Impact of recipient obesity on living donor kidney transplant outcomes: a single-center experience

The number of overweight and obese patients undergoing renal transplantation has drastically increased in the last two decades. Studies on graft survival and complication rates of these obese patients have had conflicting results, with some reporting a significant risk and others reporting relatively good outcomes. We examined 1-year outcomes in obese and nonobese patients who underwent living donor transplants at our transplant program, a slightly different approach than prior studies of deceased donor transplants into patients with high body mass index (BMI). The mean serum creatinine clearance by the modified MDRD equation at the end of 1 year in the nonobese group was 58.9 mL/min whereas the mean creatinine clearance in the obese group was 48.9 mL/min (P = .09). The length of stay, incidence of delayed graft function, and 1-year graft survival did not differ between the obese and nonobese groups. The results of this single-center experience with living donor transplant into obese subjects suggest no differences in outcomes with regard to surgical or wound complications, delayed graft function, or serum creatinine at 1 year.

An overview of the history, clinical practice concerns, comparative studies and strategies to optimize therapy of bypassing agents

Despite significant advances in the treatment of haemophilia, including availability of recombinant coagulation factor replacement products and the use of prophylactic infusion regimens, the segment of haemophilic patients who develop inhibitory antibodies remain at higher risk for morbidity and mortality associated with recurrent or uncontrolled bleeding events. Bypassing agents represent the mainstay of treatment and prevention of bleeding. The most commonly used of the currently available therapeutic agents are a plasma-based therapy, factor eight inhibitor bypassing activity, vapour heated, and a recombinant therapy, NovoSeven (recombinant activated factor VIIa). A substantial body of literature exists to document efficacy and adverse event profiles for these two products. There is, however, a paucity of data arising from adequately powered prospective trials to determine optimal treatment and dosing in various clinical situations. Certain clinical circumstances, patient profiles, individual responses, or provider predilection may lead to preferential use of one of these products over the other; however, the continued presence of both agents in the therapeutic armamentarium remains critically important to this fragile population. The historical use, clinical practice concerns, published comparative studies and methods for optimization of these two bypassing agents are reviewed.

In vivo response-adapted dose-dense (dd) doxorubicin and cyclophosphamide (AC) –> weekly carboplatin and albumin-bound paclitaxel (nab-TC)/trastuzumab (H)/bevacizumab (B) in large and inflammatory breast cancer (BC): A phase II study

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Background: We showed high pathologic complete remission (pCR) rate with dd AC weekly (wkly) cremophor(c)-TCH in HER2+ BC in contrast to dd AC c-TC in HER2- BC (SABCS 2005). We substituted nab-T for c-T, and added B in HER2- BC to exploit the known synergy between the two in preclinical models. Methods: Pts received in vivo response-adapted 2–4 cycles of AC with G/GM-CSF followed by wkly 9–12 nab-T at 100 mg/m2 and C (AUC of 2), 3 wks on, 1 wk off. HER2+ patients (pts) received concurrent 12–16 wkly H (4mg/kg induction, 2mg/kg maintenance) and HER2- pts received 6–8 bi-wkly B (10 mg/kg). 37 of the proposed 43 pts with stage II-IV BC have been enrolled. Median age is 53 (range 32–76). Results: Median ejection fraction by echocardiogram was 67% (55–78) at baseline, 65% (55–80) after 2 cycles of dd AC and 66% (55–68) following nab-TCH. Additionally, no clinical cardiac dysfunction demonstrated. Adverse event with dd AC included neutropenic fever in 2 pts. 8 of 88 dd AC cycles administered were delayed by =1 wk. Of the 37 pts evaluated, 30 were switched to nab-TCH/TCB after 2 cycles of AC for less than 50% tumor reduction and 7 completed 4 cycles. Adverse event with nab- TCH/TCB included grade III arthralgia in 2 pts and TIA in 1 pt. pCR was documented in 5 of 8 HER2+ after nab-TCH, and 3 of 10 HER2- tumors after nab-TCB. Across the spectrum of stage II-IV, inflammatory and lobular carcinoma, tumors were reduced to ≤ 5 mm in first 7 of 8 (87.5%) HER2+ and 8 of 10 (80%) HER2- BC. Progression free survival at a median follow-up of 6 months (range 2–15 month) remains 100%. Conclusion: Induction chemotherapy with dd AC followed by wkly targeted chemotherapy is well tolerated. Additionally, limiting the exposure of AC to 2 cycles in resistant BC may reduce the known cumulative cardiac toxicity and yet allow the targeting of different clones in a heterogeneous BC population.

[Table: see text]

Improving outcomes from acute kidney injury (AKI): Report on an initiative

Acute Kidney Injury (AKI) is a complex disorder for which currently there is no accepted definition. We describe an initiative to develop uniform standards for defining and classifying AKI and establish a forum for multidisciplinary interaction to improve care for patients with, or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a 2-day conference in Amsterdam in September 2005 to draft consensus recommendations for diagnosing and staging AKI. This report describes the proposed diagnostic and staging criteria for AKI and the formation of a multidisciplinary collaborative network.

Self-expanding stents for recanalization of acute cerebrovascular occlusions

BACKGROUND AND PURPOSE

Stent-assisted revascularization increases prevailing recanalization rates ( congruent with 50%-69%) for vessel occlusions recalcitrant to thrombolytics. Although balloon-mounted coronary stents can displace thrombus (via angioplasty) and retain clot along vessel walls, intracranial self-expanding stents are more flexible and exert less radial outward force during deployment, increasing deliverability and safety. To understand the effectiveness of self-expanding stents for recanalization of acute cerebrovascular occlusions, we retrospectively reviewed our preliminary experience with these stents.

MATERIALS AND METHODS

Eighteen patients (19 lesions) presenting with a clinical diagnosis of acute stroke underwent catheter-based angiography documenting focal occlusion of an intracranial artery. A self-expanding stent was delivered to the occlusion and deployed. Stent placement was the initial mechanical maneuver in 6 cases; others involved a combination of pharmacologic and/or mechanical maneuvers prestenting. GP IIb/IIIa inhibitors were administered in 10 cases intraprocedurally or immediately postprocedurally to avoid acute in-stent thrombosis.

RESULTS

Stent deployment at the target occlusion (technical success) was achieved in all cases. Thrombolysis in Cerebral Ischemia (TICI)/Thrombolysis in Myocardial Ischemia (TIMI) 2/3 recanalization (angiographic success) was achieved in 15 of 19 lesions (79%). All single-vessel lesions (n=8) were recanalized, but only 7 of 11 combination internal carotid artery and middle cerebral artery lesions were recanalized. No intraprocedural complications occurred. Seven in-hospital deaths occurred: stroke progression, 4; intracranial hemorrhage, 2; respiratory failure, 1. Seven patients had >or=4-point National Institutes of Health Stroke Scale improvement within 24 hours after the procedure, 6 had modified Rankin Score (mRS) <or=3 at discharge, and 4 had mRS <or=3 at 3 months. Overall, revascularization and improvement in clinical outcome were more likely to occur in women.

CONCLUSION

Feasibility of self-expanding stents for treatment of acute symptomatic intracranial occlusions is shown. For single-vessel lesions, stent placement with concomitant administration of IIb/IIIa inhibitors contributed to the achievement of recanalization rates exceeding those currently reported for other means of thrombolysis.

Facial motor function monitored by hand held calipers versus computer-assisted photography

BACKGROUND

It is essential to have easy to use, reliable tools to assess and compare facial function for clinical records, audit and research purposes. In this study, two different techniques were examined, Hand held calipers (HHC, as described by Burres), and computerised analysis of digital photographs (CAOP) using Adobe Photoshop 7. The aim of this study was to determine the level of agreement between two operators (physiotherapist) using HHC to measure the distance between facial landmarks, and the level of agreement between two operators (photographers) using CAOP to measure the same distance between facial landmarks and explore whether these two techniques can be used interchangeably.

METHOD

The distance between facial landmarks was measured, with the face at rest and following four standard facial expressions. All measurements were repeated one week later to permit inter/intra-rater reliability over time to be assessed. Nine female volunteers with normal facial function were included in the study.

RESULTS

The intra- and inter-rater agreement using CAOP was high whereas the agreement was low when using HHC.

CONCLUSION

Hand held calipers proved to be an unreliable technique for monitoring facial function. However digital photography when combined with Adobe Photoshop 7 provides a highly reliable objective measurement tool. It was simple to use, low cost and suitable for use in a clinical environment.

Intrauterine neutrophil activation is associated with pulmonary haemorrhage in preterm infants

BACKGROUND

Clinical and experimental studies showing lung damage associated with biologically active neutrophil derivatives suggests the possibility that intrauterine neutrophil activation may predispose to the development of pulmonary haemorrhage in extremely low birthweight infants early after birth.

OBJECTIVES

To assess neutrophil functional activity in cord blood from extremely low birthweight infants who subsequently developed severe pulmonary haemorrhage.

METHODS

Neutrophil functional activity was evaluated in the cord blood of preterm neonates (gestational age <28 weeks and weight <800 g) who developed pulmonary haemorrhage (n = 6) and in controls who did not (n = 6). Infants with congenital abnormalities and noteworthy maternal complications such as diabetes, pre-eclampsia, haemorrhagic disorders, and connective tissue disease were excluded. Neutrophils isolated from cord blood immediately after delivery were tested to evaluate neutrophil chemotaxis, random motility, and chemiluminescence. Standard methodology was used.

RESULTS

Chemotaxis and chemiluminescence of neutrophils from cord blood of infants with pulmonary haemorrhage was higher than in the controls (34.8 (2.0) v 28.6 (0.8) microm, p<0.001, and 95.8 (8.5) v 73.2 (3.6) cpm x10(3), p<0.001 respectively). Random motility of cord blood neutrophils was comparable in the two groups (28.6 (1.2) v 25.3 (1.2) microm, p<0.09).

CONCLUSIONS

Intrauterine induction of chemotactic activity and metabolic oxygenation of neutrophils may predispose to the development of pulmonary haemorrhage in extremely low birthweight infants with respiratory distress early after birth.

Measuring autonomy in disabled people: validation of a new scale in a UK population

Objective: To evaluate the validity and reliability of an English version of the Impact on Participation and Autonomy Questionnaire (IPA). The original Dutch IPA has been shown to load onto five factors.

Design: A validation study.

Setting: Outpatients clinics and people’s homes.

Subjects: Two hundred and thirteen people with multiple sclerosis, rheumatoid arthritis, spinal cord injury, and general practice attendees, stratified by level of disability (median age 54, 42% male, 58% female). Inclusion criteria: English as first language, aged 18-75, Mental Status Questionnaire score >6.

Interventions: Self- and interviewer-administered outcome measures.

Main measures: IPA, including one new item (66 participants completed the IPA on a second occasion).

Other measures: Short Form-36 Health Survey (SF-36), London Handicap Scale, three domains of the Functional Limitations Profile (FLP): household management, social integration, emotion.

Results: Confirmatory factor analysis confirmed the construct validity of the IPA (Normal Fit Index=0.98, Comparative Fit Index=0.99), indicating a good fit to the model. Convergent and discriminant validity were confirmed by the predicted associations, or lack of, with the exception of a poor association between the ‘social life/relationships’ IPA subscale and FLP-emotion. Internal reliability of the IPA was confirmed (Cronbach alphas >0.8; item-total correlations for all subscales >0.5). Test-retest reliability was confirmed for all items (weighted kappas >0.6) and subscales (intraclass correlation coefficients >0.90).

Conclusions: The English IPA is a valid, reliable and acceptable measure of participation and autonomy in people with a range of conditions and can make a unique and fundamental contribution to outcome assessment. Further research is required to examine the responsiveness of the IPA to change over time, its clinical utility and suitability for use with people from ethnic minorities and with older people.

Azurin, highly potent and selective anticancer agent for breast cancer

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Background: The use of live or attenuated pathogenic bacteria in the treatment of cancer dates back to the late nineteen hundreds when William B. Coley first reported that inducing Streptococcal infection resulted in tumor regression. However, the hazards of using live bacteria are obvious. Similarly, the results of using attenuated bacteria have been spotty and enthusiasm for it has waxed and waned. Recently, we have shown that redox protein azurin (14 kDa) secreted by an opportunistic pathogen, Pseudomonas aeruginosa, is not only cytotoxic to cancer cells in vitro but also produces tumor regression in athymic mice without producing any toxicity (PNAS, 99, 14098–14103, 2002; Science’s STKE, 158, tw416, 2002). Methods: In this study, we show the effect of 1mg/kg of azurin injected i.p. starting 72 hours after inoculation of 5x107 MCF-7 breast cancer cells in estradiol pretreated nude mice for 28 days (n = 20, control = 10, azurin-treated = 10). Results: Univariate analysis of the data showed the difference in tumor growth rates between control animals and azurin-treated animals was significant. For instance, 22 days after the start of treatment, the mean tumor volume in azurin-treated animals was only 22% of the mean tumor volume in the control mice (i.e., 0.0267 cm3 + 0.124 cm3 respectively, P = 0.0179 Kruskal-Wallis test). At the end of the experiment on the 29th day there was a reduction in the tumor volume by 85% in the treated group. We used a multivariate model, where the tumor growth over time was taken to be exponential with coefficients that were subject specific mixed effect (For control, tumor volumes = exp (−4.23 + 0.06 time) while for the treated group it was tumor volume = exp (−4.23 + 0.03 time)). The difference is statistically significant (P = 0.0456). Taken together, this in vivo data shows azurin exerts an inhibitory effect in the growth and progression of MCF-7 tumor xenotransplants. During the 28 days of treatment, treated animals did not show any sign of toxicity. Conclusions: Bacterial redox protein azurin can be explored as a novel therapeutic agent for treatment of breast cancer. Recently, we have prepared a truncated version of azurin which has 28 amino acids. It appers that this chemically synthesized peptide (2.8 kDa) has similar properties as azurin.

No significant financial relationships to disclose.

Acute decompensated heart failure: best evidence and current practice

Heart failure (HF) is one of the leading cardiovascular health problems in Europe and the United States. Acute decompensated HF remains a lethal diagnosis with a morbidity and mortality that often exceeds neoplastic or infective diseases. The incidence of HF continues to increase despite an intensive effort to increase education and delivery of healthcare to these affected patients. Yet, current guidelines in the United States do not address the management of acute decompensated HF, and focus predominantly on chronic stable systolic HF as well as patients with left ventricular dysfunction. Although the European Society of Cardiology has established some parameters for the management of acute HF, these guidelines are largely established by expert opinion, and are predominantly devoid of prospective randomized data in this cohort of patients. Current pharmacotherapies for acute decompensated HF include diuretics, neurohormonal antagonists, vasodilators, and inotropes. Regrettably, all of these drugs have their limitations in acute HF. Neurohormonal antagonists reduce morbidity and mortality, but may be inadequate to achieve and maintain the necessary hemodynamic relief required in advanced HF; while, bolus diuretics, a mainstay of initial symptomatic relief, may be maladaptive and up-regulate adverse neurohormonal regulatory mechanisms longterm with no positive impact on longterm mortality. Today, for those advanced HF patients who remain symptomatic despite optimal conventional therapy, limited treatments exist; but as newer therapies evolve, the options will expand to include more than palliative care, heart transplant and ventricular assist devices for these patients.

An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales

OBJECTIVES

To survey of the structure, processes and organisation of renal satellite units (RSUs) in England and Wales (Phase 1), and to compare the effectiveness, acceptability, accessibility and economic impact of chronic haemodialysis performed in RSUs compared to main renal units (MRUs) (Phase 2).

DATA SOURCES

Phase 1: all renal satellite units in England and Wales. Phase 2: haemodialysis patients in a representative sample (based on geography, site, private--public ownership, medical input) of 12 RSUs and their MRUs.

REVIEW METHODS

Phase 1 consisted of a questionnaire survey. Semi-structured interviews were held in a representative sample of 24 RSUs with the senior clinician, senior nurse and manager. Phase 2 consisted of a cross-sectional comparison of patients in these RSUs and patients in the parent MRUs deemed suitable for satellite care by senior staff. Clinical information was obtained from medical notes and unit computer systems. Generic and disease specific health-related quality of life (HRQoL) measures were used. Co-morbidity was assessed by the Wright/Khan Index, the Lister/Chandna score, the Modified Charlson Index, and the Karnofsky Performance Score. Statistical analyses compared RSU versus MRU patients and took account of the paired and clustered nature of the data.

RESULTS

In Phase 1, responses were received from 74/80 (93%) of RSUs; 2600 patients were being treated in these RSUs. The interviews were generally positive about the impact of RSUs in terms of improved accessibility and a better environment for chronic haemodialysis (HD) patients, and in expanding renal replacement therapy patients (RRT) capacity. In Phase 2, some 82% of eligible patients took part, 394 patients in the 12 RSUs and 342 in the parent MRUs. The response rate was similar in both groups. There were no significant differences in clinical processes of care. Most clinical outcomes were similar, especially after pooled analysis, although a few parameters were statistically significantly different -- notably the proportion achieving Renal Association Standards for adequacy of dialysis as measured by the urea reduction ratio (URR) was higher in the RSU patients. Patient-specific quality of life did not differ except on the patient satisfaction questions from the KDQOL, which were scored higher by the RSU sample. Strength of preference for health status on and off dialysis was very similar between the groups, as were EQ-5D utilities. Major adverse events were not common in the RSU patients, although there were many hypotensive episodes on HD, a proportion of which affected the duration of the HD session. Of the costs measured, the only difference that was statistically significant was for District Nurse visits. Of particular note was that despite the MRU group having a higher proportion of patients hospitalised, this did not translate into a statistically significant budgetary impact in terms of the total cost per patient of hospitalisations or mean cost per patient per hospitalisation.

CONCLUSIONS

This study has shown that RSUs are an effective alternative to MRU HD for a wide spectrum of patients. They improve geographic access for more dispersed areas and reduce patients' travel time, and are generally more acceptable to patients on several criteria. There does not seem to be an adverse impact of care in the RSUs although comparative long-term prospective data are lacking. The evidence suggests that satellite development could be successfully expanded; not all MRUs have any satellites and many have only a few. No single RSU model can be recommended but key factors would include local geography, the likely catchment population and the type of patients to be treated. There is a need for more basic budgetary information linking activity and expenditure to be available and more transparent, to perform at least an insightful top-down costing of the two care settings. Other areas suggested for further research include: a comparison of adverse events occurring in MRUs and RSUs with longer duration and larger numbers to identify more severe events, along with the more research into the scope for preventing such events, and a study into the patients deemed ineligible for satellite care. International comparisons of satellite care would also be useful.

Biopsy of the prostate guided by transrectal ultrasound: relation between warfarin use and incidence of bleeding complications

AIM

To determine the relation between warfarin use and the frequency of bleeding complications after biopsy of the prostate guided by transrectal ultrasound (TRUS).

METHODS

Overall, 1022 consecutive patients with suspected prostatic disease were followed after biopsy. Warfarin and aspirin use was determined on the day of the procedure. A TRUS-guided biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. Follow-up telephone calls were made to those who had not replied within the stipulated period.

RESULTS

Of the 1000 patients who replied, 49 were receiving warfarin, 220 were receiving aspirin and 731 were not receiving any anticoagulant drugs. Of the 49 subjects reporting current use of warfarin, 18 (36.7%) experienced haematuria, compared with 440 (60.2%) of the patients receiving no anti-coagulant drugs who reported haematuria. This was statistically significant (p = 0.001). Of the group receiving warfarin, 4 (8.2%) experienced haematospermia whereas 153 (21%) of the group receiving no anticoagulant medication reported haematospermia. This difference also was statistically significant (p = 0.030). Rectal bleeding was experienced by 7 (14.3%) of the group receiving warfarin compared with 95 (13%) in the group without anticoagulant medication, but this was not statistically significant (p = 0.80). We also demonstrated that there was no statistically significant association between the severity of the bleeding complications and medication with warfarin.

CONCLUSION

None of the group receiving warfarin experienced clinically important bleeding complications. Our results suggest that the frequency and severity of bleeding complications were no worse in the warfarin group than in the control group and that discontinuing anticoagulation medication before prostate biopsy may be unnecessary.

The body mass index is a less-sensitive tool for detecting cases with obesity-associated co-morbidities in short stature subjects

OBJECTIVE

To assess the ability of the body mass index (BMI) to detect obesity-associated morbidity in subjects with a normal or short stature.

METHODS

Information was obtained on 119 975 subjects from a cardiovascular risk factors detection program. Standardized questionnaires were used. Capillary glucose and cholesterol concentrations were measured. Diabetes, arterial hypertension and hypercholesterolemia were selected as end points. Sensitivity, specificity and the likelihood ratio for several BMI thresholds were calculated. ROC curves were constructed to identify the BMI cutoff points with best diagnostic performance. The area under the curve (AUC) was used to assess the proficiency of BMI.

RESULTS

Short stature (height </=150 cm for women or </=160 cm for men) was found in 24 854 subjects (20.7%). These cases had a higher prevalence of type II diabetes and arterial hypertension even after adjusting for confounding variables. In addition, the frequency of the abnormalities was higher even at the lowest BMI values; the prevalence increased in direct proportion with the BMI, but at a lower rate compared to cases with normal stature. The AUC for every co-morbidity was smaller in short stature subjects. The likelihood ratio for detecting co-morbidities increased at the same BMI value in subjects with or without short stature.

CONCLUSIONS

The prevalence of obesity-associated co-morbidities is higher in subjects with short stature compared to those without it. The proficiency of BMI as a diagnostic tool is poor in short stature subjects. This problem is not resolved by decreasing BMI thresholds used to define overweight.

The failing Fontan circulation: successful conversion of atriopulmonary connections

OBJECTIVES

Symptoms from low cardiac output or refractory atrial arrhythmias are complicating atriopulmonary (classical) Fontan connections. We present our experience of converting such patients to total cavopulmonary connections with and without arrhythmia surgery.

METHODS

Between 1997 and 2002, 15 patients (mean age, 19.7 +/- 7.0 years) underwent conversion operations 12.7 +/- 3.5 years after atriopulmonary Fontan operations. Preoperative New York Heart Association functional class was I in 2 patients, II in 2 patients, III in 6 patients, and IV in 5 patients. Four patients underwent intracardiac lateral tunnel conversion alone, and 11 received extracardiac total cavopulmonary connection, right atrial reduction, and cryoablation.

RESULTS

No mortality occurred. One patient had conduit obstruction in the immediate postoperative period requiring replacement, and another required a redo operation for endocarditis. Average hospitalization was 17.9 +/- 9.38 days; chest drains were removed on median day 4 (range, 1-29; mean, 7.4 +/- 7.58 days). At follow-up (mean, 42.6 +/- 22.1 months), late atrial arrhythmias had recurred in 3 of 4 patients with intracardiac total cavopulmonary connections (without ablation) and 1 of 11 patients with extracardiac total cavopulmonary connections with ablation. All patients are in New York Heart Association class I or II. Exercise ability (Bruce protocol) improved 69% from a mean of 6.18 +/- 4.01 minutes to 10.45 +/- 2.11 minutes (P <.05). Need for antiarrhythmic agents decreased postoperatively (patients receiving < or =1 antiarrhythmic: 9 preoperatively vs 15 at long-term follow-up, P <.05). No patient has required transplantation. Protein-losing enteropathy, which was present in 1 patient, improved transiently with conversion. There was 1 late death from gastrointestinal hemorrhage.

CONCLUSIONS

Fontan conversion can be achieved with low mortality and improvement in New York Heart Association class and exercise ability. Concomitant arrhythmia surgery reduces the incidence of late arrhythmias.

Breast cancer chemopreventive properties of pomegranate (Punica granatum) fruit extracts in a mouse mammary organ culture

We previously reported anticancer effects of pomegranate extracts in human breast cancer cells in vitro and also chemopreventive activity of pomegranate fermented juice polyphenols (W) in a mouse mammary organ culture (MMOC). In the present study we decided to expand the MMOC investigations to also include an evaluation of the potential chemopreventive efficacy of a purified chromatographic peak of W (Peak B), and also of whole pomegranate seed oil. In brief, an MMOC was established according to a known method. For the first 10 days of culture, the glands were treated with pomegranate fermented juice polyphenols (W), a high-performance liquid chromatographic (HPLC) peak separated from W (peak B), or pomegranate seed oil (Oil, and on day 3, exposed to the carcinogen 7,12-dimethylbenz[a]anthracene (DMBA), and for 10 days treated with the putative pomegranate chemopreventive. The glands were subsequently harvested and tumours counted by visual inspection. While W effected a 42% reduction in the number of lesions compared with control, peak B and pomegranate seed oil each effected an 87% reduction. The results highlight enhanced breast cancer preventive potential both for the purified compound peak B and for pomegranate seed oil, both greater than that previously reported for pomegranate fermented juice polyphenols.