Breast cancer survival and the timing of tumor removal during the menstrual cycle

In a retrospective cohort study of 262 premenopausal breast cancer patients treated at the Mayo Clinic between 1965 and 1985, we investigated whether survival was associated with the timing of tumor removal during the menstrual cycle. Participants were women < or = 50 years old who had not used exogenous hormones, been pregnant, been lactating, or given birth within 6 months of diagnosis. The menstrual cycle day at surgery was used to assign women to group 1 (cycle days 0-7), group 2 (cycle days 8-15), or group 3 (after cycle day 15). Cox proportional hazards analysis adjusting for age at diagnosis, stage, tumor size, grade, and node involvement showed a nonsignificantly worse survival for group 2 than for group 3 [hazard ratio (HR), 1.41; 95% confidence interval (CI), 0.89-2.23]. Stratification revealed that the association between survival and timing of tumor removal during the menstrual cycle was slightly stronger among patients with stage II disease (adjusted HR, 1.56; 95% CI, 0.92-2.63). The association was the same among patients with stage II disease and node involvement (adjusted HR, 1.57; 95% CI, 0.82-3.03). Prospective studies using hormone measurements to define menstrual cycle status more accurately than the reported day of the menstrual cycle could provide further insight about the postulated association.

Magnetic resonance imaging of the pediatric airway

OBJECTIVE

To determine the role of magnetic resonance imaging (MRI) and how it relates to endoscopy as well as to other imaging modalities in the evaluation of pediatric airway disorders.

DESIGN

A review study of children with various distal airway disorders over a 3-year period. Surgical procedures as well as all diagnostic imaging modalities were reviewed and analyzed with respect to clinical outcome.

SETTING

Academic tertiary care children's hospitals.

PATIENTS

Forty-nine children between the ages of 1 week and 14 years with the signs and symptoms of distal airway disorders.

INTERVENTIONS

Forty-five of 49 children underwent airway endoscopy. Fourteen children also underwent fluoroscopy and 4 underwent echocardiography. When indicated, open surgical repair was performed and used to verify findings in 32 cases.

RESULTS

Magnetic resonance imaging was the most accurate modality in defining extrinsic airway abnormalities. The findings of echocardiography were incorrect in 2 of 4 cases, and fluoroscopy, although accurate for tracheal narrowing and tracheomalacia, often could not elucidate that exact cause or missed left mainstem bronchial compression. Furthermore, tracheal narrowing to 50% or greater on MRI correlated 100% with the need for surgical intervention.

CONCLUSIONS

Magnetic resonance imaging is a useful modality that has allowed us to accurately diagnose extrinsic pediatric tracheal abnormalities. In certain cases, MRI scans can be obtained prior to endoscopy. In those cases, definitive endoscopy and open repair are performed at the same procedure instead of at 2 separate procedures (ie, one for diagnostic endoscopy and the other for definitive repair).

Identification and characterization of two novel SH2 domain-containing proteins from a yeast two hybrid screen with the ABL tyrosine kinase

To further our understanding of the molecular mechanism of Bcr-Abl mediated transformation, a yeast two hybrid screen was used to identify proteins binding to the Abl tyrosine kinase. Two partial cDNAs encoding novel SH2 domain-containing proteins were cloned and designated Shd and She. Both have homology to Shb, a previously reported SH2 domain-containing protein. Northern blot analysis showed that She is expressed in heart, lung, brain, and skeletal muscle, while expression of Shd is restricted to the brain. The deduced amino acid sequence of the full length mouse Shd cDNA contains an amino-terminal proline-rich region, and a carboxyterminal SH2 domain. A bacterially expressed Shd domain bound multiple tyrosine-phosphorylated proteins with relative molecular weights of 200, 170, 130, 100, 90, 78, 72 and 32 kDa from K562 cell lysates. Shd contains five YXXP motifs, a substrate sequence preferred by Abl tyrosine kinases. Shd was tyrosine phosphorylated in COS-7 cells co-transfected with Shd and c-Abl or Bcr-Abl. These results suggest that Shd may be a physiological substrate of c-Abl and may function as an adapter protein in the central nervous system.

Reproductive history, use of exogenous hormones, and risk of colorectal adenomas

Evidence suggests a role for reproductive and hormonal factors in the etiology of colorectal cancer. Investigation of adenomas, the presumed precursors of cancer, and reproductive characteristics may place such associations within a particular stage of carcinogenesis. We examined parity, age at first birth, age at menopause, and age at menarche as well as contraceptive and noncontraceptive hormone use in a case-control study of 347 women (115 cases with adenomas and 232 controls) conducted in North Carolina. Using unconditional logistic regression analysis, increasing age at menopause was found to be associated with a reduction in the risk of adenomas [odds ratio (OR), 0.26; 95% confidence interval (CI), 0.10-0.68]. An increased risk for adenomas was found for women undergoing surgical menopause as compared with women undergoing natural menopause (OR, 2.10; 95% CI, 1.05-4.21). Our results suggest a reduced risk of adenomas associated with noncontraceptive hormone use that was limited to a subgroup of women with natural menopause or bilateral oophorectomy (OR, 0.39; 95% CI, 0.15-0.97). No associations were seen between other reproductive characteristics and adenomas. These results suggest protective effects for both endogenous and exogenous female hormones that operate early in the process of carcinogenesis. Alternatively, lifestyle factors or other correlates of exogenous hormone use and delayed menopause could play a role in reduced adenoma risk.

Genetic influences on changes in body mass index: a longitudinal analysis of women twins

Numerous studies have demonstrated genetic influences on body fat, but there also may be genetic effects on its intraindividual variation over time. This study examined changes in body mass index (BMI) using longitudinal data from two examinations of the Kaiser Permanente Women Twins Study, performed a decade apart. The analysis included 630 women, 185 monozygotic and 130 dizygotic twin pairs, with average ages of 41 years and 51 years at the two examinations, respectively. Age-adjusted heritability estimates for the change in BMI over the decade ranged from 0.57 to 0.86 (all p < or = 0.001) using three different statistical analysis approaches, indicating that at least half and possibly as much as 85%+, of the variance in the change in BMI is attributable to genetic influences under a polygenic model. These estimates remained statistically significant after adjusting for environmental factors (ranging from 0.57 to 0.78) and with additional adjustment for BMI at baseline (ranging from 0.41 to 0.79), although dizygotic intraclass correlations were low after these adjustments. Thus, in addition to known environmental and behavioral influences, these results provide evidence for genetic influences on changes in BMI over a decade in women.

Computed tomography grade of splenic injury is predictive of the time required for radiographic healing

It is largely unknown when a child who has suffered a splenic laceration can return to full unrestricted activity. The purpose of this prospective study is to establish whether the grade of splenic injury is predictive of the length of time required for radiographic healing, and to determine whether there are any adverse long-term sequelae after resumption of unlimited activity. Sixty-nine patients underwent successful nonoperative management (NOM) of computed tomography (CT)-documented splenic injury over a 4-year period. Fifty-eight patients completed follow-up. Mean age was 9.8 years (range, 1 to 17) and mean injury severity score (ISS) was 14.4 (range, 4 to 38). Mechanisms of injury were motor vehicle accident (n = 11), motor vehicle pedestrian (n = 5), falls (n = 13), bike crashes (n = 12), sports (n = 8), all-terrain vehicle (n = 4), and horse (n = 5). The CT-documented injury was identified by discharge ultrasound scan (US) in all cases. There were no long-term complications. Mean time to US healing in grade I (n = 9), II (n = 26), III (n = 19), IV (n = 4) injuries was 3.1, 8.2, 12.1, and 20.7 weeks, respectively. P values were significant (P < .01) in all cases when compared with the next lower injury grade. The time to radiographic healing is directly proportional to the severity of the splenic injury. There was excellent correlation between the initial CT scan and identification of the injury on the discharge US. No long-term complications leg, delayed splenic rupture, splenic pseudocyst) were seen in this study. Pediatric patients who have suffered splenic injury can safely return to full unrestricted activity when the US documents healing.

Acupuncture in the prevention of postoperative nausea and vomiting

The efficacy of intra-operative acupuncture at the PC6 point in the prevention of postoperative nausea or vomiting was studied. A double-blind randomised controlled study of acupuncture versus placebo was performed in 81 patients scheduled for day case gynaecological laparoscopic surgery. Failure of treatment was defined as the occurrence of nausea or vomiting prior to or within 24 h of discharge. The use of acupuncture reduced the incidence of postoperative nausea or vomiting in hospital from 65% to 35% compared with placebo and after discharge from 69% to 31% compared with placebo.

Heritability of longitudinal changes in coronary-heart-disease risk factors in women twins

Numerous studies have demonstrated genetic influences on levels of coronary heart disease (CHD) risk factors, but there also may be genetic effects on the intraindividual variation in these risk factors over time. Changes in risk factors are likely to reflect genetic-environmental interactions and may have important implications for understanding CHD risk. The present study examines the heritability of changes in CHD risk factors, using data from the two examinations by the Kaiser Permanente Women Twins Study, performed a decade apart. The sample consisted of 348 pairs of women twins who participated in both examinations, including 203 MZ pairs and 145 DZ pairs. Average ages at the two examinations were 41 and 51 years, respectively. By means of three different statistical analytic approaches, moderate heritability estimates were demonstrated for changes in LDL cholesterol (h2 = .25-.36) and in HDL cholesterol (h2 = .23-.58), some of which were statistically significant. Although small to moderate heritability estimates were found for systolic blood pressure (.18-.37; P < .05 for some estimates), no genetic influence on changes in diastolic blood pressure was detected. Based on longitudinal twin data in women, this study demonstrates a genetic influence on changes in both lipoprotein risk factors and systolic blood pressure over a decade. In addition to environmental factors, which clearly are operating, the effect of various "variability genes" may be acting independently of the genetic influences on the absolute levels of these risk factors. Both mapping the gene(s) underlying intraindividual variations in these CHD risk factors and understanding their function(s) could lead to targeted intervention strategies to reduce CHD risk among genetically susceptible individuals.

Diagnosis and management of left main stem bronchus compression

There are four major variants of congenital vascular tracheal compression: innominate artery, aberrant subclavian, aorta or aortic arch anomaly, and pulmonary artery sling. These forms of vascular compression typically involve the trachea and/or the right main stem bronchus. We present eight cases of congenital vascular compression involving the left main stem bronchus. These cases represent a poorly understood variant of vascular tracheal compression. This variant represents approximately 10% of our pediatric tracheobronchial compression or stenosis patients. The finding, both noted endoscopically and now illustrated by magnetic resonance imaging, is caused by compression of the left main stem bronchus between the descending aorta and a portion of the pulmonary artery. Frequently, the descending aorta is in an abnormal anterior position with relation to the thoracic spine. Recognition of this entity is important in our experience and has influenced clinical management. In four of eight children, it required a surgical procedure directed toward the relief of the left main stem compression.

Esophageal atresia/tracheoesophageal fistula and associated congenital esophageal stenosis

BACKGROUND

The association of congenital stenosis of the distal esophagus (CES) in children with esophageal atresia/tracheoesophageal fistula complex (TEF) has been described but is thought to be rare. Most reports have been of individual or small numbers of cases.

OBJECTIVE

The objective of the study was to evaluate the incidence, clinical and radiographic features of CES associated with TEF, and to compare the clinical and radiographic features of CES with acquired anastomotic strictures in TEF patients.

MATERIALS AND METHODS

A retrospective review was undertaken of the records and radiographs of 225 infants with primary TEF repair over a 26-year period.

RESULTS

A total of 18 of 225 (8 %) cases of CES associated with TEF and 43 of 225 (19 %) cases of anastomotic strictures were identified. CES was typically a relatively long, smooth circumferential narrowing at the junction of the mid-esophagus and distal esophagus, with normal-caliber esophagus above and below; anastomotic strictures, in contrast, were focal. Diagnosis of CES was delayed in 10 cases and missed on one or more fluoroscopic studies in 14 children. Symptoms, including feeding and respiratory problems and foreign body impaction, were common in both CES and anastomotic strictures; repeated esophageal dilatations were usually necessary. Esophageal perforation complicated dilatation in 6 (33 %) young children with CES, but none of the children with anastomotic strictures (P < 0.001).

CONCLUSION

CES in combination with TEF is not rare and usually produces clinical symptoms. The diagnosis may be missed or delayed unless specifically evaluated surgically and radiologically. Esophageal dilatation in CES is potentially hazardous with a high risk of perforation, especially in young children.

A high proportion of novel mutations in BRCA1 with strong founder effects among Dutch and Belgian hereditary breast and ovarian cancer families

We have identified 79 mutations in BRCA1 in a set of 643 Dutch and 23 Belgian hereditary breast and ovarian cancer families collected either for research or for clinical diagnostic purposes. Twenty-eight distinct mutations have been observed, 18 of them not previously reported and 12 of them occurring more than once. Most conspicuously, a 2804delAA mutation has been found 19 times and has never been reported outside the Netherlands. A common haplotype spanning > or = 375 kb could be identified for each of the nine examined recurrent mutations, indicating the presence of multiple BRCA1 founder mutations in the Dutch population. The 2804delAA mutation has been estimated to have originated approximately 32 generations ago. No specific breast or ovarian cancer phenotype could be assigned to any of the common mutations, and the ovarian cancer incidence among 18 families with the 2804delAA mutation was heterogeneous.

Intrapericardial left atrial aneurysm: noninvasive diagnosis

Intrapericardial aneurysm of the left atrium is a rare cardiac anomaly. We present a 10-year-old girl in whom the diagnosis was made following referral for an abnormal configuration of the left heart border seen on chest radiography. Diagnosis was made by echocardiography, but magnetic resonance imaging defined the exact morphology and the relation to adjacent structures. Surgical removal of this aneurysm is recommended because of potentially serious complications.

Familial and personal medical history of cancer and nervous system conditions among adults with glioma and controls

The causes of glioma, the most common type of primary malignant brain tumor, are poorly understood. This study compared the personal and first-degree familial medical histories of 462 adults newly diagnosed with glioma in the San Francisco Bay Area between August 1, 1991, and March 31, 1994, with those of 443 controls who were frequency-matched on age, sex, and ethnicity. Cases and controls had equivalent personal histories of cancers other than brain cancer and most nervous system conditions, but they differed significantly regarding histories of epilepsy, seizures, or convulsions 3 or more years prior to diagnosis (odds ratio = 3.3, 95% confidence interval (CI) 1.4-7.9), chickenpox (odds ratio = 0.4, 95% CI 0.3-0.6), and shingles (odds ratio = 0.5, 95% CI 0.3-0.8). Four cases (less than 1%) and no controls had known genetic disorders (three had neurofibromatosis and one had tuberous sclerosis). Cases and controls had similar family histories of cancer and seizures. However, the odds ratio for a validated family history of primary brain tumor was 2.3 (95% CI 1.0-5.8). These results suggest that although family history of any cancer probably is not an important risk factor for adult glioma, a family history of brain tumors may play a role. Variation in exposure to or biologic response to common viral infections might play a greater role in the etiology of adult glioma than family history.

Teaching deception skills in a game-play context to three adolescents with autism

Baron-Cohen (1992) found that students with autism are impaired in their ability to deceive. A multiple-baseline across-subjects design was conceptualized to test the hypothesis that such students could be taught to deceive. Two conditions were presented in baseline and treatment phases. In Condition 1, the student guessed in which hand a small object was hidden when the experimenter presented two closed fists. In Condition 2, the student hid the object and presented two closed fists to the experimenter for a guess. Reinforcement was delivered contingently upon independent guessing during Condition 1 in both baseline and treatment phases. Under Condition 2, reinforcement was delivered noncontingently during the baseline phase and contingently upon successive approximations to the target behavior of deception during the treatment phase. All students displayed the acquisition of at least three of the responses included in the deception response during the baseline phase, and two students showed an erratic acquisition of the total skill during the baseline phase. Results indicate that students with autism can learn to deceive, even without formal intensive training.

Employment status and high blood pressure in women: variations by time and by sociodemographic characteristics

PURPOSE

The association between employment status and high blood pressure in women was examined at two time periods to determine if associations between employment status and high blood pressure varied by time period or by age, race, education, marital status, or parental status.

METHODS

Women participants from the National Health Examination Survey (1960) and the Second National Health and Nutrition Survey (1976-1980) between the ages of 25 and 64 and currently employed or keeping house were included. Logistic regression analysis was used to examine the cross-sectional association between employment status and high blood pressure in each survey, taking into account potential effect modifiers and covariates.

RESULTS

In 1960 employment was associated with a slight, but not statistically significant, elevation in odds of high blood pressure. In 1976-1980, it was associated with a modest but significant reduction in odds of high blood pressure. Variations in associations occurred by marital status (protective associations were limited to unmarried women) and race (associations were of stronger magnitude among African-American women).

CONCLUSIONS

The employment status-high blood pressure relationship shifted across surveys. Changes in the composition of the employed and nonemployed groups account for at least part of the varying relationships.

Interactive effects of depression symptoms, nicotine dependence, and weight change on late smoking relapse

Signal detection methods were used to develop an algorithm useful in distinguishing those at risk for late relapse from those likely to maintain abstinence. Four subgroups with 24-month survival (nonrelapse) rates ranging from 79% to 33% were identified. Among participants whose depression symptoms decreased from baseline to the end of treatment, lower levels of nicotine dependence were associated with less relapse at the 24-month follow-up (odds ratio = 2.77; 95% confidence interval: 1.36-5.62). Among participants whose depression symptoms increased from baseline to the end of treatment, greater weight gain was associated with less relapse at follow-up (odds ratio = 2.90; 95% confidence interval: 1.41-5.96). This study suggested that it may become possible to use both baseline and treatment information to "titrate" interventions.

MR evaluation of right pulmonary agenesis and vascular airway compression in pediatric patients

OBJECTIVE

The purpose of this study was to evaluate the spectrum of airway and vascular anomalies in agenesis of the right lung and to assess the role of imaging in defining the anatomy.

CONCLUSION

Symptomatic children with right lung agenesis often have anatomic distortion of the airway with vascular compression, and occasionally they have intrinsic airway stenosis. MR imaging most accurately defines the entire spectrum of airway and vascular anatomic abnormalities. Precise delineation of the anatomy is essential in patient management and surgical planning.

Internal hernia and volvulus of the small bowel following liver transplantation

Internal herniation with volvulus of the small intestine is an uncommon, but potentially fatal, complication after liver transplantation. We present here four cases in which the herniation occurred around the Roux-en-Y loop used for the biliary reconstruction. One patient died due to intestinal and liver allograft necrosis; another lost almost the entire small intestine and has since undergone successful intestinal transplantation. Two patients survived following surgery that involved reduction of the hernia and closure of the mesenteric defect. Clinical diagnostic implications emphasize early diagnosis and appropriate operative intervention.

Splenic lymphangiomatosis in children

PURPOSE

To study the clinical and imaging features of splenic lymphangiomatosis.

MATERIALS AND METHODS

The clinical and abdominal imaging data of 10 children with splenic lymphangiomatosis were retrospectively reviewed. The modalities used in the study included computed tomography (CT) (10 patients), sonography (five patients), and magnetic resonance (MR) imaging (two patients). Pathologic confirmation of lymphangiomatosis was obtained in nine patients.

RESULTS

Splenic lymphangiomatosis was discovered incidentally in all cases and was a key finding in enabling the correct diagnosis in six children with extrasplenic disease as well. Only two children had clinical splenomegaly. Sonograms and MR images showed multiple, wEll-defined cysts. Multiple, low-attenuation lesions that did not enhance with intravenous administration of contrast material (n = 8) or a mottled spleen (n = 2) were seen at CT. One of the mottled spleens had target lesions on an early (arterial) image obtained after administration of a bolus of contrast material. One child underwent a splenectomy; one child underwent therapeutic embolization. Eight patients remained asymptomatic with respect to the spleen 1-20 years later.

CONCLUSION

Splenic lymphangiomatosis is often an incidental imaging finding that frequently has a characteristic imaging appearance. The recognition of this appearance helps in diagnosis of this disease and may prevent the need for further invasive procedures. Splenic changes can be isolated or can coexist with bone or soft-tissue lymphangiomas.

Interactive effects of depression symptoms, nicotine dependence, and weight change on late smoking relapse

Signal detection methods were used to develop an algorithm useful in distinguishing those at risk for late relapse from those likely to maintain abstinence. Four subgroups with 24-month survival (nonrelapse) rates ranging from 79% to 33% were identified. Among participants whose depression symptoms decreased from baseline to the end of treatment, lower levels of nicotine dependence were associated with less relapse at the 24-month follow-up (odds ratio = 2.77; 95% confidence interval: 1.36-5.62). Among participants whose depression symptoms increased from baseline to the end of treatment, greater weight gain was associated with less relapse at follow-up (odds ratio = 2.90; 95% confidence interval: 1.41-5.96). This study suggested that it may become possible to use both baseline and treatment information to "titrate" interventions.

Left pulmonary artery sling: diagnosis and delineation of associated tracheobronchial anomalies with MR

BACKGROUND

The left pulmonary artery sling anomaly (SLPA) has generated controversy about its diagnosis, imaging and management particularly with regard to associated tracheobronchial anomalies. Objective. To evaluate the role of MR imaging in defining airway and vascular relationships in SLPA.

MATERIALS AND METHODS

Retrospective review of the imaging and clinical records of three children with SLPA who underwent MRI including three dimensional image reconstruction. MR was compared and correlated with other imaging methods: plain chest radiographs (3); bronchoscopy (3); barium esophagram (1); echocardiography (2); cineangiography (2).

RESULTS

MRI was vastly superior to other methods for clearly depicting airway and vascular anatomy and interrelationships. Good quality imaging and safe sedation was easily achieved in young infants. MR also provided accurate noninvasive evaluation of the reconstructed pulmonary artery and airway postoperatively.

CONCLUSION

MR is capable of differentiating the two subtypes of SLPA. Specific delineation of vascular and airway anatomy and spatial relationships is essential for surgical management: reimplantation of LPA in type I and both LPA reimplantation and airway reconstruction in type II because of associated long segment airway stenosis.