country, and undertaken just before the rainy season, suggests far lower levels of 7% for S. mansoni and S. haematobium. The differences could be due to seasonal variation (the survey in Karonga district was conducted after the rainy season). This possibility is supported by a low prevalence found in Karonga district in samples collected in November 2001, prior to the rains (unpublished observation, MA Perez). Supporting evidence is seen in the prevalence rates found in urban areas where rains would not affect transmission as much as in rural areas. Similar results are found in previous studies in urban Blantyre: S. mansoni (0%), Ascaris (18%) and Hookworm (0.4%) [®, Intercep Ltd) in order to concentrate the stools and achieve high diagnostic sensitivity. Because of the dissimilar laboratory methods we have been unable to include results for the Northern Lakeland Ecological zone in the estimate of overall prevalences for the whole country. The northern lakeshore zone has tended to have high prevalences. The impact of omitting this zone is likely to underestimate the national results. We intend to survey the zone using our own laboratory methods when funds are available to complete the national picture.The overall prevalence of STHs is lower than expected. The survey conducted in Karonga District  finds am (0.4%) . Anotherm (0.4%)  was usedm (0.4%) ,18. On tAlthough this survey is designed to be representative of this age group in Malawi, it is limited in scale by the budget ($12,000). This is an important limitation when one considers that the distribution of schistosomiasis in populations is likely to be highly localized . The popDrug treatment has been widely if intermittently available. The National Schistosomiasis Control Programme does not have documented evidence of where and when universal drug treatment has been offered to communities. Nor does it have details of where and when Praziquantel has been available for prescription to symptomatic individuals at health centres and hospitals. Supplies and universal treatment programmes have tended to depend on intermittent interest and funding from NGOs. However Praziquantel seems to have been widely available  and may have had an effect. In this survey of 264 people living in high risk villages in eleven randomly selected districts 71% reported receiving anti-schistosomiasis treatment.Ascaris lumbricoides (1.9%), Hookworm (24%), and S. mansoni (16%) in four schools. The last survey done in 2000 showed an overall prevalence of A. lumbricoides (0.4%) and Hookworm (1.5%) on the four schools after two consecutive courses of treatment . Similar interventions may have had an effect on the prevalence of infections in other parts of the country.Several NGOs such as Save the Children (US) in Mangochi and World Vision in Chikwawa in recent years have studied helminth infections in schoolchildren. Save the Children (US) surveyed and treated schoolchildren in the entire Mangochi District after finding a prevalence of Another possible explanation for the unexpectedly low prevalence results could be due to a sampling method that selected a low preponderance of schools in high risk areas. However the results of the analysis looking at expected and actual prevalence found in each school suggest this did not happen. Unexpected results were found in the expected low prevalence as much as in the expected high prevalence schools using the McNemar test for symmetry actual (p = 0.29).S. haematobium now is not due to asymmetric sampling of low risk schools; it is due to a marked trend of a reduced prevalence across the board. It is not just the high risk schools that have lower prevalence now. Low risk schools have lower rates as well. Compared to the historical results for Malawi districts compiled by the London School of Hygiene and Tropical Medicine for the Schistosomiasis Control Initiative in 2001, prevalence has fallen overall by 24%, and this reduction is true for low as well as high prevalence schools. Our interpretation is that the results reflect a widespread reduction in schistosomiasis prevalence and not a biased sample in the current survey which inadvertently missed schools in high risk areas. However bias may still be an explanation for the change. The widespread reduction in prevalence could be due to bias in the selection of high risk schools in the historic studies rather (than in the selection of low risk schools in our survey). Our sampling fraction of 30 of a possible 3,900 schools is sufficient to give statistical confidence in our overall prevalence result of 6.9% (95% CI 1.9 – 11.9%) for S. haematobium so long as our schools and Traditional Authorities were chosen randomly, which they were.The reason for the comparative low prevalence rate of Of the questions asked, only the red urine question is sufficiently sensitive and specific to be used as a screening test. It is a cheap way of assessing schistosomiasis prevalence and as such may be useful to identify hot spots within districts.Past control programmes, despite their fragmentary application in Malawi, seem to have achieved much in recent years. High intensity infections are now rare, and it is of course these that are thought to cause morbidity. There remain some high prevalence locations but these are uncommon now. The survey findings suggest that future approaches to control can focus on the identification of hot spots through local surveys. These should be undertaken in districts in high prevalence ecological zones, probably through "red urine" questionnaire surveys of school children. Because of the low positive predictive value of the "red urine" question, a low threshold should be used to categorise each school. The categorisation as proposed in Table The highly effective drugs now available and the control methods used in Malawi seem to have reduced the prevalence of both schistosomiasis and soil helminths to low levels.There remain some localised areas of high prevalence for which local control measures will be required. It seems that the epidemiology of these diseases makes local control at district level or below the preferred public health approach.The author(s) declare that they have no competing interests.BS conceived the survey and provided logistical advice. CB designed the survey and undertook the final analysis and first drafting. BP supervised the survey and undertook the initial analysis. PM undertook the randomization and led the survey team. MP supervised the quality control of the laboratory work. All contributed to the final report.The pre-publication history for this paper can be accessed here:questionnaire; the questionnaire in Chichewa used in the schools to find out about the health of the pupils surveyed.Click here for file