Breast cancer local recurrence: risk factors and prognostic relevance of early time to recurrence

BACKGROUND

Local recurrence occurs in 10%-20% of patients treated with breast-conserving surgery for stage I-II breast cancer. The aim of the present study was to investigate breast cancer local recurrence, potential risk factors, and prognostic impact.

METHODS

A total of 503 patients treated with breast-conserving surgery were included in the study. All patients underwent axillary dissection and postoperative radiotherapy, and all patients had negative margins at pathological examination. Median follow-up was 82 months. Local recurrence was classified as early when it occurred within 2 years from surgery. The risk factors for local recurrence and overall survival were estimated by univariate and multivariate analyses.

RESULTS

Forty-six cases (9.1%) of local recurrence were observed, 11 of which occurred within 24 months of surgery; the other 35, sometime later. Statistically significant risk factors for local recurrence were premenopausal status, peritumoral vascular invasion, multifocality, and absence of estrogen receptors. Independent negative prognostic factors for overall survival at 5 and 10 years were N stage, absence of estrogen receptors, and early time to recurrence. Overall survival at 10 years was 10.0% for patients with early recurrence, 87.5% for patients with late recurrence, and 87.9% for patients without recurrence.

CONCLUSIONS

None of the studied clinicopathological characteristics alone is a determinant for the choice of surgical treatment. Younger patients treated with breast-conserving surgery should receive aggressive postsurgical treatment and should be followed with an intensive follow-up program when metastatic axillary lymph nodes, negative estrogen receptors, or peritumoral vascular invasion are present.

[Ageing and male sexuality]

Visceral, hormonal and neuroendocrine changes after the sixth decade of life result from slowing down and alteration in metabolic, hormonal, protein, lipid and glucose turnover, progressive receptor insensitivity, degenerative processes--primarily arteriosclerosis--of the endocrine and non endocrine tissues. Unlike menopause, andropause has no biological speed; it is neither rapid nor marked by macroscopically evident psychobehavioral change, as occurs in women. Because of its indistinct and widely variable nosographic contours, the male climacterium is more complex. The challenge to the clinical sexologist, therefore, is to identify appropriate treatment approaches for an ageing population with an increasingly longer life expectancy and the right to a sexually satisfying life.

Clinical phenotype of an Italian family with a new mutation in the PRPF8 gene

PURPOSE

To report the clinical and functional characteristics of an autosomal dominant retinitis pigmentosa (ADRP) family with a novel point mutation (P2301S) in the PRPF8 gene.

METHODS

PRPF8 gene analysis and complete ophthalmologic examination in an ADRP family.

RESULTS

Clinical examination revealed the typical RP phenotype in all family members. Electroretinography showed preserved ERG photopic responses. Genetic analysis showed that the P2301S missense mutation segregated with the disease in all subjects.

CONCLUSIONS

Unlike previously reported families, the PRPF8 gene mutation in our family is associated with a mild phenotype in which cone function is partially preserved.

[Research interest by general practitioners: a survey]

BACKGROUND

For doing research on topics in primary care medicine participation of primary care physicians is necessary. Research in this field of medicine is only marginally established in Switzerland.

OBJECTIVE

In a postal survey we evaluate the general attitudes of physicians towards research in the field of primary care. In particular we were interested in their willingness to participate in research projects and the facilitating and impeding factors to take part in such projects.

METHODS

A purpose designed questionnaire was sent by post to 3044 primary care physicians in the central and eastern parts of Switzerland.

RESULTS

The return rate was 52%. A majority of 94% of the responding physicians revealed interest in primary care research and 60% of all responders are willing to participate actively in such projects. They are prepared to spend about 15 min a day for data acquisition. Their willingness to participate depends on the conditions that, first, the research topic is relevant for daily practice and, second, boards odder Continuous Medical Education credits for time spent for research. Time constraints, additional administrative work and lack of relevance of research topics to daily practice are the main barriers.

CONCLUSION

This survey demonstrates the general interest of primary care physicians to participate in relevant research projects. Therefore the structure to set up such research should be established.

Lymphatic vessels in human sural nerve: immunohistochemical detection by D2-40

Lymphatics were detected in the epineurium of the human sural nerve by D-240 immunostaining and confirmed by ultrastructural examination.

A self-administered questionnaire of ulnar neuropathy at the elbow

We report a new self-administered questionnaire for assessment of symptom severity of ulnar neuropathy at the elbow (UNE). The new UNE and Levine's questionnaires were administered to a sample of UNE subjects and for comparison also to a sample of subjects with carpal tunnel syndrome (CTS). We enrolled 89 consecutive patients (32 women, 57 men, mean age 52.3 years) with UNE and 203 consecutive patients (157 women and 46 men, mean age 53.7 years) with CTS. The protocol of the study consisted in self-administration of the new UNE and Levine's questionnaires, as well as scoring of clinical and electrophysiological severity of entrapment syndromes with ordinal scales. The UNE questionnaire (UNEQ) includes nine questions and considers numbness and tingling in the fourth and fifth fingers, elbow pain and modification of pain and paraesthesia with elbow position. A score from 1 (absence of symptom) to 5 (most severe) is assigned for each question. The overall score is calculated as the mean of the nine scores. Test-retest reliability, internal consistency and validity were assessed. Responsiveness was also tested in a sample of patients undergoing conservative treatment. The UNEQ was reproducible. Spearman's correlation coefficient between scores at successive observations (test-retest reliability), assessed in the first 44 patients, was 0.97 and Cohen coefficients kappa for single items were between 0.64 and 0.81. Internal consistency was high: Cronbach's alpha, which summarises interitem correlations among all items of UNEQ, was 0.87. Validity was demonstrated by a direct correlation with UNE clinical and electrophysiological severity scores (0.65 and 0.35). On the contrary, Spearman's correlation coefficients between UNEQ and clinical and electrophysiological CTS severity scores were low (0.11 and 0.02, respectively). Responsiveness was calculated at 6-8 months follow-up in 25 cases. The effect size was 0.46. The Wilcoxon rank-test showed significant improvement between basal and follow-up UNEQ scores (Z=-2.39, p=0.017), but not Boston Questionnaire scores. There was also significant correlation between UNEQ changes and an arbitrary scale of patient satisfaction at follow-up (r=0.85, p<0.001). The UNEQ is reproducible, internally consistent and valid. Although further studies are required to test its responsiveness to clinical changes, UNEQ may be also considered responsive. UNEQ can be used to measure subjective discomfort in UNE patients.

Correlation between pentosidine and endothelin-1 in subjects undergoing chronic hemodialysis

Advanced glycation end-products (AGEs), which accumulate in the blood and tissues of patients with chronic renal failure (CRF) undergoing chronic hemodialysis, play an important role in the pathogenesis of uremic complications. Endothelin 1 (ET1), a 21-amino acid peptide with vasoconstricting and mitogenic properties, is an important factor in the endothelial dysfunction occurring in uremia. The circulating levels of both AGEs and ET1 have been reported to be increased in chronic renal failure. In the present study we evaluated the possible relationship between pentosidine and ET1 plasma levels in CRF patients undergoing chronic hemodialysis treatment. The plasma concentrations of "free" and bound pentosidine (HPLC methods) and endothelin-1 (RIA method) were measured before the hemodialysis session in 40 nondiabetic CRF patients (22 males and 18 females; 54+/-3 years) on chronic hemodialysis for at least 1 year. Forty age- and sex-matched normal subjects served as a control group. In hemodialyzed patients, the overall pentosidine residues and pentosidine-free adduct plus pentosidine-free adduct bound reversibly to protein levels (24.9+/-2.04 pmol/mg protein and 110.5+/-5.9 pmol/ml, respectively) were significantly higher than those recorded in normal subjects (2.0+/-0.2 pmol/mg protein and 0.7+/-0.2 pmol/ml, respectively ). Endothelin-1 was also significantly (p<0.01) increased in CRF patients (10.6+/-0.4 pmol/ml in CRF patients and 2.7+/-0.3 pmol/ml in normal subjects). A significant positive correlation (p<0.01) was seen between "total" pentosidine (pentosidine residues and pentosidine-free adduct plus pentosidine-free adduct bound reversibly to protein) levels and endothelin-1 plasma values. The correlation between pentosidine and endothelin-1 provides further evidence that some AGEs exert a detrimental effect on the vascular endothelium, thereby contributing to the hypertension and other cardiovascular damage seen in CRF patients.

Thalidomide plus monthly high-dose dexamethasone in chemorefractory myeloma. Results of a phase II clinical study

Thalidomide is a potent anti-myeloma drug which can produce up to a 30-50% overall response rate (ORR) in pre-treated, chemorefractory multiple myeloma. Most authors agree with using 200 mg/daily with associated high dose dexamethasone (40 mg/daily x 4 days, 3 times monthly) considering lower doses investigational. We report our experience using thalidomide 100 mg/daily plus dexamethasone 40 mg/daily once a month, in 27 pre-treated patients. Thalidomide dose excalation and/or association with other drugs were established on the basis of the patient's response. Median age was 69 years (range 50-83 years) and 16 male and 11 female patients were treated. All patients had received more than 1 treatment line (range 1-5). Thalidomide was increased up to 300 mg/daily in 10 patients and 1 patient received up to 400 mg/daily. Two patients were not evaluable because of early death, 1 did not tolerate thalidomide because of pulmonary and neurological side-effects. Sixteen patients responded to this treatment, with an ORR of 66%. The combination of low-dose thalidomide plus monthly high-dose dexamethasone in chemorefractory myeloma showed interesting palliative results. According to our data, increasing thalidomide dosage and/or adding further drugs does not generally produce significant improvement.

The Impact of Proficiency on Syntactic Second-language Processing of German and Italian: Evidence from Event-related Potentials

The present study investigated the role of proficiency in late second-language (L2) processing using comparable stimuli in German and Italian. Both sets of stimuli consisted of simple active sentences including a word category violation, a morphosyntactic agreement violation, or a combination of the two. Four experiments were conducted to study high- and low-proficiency L2 learners of German as well as high- and low-proficiency L2 learners of Italian. High-proficiency L2 learners in both languages showed the same event-related potential (ERP) components as native speakers for all syntactic violations. For the word category violation, they displayed an early anterior negativity (ELAN), an additional negativity reflecting reference-related processes, and a late P600 evidencing processes of reanalysis. For the processing of the morphosyntactic error, an anterior negativity (LAN) and a P600 were observed, whereas for the combined violation, the same ERP components were found as in the pure category violation. In high-proficiency L2 learners, the timing of the processing steps was equivalent to that of native speakers, although some amplitude differences were present. Low-proficiency L2 learners, however, showed qualitative differences in the agreement violation characterized by the absence of the LAN and quantitative differences reflected in a delayed P600 in every violation condition. These findings emphasize that with a high proficiency, late L2 learners can indeed show native-like neural responses with the timing approximating that of native speakers. This challenges the idea that there are fundamental differences in language processing in the brain between natives and late L2 learners.

Deficits of glutamate transmission in the striatum of experimental hemiballism

Hemiballism (HB) is a quite rare disorder, generally secondary to stroke, neoplasms or demyelinating plaques, classically considered as almost pathognomonic of a lesion in the subthalamic nucleus (STN). This alteration causes involuntary movements in the chorea-ballism spectrum. One theory is that the output nuclei of the basal ganglia are overinhibited in HB, while little is known about the physiological state of the striatum, the major input structure of the basal ganglia. In the present study, we recorded spontaneous and miniature excitatory and inhibitory postsynaptic currents (sEPSCs, mEPSCs, sIPSCs, mIPSCs) from projection neurons of the striatum of experimental HB. We found a selective reduction of striatal sEPSC and mEPSC frequency following chemical lesion of the STN of the rat, suggesting that reduced synaptic excitation of the input structure of the basal ganglia represents a physiological correlate of HB.

A new ELISA for determination of potency in snake antivenoms

A competitive ELISA for potency determination of bothropic equine antivenom was developed and compared to the conventional in vivo ED(50) assay, with the aim of partially substituting the in vivo assay in the monitoring of antivenom immunoglobulin levels. On this purpose, blood samples were taken at different times during and after the immunization protocol of the lot of horses used for production of snake antivenom at the Instituto de Higiene, Uruguay. Both the competitive ELISA and the ED(50) assay were performed on those samples. In addition, a group of five commercial pepsin-digested antivenoms were tested by both methods. A significant (P<0.001) correlation (Pearson's r=0.957) was found between the ELISA titres and the corresponding ED(50) values, indicating that the in vitro test can estimate the neutralizing antibody capacity of the sera as well as the in vivo assay. By means of this new ELISA, it was found that the immunized animals maintained good venom antibody titres, in the order of 20-50% of the maximum achieved, even 10 month after the end of the immunization schedule. The main advantage of our ELISA design is its ability to correctly estimate the neutralization capacity of crude hyperimmune plasma and antivenom sera independently of their antibody composition in terms of whole IgG or F(ab')(2) fragment.

Nutritional surveillance in Tuscany: eating habits at breakfast, mid-morning and afternoon snacks among 8-9 y-old children

INTRODUCTION

The prevalence of overweight and obesity in children is rapidly increasing in many countries. For that it has been interesting to investigate the eating habits of 8-9 y-old Tuscany children by paying attention to their meals frequency per day and their food choices in total and in relation to children's Body Mass Index (BMI) classes. In addition we considered some environment factors that could affect the children eating behaviours, such as mother's BMI and their education level.

METHODS

A statistical sample of 3076 (1583 males, 1493 females), 8-9 year-old school-children was collected; weight and height were measured using standardized personnel and instruments. BMI classes were calculated using Cole et al.'s cutoff for children and adolescents. In order to evaluate the consumption frequency of individual meals and various foods, a Food Frequency Questionnaire (FFQ) was used, which was completed by the children themselves at school. A self-administered questionnaire revealed the weight and height of parents and their educational levels. Three educational levels were established: high, medium and low.

RESULTS

The results showed that 92.3% of children ate breakfast from 4-7 times a week, the vast majority at home, while only 3% declared consuming breakfast never or almost never The most preferred breakfast consisted of milk and biscuits for all children's BMI classes. 95.9% of children reported having midmorning snack at school; fruit juice and tea are the most frequently consumed liquid foods, and pizza, salami sandwiches and pre-packaged snacks are the most frequently consumed solid foods in all BMI classes. 93.6% ate afternoon snack for the most part at home, even if 12% of children reported consuming it elsewhere; fruit juice and tea with pizza, sandwiches and pre-packaged snacks are still the most highly consumed foods by all children's BMI classes. The consumption frequency of breakfast (P < 0.001), mid-morning (P < 0.05) and afternoon snack (P < 0.05) of 8-9 y-old Tuscany children decrease with increase the children's BMI classes. The same tendency may be noted for the consumption frequency of breakfast in relation to mother's BMI (P < 0.05) and their education level (P < 0.05). This data strengthens the thesis that some home environments can affect the children's eating behaviours.

CONCLUSION

No substantial differences in food choices at the meals analyzed were determined among normal weight, overweight and obese children. Children of normal weight had a greater tendency to consume meals more regularly. Mother's BMI and their education level can have influence on children's eating behaviours.

Gastrointestinal stromal tumours overexpress fatty acid synthase

Fatty acid synthase (FASN), a key enzyme for de novo lipogenesis, is overexpressed in many malignant tumours and is associated with aggressive biological behaviour. FASN expression and its possible relationship with more aggressive behaviour in gastrointestinal stromal tumours (GISTs) have not been addressed to date. Here, FASN expression was assessed by immunohistochemistry in 60 primary GISTs (28 low/intermediate risk and 32 high risk) and seven metastatic GISTs. Sixteen smooth muscle gastrointestinal tumours were used as controls. FASN was overexpressed in 36 of 60 GISTs (60%): in 12 of 28 (42%) low/intermediate-risk GISTs and in 24 of 32 (75%) high-risk GISTs (p<0.05). Two primary and seven metastatic GISTs and five GIST cell lines (GIST882, GIST430, GIST522, GIST62, and GIST48), analysed by western blot, showed variable FASN expression. Most metastatic samples expressed high levels of FASN protein. Additionally, seven of 60 GISTs showed a proliferation rate higher than 10% by Ki67 and all of them expressed FASN (p<0.04). Finally, proliferation and apoptosis were investigated after FASN silencing in GIST882 cells, which displayed the highest FASN expression. siRNA-mediated FASN knock-down inhibited expression of the proliferation marker cyclin A, whereas no changes in p27 and cleaved PARP expression were seen. It is concluded that FASN is preferentially overexpressed in high-risk and metastatic GISTs, and that its overexpression likely contributes to cell proliferation.

Secondary effluent disinfection: PAA long term efficiency

The paper summarizes the results of a bench-scale study to evaluate the long-term disinfection efficiency of peracetic acid (PAA). Bacterial counts were repeated 5, 24, and 29 h after the end of the disinfection test, to simulate real re-growth conditions (no residual quenching) and, for the 5 h interval, the potential re-growth (quenching of residual PAA). Fecal coliforms, Escherichia coli, and total heterotrophic bacteria (THB) were enumerated by traditional plate count technique; THB were also enumerated by cytometry. After disinfection, the residual PAA concentration became negligible in about 5 to 11 h, depending on the tested doses. Microbial counts showed that no appreciable re-growth took place after 29 h for coliform group bacteria. For THB, the previously cited enumeration techniques gave different results in re-growth tests, especially for the lowest PAA doses. Indeed plate count technique evaluates the ability to form colonies, while cytometry enumerates intact membrane cells. No regrowth took place, even when no residual disinfectant was present, suggesting that bacteria are unable, even at the lowest doses, to repair damage caused by the PAA disinfecting action. PAA was found to be an efficient disinfecting agent, not only as a bacteriostatic, but also as a bactericide.

Pseudoaneurysm of the splenic artery fistulized in the stomach and associated to a pancreatic pseudocyst: case report

A case of pseudoaneurysm of the splenic artery fistulized in the stomach and associated to a pancreatic pseudocyst is presented. A diabetic and alcoholist 40-year-old man was referred for gastrointestinal bleeding. Esophagogastro-duodenoscopy showed a tumefaction of the little gastric curve and a gastric bleeding fistula. A computed tomography demonstrated a pseudoaneurysm of the splenic artery fistulized in the stomach and associated to pancreatic pseudocyst. Marsupialization of the pancreatic pseudocyst, ligature of the splenic artery, splenectomy and closure of the gastric bleeding fistula were performed. There were no postoperative complications and the follow-up showed no other complications. Aneurysms and pseudoaneurysms of the splenic artery are very frequent, generally asymptomatic (70% of the cases) and in half of the cases they are occasionally diagnosticated. The bleeding of pseudoaneurysm for rupture or fistulization is a very rare and serious complication associated to a high percentage of mortality.

The ratio between arterio-venous PCO2 difference and arterio-jugular oxygen difference as estimator of critical cerebral hypoperfusion

AIM

The aim of this study was to evaluate the arterio-venous difference in carbon dioxide tension (DPCO2) and the ratio between DPCO2 and arterio-jugular oxygen difference (AJDO2) as indicators of compensated or uncompensated cerebral hypoperfusion.

METHODS

Cerebral blood flow (CBF) was reduced stepwise in 6 pigs by inducing intracranial hypertension with consequently cerebral perfusion pressure (CPP) reduction: CBF 100%, 50-60 % of baseline, 20-30% of baseline. Intracranial pressure (ICP), mean arterial pressure (MAP), CPP and CBF (laser-Doppler method) were continuously recorded. Superior sagittal sinus was punctured for the determination of AJDO2 and DPCO2.

RESULTS

CBF impairment was accompanied by changes in AJDO2 from 6.03 +/- 1.21 vol% to 7.32 +/- 1.30 vol%, up to 8.07 +/- 1.32 vol% (P < 0.01), in DPCO2 from 12.17 +/- 3.25 mmHg to 16 +/- 4.12 mmHg, up to 26.5 +/- 6.41 mmHg (P < 0.01), and DPCO2/AJDO2 ratio from 2.05 +/- 0.39 to 2.06 +/- 0.72 up to 3.41 +/- 1.09 in the 3 phases (P < 0.05).

CONCLUSIONS

When CBF declines AJDO2 increases, indicating greater extraction of O2 to satisfy aerobic metabolism. However, this mechanism can no longer compensate once a critical CBF threshold is reached. DPCO2 rises slowly during moderate CBF reduction because of defective washout; the rise is steeper during marked CBF impairment when anaerobic metabolism takes place. During cerebral hypoperfusion the venous blood gases and acid base variables mirror the degree of cerebral perfusion. In particular the DPCO2, and the DPCO2/ AJDO2 ratio may be useful markers of critical brain hypoperfusion.