Geographic disparity in the use of surgical management (SM) and radiotherapy (RT) for female breast cancer (BC) in Wisconsin (WI)

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Background: The WICaRE Program is a part of the cross sectional Patterns of Care Study–Breast and Prostate (PoC-BP) that sought to evaluate the patterns of BC care in the state WI and to identify areas for potential improvement in data collection and factors associated with variation in care. This study was to examine the geographic disparities in SM and the use of RT in female BC patients diagnosed in WI in 2004.

Methods: The Wisconsin Cancer Reporting System (WCRS) receives reports from 130+ facilities. Information of patient (disease status, sociodemographic, treatment, county of residence) was obtained from cancer registries and supplemental data was reabstracted from medical charts across 66 counties. Geographic regions were counties grouped by WI Dept. of Health Services (DHS) as Northeastern (NE), Northern (N), Southeastern (SE), Southern (S), Western (W).

Results: A total of 1037 cases were reported. 25% age 20-49, 49% age 50-69, and 28% age 70+; Caucasian had 82%, black 10% and others 8%. 34% had T1 stage, 9% T2, 4% T3+, and 53% TX-T0/unknown stage. 46% had reported mild comorbidity, 9% had moderate or severe comorbidity. Majority (73%) lived in the Metropolitan Statistical Area (MSA). 29% patients from NE region, 10% from N, 36% SE, 17% S and 8% W. Patients in the S and W had significantly lower % who received RT (46 and 48% respectively) than those in NE (61%), N (62%) and SE (63%), p=0.01; % mastectomy (MA) by regions were 43% (NE), 42% (N), 33% (SE), 47% (S) and 35% (W), p=0.009. Multivariate models adjusting for disease status, comorbidity, and sociodemographic factors showed that patients in MSA region were more likely to have RT compared to those in non-MSA (odds ratio, OR=1.66, 95%CI=1.14-2.40), but those in S were less likely than those in SE (OR=0.59, 95%CI=0.38-0.91). Patients in MSA had a decreased likelihood of undergoing mastectomy. NE (OR=1.6, 95%CI=1.08-2.29) and S (OR= 2.04, 95%CI=1.31-3.17) had significantly higher odds of having MA than those in SE.

Conclusions: This study showed evidence of geographic disparity in medical care for BC patients in Wisconsin. Identifying factors mediating this disparity will help in developing appropriate treatment options and improving outcomes.

Regional mRNA expression of the endogenous opioid and dopaminergic systems in brains of C57BL/6J and 129P3/J mice: strain and heroin effects

We have previously shown strain and dose differences in heroin-induced behavior, reward and regional expression of somatostatin receptor mRNAs in C57BL/6J and 129P3/J mice. Using Real Time PCR we examined the effects of five doses of heroin on the levels of the transcripts of endogenous opioid peptides and their receptors and dopaminergic receptors in the mesocorticolimbic and nigrostriatal pathways in these same mice. Compared to C57BL/6J animals, 129P3/J mice had higher mRNA levels of Oprk1 in the nucleus accumbens and of Oprd1 in the nucleus accumbens and a region containing both the substantia nigra and ventral tegmental area (SN/VTA). In the cortex of 129P3/J mice, lower levels of both Oprk1 and Oprd1 mRNAs were observed. Pdyn mRNA was also lower in the caudate putamen of 129P3/J mice. Strain differences were not found in the levels of Oprm1, Penk or Pomc mRNAs in any region examined. Within strains, complex patterns of heroin dose-dependent changes in the levels of Oprm1, Oprk1 and Oprd1 mRNAs were observed in the SN/VTA. Additionally, Oprd1 mRNA was dose-dependently elevated in the hypothalamus. Also in the hypothalamus, we found higher levels of Drd1a mRNA in C57BL/6J mice than in 129P3/J animals and higher levels of DAT (Slc6a3) mRNA in the caudate putamen of C57BL/6J animals than in 129P3/J counterparts. Heroin had dose-related effects on Drd1a mRNA in the hypothalamus and on Drd2 mRNA in the caudate putamen.

Swallow induces a peristaltic wave of distension that marches in front of the peristaltic wave of contraction

BACKGROUND

Current understanding is that swallow induces simultaneous inhibition of the entire esophagus followed by a sequential wave of contraction (peristalsis). We observed a pattern of luminal distension preceding contraction which suggested that inhibition may also traverses in a peristaltic fashion. Our aim is to determine the relationship between contraction and luminal distension during bolus transport.

METHODS

Eight subjects using two solid-state pressure and two ultrasound (US) transducers were studied. Synchronous pressure and US images were obtained with wet swallows and after edrophonium and atropine. Luminal cross-sectional area (CSA) at 2 cm and 12 cm above the lower esophageal sphincter (LES) were recorded. Relationship between pressure and CSA at each site, propagation velocity of peak pressure and peak distension waves were determined. Fluoroscopy coupled with manometry was also performed in five normal subjects.

KEY RESULTS

Esophageal distension precedes contraction wave at both-recorded sites. During distension, esophageal pressure remains constant while luminal CSA increases significantly. The onset and the peak of distension wave traverses in a peristaltic fashion between both sites. A tight coupling exists between the peak distension and peak contraction waves with similar velocities (3.7 cm s(-1) and 3.6 cm s(-1)) of propagation. The degree of distension is greater at 2 cm compared to 12 cm. Atropine and edrophonium reduced and increased the contraction pressure respectively, without affecting the distension wave. Fluoroscopic study confirmed that the wave of distension traverses the esophagus in a peristaltic fashion.

CONCLUSIONS & INFERENCES

Distension and contraction waves are tightly coupled to each other and both traverse in a peristaltic fashion.

Penicillium marneffei infection presenting as an immune reconstitution inflammatory syndrome in an HIV patient

We describe a case of Penicillium marneffei infection acquired in Thailand, manifesting as an immune reconstitution inflammatory syndrome (IRIS) in a Caucasian man with advanced HIV-related immunosuppression (CD4 72 cells/mm3). Initial presentation was consistent with Pneumocystis jirovecii pneumonia, and empirical co-trimoxazole resulted in clinical improvement. One month after initiating antiretroviral therapy (ART), an enlarging scaly lesion on his forehead and erythematous nodules on his face, trunk and limbs developed. P. marneffei was isolated from a skin aspirate. Response to antifungal therapy was complicated by drug interactions but cure was complete after four months of treatment. Few cases of IRIS associated with P. marneffei have been reported.

Induction of pancreatic phenotypes in central nervous system derived pluripotential progenitor cells

Fetal rat brain stem cells (RSCs) have been induced to express pituitary properties when exposed to pituitary cells (U et al., 2002). In this study, we explored whether these RSCs could also be influenced to acquire properties characteristic of the pancreas. To this end, RSCs in culture were exposed to media conditioned by rat islet tumor cells and media containing Exendin-4 and nicotinamide since both have been shown to induce pancreatic phenotypes in embryonic stem cells. Lastly, an expression construct for pdx-1 was introduced into RSCs. The expression of pancreatic markers was analyzed using RT-PRC and immunocytochemistry. When RSCs were exposed to rat islet tumor cell conditioned media and media containing Exendin-4 and nicotinamide, the expression of pdx-1, insulin and somatostatin were observed. They also acquired a spherical shape typical of pancreatic cells in culture. Under these varied conditions, transcriptional factors essential to pancreatic development such as pdx-1 and Isl-1 were induced. The critical role of pdx-1 in stimulating certain endocrine pancreatic properties in RSCs was further confirmed upon the introduction of an expression construct for pdx-1 which markedly induced insulin and somatostatin. Taken together, these findings suggests that fetal brain stem cells are pluripotent and can be reprogrammed to acquire pancreatic properties through pathways which involved the transcription factor Pdx1.

Association of polymorphisms of the cannabinoid receptor (CNR1) and fatty acid amide hydrolase (FAAH) genes with heroin addiction: impact of long repeats of CNR1

Alterations in expression of a cannabinoid receptor (CNR1, CB1), and of fatty acid amide hydrolase (FAAH) that degrades endogenous ligands of CB1, may contribute to the development of addiction. The 385C>A in the FAAH gene and six polymorphisms of CNR1 were genotyped in former heroin addicts and control subjects (247 Caucasians, 161 Hispanics, 179 African Americans and 19 Asians). In Caucasians, long repeats (>or=14) of 18087-18131(TAA)(8-17) were associated with heroin addiction (P=0.0102). Across three ethnicities combined, a highly significant association of long repeats with heroin addiction was found (z=3.322, P=0.0009). Point-wise significant associations of allele 1359A (P=0.006) and genotype 1359AA (P=0.034) with protection from heroin addiction were found in Caucasians. Also in Caucasians, the genotype pattern, 1359G>A and -6274A>T, was significantly associated with heroin addiction experiment wise (P=0.0244). No association of FAAH 385C>A with heroin addiction was found in any group studied.

Acute withdrawal from chronic escalating-dose binge cocaine administration alters kappa opioid receptor stimulation of [35S] guanosine 5'-O-[gamma-thio]triphosphate acid binding in the rat ventral tegmental area

There is evidence that the kappa opioid system plays an important role in cocaine addiction and that chronic cocaine administration and withdrawal from chronic cocaine alter kappa opioid receptor (KOPr) density. The present study employed in situ [(35)S]guanosine 5'-O-[gamma-thio]triphosphate acid (GTPgammaS) binding autoradiography to measure KOPr-stimulated activation of G-protein in the caudate putamen, nucleus accumbens core and shell, lateral hypothalamus, basolateral amygdala, substantia nigra compacta, substantia nigra reticulata and ventral tegmental area (VTA), in response to chronic cocaine administration or acute and chronic withdrawal from chronic cocaine. Male Fischer rats were injected i.p. with saline or cocaine three times daily at 1 h intervals in an escalating-dose paradigm for 14 days (from 3x15 mg/kg/injection on days 1-3 up to 3x30 mg/kg/injection on days 10-14). Identically treated separate groups were withdrawn from cocaine or saline for 24 h or 14 days. No significant change in KOPr agonist U-69593-stimulated [(35)S]GTPgammaS was found in the seven regions studied 30 min or 14 days after chronic 14 days escalating-dose binge cocaine administration. However there was an increase in KOPr -stimulated [(35)S]GTPgammaS binding in the VTA (P<0.01) of rats withdrawn for 24 h from chronic cocaine. Our results show a cocaine withdrawal induced increase of KOPr signaling in the VTA, and suggest that the KOPr may play a role in acute withdrawal from cocaine.

"They just don't get it!" When family disagrees with expert opinion

The notions of "expert" and "expertise" imply that some people have more credibility than others on certain matters. While expert authority is often taken for granted, there are questions as to whether expert power in some cases can be a form of epistemic oppression. Informed by bedside disagreements between family and clinicians as well as feminist discussions of epistemic oppression, this paper argues for a commitment to epistemic humility and the adoption of a two-way collaborative approach between clinicians and families that can help to enhance professionals' own understanding of their theoretical framework and also promote responsive patient care.