Anti-human epidermal growth factor receptor 2 monoclonal antibody therapy for breast cancer

BACKGROUND

Advances in molecular biology and improved understanding of tumour biology have led to the development of novel treatments for cancer. Trastuzumab (Herceptin; Genentech, San Francisco, California, USA) is a monoclonal antibody directed against human epidermal growth factor receptor (HER) 2 protein, which is overexpressed in a wide variety of human cancers, including 20-30 per cent of human breast cancers. HER-2 plays an important role in oncogenic transformation, tumorigenesis and metastatic spread. Overexpression is associated with a poor prognosis and predicts a poor response to several treatment modalities.

METHOD

Literature relating to the monoclonal antibody was identified by a Medline literature search and by cross-referencing from the references of seminal articles on the subject. Four major clinical trials were identified and reviewed.

RESULTS AND CONCLUSION

In clinical trials approximately 15-20 per cent of patients with HER-2-overexpressing tumours benefited from treatment with trastuzumab. In sensitive patients the antibody appeared to have intrinsic anticancer activity when given as a single agent. In combination chemotherapy it appeared to act synergistically with other agents. Ongoing research is evaluating trastuzumab in combination with numerous standard chemotherapy regimens and with other novel chemotherapeutic agents. Clinical trials have also revealed several serious side-effects of monoclonal antibody therapy. Most notable is an unpredictable cardiotoxicity, especially when used in combination with anthracycline-based chemotherapy regimens.

Genetic characterisation of the Uruguayan Creole horse and analysis of relationships among horse breeds

The genetic variability within the Uruguayan Creole horse and its relationship to a group of geographically or historically related breeds (Spanish Pure-bred, Barb, Quarter horse, Paso Fino, Peruvian Paso, Arabian and Thoroughbred horse), was evaluated using 25 loci (seven of blood groups, nine of protein polymorphisms and nine microsatellites) analyzed on a total of 145 Uruguayan Creole horses. In this study, blood group and protein polymorphism variants that are considered to be breed markers of Spanish Pure-bred and Barb horses were detected in the Creole breed. Conversely, some microsatellites and protein polymorphisms alleles were found uniquely in the Creole horse. American horse breeds together with Barb and Arabian horses clearly formed a separate cluster from the Spanish pure-bred and Thoroughbred breeds, as shown by an UPGMA dendrogram based on Nei's standard genetic distance. Data in this study provided evidence for considerable genetic variation within Uruguayan Creole horses and of a distinctive breed profile. Both traits were most likely inherited from the XVIth century Spanish horses, more closely related to Barb than to Spanish Pure-bred.

Pregnancy-associated breast cancer

Twelve premenopausal women diagnosed with pregnancy-associated breast cancer between May 1985 and October 1999 were reviewed. Three patients were diagnosed in the first trimester of pregnancy, five in the second trimester, and three during the third trimester. There was one patient who was five weeks postpartum. At the time of diagnosis nine patients had lymph node involvement and two of these had metastatic disease. Four patients received primary chemotherapy. The remainder had surgery. Five patients died, two had metastatic disease at time of diagnosis, median survival was 31 months. There were three fetal deaths, one termination and two during primary chemotherapy. The diagnosis of breast cancer during pregnancy is difficult. Presentation is usually at an advanced stage. Surgery can be safely performed during pregnancy and adjuvant chemotherapy should not be postponed until after delivery.

Comparison of dobutamine-based and milrinone-based therapy for advanced decompensated congestive heart failure: Hemodynamic efficacy, clinical outcome, and economic impact

BACKGROUND

The use of parenteral positive inotropic agents still remains a major component of therapy for patients with advanced decompensated congestive heart failure (CHF). However, no consensus guidelines have been developed for the appropriate selection of a first-line inotropic therapy. We sought to compare the clinical outcome and economic cost of dobutamine-based and milrinone-based therapy in patients with acute exacerbation of CHF.

METHODS AND RESULTS

We retrospectively analyzed the outcome of 329 patients admitted to the heart failure unit with acute exacerbation of CHF. More patients were treated with dobutamine-based therapy (269/329, 81.7%) than with milrinone-based therapy (60/329, 18.3%). Both groups had similar baseline characteristics and similar hemodynamic profiles at baseline, with the exception of higher mean pulmonary arterial pressure in the milrinone group (47 mm Hg vs 42 mm Hg, P <.001). One hundred nine patients (40%) of the dobutamine group required parenteral nitroprusside for hemodynamic optimization compared with 11 patients (18%) in the milrinone group (P <.001). The use of parenteral nitroglycerin and dopamine was similar in both groups. There was no significant difference in the in-hospital mortality rate (dobutamine 7.8% vs milrinone 10%) or clinical outcome between the 2 groups. However, the average direct drug cost per patient was significantly reduced in the dobutamine group compared with the milrinone group ($45 +/- $10 vs $1855 +/- $350, P <.0001).

CONCLUSION

Dobutamine-based therapy is an attractive approach for the treatment of decompensated advanced heart failure, achieving comparable clinical efficacy to milrinone with a significantly reduced economic cost.

Complex high-resolution linkage disequilibrium and haplotype patterns of single-nucleotide polymorphisms in 2.5 Mb of sequence on human chromosome 21

One approach to identify potentially important segments of the human genome is to search for DNA regions with nonrandom patterns of human sequence variation. Previous studies have investigated these patterns primarily in and around candidate gene regions. Here, we determined patterns of DNA sequence variation in 2.5 Mb of finished sequence from five regions on human chromosome 21. By sequencing 13 individual chromosomes, we identified 1460 single-nucleotide polymorphisms (SNPs) and obtained unambiguous haplotypes for all chromosomes. For all five chromosomal regions, we observed segments with high linkage disequilibrium (LD), extending from 1.7 to>81 kb (average 21.7 kb), disrupted by segments of similar or larger size with no significant LD between SNPs. At least 25% of the contig sequences consisted of segments with high LD between SNPs. Each of these segments was characterized by a restricted number of observed haplotypes,with the major haplotype found in over 60% of all chromosomes. In contrast, the interspersed segments with low LD showed significantly more haplotype patterns. The position and extent of the segments of high LD with restricted haplotype variability did not coincide with the location of coding sequences. Our results indicate that LD and haplotype patterns need to be investigated with closely spaced SNPs throughout the human genome, independent of the location of coding sequences, to reliably identify regions with significant LD useful for disease association studies.

A quantitative risk assessment for the occurrence of campylobacter in chickens at the point of slaughter

A quantitative risk assessment model investigating the risk of human infection with campylobacter from the consumption of chicken meat/products is currently being formulated. Here such an approach is used to evaluate the probability that a random bird, selected at slaughter from Great Britain's national poultry flock, will be campylobacter-positive. This is determined from the probability that a flock chosen at random contains at least one colonized bird and the within-flock prevalence of such a flock at slaughter. The model indicates that the probability bird chosen at random being campylobacter-positive at slaughter is 0.53. This probability value has associated uncertainty, the 5th percentile being 0.51 and the 95th percentile 0.55. The model predicts that delaying the age at first exposure to campylobacter can have a significant impact on reducing the probability of a bird being campylobacter-positive at slaughter. However, implementation of current biosecurity methods makes this difficult to achieve.

Value of sentinel node biopsy in the management of breast cancer

AIMS

To determine the rate of detection of the sentinel node using both blue dye and radioisotope, and the accuracy with which the sentinel node histology reflects the nodal status of the axilla in a series of patients with clinically node-negative breast cancer.

PATIENTS AND METHODS

During a 32-month period from May 1998 to December 2000, 73 patients with clinically node-negative breast cancer underwent sentinel node biopsy immediately followed by formal axillary lymphadenectomy. The sentinel node(s) was identified using a combination of lymphoscintigraphy, blue dye and an intraoperative hand-held gamma probe.

RESULTS

The mean age of the 73 patients was 58 years (range 32-83 years). Twenty-six per cent (19/73) had previous surgical/excisional biopsy. Pre-operative lymphoscintigraphy was positive in 74% (54/73) of patients. Combination of blue dye and radioisotope was better than either method in isolation for identifying the sentinel node, yielding a success rate of 96% (70/73). A total of 32 cases proved to have positive nodal disease on histological examination. In 44% (14/32) of patients, the sentinel node was the only positive node. Forty-seven per cent (15/32) of patients in whom the sentinel node was positive also had positive nodes in the axillary nodal basin. There were 3/32 false negative cases, giving a false negative rate of 9.4%.

CONCLUSION

Sentinel node biopsy will have a role in the management of breast cancer. However, widespread adaptation of this technique awaits the results of prospective, randomised trials.

Safety guidelines for radiolocalised sentinel node resection

BACKGROUND

Sentinel node radiolocalisation procedures are associated with low levels of radiation exposure. Radioactive material is present in the operating theatre and pathology laboratory. In most hospitals there are no official regulations in place for sentinel node radiation exposure.

AIM

To establish guidelines on the safety of sentinel node mapping with emphasis on the management of radioisotopes.

METHODS

The current literature regarding sentinel node procedures and radiation safety was reviewed. EU and US radiation safety regulations were scrutinised.

RESULTS

Personnel involved in sentinel node procedures are exposed to low levels of radiation. These levels are not high enough to require designated radiation workers in the theatre and pathology laboratory. Awareness of radiation safety and certain precautions during the procedure and processing of the specimen can further reduce levels of exposure.

CONCLUSION

Although low levels of radiation exposure are associated with sentinel node procedures, awareness of radiation safety and adherence to regulations, along with close interdepartmental co-operation, are recommended for further reduction in radiation exposure and safe application of this technique.

Toe-to-finger transfer for post-traumatic reconstruction of the fingerless hand

OBJECTIVE

To assess the utility of toe-to-finger transfers (TFTs) for post-traumatic reconstruction of the fingerless hand.

DESIGN

A case series.

SETTING

A regional trauma centre.

PATIENTS

Eight men, mean age was 36 years (range from 25-59 yr), who had lost all the fingers from a hand due to a crush-degloving injury (6 patients), frostbite (1 patient) or a burn injury (1 patient).

INTERVENTION

TFT. Twelve TFTs were cone and the mean time from injury to reconstruction was 17.2 months.

MAIN OUTCOME MEASURES

Objective (range of motion, moving 2-point discrimination, grip strength, key pinch, Jebsen-Taylor hand assessment, return to work) and subjective (activities of daily living and a questionnaire) measures.

RESULTS

Eleven of the 12 transfers survived. Six of the 7 in whom the transfer was successful were available for follow-up (mean 45 mo). Range of motion was 10 degrees at the distal interphalangeal joint, 18 degrees at the proximal interphalangeal joint and 59 degrees at the metacarpophalangeal joint. Sensation was protective in all. Grip strength and key pinch were 26.1% and 70.2% of the contralateral hand respectively. Jebsen-Taylor assessment indicated that basic activities were possible but slowed. All 6 patients returned to work and could perform 92.6% of the activities of daily living unassisted. Hand and foot symptoms were mild. Two-thirds were appearance conscious, 5 of the 6 went on to altered vocations and all reported overall satisfaction as high.

CONCLUSION

This study supports TFT for reconstruction of the fingerless hand in that, although transferred toe function may be poorer than a normal finger, the hand is restored to a useful, sensate and versatile functional unit, such that global hand and patient function, as well as patient satisfaction, are very good.

Use of capnography in the delivery room for assessment of endotracheal tube placement

OBJECTIVE

Determine whether end-tidal CO(2) (ETCO(2)) monitoring allows for more rapid discrimination of tracheal versus esophageal intubation than standard clinical assessment during neonatal resuscitation in the delivery room.

STUDY DESIGN

Endotracheal tube (ETT) placement was assessed using either a hand-held monitor that displayed graphic and quantitative ETCO(2) by an investigator not involved in the resuscitation, or using clinical parameters by the resuscitation team unaware of the ETCO(2) data. The time differences between ETCO(2) and clinical determinations of ETT placement were compared.

RESULTS

Capnography correctly identified all 16 tracheal and 11 esophageal intubations performed on 16 study infants. The median times (and range) in seconds required for capnographic and clinical determination of tracheal intubation were 9 (4 to 26) vs. 35 (18 to 70), p<.001, and for esophageal intubation were 9 (4 to 17) vs. 30 (25 to 111), p=.001.

CONCLUSION

Capnography allowed more rapid determination of both tracheal and unintended esophageal intubation than clinical assessment.

A village would be nice but...it takes a long-acting contraceptive to prevent repeat adolescent pregnancies

OBJECTIVE

To determine which components of a comprehensive, multidisciplinary, adolescent-oriented maternity program help teenage mothers delay subsequent pregnancies.

DESIGN/SETTING/PATIENTS

A cohort of 373 participants in a comprehensive, multidisciplinary, adolescent-oriented maternity program was studied.

INTERVENTION

The program was designed to prevent rapid subsequent pregnancies directly by simplifying access to contraceptives and indirectly by discouraging school drop-out and encouraging the pursuit of careers incompatible with closely spaced childbearing. Parents and children were seen together; nine visits were scheduled during the first postpartum year and four visits during the second year.

MAIN OUTCOME MEASURE

Repeat adolescent pregnancy.

RESULTS

The repeat pregnancy rate was 14% at 1 year and 35% at 2 years. Teenage mothers who became pregnant exhibited significantly more repeat pregnancy risk factors but were as compliant with clinic visits as their nonpregnant peers. The contraceptive choices the teenagers made during the puerperium had the most profound effect on their subsequent fertility. A logistic regression analysis identified failure to use Norplant during the puerperium as the strongest predictor of repeat pregnancy during the first 2 postpartum years (relative risk [RR]=8.89; 95% confidence interval [CI]=2.80-28.50). Exhibiting nine or more repeat pregnancy risk factors (RR=2.37; 95% CI=1.38-4.06) and not using Depo-Provera during the puerperium (RR=2.30; 95% CI=1.60-3.29) also predicted repeat conception, but clinic visits and return to school postpartum did not.

CONCLUSIONS

Using a long-acting hormonal contraceptive during the puerperium was associated with pregnancy prevention during the first 2 postpartum years, but frequent clinic visits, contact with supportive healthcare and social service providers, and return to school were not.

The value of sentinel node mapping for staging melanoma

One of the most important prognostic features of malignant melanoma is the involvement of regional lymph nodes. Sentinel lymph node biopsy (SLNB) is increasingly used to stage melanoma in order to avoid lymph node dissection in patients who clinically have no lymph node involvement. We present a prospective study of 27 patients who underwent SLNB from November 1999. Lymphoscintigraphy was done on the day of surgery, and SLNB guided by blue dye and/or gamma probe performed. A sentinel node was identified in all 27 patients, mean age 46 years. The mean Breslow thickness was 1.63mm. Excision of 1-3 sentinel nodes (mean 1.5) was performed. In 3/27 patients metastatic disease was detected in the sentinel node, 2 patients had therapeutic lymph node dissections, and one had chemotherapy. There were no major complications. SLNB is a valuable technique for staging melanoma, however impact on overall survival requires longer follow up.

Adolescents at risk for mistreating their children. Part I: Prenatal identification

OBJECTIVE

To determine if the Family Stress Checklist helps prenatal care providers identify adolescents who are at risk for mistreating their children.

METHODS

We studied 262 participants in a comprehensive, adolescent-oriented maternity program. During the prenatal period, the Family Stress Checklist was used to quantify abuse potential, with scores >25 defining high risk. Information about the social context of the pregnancy and the pattern of health care utilization was obtained with a self-administered questionnaire, and by reviewing the medical records. Major disruption of primary care giving by the adolescent mother was classified hierarchically as abuse, neglect, and abandonment.

RESULTS

Family Stress Checklist scores ranged from 0 to 65 (mean + SD = 20.1 + 1.4); 113 (43%) of the 262 teenagers were classified as high risk. High and low risk adolescent mothers made an equivalent number of health maintenance and Emergency Department visits, but the high risk group initiated significantly more acute care visits (6.0 + 4.1 compared to 3.9 + 3.3; p < .0001). After controlling for pre-existing sociodemographic differences, high risk 1-year-olds were 8.41 (95% CI: 1.77-40.01) times and high risk 2-year-olds 5.19 (95% CI: 1.99-13.60) times more likely to have been mistreated than their low risk counterparts.

CONCLUSIONS

Prenatal care providers can use the Family Stress Checklist to systematically identify a subgroup of adolescent mother whose excessive use of the acute medical care services and propensity for mistreating their children suggests the need for additional support services.

Adolescents at risk for mistreating their children. Part II: A home- and clinic-based prevention program

OBJECTIVE

To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect.

METHODS

We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment.

RESULTS

Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother's custody.

CONCLUSIONS

Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children.

Developing actionable dietary guidance messages: dietary fat as a case study

Although consumers say they are concerned about nutrition and are aware that eating a healthful diet is important for good health, this knowledge does not always translate into healthful diet behaviors or motivate behavior change. In an effort to better understand consumer attitudes about nutrition and to explore alternatives for communicating dietary advice in language that is meaningful and motivates behavior change, the International Food Information Council (IFIC) conducted qualitative research with consumers (using focus groups) and registered dietitians (using telephone interviews) in 1998 and 1999. Results of the research are presented using dietary fat as a case study. Findings from the IFIC research were reported to the Dietary Guidelines Advisory Committee to assist the Committee in developing meaningful and action-oriented dietary advice related to dietary fat for inclusion in the 2000 Dietary Guidelines for Americans that would be motivating and easy for consumers to implement. The recommendation to moderate fat intake in the new dietary guideline, "Choose a diet that is low in saturated fat and cholesterol and moderate in total fat" is consistent with communication recommendations in the IFIC research. Further, the moderate fat message is empowering because it suggests an achievable dietary regimen and reduces guilt and worry about foods. It allows flexibility to enjoy desired foods and promotes using common sense when it comes to diet. Several issues emerged from the IFIC research that apply to general nutrition communications with consumers, whether it be through national nutrition recommendations or in one-on-one counseling situations: to be effective, messages to consumers about nutrition, and specifically dietary fat, must address sources of discomfort about dietary choices; they must engender a sense of empowerment; and they should motivate both by providing clear information that propels toward taking action and appeals to the need to make personal choices.

A high-resolution radiation hybrid map of the human genome draft sequence

We have constructed a physical map of the human genome by using a panel of 90 whole-genome radiation hybrids (the TNG panel) in conjunction with 40,322 sequence-tagged sites (STSs) derived from random genomic sequences as well as expressed sequences. Of 36,678 STSs on the TNG radiation hybrid map, only 3604 (9.8%) were absent from the unassembled draft sequence of the human genome. Of 20,030 STSs ordered on the TNG map as well as the assembled human genome draft sequence and the Celera assembled human genome sequence, 36% of the STSs had a discrepant order between the working draft sequence and the Celera sequence. The TNG map order was identical to one of the two sequence orders in 60% of these discrepant cases.

Tattooing, body piercing, and branding are on the rise: perspectives for school nurses

This journal presented the first nursing information on adolescents and tattooing 6 years ago, and 5 years ago, information was provided about body piercing. These were published to help school nurses assist adolescents become informed decision makers. Another purpose was to prevent risks and, if possible, help dissuade adolescents from tattooing and body piercing. Continuing this theme, the latest information and trends are reported and discussed, and new information on scarification and branding is presented. If an adolescent wants some form of body art (tattooing, body piercing, or branding), they will often obtain it regardless of regulations, risks, or money. School nurses can take a powerful, proactive role by sharing applicable information, realistic concerns, and care instructions about tattooing, body piercing, and branding. Specific information, risks, and care about each form of procedure is presented. A convenient reference table is available for nurses and students. Additionally, nursing actions are suggested including making changes in health policies regarding body art on a local and state level.

Evaluation of the fluorescence polarization assay and comparison to other serological assays for detection of brucellosis in cervids

The complement fixation test (CFT), competitive enzyme immunoassay (CELISA), indirect enzyme immunoassay (IELISA) and fluorescence polarization assay (FPA) were evaluated for the detection of antibodies to Brucella abortus and Brucella suis biotype 4 in caribou (Rangifer tarandus caribou), elk (Cervus elapus), red deer (Cervus elapus), and reindeer (Rangifer tarandus tarandus). When combining the data the FPA and the CELISA were determined to be the most suitable tests for serodiagnosis of Cervidae. The overall actual sensitivity of the CFT and the IELISA was 100%. The overall actual sensitivity for the CELISA and FPA was 99%. The overall relative specificity of the CFT (including treatment of anti-complementary data as positive or negative for analysis), the CELISA, the IELISA and the FPA were 65%, 93%, 99%, 99%, and 99%, respectively. The specificities of the buffered plate agglutination test (BPAT), the CFT, the CELISA, the FPA and the IELISA for 55 elk vaccinated with B. abortus strain 19 and tested 4 mo post vaccination were 14%, 31%, 51%, 84%, and 2%, respectively. The FPA is the diagnostic test of choice because it has sensitivity and specificity values comparable to the CELISA; it has the capability to distinguish vaccinal antibody and antibody resulting from exposure to cross-reacting organisms such as Yersinia enterocolitica 0:9 from antibody to Brucella spp. in most cases; it is technically simple to do; it is adaptable to field use and it is relatively inexpensive.

Using a fading procedure to increase fluid consumption in a child with feeding problems

Stimulus fading was combined with differential reinforcement and extinction to increase intake of a calorie-dense fluid by a 6-year-old child with feeding problems. The fading procedure consisted of adding Carnation Instant Breakfast and then milk to water (a fluid the child would drink).