Doping of GaN by Ion Implantation: Does it Work?

Epitaxially grown GaN by metal organic chemical vapor deposition (MOCVD) on SiC were implanted with 100 keV Si+ (for n-type) and 80 keV Mg+ (for p-type) with various fluences from 1×1012 to 7×1015 ions/cm2 at liquid nitrogen temperature (LT), room temperature (RT), and 700 °C (HT). High temperature (1200 °C and 1500 °C) annealing was carried out after capping the GaN with epitaxial AIN by MOCVD to study damage recovery. Samples were capped by a layer of AIN in order to protect the GaN surface during annealing. Effects of implant temperature, damage and dopant activation are critically studied to evaluate a role of ion implantation in doping of GaN. The damage was studied by Rutherford Backscattering/Channeling, spectroscopic ellipsometry and photoluminescence. Results show dependence of radiation damage level on temperature of the substrate during implantation: implantations at elevated temperatures up to 550 °C decrease the lattice disorder; “hot implants” above 550 °C can not be useful in doping of GaN due to nitrogen loss from the surface. SE measurements have indicated very high sensitivity to the implantation damage. PL measurements at LT of 80 keV Mg+ (5×1014 cm-2) implanted and annealed GaN showed two peaks : one ∼100 meV and another ∼140 meV away from the band edge.

Pathways through services for offenders with intellectual disability: a one- and two-year follow-up study

The pathways through services for offenders with intellectual disability were reviewed. Participants were 197 offenders with intellectual disability accepted into three types of community and three types of secure forensic intellectual disability services. They were first compared with 280 participants referred but not accepted into services and were then followed-up for 2 years to review pathways through services. Those accepted into services had a higher charge rate than did those who were referred (46% and 25%, respectively). The greatest diversity in pathway was seen in participants in community forensic intellectual disability and inpatient services. Individuals in secure settings showed the least diversity over time, and, similarly, a relatively high percentage of those accepted into generic community services remained in these services.

Referrals into services for offenders with intellectual disabilities: variables predicting community or secure provision

BACKGROUND

There is a need for research to promote an understanding among service developers on why people with intellectual disabilities (ID) are referred to offender services in order for them to receive appropriate assessment and treatment. Previous studies investigating referrals into forensic ID services have concentrated on referral sources and administrative variables such as legal status.

AIMS

To construct a predictive model for choice of service referral based on a comprehensive range of information about the clientele.

METHOD

We conducted a case record study of 336 people referred to community services and 141 to secure provision. We gathered information on referral source, demographics, diagnosis, index behaviour, prior problem behaviours and history of abuse.

RESULTS

Comparisons revealed 19 candidate variables which were then entered into multivariate logistic regression. The resulting model retained six variables: community living at time of referral, physical aggression, being charged, referral from tertiary health care, diverse problem behaviour and IQ < 50, which correctly predicted the referral pathway for 85.7% of cases.

CONCLUSIONS

An index act of physical aggression and a history of diversity of problem behaviours as predictors against the likelihood of community service referral suggest that professionals have similar concerns about people with ID as they do about their more average offending peers; however, the more severe levels of ID mitigated in favour of community referral, regardless. Offenders with ID tend to be referred within levels of service rather than between them, for example, form tertiary services into generic community services.

Evaluation of Adjuvant! Online to predict the effect of optimal endocrine therapy (ovarian function suppression plus tamoxifen) for premenopausal breast cancer patients with estrogen-receptor-positive breast cancer

585

Background: Adjuvant! Online (AOL) is a user-friendly, web-based tool that provides estimates of adjuvant therapy outcomes for individual patients. While reliable evidence underpins estimates for most patient cohorts, there is a paucity of data on the effect of adding chemotherapy to complete estrogen blockade for premenopausal women with estrogen-receptor positive breast cancer. Methods: International Breast Cancer Study Group (IBCSG) Trial 11–93 enrolled 174 premenopausal women with estrogen-receptor positive, node-positive breast cancer from 1993 to 1998. Fifty percent of patients had 1 positive axillary lymph node and 97% had between 1 and 3 positive nodes. Patients were randomized to receive ovarian function suppression plus five years of tamoxifen with or without chemotherapy. The estimated hazard rates and corresponding 10-year relapse-free survival percents obtained from Trial 11–93 data (Breast Cancer Res Treat. 2009;113:137–144) were compared with those predicted using AOL. Results: The 10-year relapse-free survival percents predicted from AOL were 64.4% (95% CI, 61.9% to 67.2%) for endocrine therapy alone and 74.9% (95% CI, 73.1% to 76.8%) for chemoendocrine therapy. By contrast, these estimates in Trial 11–93 were 76.4% (95% CI, 65.8% to 84.0%) for endocrine therapy alone and 74.9% (95% CI, 64.5% to 82.7%) for chemoendocrine therapy. The AOL estimate for the endocrine alone control group is lower than that observed in Trial 11–93 (p = 0.03), while the estimates for the two chemoendocrine therapy groups are similar. Conclusions: AOL appears to underestimate the effectiveness of adjuvant endocrine therapy alone for premenopausal women with endocrine responsive breast cancer, thus overestimating the added benefit - if any - from chemotherapy for this patient population. Prospective clinical trials addressing the question are warranted.

No significant financial relationships to disclose.

Phase II study of induction and adjuvant bevacizumab in patients with stage IB-IIIA non-small cell lung cancer (NSCLC) receiving induction docetaxel and cisplatin

7531

Background: VEGF supports growth of NSCLC and is blocked by bevacizumab. Bevacizumab with chemotherapy is an established treatment for advanced NSCLC. We conducted this study to assess the efficacy and toxicity of induction bevacizumab (Bev) with cisplatin (C) and docetaxel (D) in patients with resectable NSCLC. Methods: All patients (pts) had resectable Stage IB-IIIA NSCLC and received up to 4 cycles of D 75 mg/m2 and C 75 mg/m2 followed by surgery. Pts with non-squamous NSCLC also received 3 cycles of Bev 15 mg/kg along with induction DC (Bev-DC). Bev was not given in pre-operative cycle 4. Pts with squamous or central tumors or hemoptysis received 4 cycles of DC only (DC). All resected pts were eligible for adjuvant Bev 15 mg/kg q3 weeks for 1 year. The primary endpoint was rate of downstaging from pre-operative clinical stage to pathologic stage. Results: From Aug 2005 - Nov 2008, 47 pts were enrolled: 27 women; median age 62; Stage 1B -15%, Stage II-17%, Stage IIIA-68%. Of 36 pts given Bev-DC, 15/30 (50%) who have completed surgery were downstaged. Of 11 pts given DC, 3/11 (27%) were downstaged. In Bev-DC group, 22/33 (67%) completed all 4 cycles of DC without a dose reduction and 28/33 pts (85%) completed all 3 planned cycles of Bev. Pts received <3 cycles due to: hemoptysis (n=3), consent withdrawal (n=1), hypertension (n=1), and sepsis (n=1). For DC, 6/11 pts (55%) completed all 4 cycles of DC without a dose reduction. 42/43 patients were resected. R0 resection rate: 29/31 for Bev-DC and 9/11 for DC. Grade 3/4 surgical complications were seen in 5/31 pts (16%) in Bev-DC and 1/11 (9%) in DC. Only 17/41 (41%) who completed surgery received adjuvant bev (median 6 cycles), and 7/41 (17%) completed all adjuvant Bev. Pts did not receive adjuvant Bev due to: POD prior to adjuvant Bev (n=9), POD during adjuvant Bev (n=6), toxicity (n=4), consent withdrawal (n=1), RT for unresectable disease (n=1), surgical complications (n=4), chemotherapy complications (n=4). No treatment related deaths. Conclusions: Induction chemotherapy with Bev-DC in NSCLC is feasible and is associated with an improved rate of downstaging compared with historical controls (33%). In patients treated with DC-Bev, grade 3/4 surgical complications were increased by 7%.

[Table: see text]

Engagement and retention in specialist services for people with personality disorder

OBJECTIVE

To quantify levels of engagement and retention in specialist services for people with personality disorder (PD).

METHOD

Demographic and clinical data were collected on referrals to 10 specialist services for people with PD. Follow-up data on retention and drop-out from services were collected over the following 30 months.

RESULTS

Seven hundred and thirteen (60.1%) of 1186 people referred to services were taken by them, of whom 164 (23.0%) subsequently dropped out prior to the completion of an episode of care. Men, younger people and those with higher levels of personality disturbance were less likely to complete a package of care.

CONCLUSION

Specialist community-based services for adults with PD are able to engage most of those that are referred to them, but further efforts need to be made to find ways to engage younger people and men with PD.

Pilot study of a novel educational programme for 11-16 year olds with type 1 diabetes mellitus: the KICk-OFF course

AIMS

To pilot an educational programme (KICk-OFF) for children and adolescents with type 1 diabetes mellitus (DM). Evaluation included (i) independent assessment of curriculum quality, (ii) acceptability to families and (iii) possible impact on standardised outcome measures (HbA1c, body mass index (BMI), diary reports of hypoglycaemia, quality of life (QoL)).

METHODS

48 children aged 11-16 years (mean age 13.60 (SD 1.36) years) were recruited from three UK centres. Six 5-day outpatient courses on carbohydrate counting and insulin dose adjustment were held. Semi-structured interviews were conducted with children and parents before and after the course. Glycaemic control (HbA1c), BMI and frequency of hypoglycaemia were assessed before the course and at 3 and 6 months after intervention. QoL was assessed before the course and at 2 weeks, 3 and 6 months.

RESULTS

Educational evaluation indicated the course format was appropriate and consistent. Parent and child interviews suggested that pre-course expectations were largely met. There were no changes in HbA1c, BMI or episodes of hypoglycaemia, but children and parents reported improved QoL (p<0.05).

CONCLUSIONS

KICk-OFF was well-received by children and parents and was associated with improved QoL. In this small pilot study, glycaemic control did not change but findings justify conducting a future randomised controlled trial involving a revised curriculum, a larger study population including a control group and longer follow-up.

Selective PKC beta inhibition with ruboxistaurin and endothelial function in type-2 diabetes mellitus

PURPOSE

Type-2 diabetes mellitus increases risk of atherosclerotic cardiovascular disease. However, the mechanisms linking hyperglycemia and atherosclerosis remain poorly understood. One proposed mechanism involves endothelial dysfunction via activation of protein kinase C beta (PKC beta). Prior studies demonstrate beneficial effects of PKC beta inhibition on microvascular parameters, but, to date, no study has examined the effect on macrovascular atherosclerotic readouts.

METHODS

The goal of this double-masked, placebo-controlled trial in type-2 diabetes was to assess the effect of the PKC beta-specific inhibitor, ruboxistaurin (32 mg/day for 6 weeks) on ultrasound assessed brachial artery flow mediated dilatation (FMD), a surrogate of macro vascular endothelial function, and urinary isoprostanes, indices of oxidant stress.

RESULTS

Compared to placebo, ruboxistaurin tended to improve FMD (difference in 6-week change in FMD, mean +/- SD millimeter) at one (0.13 +/- 0.26 mm, p = 0.08) and 5 min (0.12 +/- 0.21 mm, p = 0.02) after cuff deflation, but had no effect on nitroglycerin-mediated dilatation or urinary isoprostanes.

CONCLUSIONS

This proof of concept trial is the first to suggest that specific inhibition of PKC beta may improve macro vascular endothelial function in type-2 diabetes. Larger trials including clinical endpoints are warranted to determine the potential efficacy of PKC beta inhibition in reducing atherosclerotic cardiovascular complications in diabetes mellitus.

Elation or frustration? Outcomes following the provision of equipment during the Communication Aids Project: data from one CAP partner centre

BACKGROUND

The Communication Aids Project (CAP) was a 4-year initiative by the UK Department for Education and Skills to provide communication equipment for students who were unable to speak in order to facilitate their access to education. Each child was given three goals or targets which were then evaluated after 6 months of provision of the communication aid.

METHODS

We evaluated the targets of 60 children, between the ages of 3 and 18 years. Six months after receipt of equipment, the targets were mailed to the initial referrer who was requested to record whether the child had achieved, partially achieved or not achieved each target. Evidence and explanations of these outcomes were also requested. Data were analysed using descriptive statistics, and the explanations were grouped into common themes using a keyword analysis.

RESULTS

Sixty-three per cent of targets were not achieved and 36% were achieved. We investigated any possible associations to attempt to explain some of the possible reasons for the children's non-achievement of targets. Targets were grouped into operational, linguistic, social and academic, but there were no differences between the successes because of target type. Age may be an influence on success, but neither school placement or type of communication aid influenced success. The explanations for non-achievement highlighted the misunderstanding or interpreting of the underlying skills of the communication aid user as a potential cause.

CONCLUSION

The CAP raised the profile of children with Augmentative and Alternative Communication needs within education. However, only one-third of the targets of children using the equipment were achieved. The reasons for this include inappropriate provision of equipment, demands of the equipment, lack of appropriate support and targets. The major consequence, however, is the need for detailed assessment and provision appropriate to the individual needs of each child. There is a need for research into the best methods of providing communication aids and the support needed for successful communication.

Anaesthetic considerations for interventional neuroradiology

In the past decade, the neuroradiological diagnosis and treatment of cerebrovascular diseases has undergone significant advances. With the introduction of varying diagnostic and interventional neuroradiological techniques and advances in the materials used for endovascular treatment, increasingly complex diagnostic and therapeutic neuroradiological procedures are being performed on extremely sick patients. As the interventional neuroradiology field expands, the neuroanaesthetist will become more involved in management of patients undergoing neuroradiological procedures. This produces challenges for the neuroanaesthetist, and understanding the anaesthetic implications of the current developments in neuroradiology is important in the management of these patients. This review provides an overview of diagnostic and therapeutic neuroradiological procedures, with special reference interventional neuroradiology, and the anaesthetic management of patients undergoing these procedures.

Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series

OBJECTIVES

To investigate the effect of reinforcing a narrow-spectrum antibiotic policy on antibiotic prescription and Clostridium difficile infection (CDI) rates by feedback of antibiotic use to doctors, as part of a departmental audit and feedback programme.

DESIGN

A prospective controlled interrupted time-series (ITS) study, with pre-defined pre- and post-intervention periods, each of 21 months.

SETTING

Three acute medical wards for elderly people in a teaching hospital.

PARTICIPANTS

Six thousand one hundred and twenty-nine consecutive unselected acute medical admissions aged >or=80 years.

INTERVENTIONS

A 'narrow-spectrum' antibiotic policy (reinforced by an established programme of audit and feedback of antibiotic usage and CDI rates) was introduced, following an unplanned rise in amoxicillin/clavulanate (Augmentin) use. It targeted broad-spectrum antibiotics for reduction (cephalosporins and amoxicillin/clavulanate) and narrow-spectrum antibiotics for increase (benzyl penicillin, amoxicillin and trimethoprim). Changes in the use of targeted antibiotics (intervention group) were compared with those of untargeted antibiotics (control group) using segmented regression analysis. Changes in CDI rates were examined by the Poisson regression model. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition rates acted as an additional control.

RESULTS

There was a reduction in the use of all targeted broad-spectrum antibiotics and an increase in all targeted narrow-spectrum antibiotics, statistically significant for sudden change and/or linear trend. All other antibiotic use remained unchanged. CDI rates fell with incidence rate ratios of 0.35 (0.17, 0.73) (P=0.009). MRSA incidence did not change [0.79 (0.49, 1.28); P=0.32].

CONCLUSIONS

This is the first controlled prospective ITS study to use feedback to reinforce antibiotic policy and reduce CDI. Multicentre ITS or cluster randomized trials of this and other methods need to be undertaken to establish the most effective means of optimizing antibiotic use and reducing CDI.

Big brown dog or brown big dog? An electrophysiological study of semantic constraints on prenominal adjective order

Event-related brain potentials (ERPs) were recorded while participants read and made acceptability judgments about sentences containing three types of adjective sequences: (1) normal sequences--e.g., Jennifer rode a huge gray elephant; (2) reversed sequences that violate grammatical-semantic constraints on linear order--e.g., *Jennifer rode a gray huge elephant; and (3) contradictory sequences that violate lexical-semantic constraints on compositionality--e.g., *Jennifer rode a small huge elephant. Relative to the control condition, the second adjective elicited a reduced N400 and an enhanced P600 in both the reversal condition and the contradiction condition. We present several alternative accounts of these two effects, but favor an interpretation which treats them as reflecting semantic and syntactic aspects of a temporary reanalysis of the adjective order construction. Furthermore, relative to the control condition, the final noun elicited a robust N400 in the contradiction condition but not in the reversal condition. We suggest that this effect indexes the full registration of the lexical-semantic incompatibility of the two adjectives in the contradiction condition. Finally, we discuss how all of these findings fit into the broader context of recent ERP studies that have reported atypical N400s and robust P600s in response to certain types of semantic anomalies.

Endothelial dysfunction: a link among preeclampsia, recurrent pregnancy loss, and future cardiovascular events?

We tested the hypothesis that endothelial dysfunction could cause placentation-related defects, persist after the complicated pregnancy, and probably cause cardiovascular disease later in life. Brachial arterial reactivity and factors related to endothelial dysfunction, such as circulating cholesterol, uric acid, nitrites, l-arginine, asymmetrical dimethylarginine, vascular endothelial growth factor, and soluble vascular endothelial growth factor receptor-1, in women with previous healthy pregnancies (n=22), patients with severe preeclampsia (n=25), or patients with recurrent pregnancy loss (n=29), at day 10 of the luteal phase of an ovulatory cycle an average of 11 to 27 months after pregnancy were evaluated. Both groups with placentation defects had a significant decrease in endothelium-dependent dilatation, a higher rate of endothelial dysfunction, lower serum nitrites, and higher cholesterol as compared with control subjects; subjects with previous preeclampsia additionally had higher normal blood pressures and a greater parental prevalence of cardiovascular disease. Patients with recurrent pregnancy loss also demonstrated a significantly lower endothelium-independent vasodilatation. A trend to an inverse correlation was found between serum cholesterol serum and endothelial-mediated vasodilatation in the whole study population. Uric acid, l-arginine, asymmetrical dimethylarginine, vascular endothelial growth factor, and soluble vascular endothelial growth factor receptor-1 were similar in all of the groups. We postulate that endothelial dysfunction may represent a link between preeclampsia and increased cardiovascular disease latter in life and propose that women with unexplained recurrent miscarriages are also at increased cardiovascular risk. The identification and correction of endothelial dysfunction detected during the reproductive stage on obstetric outcome and on cardiovascular diseases needs to be elucidated.

Serum Uric Acid: A Risk Factor and a Target for Treatment?

Serum uric acid was first noted to be associated with increased BP by Frederick Mohamed in the 1870s. Although the link was rediscovered periodically over the years, it generally was dismissed as a surrogate marker for decreased renal function that led to increased uric acid and increased risk for hypertension and cardiovascular (CV) disease. Recently, however, several lines of evidence suggest that increased serum uric acid may be a significant modifiable risk factor. Increased serum uric acid is associated with increased risk for future hypertension in several large longitudinal clinical trials as well as an independent risk factor for poor CV prognosis. Animal model experiments demonstrate that increased serum uric acid causes increased BP that initially is reversible but becomes irreversible, salt sensitive, and uric acid independent over time. The mechanisms include the direct action of uric acid on smooth muscle and vascular endothelial cells. Finally, in adolescents with new-onset essential hypertension, the prevalence of elevated serum uric acid is >90%, and preliminary clinical trial evidence suggests that agents that lower serum uric acid may lower BP in this select population. Although the investigations are still preliminary, serum uric acid represents a possible new and intriguing target for the reduction of morbidity and mortality associated with hypertension and CV disease.

Haptoglobin beta chain isoforms in the plasma and peritoneal fluid of women with endometriosis

OBJECTIVE

To estimate the expression of haptoglobin (Hp) beta chain isoforms in the peritoneal fluid (PF) and plasma (PL) of women with and without endometriosis.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Seventy-two patients with endometriosis and 35 controls.

INTERVENTION(S)

Peritoneal fluid and PL samples were subjected to two-dimensional gel electrophoresis, silver stained, digitally captured, and compared by semiquantitative computerized analysis.

MAIN OUTCOME MEASURE(S)

Expression of Hp beta chain isoforms.

RESULT(S)

No significant difference was observed in the frequency of expression of the Hp beta chain isoforms between the two groups. One beta chain isoform (HpbetaE; molecular weight, 38.40 +/- 0.94 kD; and isoelectric point, 5.63 +/- 0.17) had significantly higher expression in both the PF and PL of women with endometriosis than in the PF and PL of controls. No significant difference was observed in HpbetaE expression between women with mild (revised American Fertility Society [rAFS], stage I-II) and severe (rAFS, stage III-IV) endometriosis. In the control group, HpbetaE expression was correlated with the phase of the menstrual cycle.

CONCLUSION(S)

Women with endometriosis have higher PF and PL levels of HpbetaE. Further investigation should be aimed at producing antibodies against the HpbetaE-specific epitopes to determine whether its measurement may improve the clinical diagnosis of endometriosis.

Bispectral index monitoring may not reliably indicate cerebral ischaemia during awake carotid endarterectomy † †This study was conducted in the Department of Neurosurgery, Newcastle General Hospital, Newcastle Upon Tyne NE4 6BE, UK. Preliminary results were presented at the British Neurosurgery Research Group Meeting, Sheffield, March 29–30, 2001

BACKGROUND

Intraoperative ischaemia during carotid cross-clamping in patients undergoing carotid endarterectomy (CEA) is a major complication and prompt recognition of insufficient collateral blood supply is crucial. Electroencephalogram (EEG) is believed to be one of the useful forms of monitoring cerebrovascular insufficiency during CEA. The aim of this study was to evaluate the utility of bispectral index (BIS) monitoring, a processed EEG parameter, for the reliable detection of intraoperative cerebral ischaemia during awake CEA.

METHODS

We monitored 52 patients continuously with the BIS monitor together with assessment of neurological function (contralateral upper and lower limb strength and the verbal component of the Glasgow Coma Scale for speech) in patients undergoing awake CEA.

RESULTS

Overall mean BIS value in all patients was 96 (SD 2.9). In five patients who showed clinical evidence of cortical ischaemia during carotid cross-clamping, there was no change in the original range of BIS values throughout the procedure (96.7 [3.2]). In one patient BIS values decreased to 38 about 5 min after the incision and recovered within the next 10 min. The mean BIS value in the remaining 46 patients who did not develop clinical signs of ischaemia was 95.4 (2.6). Three cases are presented which demonstrate the inability of the BIS monitor to detect cerebral ischaemia.

CONCLUSIONS

Lack of correlation of BIS with the signs of cerebral ischaemia during CEA makes it unreliable for detection of cerebrovascular insufficiency. We conclude that awake neurological testing is the preferred method of monitoring in these patients.

Adolescents' and their parents' views on the acceptability and design of a new diabetes education programme: a focus group analysis

BACKGROUND

The present study was conducted as part of an ongoing project to develop an innovative educational intervention for young people with type 1 diabetes. We aimed to seek the views of children and adolescents with type 1 diabetes and their parents regarding (i) the acceptability of the new programme and (ii) practical aspects regarding course design and delivery.

METHODS

Twenty-four children and 29 parents attended one of eight separate focus groups. Semi-structured interview schedules were developed around two main areas of discussion: views on the education programme; and views on the design and delivery of current and future education. Discussions were tape-recorded and transcribed, before undergoing systematic qualitative analysis.

RESULTS

Participants agreed that the proposed intervention was feasible, and were enthusiastic that it could improve quality of life and 'normality'. Potential problems included self-management during school-time and parental anxiety. In terms of course design/delivery, participants emphasized the need to maximize enjoyment on the course (e.g. integrating fun and practical sessions, holding parts of the course outside of the clinic setting), and encourage effective learning and adherence to the regimen (e.g. including separate parent education, and using IT-based reference material).

CONCLUSIONS

The qualitative methodology proved an effective way of eliciting child and parent views and informing the development of the proposed intervention. These findings can now be incorporated into the development of the education programme.

Toremifene and tamoxifen are equally effective for early-stage breast cancer: first results of International Breast Cancer Study Group Trials 12-93 and 14-93

BACKGROUND

Toremifene is a chlorinated derivative of tamoxifen, developed to improve its risk-benefit profile. The International Breast Cancer Study Group (IBCSG) conducted two complementary randomized trials for peri- and postmenopausal patients with node-positive breast cancer to compare toremifene versus tamoxifen as the endocrine agent and simultaneously investigate a chemotherapy-oriented question. This is the first report of the endocrine comparison after a median follow-up of 5.5 years.

PATIENTS AND METHODS

1035 patients were available for analysis: 75% had estrogen receptor (ER)-positive primary tumors, the median number of involved axillary lymph nodes was three and 81% received prior adjuvant chemotherapy.

RESULTS

Toremifene and tamoxifen yielded similar disease-free (DFS) and overall survival (OS): 5-year DFS rates of 72% and 69%, respectively [risk ratio (RR)=0.95; 95% confidence interval (CI)=0.76-1.18]; 5-year OS rates of 85% and 81%, respectively (RR = 1.03; 95% CI = 0.78-1.36). Similar outcomes were observed in the ER-positive cohort. Toxicities were similar in the two treatment groups with very few women (<1%) experiencing severe thromboembolic or cerebrovascular complications. Quality of life results were also similar. Nine patients developed early stage endometrial cancer (toremifene, six; tamoxifen, three).

CONCLUSIONS

Toremifene is a valid and safe alternative to tamoxifen in postmenopausal women with endocrine-responsive breast cancer.

Site of primary tumor has a prognostic role in operable breast cancer: the international breast cancer study group experience

PURPOSE

Cancer presenting at the medial site of the breast may have a worse prognosis compared with tumors located in external quadrants. For medial tumors, axillary lymph node staging may not accurately reflect the metastatic potential of the disease.

PATIENTS AND METHODS

Eight-thousand four-hundred twenty-two patients randomly assigned to International Breast Cancer Study Group clinical trials between 1978 and 1999 were classified as medial site (1,622; 19%) or lateral, central, and other sites (6,800; 81%). Median follow-up was 11 years.

RESULTS

A statistically significant difference was observed for patients with medial tumors versus those with nonmedial tumors in disease-free survival (DFS; 10-year DFS, 46% v 48%; HR, 1.10; 95% CI, 1.02 to 1.18; P = .01) and overall survival (10-year OS 59% v 61%; HR, 1.09; 1.01 to 1.19; P = .04). This difference increased after adjustment for other prognostic factors (HR, 1.22; 95% CI, 1.13 to 1.32 for DFS; and HR, 1.24; 95% CI, 1.14 to 1.35 for OS; both P = .0001). The risk of relapse for patients with medial presentation was largest for the node-negative cohort and for patients with tumors larger than 2 cm. In the subgroup of 2,931 patients with negative axillary lymph nodes, 10-year DFS was 61% v 67%, and OS was 73% v 80% for medial versus nonmedial sites, respectively (HR 1.33; 95% CI, 1.15 to 1.54; P = .0001 for DFS; and HR 1.40; 95% CI, 1.17 to 1.67; P = .0003 for OS).

CONCLUSION

Tumor site has a significant prognostic utility, especially for axillary lymph node-negative disease, that should be considered in therapeutic algorithms. New staging procedures such as biopsy of the sentinel internal mammary nodes or novel imaging methods should be further studied in patients with medial tumors.

Rational development of LEA29Y (belatacept), a high-affinity variant of CTLA4-Ig with potent immunosuppressive properties

Current success in organ transplantation is dependent upon the use of calcineurin-inhibitor-based immunosuppressive regimens. Unfortunately, current immunotherapy targets molecules with ubiquitous expression resulting in devastating non-immune side effects. T-cell costimulation has been identified as a new potential immunosuppressive target. The best characterized pathway includes CD28, its homologue CTLA4 and their ligands CD80 and CD86. While an immunoglobulin fusion protein construct of CTLA4 suppressed rejection in rodents, it lacked efficacy in primate transplant models. In an attempt to increase the biologic potency of the parent molecule a novel, modified version of CTLA4-Ig, LEA29Y (belatacept), was constructed. Two amino acid substitutions (L104E and A29Y) gave rise to slower dissociation rates for both CD86 and CD80. The increased avidity resulted in a 10-fold increase in potency in vitro and significant prolongation of renal allograft survival in a pre-clinical primate model. The use of immunoselective biologics may provide effective maintenance immunosuppression while avoiding the collateral toxicities associated with conventional immunsuppressants.