tbuckley/cabot-search huggingface dataset:
MicroRNA-1291 effects on pancreatic cancer (PC) cells sensitivity to arginine deprivation and chemotherapy through modulation of ASS1 and GLUT1.
Authors: Edward Jae-hoon Kim, Mei-Juan Tu, Zhijian Duan, Frank J Gonzalez, Richard J. Bold, Aiming Yu
Journal: Journal of Clinical Oncology (2018)

334 Background: Cancer cells are reprogrammed to become addicted to a continuous supply of nutritional glucose and semi-essential amino acids like arginine, to drive synthesis of critical macromolecules for proliferation, tumorigenesis and metastasis. This dependence on nutritional supply makes cancer cells potentially vulnerable to deprivation by agents like pegylated arginine deiminase (ADI-PEG) which converts arginine back to citrulline. However, this vulnerability depends on limited ability of cancer cells to make arginine. PC cells that express high levels of argininosuccinate synthase 1 (ASS1), the rate limiting enzyme in cellular arginine synthesis, appear to be resistant to ADI-PEG. Our recent study showed that miR-1291 modulates factors in nutrient metabolism including ASS1 and GLUT1. We have developed a novel method to bioengineer miR-1291 agents for treatment. The aim of the current study was to evaluate if miR-1291 could enhance efficacy of metabolism-targeting drugs in PC. Methods: Cell proliferation was measured by CellTiter-Glo assay. Mature miR-1291 levels were determined by stem-loop reverse transcription real-time PCR assay. GLUT1 and ASS1 protein levels in miR-1291-treated pancreatic cancer cell lines were assessed by Western blot. Glucose uptake in AsPC-1 and PANC-1 cell lines was determined with a fluorescent probe, 2-NBDG. Results: A bioengineered pre-miR-1291 was processed to high levels of mature miR-1291 in PC cells. L3.3 and PANC-1 cells endogenously express high levels of ASS-1 and are resistant to arginine deprivation by ADI-PEG. ASS1 protein was downregulated by miR-1291 in L3.3 and PANC-1 cells and sensitized pancreatic cancer cells to ADI-PEG. In addition, miR-1291 significantly downregulated the protein levels of GLUT1 in AsPC-1 cells, leading to a lower glucose uptake capacity and a greater sensitivity to chemotherapy. Conclusions: Our results demonstrate that miR-1291 sensitizes PC cells to arginine deprivation and chemotherapy through downregulation of ASS1 and GLUT1. These results provide new insight into the mechanistic actions of miR-1291 and provide a new strategy for treatment of pancreatic cancer.
Government announces details of new GP contract for England
Authors: Helen Jaques
Journal: BMJ (2012)

Full details of the government’s planned changes to the general medical services (GMS) contract for 2013-14 for GPs in England have been unveiled by the Department of Health. They include how the minimum practice income guarantee (MPIG) will be phased out over seven years and how thresholds for 20 Quality and Outcome Framework (QOF) indicators will be raised.

The BMA believes that the proposals will increase GPs’ workload and cut practices’ core funding. “The government has not fully considered the overall impact on practices of all these changes being implemented together,” said Laurence Buckman, chairman of the BMA’s General Practitioners Committee. “This could make it difficult for some practices to maintain the level of care they currently offer, let alone increase their capacity to meet the demands of these new proposals.”

The …
Effectiveness and safety of anticoagulants for the treatment of venous thromboembolism in patients with cancer
Authors: Michael B. Streiff, Dejan Milentijevic, Keith McCrae, Daniel Yannicelli, Jonathan Fortier, Winnie W. Nelson, François Laliberté, Concetta Crivera, Patrick Lefebvre, Jeff Schein, Alok A. Khorana
Journal: American Journal of Hematology (2018)

Abstract Anticoagulation is used to treat venous thromboembolism (VTE) in cancer patients, but may be associated with an increased risk of bleeding. VTE recurrence and major bleeding were assessed in cancer patients treated for VTE with the most currently prescribed anticoagulants in clinical practice. Newly diagnosed cancer patients (first VTE 1/1/2013‐05/31/2015) who initiated rivaroxaban, low‐molecular‐weight heparin (LMWH), or warfarin were identified from Humana claims data and observed until end of eligibility or end of data availability. VTE recurrence was a hospitalization with a primary diagnosis of VTE ≥7 days after first VTE. Major bleeding events on treatment were identified using validated criteria. Cohorts were compared using Kaplan–Meier rates at 6 and 12 months and Cox proportional hazards models. Cohorts were adjusted for their differences at baseline. A total of 2428 patients (rivaroxaban: 707; LMWH: 660; warfarin: 1061) met inclusion criteria. Patient characteristics were well balanced after weighting. There was a trend for lower VTE recurrence rates in rivaroxaban users compared to LMWH users at 6 months (13.2% vs. 17.1%; P = .060) and significantly lower at 12 months (16.5% vs. 22.2%; P = .030) [HR: 0.72, 95% CI: (0.52‐0.95); P = .024]. VTE recurrence rates were also lower for rivaroxaban than warfarin users at 6 months (13.2% vs. 17.5%; P = .014) and 12 months (15.7% vs. 19.9%; P = .017) [HR: 0.74, 95% CI: (0.56‐0.96); P = .028]. Major bleeding rates were similar across cohorts. This real‐world analysis suggests cancer patients with VTE treated with rivaroxaban had significantly lower risk of recurrent VTE and similar risk of bleeding compared to those treated with LMWH or warfarin.
Epidural block in local kidney cancer as a way to preserve the adrenal function influencing urine formation processes.
Authors: Elena Frantsiyants, Oleg Ivanovich Kit, Larisa S. Kozlova, Dmitry A. Rozenko, Valeria A. Bandovkina, Natalia D. Cheryarina, Sergey N Dimitriadi, Natalya D. Ushakova, Ludmila Ya. Rozenko, Maksim N. Duritskiy
Journal: Journal of Clinical Oncology (2018)

592 Background: Our purpose was to study the dynamics of cortisol (C) and aldosterone (A) in the blood plasma in patients receiving surgery with the epidural block (EB) for local kidney cancer. Methods: 58 patients aged 56.5±8.7 years underwent partial nephrectomy with warm ischemia for 15-20 minutes (EB – 35 patients, standard anesthesia (SA) - 23 patients). EB involved catheterization of the epidural space at Th10-L1 with the following infusion of a mixture of ropivacaine 2 mg/ml and epinephrine 2 μg/ml at 6-10 ml/hr using a syringe doser, intraoperatively and within the first three postoperative days. The levels of C and A were studied by radioimmunoassay in the blood plasma of patients before the surgery (b/s), 40 min after the start of the surgery (40' s/s) and on days 1 and 3 after the surgery (a/s). Results were compared to the levels in the blood plasma of 32 healthy donors (N). Results: C and A exceeded N in all patients b/s (p &lt; 0.01). C increased by an order of magnitude 40' s/s only in SA (p &lt; 0.001), while A increased in all patients, compared to the levels b/s. C decreased by 1.5 times in EB on day 1 a/s; C in SA was similar to the levels b/s; A decreased to similar levels in all patients but was still higher than N by 1.4 times on average (p &lt; 0.01). The C levels remained stable in all patients on day 3; A levels became normal in EB only, while in SA they were 2.1 times lower which caused the loss of salts and fluid. Conclusions: SA affected the regulation of the adrenal function by the central nervous system and urine formation processes in the kidney. In SA, abnormal C and A levels preserve for a longer period of time enhancing the water and salt imbalance in the body. Significant decrease of C and the normalization of A in EB indicate the preservation of the adrenal function influencing urine formation processes in the kidney. In local kidney cancer, it is advisable to use epidural block instead of standard anesthesia as the latter blocks regulatory functions of the central nervous system.
Anti-apoptotic activity of human matrix metalloproteinase-2 attenuates diabetes mellitus
Authors: Kota Nishihama, Taro Yasuma, Yutaka Yano, Corina N. D' Alessandro-Gabazza, Masaaki Toda, Josephine A. Hinneh, Prince Baffour Tonto, Atsuro Takeshita, Toshiaki Totoki, Rumi Mifuji-Moroka, Tetsu Kobayashi, Motoh Iwasa, Yoshiyuki Takei, John Morser, Isaac Cann, Esteban C. Gabazza
Journal: Metabolism (2018)
Structural Basis for Draxin-Modulated Axon Guidance and Fasciculation by Netrin-1 through DCC
Authors: Ying Liu, Tuhin Bhowmick, Yiqiong Liu, Xuefan Gao, Haydyn D.T. Mertens, Dmitri I. Svergun, Junyu Xiao, Yan Zhang, Jia-huai Wang, Rob Meijers
Journal: Neuron (2018)

Axon guidance involves the spatiotemporal interplay between guidance cues and membrane-bound cell-surface receptors, present on the growth cone of the axon. Netrin-1 is a prototypical guidance cue that binds to deleted in colorectal cancer (DCC), and it has been proposed that the guidance cue Draxin modulates this interaction. Here, we present structural snapshots of Draxin/DCC and Draxin/Netrin-1 complexes, revealing a triangular relationship that affects Netrin-mediated haptotaxis and fasciculation. Draxin interacts with DCC through the N-terminal four immunoglobulin domains, and Netrin-1 through the EGF-3 domain, in the same region where DCC binds. Netrin-1 and DCC bind to adjacent sites on Draxin, which appears to capture Netrin-1 and tether it to the DCC receptor. We propose the conformational flexibility of the single-pass membrane receptor DCC is used to promote fasciculation and regulate axon guidance through concerted Netrin-1/Draxin binding.Video AbstracteyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiNWUxMDhjZmJiYWU2NzdhNzE2MzA4YTEwNmNlYmViZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NzUxOTA4fQ.hOllxdOdKGWqYPixvYjTWoFyBLNN31Wow_qNIsU4J5VkbIQisrLV5T62xuFvNebHFuuKsaqgh30Lp-1knZCLz13B-N8OVthsVSWTg65tBf5skSELLM9AY3u_E2V9gJLh7jebS2LHv8MiHH2zhM5FvUc06MR_jqiWbrq3wBcW4Bvvv7HvPTljxHpWVpE89A-ZCWXCxxyWJFIGreSGEwr0Fn4NMvV7pFx-_LzOcuIlZ5jLFkHKX44kA8fKsgb51xelMNvno3e7Qc9tomkBWB7xNyygTk4pYG8qRYzO_69KSfXE48LFSx73Ve7n3TrbqC9faOIOhiBXdXjUsXOVIH3acg(mp4, (28.91 MB) Download video
First-line chemotherapy with docetaxel, oxaliplatin, and timed-flat infusion 5Fluorouracil in metastatic gastro-esophageal adenocarcinomas: The experience with FD/FOx regimen.
Authors: Alessio Cortellini, Alessandro Parisi, Katia Cannita, Luca Napoleoni, Paola Lanfiuti Baldi, Olga Venditti, Giampiero Porzio, Corrado Ficorella
Journal: Journal of Clinical Oncology (2018)

178 Background: Triplet chemotherapies, with fluoropyrimidines, platin derivates and Docetaxel, represent an option for first line treatment of metastatic Gastro-Esophageal Adenocarcinoma (mGEA). To increase tolerability and dose intensity (DI), we previously developed an alternative way of administration of 5Fluorouracil (5FU), with nocturnal “timed-flat infusion” (TFI) (from 10:00 PM to 10:00 AM), without 5FU bolus and Folinic Acid, in several combination-schedules in breast and colorectal cancers. Methods: We report a retrospective analysis of 27 mGEA patients (pts) treated with FD/FOx regimen, a schedule of weekly TFI/5FU for two nights at 1000 or 900 mg/m 2 /night, associated to alternating Docetaxel at 50 mg/m 2 on days 1 and 15, and Oxaliplatin at 80 mg/m 2 on days 8 and 22, cycles repeated every 4 weeks. Results: From June 2007 to July 2017, 17 pts (62.9%) were treated with standard FD/FOx and 10 pts (37.1%) with modified FD/FOx (defined by any projected dose reduction compared to standard) due to age, PS and comorbidities. Median age was 60 years (range 41-80), male/female ratio 19/8, ECOG-PS 0, 7 (26%), 1, 16 (59%), 2, 4 (15%); 17 pts (62.9%) had a Cumulative Illness Rating Scale Intermediate stage, 1 patient (3.7%) a Secondary one. Thirteen pts (48%) had unresected primary tumor. ORR, median PFS and median OS were 73.9% (α0.05, CI±18), 13 and 16 months, respectively. The only G4 toxicity was neutropenia (11.1%); G3 were: neutropenia (29.6%), asthenia (22.2%), diarrhea (22.2%); most relevant G2 toxicities were: nausea (33.3%), anorexia (40.7%), neuropathy (37.0%) and anemia (40.7%). No febrile neutropenia was observed. The received (r)DI were 80% of standard full dose of each drug: Docetaxel 20 mg/m 2 /week, Oxaliplatin 32 mg/m 2 /week and 5FU 1440 mg/m 2 /week. Out of 21 pts who progressed to FD/FOx, 13 pts (48.1%) underwent a second line therapy (6 rechallenges with taxanes). Conclusions: Even if requires a careful management, FD/FOx is a feasible option for first line treatment of mGEA pts, particularly in needing of tumor shrinkage, with significant activity, high rDIs, and acceptable safety profile when compared to literature.
Neoadjuvant combination immunotherapy with pembrolizumab and high dose IFN-α2b in locally/regionally advanced melanoma.
Authors: Ahmad A. Tarhini, Yan Lin, Joseph J. Drabick, Rogerio Izar Neves, Marc S. Ernstoff, Igor Puzanov, Priyanka Vallabhaneni, James F. Pingpank, Matthew Peter Holtzman, Cindy Sander, John M. Kirkwood
Journal: Journal of Clinical Oncology (2018)

181 Background: Neoadjuvant pembrolizumab at 200 mg in combination with high dose IFNα2b (HDI) for locally/regionally advanced or recurrent melanoma may improve the clinical outcomes of these high risk patients (pts), and provide access to blood and tumor pre/post pembro-HDI to illuminate the host effector and suppressor immune mechanisms. Methods: Pts were treated with pembro 200 mg IV every 3 weeks (wk) x 2 doses followed by definitive surgery, then every 3 wks for up to one year. HDI (20 MU/m²/d IV x 5 days (d)/wk for 4 wks then 10 MU/m²/d SC every other d TIW for 48 wks) was given concurrently. Tumor samples were obtained at baseline and at definitive surgery (wk 6-8) and serum/PBMC at baseline, 6 wks, 3, 6, 12 months (mo). Results: Twenty evaluable pts (14 male, 6 female, 14 cutaneous primary, 4 unknown, 3 mucosal), age 29-82 were treated. 5 had Stage IIIB (N1b, N2b, M2c), 11 IIIC (N3) and 4 IV (M1a, M1b) melanoma. Over 230 cycles have been delivered to date (median 14). Worst toxicities included grade (Gr) 3: fatigue (8; 40%), ↑CPK (5; 25%), hypophosphatemia (5; 25%), ↑lipase (3; 15%), lymphopenia (3; 15%), hypertension (2; 10%), diarrhea/colitis (1; 5%), arthralgia (1, 5%), syncope (1, 5%), hyponatremia (1, 5%), neutropenia (1; 5%), anemia (1, 5.00%) nausea (2, 10%), flu like symptoms (1, 5%). There were 3 Gr 4 events (CPK, hyperglycemia, lymphopenia). One suspected grade 5 event occurred 6 months after completion of therapy with autopsy evidence of pneumonia and myocarditis. Among 20 evaluable pts, 4 relapsed and 1 died. Median follow-up for pts who have not relapsed is 11 months. The radiologic preoperative response rate (WHO; unconfirmed) was 65%. The pathologic complete response rate (no viable tumor on histologic assessment) was 35%. Conclusions: Neoadjuvant pembro-HDI exhibited promising clinical activity. Longer follow up is underway in order to define the long term benefits and risks. Clinical trial information: NCT02339324.
Abstract P5-19-07: Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership
Authors: N Nixon, C Simmons, J Lemieux, S Verma
Journal: Cancer Research (2018)

Abstract Background: Research priorities are generally determined by funders and researchers without direct involvement and input from patients and caregivers. Certain disease areas have incorporated the patient voice to determine patient driven priorities. In this study, this approach was employed to better understand the needs and priorities of metastatic breast cancer patients and their caregivers. Methods: This study was conducted using methodology outlined by the James Lind Alliance. A steering committee of patients, physicians, patient advocates, and allied health care professionals was assembled to oversee the research study. The initial survey collected unanswered research questions from patients, caregivers, and clinicians. Responses were collected and categorized by consensus of the steering committee. Here we present the results from the national survey. Results: Between November 2016 and April 2017, 733 responses from 311 individuals were collected (62% patients, 11% physicians, 9% caregivers or relatives, 5% nurses/allied health professionals, 2% patient organization representatives, and 10% other). The main themes for key patient priorities are: 136 (19%) related to treatment and monitoring, 78 (11%) linked lifestyle and alternative therapy, 58 (8%) regarded tumour biology, 53 (7%) regarded psychosocial aspects, 46 (6%) to diagnosis, 35 (5%) to toxicity, 24 (3%) to prevention, and 17 (2%) to young or pre-menopausal population. Two hundred and eighty-six (39%) were considered out of scope. The most frequently identified priorities included the role of alternative therapies for improving survival, the role of immune therapy for treating metastatic breast cancer, and the potential for improving outcomes with early detection/surveillance with modern treatment and diagnostic modalities. Conclusion: Patient derived research priorities in advanced breast cancer point to an improved understanding of alternative therapies, integration of immune therapy and a focus on early detection of relapse. These priorities should be addressed by the research community to meet the needs of our patients with advanced breast cancer. Citation Format: Nixon N, Simmons C, Lemieux J, Verma S. Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-07.
Phase II study of olaparib for BRCAness phenotype in pancreatic cancer.
Authors: Talia Golan, Gauri R. Varadhachary, Tal Sela, David R. Fogelman, Naama Halperin, Rachna T. Shroff, Sharon Halparin, Lianchun Xiao, Dan Aderka, Anirban Maitra, Aliza Ackerstein, Robert A. Wolff, Einat Shacham-Shmueli, Milind M. Javle
Journal: Journal of Clinical Oncology (2018)

297 Background: The subtype of pancreatic ductal adenocarcinoma cancer (PDAC) patients with DNA damage repair (DDR) deficiency from BRCA1/2 mutations has a favorable prognosis and is sensitive to platinum analogues and PARP inhibition. About 10-20% of PDAC patients have DDR deficiency without BRCA mutations (BRCA ness). The efficacy of olaparib in this population is unknown. Methods: Two parallel phases II trials (Israel and U.S.) are ongoing to determine the efficacy of olaparib in advanced PDAC with BRCA ness. Inclusion criteria: ≥ 1 prior systemic therapy for advanced PDAC, ECOG 0-1, germline BRCA 1/ 2 ( gBRCA) mutation negative, previously known DDR genetic aberrations (DDR-GA), family history of BRCA-associated cancers in ≥2 first-degree relatives (without DDR-GA), ATM loss by IHC (Israel only). Primary and secondary endpoints are objective response rate and PFS, respectively. With an type I error rate α of 0.1 and a β error rate of 0.2, and assuming P0 and P1 are 5% and 20%, respectively, study will enroll 24 patients at each site. Results: Thus far, 21 and 11 patients treated in Israel and U.S; respectively. DDR phenotype: Family history of BRCA cancer without DDR-GA (n = 14), DDR-GA (n = 12), ATM loss by IHC (n = 5). DDR-GAs were ATM (n = 6), PALB2 (n = 1), BRCA somatic (2), FANCB (1), PTEN (1) and CCNE1 (1). Efficacy data are in Table. Common toxicities were grade 1-2 anemia, fatigue and nausea. No responses were observed in platinum refractory cases. Conclusions: Olaparib was tolerated well in this study population. Olaparib showed encouraging initial antitumor activity in platinum-sensitive, gBRCA negative PDAC patients with DDR GA and in patients with family history of BRCA cancers (without identifiable DDR-GA). Clinical trial information: NCT02677038 ; NCT02511223. [Table: see text]
Targeting CD19-negative relapsed B-acute lymphoblastic leukemia using trivalent CAR T cells.
Authors: Kristen Fousek, Junji Watanabe, Ann George, Xingyue An, Heba Samir Samaha, Shoba Alaska Navai, Tiara T Byrd, Albert Jang, Hye Na Kim, Sujith Joseph, Matthew Baker, Navin Varadarajan, Meenakshi G. Hegde, Yong-Mi Kim, Nora Heisterkamp, Hisham M. Abdel-Azim, Nabil M. Ahmed
Journal: Journal of Clinical Oncology (2018)

121 Background: Chimeric antigen receptor (CAR) T cells targeting CD19 have shown remarkable efficacy in treating relapsed B cell acute lymphoblastic leukemia (B-ALL). However, recent reports show that up to 40% of patients who relapse after CD19 CAR T cell therapy have CD19-negative disease, justifying a need to expand CAR T cell therapy for B-ALL to include additional tumor-associated antigens. We hypothesize that targeting CD19, CD20, and CD22 will improve B-ALL therapy outcomes and control disease progression during CD19-negative relapse. Methods: We designed two trivalent CAR T cell products with exodomains derived from single chain variable fragments (ScFv) targeting CD19, CD20, and CD22. Each CAR contains the 4-1BB and T-cell receptor zeta chains. Donor T cells were engineered to express the CARs using a retroviral system. We used primary CD19-negative relapsed bone marrow samples and CRISPR CD19 knockouts of primary ALL to model CD19 escape and standard cytotoxicity and immune assays to evaluate anti-tumor efficacy. Results: Due to the use of viral 2A sequences we detected near equal expression of each CAR by flow cytometry. The first T cell product expresses three CARs individually (TriCAR), and the second expresses a single CAR targeting CD19 and a second bi-specific CAR targeting CD20 and CD22 via a tandem arrangement (SideCAR). Using primary B-ALL cells, we observed that TriCAR and SideCAR T cells killed ALL cells more robustly than CD19 CAR T cells at low E:T ratios. Further, in ImageStream analysis of single cell interactions between CAR T cells and primary B-ALL cells, TriCAR T cells exhibited increased actin polymerization compared to CD19 CAR T cells, suggesting remodeling and increased cell activation. Finally, in multiple models of CD19 escape in primary ALL, we showed that trivalent CAR T cells mitigated CD19 negative relapse, producing IFN-γ/TNF-α and killing CD19-negative primary ALL, while CD19 CAR T cells remained ineffective. Conclusions: Trivalent CAR T cells effectively target primary ALL cells with varying antigen profiles and mitigate CD19-negative relapse. This strategy has the potential for use as an initial CAR therapy in relapsed ALL or a salvage therapy for patients with CD19-negative disease.
Spectrum of CFTR gene sequence variants in a northern Portugal population
Authors: A. Grangeia, S. Alves, L. Gonçalves, I. Gregório, A.C. Santos, H. Barros, A. Barros, F. Carvalho, C. Moura
Journal: Pulmonology (2018)

In Portugal, the spectrum of Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene variants is not known. The main objective of this work was to determine the type and frequency of CFTR variants in a sample from northern Portugal by the complete analysis of the CFTR coding sequencing performed in 512 Portuguese children. A total of 30 different CFTR sequence variants, already reported as cystic fibrosis (CF) or CFTR related disorders variants, were detected. Ninety-two children (18.0%; 95%CI: 14.7–21.6) were found to be carriers of one sequence variant and 8 (1.6%; 95%CI: 0.7–3.1) had two sequence variants. Taking into consideration only variants that may cause CF when combined with a pathogenic CF variant, the CF pathogenic variant carrier frequency was 3.3% (95%CI: 1.9–5.3). One (0.2%; 95%CI: 0.01–0.7) child presented two CF pathogenic variants. The majority of CFTR variants detected have been associated with a less severe CF phenotype. A wide spectrum of CFTR variants was identified, confirming the highest CFTR allelic heterogeneity previously reported in Mediterranean country. Additionally, better knowledge about the CFTR sequence variation spectrum may contribute to more efficient genetic testing in the Portuguese population.