Transitioning a cardiovascular health and rehabilitation programme to a virtual platform during covid 19

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Our Hearts Our Minds

Purpose

Can a virtual cardiovascular prevention and rehabilitation programme be as effective as face-to-face programme.

Background

The Our Hearts Our Minds (OHOM) prevention and rehabilitation programme rapidly transitioned to a virtual platform in the covid era.  Here we compare if a virtual programme potentially could offer the same standard of the nursing intervention (education, smoking cessation, medical risk factor management and psychosocial health) as the previous face to face programme

Methods

Both the initial assessment (IA) and end of programme (EOP) assessments were conducted via telephone/video as per patient preference. The following measures were recorded at both time points (home blood pressure (BP) monitors were provided)

Smoking (self report) BP/Heart rate, Lipids/HbA1c (facilitated by phlebotomy hub), cardio protective drugs (doses, adherence), Hospital Anxiety and Depression score, EuroQoL

Nursing Intervention Smoking cessation counselling and pharmacotherapy where appropriate

Weekly meeting with cardiologist to optimise BP and lipid management and up titration cardio protective drugs

Bimonthly virtual coaching consultation for monitoring/goal resetting

Bimonthly group video education sessions

Results

From April to November 2020, of the 432 referrals received 400 were eligible with 377 accepting the offer of an IA (94% response rate). 262 have had an IA with the remaining 115 awaiting an assessment date.  Of the completed IA’s 257 were willing to attend the programme (98% uptake).  120 had been offered an end of programme assessment with 114 attending (96% of those offered). The results for the virtual programme were then compared to the same period one year previously when the programme was fully face to face and are outlined in the table below.

The comparison of results delivered via remote delivery are remarkably similar to those achieved in the previous year delivered via face to face.

Conclusion

Initial data has shown that virtual delivery of the nursing component of the OHOM prevention/rehabilitation programme was highly acceptable to patients and was as effective as that of the traditional face to face service.

Table 1 below exhibits the clinical and patient-reported outcomes.

A microdosimetric analysis of the interactions of mono-energetic neutrons with human tissue

Nuclear reactions induced during high-energy radiotherapy produce secondary neutrons that, due to their carcinogenic potential, constitute an important risk for the development of iatrogenic cancer. Experimental and epidemiological findings indicate a marked energy dependence of neutron relative biological effectiveness (RBE) for carcinogenesis, but little is reported on its physical basis. While the exact mechanism of radiation carcinogenesis is yet to be fully elucidated, numerical microdosimetry can be used to predict the biological consequences of a given irradiation based on its microscopic pattern of energy depositions. Building on recent studies, this work investigated the physics underlying neutron RBE by using the microdosimetric quantity dose-mean lineal energy (y‾_D) as a proxy. A simulation pipeline was constructed to explicitly calculate the y‾_D of radiation fields that consisted of (i) the open source Monte Carlo toolkit Geant4, (ii) its radiobiological extension Geant4-DNA, and (iii) a weighted track-sampling algorithm. This approach was used to study mono-energetic neutrons with initial kinetic energies between 1 eV and 10 MeV at multiple depths in a tissue-equivalent phantom. Spherical sampling volumes with diameters between 2 nm and 1 μm were considered. To obtain a measure of RBE, the neutron y‾_D values were divided by those of 250 keV X-rays that were calculated in the same way. Qualitative agreement was found with published radiation protection factors and simulation data, allowing for the dependencies of neutron RBE on depth and energy to be discussed in the context of the neutron interaction cross sections and secondary particle distributions in human tissue.

Molecular epidemiology of multi- and extensively-drug-resistant Mycobacterium tuberculosis in Ireland, 2001-2014

OBJECTIVES

The primary objective of this work was to examine the acquisition and spread of multi-drug resistant (MDR) tuberculosis (TB) in Ireland.

METHODS

All available Mycobacterium tuberculosis complex (MTBC) isolates (n = 42), from MDR-TB cases diagnosed in Ireland between 2001 and 2014, were analysed using phenotypic drug-susceptibility testing, Mycobacterial-Interspersed-Repetitive-Units Variable-Number Tandem-Repeat (MIRU-VNTR) genotyping, and whole-genome sequencing (WGS).

RESULTS

The lineage distribution of the MDR-TB isolates comprised 54.7% Euro-American, 33.3% East Asian, 7.2% East African Indian, and 4.8% Indo-Oceanic. A significant association was identified between the East Asian Beijing sub-lineage and the relative risk of an isolate being MDR. Over 75% of MDR-TB cases were confirmed in non-Irish born individuals and 7 MIRU-VNTR genotypes were identical to clusters in other European countries indicating cross-border spread of MDR-TB to Ireland. WGS data provided the first evidence in Ireland of in vivo microevolution of MTBC isolates from drug-susceptible to MDR, and from MDR to extensively-drug resistant (XDR). In addition, they found that the katG S315T isoniazid and rpoB S450L rifampicin resistance mutations were dominant across the different MTBC lineages.

CONCLUSIONS

Our molecular epidemiological analyses identified the spread of MDR-TB to Ireland from other jurisdictions and its potential to evolve to XDR-TB.

Racial/ethnic subgroup differences in outcomes and acceptability of an Internet-delivered intervention for substance use disorders

The Therapeutic Education System (TES), an Internet version of the Community Reinforcement Approach plus prize-based motivational incentives, is one of few empirically supported technology-based interventions. To date, however, there has not been a study exploring differences in substance use outcomes or acceptability of TES among racial/ethnic subgroups. This study uses data from a multisite (N = 10) effectiveness study of TES to explore whether race/ethnicity subgroups (White [n = 267], Black/African American [n = 112], and Hispanic/Latino [n = 55])moderate the effect of TES. Generalized linear mixed models were used to test whether abstinence, retention, social functioning, coping, craving, or acceptability differed by racial/ethnic subgroup. Findings demonstrated that race/ethnicity did not moderate the effect of TES versus TAU on abstinence, retention, social functioning, or craving. A three-way interaction (treatment, race/ethnicity, and abstinence status at study entry) showed that TES was associated with greater coping scores among nonabstinent White participants (p = .008) and among abstinent Black participants (p < .001). Acceptability of the TES intervention, although high overall, was significantly different by race/ethnicity subgroup with White participants reporting lower acceptability of TES compared to Black (p = .006) and Hispanic/Latino (p = .008) participants. TES appears to be a good candidate treatment among a diverse population of treatment-seeking individuals with substance use disorders.

Pathologic complete response predicts recurrence-free survival more effectively by cancer subset: results from the I-SPY 1 TRIAL--CALGB 150007/150012, ACRIN 6657

PURPOSE

Neoadjuvant chemotherapy for breast cancer provides critical information about tumor response; how best to leverage this for predicting recurrence-free survival (RFS) is not established. The I-SPY 1 TRIAL (Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis) was a multicenter breast cancer study integrating clinical, imaging, and genomic data to evaluate pathologic response, RFS, and their relationship and predictability based on tumor biomarkers.

PATIENTS AND METHODS

Eligible patients had tumors ≥ 3 cm and received neoadjuvant chemotherapy. We determined associations between pathologic complete response (pCR; defined as the absence of invasive cancer in breast and nodes) and RFS, overall and within receptor subsets.

RESULTS

In 221 evaluable patients (median tumor size, 6.0 cm; median age, 49 years; 91% classified as poor risk on the basis of the 70-gene prognosis profile), 41% were hormone receptor (HR) negative, and 31% were human epidermal growth factor receptor 2 (HER2) positive. For 190 patients treated without neoadjuvant trastuzumab, pCR was highest for HR-negative/HER2-positive patients (45%) and lowest for HR-positive/HER2-negative patients (9%). Achieving pCR predicted favorable RFS. For 172 patients treated without trastuzumab, the hazard ratio for RFS of pCR versus no pCR was 0.29 (95% CI, 0.07 to 0.82). pCR was more predictive of RFS by multivariate analysis when subtype was taken into account, and point estimates of hazard ratios within the HR-positive/HER2-negative (hazard ratio, 0.00; 95% CI, 0.00 to 0.93), HR-negative/HER2-negative (hazard ratio, 0.25; 95% CI, 0.04 to 0.97), and HER2-positive (hazard ratio, 0.14; 95% CI, 0.01 to 1.0) subtypes are lower. Ki67 further improved the prediction of pCR within subsets.

CONCLUSION

In this biologically high-risk group, pCR differs by receptor subset. pCR is more highly predictive of RFS within every established receptor subset than overall, demonstrating that the extent of outcome advantage conferred by pCR is specific to tumor biology.

A case report: lobular carcinoma in situ in a male patient with subsequent invasive ductal carcinoma identified on screening breast MRI

Lobular carcinoma in situ is a form of in situ neoplasia that develops within the terminal lobules of the breast. It is an extremely rare finding in males due to the lack of lobular development in the male breast. The authors herein report an unusual case of incidentally discovered lobular carcinoma in situ in a male patient with recurrent bilateral gynecomastia who was subsequently diagnosed with invasive ductal carcinoma of the left breast. The pathology of lobular carcinoma in situ in a male as well as screening MRI surveillance of male patients at high risk for breast cancer are discussed, emphasizing the importance of screening and imaging follow up in men who are at high risk for breast cancer.

Chemotherapy response and recurrence-free survival in neoadjuvant breast cancer depends on biomarker profiles: results from the I-SPY 1 TRIAL (CALGB 150007/150012; ACRIN 6657)

Neoadjuvant chemotherapy for breast cancer allows individual tumor response to be assessed depending on molecular subtype, and to judge the impact of response to therapy on recurrence-free survival (RFS). The multicenter I-SPY 1 TRIAL evaluated patients with ≥ 3 cm tumors by using early imaging and molecular signatures, with outcomes of pathologic complete response (pCR) and RFS. The current analysis was performed using data from patients who had molecular profiles and did not receive trastuzumab. The various molecular classifiers tested were highly correlated. Categorization of breast cancer by molecular signatures enhanced the ability of pCR to predict improvement in RFS compared to the population as a whole. In multivariate analysis, the molecular signatures that added to the ability of HR and HER2 receptors, clinical stage, and pCR in predicting RFS included 70-gene signature, wound healing signature, p53 mutation signature, and PAM50 risk of recurrence. The low risk signatures were associated with significantly better prognosis, and also identified additional patients with a good prognosis within the no pCR group, primarily in the hormone receptor positive, HER-2 negative subgroup. The I-SPY 1 population is enriched for tumors with a poor prognosis but is still heterogeneous in terms of rates of pCR and RFS. The ability of pCR to predict RFS is better by subset than it is for the whole group. Molecular markers improve prediction of RFS by identifying additional patients with excellent prognosis within the no pCR group.

The emerging role of IG-IMRT for palliative radiotherapy: a single-institution experience

Many modern radiotherapy centers now have image-guided intensity-modulated radiotherapy (ig-imrt) tools available for clinical use, and the technique offers many options for patients requiring palliative radiotherapy. We describe a single-institution experience with ig-imrt for short-course palliative radiotherapy, highlighting the unique situations in which the technique can be most effectively used.

Vascular endothelial growth factor and its relationship to the prognosis and treatment of breast, ovarian, and cervical cancer

Tumor neovascularization is a complex process that plays a crucial role in the development of many different types of cancer. Vascular endothelial growth factor (VEGF) is a potent mitogen that is involved with mitogenesis, angiogenesis, endothelial survival, and the induction of hematopoiesis. By increasing vascular permeability in endothelial cells, it helps tumors recruit wound-healing proteins fibrin and fibrinogen from the plasma, suggesting that tumor formation is a process of abnormal wound healing dependent on the ability to generate a blood supply. The human female reproductive tract is highly dependent on VEGF for normal functions such as endometrial proliferation and development of the corpus luteum. The unique influence of female sex steroid hormones on the expression and activity of VEGF deems angiogenesis an important facet of the development of breast and ovarian cancer. Additionally, the up-regulation of VEGF by the E6 oncoprotein of the human papillomavirus suggests that VEGF plays an important role in the development of cervical cancer. Clinical trials have investigated the humanized monoclonal antibody bevacizumab as potential treatment for all three forms of cancer; the data show that in breast cancer, the use of bevacizumab may lengthen the disease-free survival for women with advanced breast cancer, but does not appear to change their overall survival. It may have a role as salvage chemotherapy for ovarian and cervical cancer, though further research is needed to establish it as a definitive form of treatment.

Detection of locally advanced breast cancer in the I-SPY TRIAL (CALGB 150007/150012, ACRIN 6657) in the interval between routine screening

1503

Background: It is assumed that most locally advanced breast cancers (LABC) could be detected at an earlier stage with routine screening. However, LABCs may present between screens as interval cancers (IC). ICs present at an earlier age, with higher grade, larger size, and are associated with lower survival, compared to screen-detected cancers (SDC), and comprise 17% of cancers from population-based screening programs. We evaluated the screening history in patients with LABCs from the I SPY TRIAL, to determine the frequency of screening and ICs. Methods: Of 221 pts enrolled in the I-SPY TRIAL, a multisite neoadjuvant study for women with LABCs > 3cm in size, screening history and presentation were retrospectively collected for 154. Two groups, screened (S), defined as a mammogram within 2 years, or non screened (NS), previous mammogram more than 2 years prior, were evaluated (Table). The frequency of ICs at 1 and 2 years was determined in S pts. Frequency of mammographically occult (MO) tumors was determined for all. Results: Of the total, 99 (64%) and 55 (36%) were NS and S, respectively. Mean tumor size for all pts was 6.7cm. Only 11 (20%) of S pts were SDCs and 44 (80%) were ICs, with 24 (63%) diagnosed within 1 year and 14 (37%) between 1 and 2 yrs of their last normal mammogram. 24 (24%) NS patients were younger than the recommended screening age of 40; in the remaining 75 pts, 9 (12%) were MO. Only 20% of IC tumors were MO. ICs were of higher grade (44% vs 11% grade III), and tumor size (7.0cm vs 4.4cm) than their SDC counterparts. 80% of cancers detected in I SPY were NKI70 gene test poor prognosis. Relationship to breast density and subtype is currently being assessed. Conclusions: Women presenting with LABCs have a high likelihood (80%) of an IC. This suggests that the growth rate of LABCs precludes early detection by conventional screening. Understanding the biology of ICs will be important to develop better strategies for prevention and early detection.

[Table: see text]

No significant financial relationships to disclose.

Simultaneous treatment of multiple basal cell carcinoma lesions

We present a rare case of advanced basal cell carcinoma where multiple large lesions, located on the anterior chest wall and back, were treated simultaneously using tomotherapy (TomoTherapy HiArt; TomoTherapy Inc, Madison, WI). A 74-year-old man presented with seven to eight separate extensive lesions on his body, some with a duration of 7 years or more. The image-guidance component of tomotherapy allowed daily verification of the position of the target and critical structures, enabling accurate targeting in the vicinity of sensitive critical structures. Intensity-modulated radiotherapy on a conventional linear accelerator would have required junctioning of multiple complex plans, owing to the large treatment area, and most likely sequential treatment strategies to target anterior and posterior lesions. Helical tomotherapy allowed the three largest lesions to be treated simultaneously and thus eliminated the need for multiple courses of treatment.

Sentinel node biopsy performed in the neoadjuvant setting for breast cancer: results from the I-SPY TRIAL (CALGB 150007/150012 & ACRIN 6657)

Abstract #202

Introduction: Controversy remains over whether to perform sentinel node biopsy (SNB) before or after neoadjuvant chemotherapy (NAC). We examined the practice patterns, feasibility, and accuracy of this procedure in high risk breast cancer patients treated with NAC in a multi-institutional correlative science study.&#x2028; Methods: Patients with biopsy-proven breast cancer &gt;3 cm enrolled into the I-SPY TRIAL to undergo 4 weeks of anthracycline-based NAC, 4 weeks of taxane treatment, then surgical intervention. Study protocol did not dictate axillary treatment. Timing of SNB was dictated by the surgeon. Practice patterns, outcome of SNB and axillary lymph node dissection (ALND), locoregional recurrence and distant metastases were recorded with a mean follow-up of 2.9 years.&#x2028; Results: 237 patients enrolled, 221 completed the trial, 210 had complete data at the time of analysis; Table 1 shows axillary practice patterns.&#x2028; &#x2028; Overall, 43% had a positive SNB and/or ALND after NAC. 129 (61% of 210) patients presented with clinically positive nodes, 39 of which had a post-NAC SNB. 5/39 had no ALND (all SNB negative). Table 2 shows results for those who had a post-NAC SNB and ALND. For this subset of patients, sentinel node ID, accuracy, and false negative (FN) rates were 80%, 91% and 15% respectively. If SNB was negative, 20% of patients still had a positive ALND. 81 (39% of 210) patients presented with clinically negative nodes, 22 of which had a post-NAC SNB. 8/22 post-NAC SNB patients had no ALND (6 negative, 2 positive for 1mm disease). Table 2 shows results for those who had a post-NAC SNB and ALND. For this subset of patients, sentinel node ID, accuracy, and FN rates were 100%, 100% and 0%.&#x2028; &#x2028; Overall, there were 26 deaths; 96% occurred in those who presented with clinically positive nodes, 77% had positive post-NAC nodes. A negative axilla post-NAC was predictive of longer DFS over those with axillary disease post-NAC (p&lt;0.05).&#x2028; Conclusions: In clinically node negative patients, post-NAC SNB is feasible and accurate before or after NAC. Our data suggests that a post-NAC SNB is sufficient; this avoids an additional operation and allows us to gain information on post-NAC axillary status which is of prognostic significance. In clinically positive patients, SNB does not adequately reflect axillary disease; even when SNB was negative, 20% still had axillary disease. At this time, we recommend that ALND be performed on all clinically node positive patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 202.

Study of quadrant high-dose intraoperative radiation therapy for early-stage breast cancer

BACKGROUND

Partial breast irradiation has been tested in limited pilot studies and shown to provide acceptable cosmesis, minimal toxicity and adequate local control. The aim of this study was to determine the feasibility of using quadrant high-dose intraoperative radiation therapy (IORT) for the treatment of early-stage breast cancer.

METHODS

Fifty-two women with early-stage breast cancer were treated with breast-conserving therapy and IORT between October 2002 and January 2006. The first 18 women received a radiation dose of 20 Gy. The protocol was then amended and the remaining 34 women were treated with 18 Gy. Each patient was evaluated after surgery, and at 3, 6 and 12 months; complications, toxicity and cosmetic outcomes were recorded by the breast surgeon.

RESULTS

Women treated with 18 Gy appeared to have a more favourable cosmetic outcome compared with the earlier treatment group. At last follow-up, none of the women treated on the protocol had a breast recurrence.

CONCLUSION

Experience suggests that this IORT technique is feasible, although further follow-up is necessary to assess its therapeutic value.

Is the "10% rule" equally valid for all subsets of sentinel-node-positive breast cancer patients?

BACKGROUND

In breast cancer, a combination of radioisotope and blue dye mapping maximizes the success and accuracy of sentinel node (SLN) biopsy. When multiple radioactive nodes are present, there is no single definition of isotope success, but the popular "10% rule" dictates removal of all SLN with counts >10% of the most radioactive node. Here we determine how frequently a positive SLN would be missed by the 10% rule.

METHODS

Between 9/96 and 12/04, we performed 6,369 successful SLN biopsies using (99m)Tc sulfur colloid and isosulfan blue dye, removing as SLN all radioactive and/or blue nodes, and taking counts from each node ex vivo. Standard processing of all SLNs with a benign frozen section included hematoxylin and eosin (H&E) staining, serial sectioning, and immunohistochemistry (IHC).

RESULTS

33% of patients (2,130/6,369) had positive SLNs. Of these patients, 1,387/2,130 (65%) had >1 SLN identified. The most radioactive SLN was benign in 29% (398/1,387), and 107/1,387 (8%) had a positive SLN that was neither blue nor the hottest. From this group 1.7% (24/1387) of patients had positive SLN with counts <10% radioactive counts of the hottest node. The 10% rule captured 98.3% of positive nodes in patients with multiple SLNs. No patient characteristics were predictive of failure of the 10% rule.

CONCLUSION

With combined isotope and blue dye mapping, the 10% rule is a robust guideline and fails to identify only 1.7% (24/1387) of all SLN-positive patients with multiple SLNs. This guideline appears to be equally valid for all subsets of patients.

Organ and fetal absorbed dose estimates from 99mTc-sulfur colloid lymphoscintigraphy and sentinel node localization in breast cancer patients

The purpose of this retrospective study was to determine whether lymphoscintigraphy (LSG) for sentinel lymph node (SNL) mapping in a woman with a breast mass presents an unacceptable risk to her fetus. We assessed radiation-absorbed dose to various organs from 99mTc-sulfur colloid (TSC) LSG using standard internal absorbed dose assessment methodologies for both reference phantoms as well as for phantom models using the specific patient population characteristics such as total body and injected organ mass. The study also projected the radiation-absorbed dose to the fetus from LSG for SLN mapping.

METHODS

Data from 1,021 nonpregnant women with early-stage breast cancer who underwent SLN mapping and biopsy procedures were analyzed. Patients had a single-site intradermal injection of unfiltered TSC in 0.05 mL normal saline: 3.7 MBq (0.1 mCi) on the morning of surgery (1-d protocol) or 18.5 MBq (0.5 mCi) on the afternoon before surgery (2-d protocol). A standard internal dose calculation methodology was used to calculate absorbed doses to various organs and to a modeled fetus at 3-, 6-, and 9-mo gestation from the injection site as well as from systemic activity.

RESULTS

The highest estimated absorbed doses were observed for the reference 9-mo-pregnant model under the 2-d protocol. Absorbed doses of 14.9, 0.214, 0.062, 0.151, 0.004, 0.163, 0.075, and 0.014 mGy were received by the injected breast, heart, liver, lung, ovaries, thymus, total body, and fetus, respectively. Effective doses from the 2-d protocol were estimated to be 0.460, 0.186, and 0.245 mSv for the reference population, the total Memorial Sloan-Kettering Cancer Center (MSKCC) study patient population, and childbearing-age MSKCC patient population (i.e., <45 y old), respectively.

CONCLUSION

SLN procedures lead to a negligible dose to the fetus of 0.014 mGy or less. This is much less than the National Council on Radiation Protection and Measurements limit to a pregnant woman. Calculations using actual patient population characteristics resulted in lower organ dose estimates than more conservative reference models.

Paired ductal lavage and fine-needle aspiration specimens from patients with breast carcinoma

Ductal lavage (DL) is a new procedure for sampling of the mammary epithelium, but experience with this technique remains limited. We compared the findings in paired DL and fine-needle aspiration (FNA) specimens obtained from patients with breast carcinoma. Four reviewers evaluated all DL samples. Two reviewers also examined the FNA material and compared cellular composition and morphologic findings in paired samples. DL and FNA samples from six patients were satisfactory for evaluation. Two DL samples showed marked atypia, one showed mild atypia, and two were benign; there was no agreement in one case (mild atypia vs. benign). Overall, the atypical cells in DL samples resembled those in the paired FNA material, but low degree of cytologic atypia and relative paucity of atypical cells limited their correct identification. The interpretation of DL samples is more challenging than that of FNA material, but similar criteria apply. To increase the sensitivity of DL, the number of epithelial cells required for a satisfactory sample should be higher than previously set.

The risk of axillary relapse after sentinel lymph node biopsy for breast cancer is comparable with that of axillary lymph node dissection: a follow-up study of 4008 procedures

OBJECTIVE

We sought to identify the rate of axillary recurrence after sentinel lymph node (SLN) biopsy for breast cancer.

SUMMARY BACKGROUND DATA

SLN biopsy is a new standard of care for axillary lymph node staging in breast cancer. Nevertheless, most validated series of SLN biopsy confirm that the SLN is falsely negative in 5-10% of node-positive cases, and few studies report the rate of axillary local recurrence (LR) for that subset of patients staged by SLN biopsy alone.

METHODS

Through December of 2002, 4008 consecutive SLN biopsy procedures were performed at Memorial Sloan-Kettering Cancer Center for unilateral invasive breast cancer. Patients were categorized in 4 groups: SLN-negative with axillary lymph node dissection (ALND; n = 326), SLN-negative without ALND (n = 2340), SLN-positive with ALND (n = 1132), and SLN-positive without ALND (n = 210). Clinical and pathologic characteristics and follow-up data for each of the 4 cohorts were evaluated with emphasis on patterns of axillary LR.

RESULTS

With a median follow-up of 31 months (range, 1-75), axillary LR occurred in 10/4008 (0.25%) patients overall. In 3 cases (0.07%) the axillary LR was the first site of treatment failure, in 4 (0.1%) it was coincident with breast LR, and in 3 (0.07%) it was coincident with distant metastases. Axillary LR was more frequent among the unconventionally treated SLN-positive/no ALND patients than in the other 3 conventionally treated cohorts (1.4% versus 0.18%, P = 0.013).

CONCLUSIONS

Axillary LR after SLN biopsy, with or without ALND, is a rare event, and this low relapse rate supports wider use of SLN biopsy for breast cancer staging. There is a low-risk subset of SLN-positive patients in whom completion ALND may not be required.

Ductal lavage in patients undergoing mastectomy for mammary carcinoma

BACKGROUND

Ductal lavage (DL) is a new method for the sampling of breast epithelium. Data regarding its sensitivity in the detection of epithelial abnormalities, including carcinoma in situ (CIS), remains limited.

METHODS

DL was performed in the affected breasts of 26 women undergoing mastectomy for mammary carcinoma and in the clinically normal breast of 4 additional women undergoing risk-reducing mastectomy. After surgery, dye was injected through the microcatheter used for DL. Three cytopathologists independently reviewed all DL slides and the data reflect consensus by at least two reviewers. Interobserver agreement was assessed. The findings in DL samples were correlated with the features of CIS in the mastectomy specimens.

RESULTS

Four (14%) of 29 DL samples satisfactory for evaluation showed marked atypia, 10 (34%) showed mild atypia, and 15 (52%) were benign. No DL sample was clearly malignant. Interobserver agreement was good (average kappa = 0.52). Of the DL samples satisfactory for evaluation, 27 had been obtained from 24 breasts containing CIS, which included 18 ductal CIS (DCIS), 3 lobular CIS (LCIS), 2 DCIS and LCIS, and 1 solid CIS with mixed ductal and lobular features. Invasive carcinoma was present in 20 samples. Two DL samples from breasts with extensive LCIS showed mild atypia and injected dye was identified in ducts and lobules involved by LCIS.

CONCLUSIONS

DL had low sensitivity for CIS in breasts that also contained invasive carcinoma. The use of DL remains investigational, and close follow-up should be continued for all patients undergoing DL, including those with benign diagnoses.

A randomized controlled study of the acute and chronic effects of cooling therapy for MS

BACKGROUND

Cooling demyelinated nerves can reduce conduction block, potentially improving symptoms of MS. The therapeutic effects of cooling in patients with MS have not been convincingly demonstrated because prior studies were limited by uncontrolled designs, unblinded evaluations, reliance on subjective outcome measures, and small sample sizes.

OBJECTIVE

To determine the effects of a single acute dose of cooling therapy using objective measures of neurologic function in a controlled, double-blinded setting, and to determine whether effects are sustained during daily cooling garment use.

METHODS

Patients (n = 84) with definite MS, mild to moderate disability (Expanded Disability Status Scale score < 6.0), and self-reported heat sensitivity were randomized into a multicenter, sham-treatment controlled, double-blind crossover study. Patients had the MS Functional Composite (MSFC) and measures of visual acuity/contrast sensitivity assessed before and after high-dose or low-dose cooling for 1 hour with a liquid cooling garment. One week later, patients had identical assessments before and after the alternate treatment. Patients were then re-randomized to use the cooling garment 1 hour each day for a month or to have observation only. They completed self-rated assessments of fatigue, strength, and cognition during this time, and underwent another acute cooling session at the end of the period. After 1 week of rest, they had identical assessments during the alternate treatment.

RESULTS

Body temperature declined during both high-dose and low-dose cooling, but high-dose produced a greater reduction (p < 0.0001). High-dose cooling produced a small improvement in the MSFC (0.076 +/- 0.66, p = 0.007), whereas low-dose cooling produced only a trend toward improvement (0.053 +/- 0.031, p = 0.09), but the difference between conditions was not significant. Timed gait testing and visual acuity/contrast sensitivity improved in both conditions as well. When patients underwent acute cooling following a month of daily cooling, treatment effects were similar. Patients reported less fatigue during the month of daily cooling, concurrently on the Rochester Fatigue Diary and retrospectively on the Modified Fatigue Impact Scale.

CONCLUSIONS

Cooling therapy was associated with objectively measurable but modest improvements in motor and visual function as well as persistent subjective benefits.

What Every NURSE Needs To Know About NOCTURNAL SLEEP-RELATED eating DISORDER

This article provides information about a bizarre pattern of eating while asleep called nocturnal sleep-related eating disorder. People with this disorder, which has begun to be studied only recently, demonstrate features of both a sleep disorder and an eating disorder. Many clients are reluctant to initiate discussions regarding this condition because of feelings of powerlessness and shame. Other clients do not discuss their symptoms because nurses and other clinicians fail to gather accurate assessment data due to lack of knowledge within the professional community regarding the disorder. This review includes the historical background, definition of terms, and clinical manifestations of nocturnal sleep-related eating. In addition, emphasis on assessment and clinical management are included. Safety issues, the need to educate health care providers, and the role of the nurse in advocating for appropriate diagnosis, treatment, and referral are addressed.

Survey and workshop initiative on community nurses' knowledge of the Internet

Information technology in the nursing profession has been in existence for years, but only now with the growing presence of the Internet is it viewed as a possible platform to help meet the need for nurses' continuing educational development. For this to happen, it is important to know qualified nurses' experience with the Internet. In the United Kingdom, there is little understanding of whether community nurses have experience in using the Internet and if they do, how they use it. This article reports the findings of a survey questionnaire, taken in 1998, that was designed to target a random sample of 100 community nurses in Aberdeen, Scotland, to gauge awareness and attitudes toward the use of electronic sources of information for continuing education purposes. The response rate for the questionnaire was 83% (n = 83). A series of workshops was also undertaken, exploring the potential of the Internet and its access. A total of 52 people attended the workshops. One of the main aims of the workshops was to demystify the image of the computer, breaking down barriers for those with little or no experience in this field. The major findings of the survey and workshops indicate that although many respondents were interested in the potential benefits of the Internet to access information, there was little use made of and limited access to computer equipment.

Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion?

BACKGROUND

Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to determine the incidence of sentinel node metastases in patients with high-risk ductal carcinoma-in-situ (DCIS) and DCIS with microinvasion (DCISM).

METHODS

From November 1997 to November 1999, all patients who underwent sentinel node biopsy for high-risk DCIS (n = 76) or DCISM (n = 31) were enrolled prospectively in our database. Patients with DCIS were considered high risk and were selected for sentinel lymph node biopsy if there was concern that an invasive component would be identified in the specimen obtained during the definitive surgery. Patients underwent intraoperative mapping that used both blue dye and radionuclide. Excised sentinel nodes were serially sectioned and were examined by hematoxylin and eosin and by immunohistochemistry.

RESULTS

Of 76 patients with high-risk DCIS, 9 (12%) had positive sentinel nodes; 7 of 9 patients were positive for micrometastases only. Of 31 patients with DCISM, 3 (10%) had positive sentinel nodes. 2 of 3 were positive for micrometastases only. Six of nine patients with DCIS and three of three with DCISM and positive sentinel nodes had completion axillary dissection; one patient with DCIS had an additional positive node detected by conventional histological analysis.

CONCLUSIONS

This study documents a high incidence of lymph node micrometastases as detected by sentinel node biopsy in patients with high-risk DCIS and DCISM. Although the biological significance of breast cancer micrometastases remains unclear at this time, these findings suggest that sentinel node biopsy should be considered in patients with high-risk DCIS and DCISM.

Use of a simple pain model to evaluate analgesic activity of ibuprofen versus paracetamol

OBJECTIVE

To evaluate the analgesic activity of ibuprofen against paracetamol using a simple pain model.

DESIGN

A double-blind study.

SETTING

Twenty general practitioners in Harare, Zimbabwe.

PATIENTS

Adults with acute sore throat of a maximum of two days' duration.

INTERVENTIONS

One hundred and thirteen patients with acute pain associated with tonsillo-pharyngitis randomly received either 400 mg ibuprofen or 1000 mg paracetamol. The study design included repeated administration up to 48 hours to assess tolerability.

MAIN OUTCOME MEASURES

At hourly intervals for six hours after the first dose of treatment, the patients evaluated pain intensity on swallowing, difficulty in swallowing and global pain relief according to visual analogue scales.

RESULTS

Ibuprofen 400 mg was significantly more effective than paracetamol 1000 mg in all three ratings, at all time-points for pain intensity and difficulty in swallowing, and from two hours onwards for pain relief. There were no serious adverse effects and no statistically significant difference in the incidence of adverse effects in the two treatment groups.

CONCLUSIONS

Sore throat pain provided a sensitive model to assess the analgesic efficacy of class I analgesics and discriminated between the analgesic efficacy of ibuprofen and paracetamol.

Quantification of thymic function by measuring T cell receptor excision circles within peripheral blood and lymphoid tissues in monkeys

The thymus is the primary organ responsible for the production of mature TCR alpha / beta T cells. Quantification of a DNA excision circle that is produced during TCR rearrangement, termed a signal joint TCR rearrangement excision circle (sjTREC) can be used as a measure of thymic function. Here sjTREC measurement has been applied to two monkey species used as animal models of human disease, rhesus macaques (Asian origin) and sooty mangabeys (African origin). Initial PCR analysis determined that the TCR deltaRec-PsiJalpha rearrangement leading to sjTREC formation occurs in both species. Primers to a DNA sequence conserved in macaques, mangabeys and humans were used in a quantitative competitive PCR assay to quantify sjTREC. We found that as in humans, sjTREC in these two monkey species decline with age. sjTREC are first generated in thymocytes during the early stages of TCR rearrangement. Lymph node CD4(+) and CD8(+) T cells contain more sjTREC than peripheral blood T cell populations, suggesting that recent thymic emigrants home to the lymphoid tissues. The sjTREC level is significantly higher within the peripheral blood CD4(+) and CD8(+) T cells of mangabeys compared to macaques. Removal of the thymus in four macaques led to a profound decrease in peripheral blood sjTREC level by 1 year post-thymectomy, indicating the lack of a significant extra-thymic source of peripheral naive T cells in macaques. Our results indicate that production, trafficking, and proliferation of recent thymic emigrants in these two monkey species represents a useful animal model system for understanding human immunological disorders.

B7.1 costimulation increases T-cell proliferation and cytotoxicity via selective expansion of specific variable alpha and beta genes of the T-cell receptor

BACKGROUND

Optimal T-cell activation requires not only ligation of the T-cell receptor (TcR) but also delivery of costimulatory signals by various accessory molecules. The interaction of the costimulatory molecule B7.1 (CD80) with its receptor CD28 provides a strong positive signal to T cells.

METHODS

The B7.1 gene was transduced into cultured human ovarian, breast, and pancreatic tumor cells by using a retroviral vector. Autologous as well as allogeneic naive T-cells were stimulated with either wild-type or B7.1-transduced tumor cells in a mixed lymphocyte tumor cell culture (MLTC). In addition to cytolytic activity, T-cell proliferation, T-cell subset composition, and the frequencies of TcR variable (V) alpha and beta genes were compared in T cells from both types of MLTC.

RESULTS

Introduction of the B7.1 gene into tumor cells was successful in all tumors to a varying degree. Those tumors expressing high levels of B7.1 induced significantly higher levels of T-cell proliferation than wild-type tumor cells. T-cell subset composition did not markedly differ between T cells stimulated with wild-type tumor cells or B7.1-expressing tumor cells. However, T cells stimulated with B7.1-expressing tumor cells showed a significantly increased cytolytic potential. The increased cytotoxic T lymphocyte activity was associated with a higher frequency of specific TcR V alpha and V beta genes. In addition, B7.1 costimulation promoted oligoclonality among the responding T cells.

CONCLUSIONS

These data suggest that costimulation through B7.1 promotes T-cell proliferation and cytotoxic activity through clonal expansions of T cells bearing antigen-specific TcR V alpha and V beta genes and through promotion of oligoclonality. The data also suggest that promoting B7.1-mediated costimulation is an important aspect of immune therapies.

Natural history of fetuses with cleft lip

The prospect of fetal surgery for cleft lip is predicated on our ability to accurately identify fetuses with clefts and exclude those that have associated anomalies. Prenatal ultrasound is currently the most appropriate means with which to do this. We reviewed the ultrasonographic data from two large perinatal referral institutions to determine the natural history of fetuses with cleft lip who may be candidates for fetal surgery. Forty fetuses had a cleft lip diagnosed prenatally by ultrasound. In this group, severe associated anomalies were common (30 of the 40) and multiple (23 of the 40) in a majority of fetuses. Life-threatening anomalies, such as central nervous system and cardiac anomalies, were the most common defects. As a result, many fetuses were aborted therapeutically or died in the perinatal period. Out of 12 surviving fetuses, only six had isolated clefts, and two surviving fetuses, diagnosed with isolated cleft lip, had no defect identified postnatally. This information has important implications for the perinatal management of fetuses with cleft lip and the potential role of fetal intervention.

Neonatal outcome after active perinatal management of the very premature infant between 23 and 27 weeks' gestation

OBJECTIVE

To record the effect of aggressive perinatal management on neonatal outcome in the very premature infant.

METHODS

A retrospective chart review of 114 infants born between 23 and 27 weeks' gestation, managed by one perinatal transport service at one hospital between July 1989 and December 1993. Fetuses > 23 weeks' gestation were considered viable and were managed with tocolytics, antibiotics, and surfactant at the discretion of the treating physician. Morbidity and mortality rates in the first 6 months, including stillbirths were analyzed. A major neurologic condition was defined as ultrasonographic evidence of grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia.

RESULTS

Both neonatal mortality rate and the incidence of stillbirths decreased with advancing gestational age. Of 24 infants born at 23 weeks' gestation, 33% were stillborn and 13% were alive at 6 months. This survival rate improved to 48% for infants delivered at 24 weeks' gestation, and to 68%, 75%, and 71% for those delivered at 25, 26, and 27 weeks' gestation, respectively. The percentage of infants who survived without a major neurologic condition increased with advancing gestational age at delivery from 13% at 23 weeks' gestation to 40% at 24 weeks, 48% at 25 weeks, 70% at 26 weeks, and 71% at 27 weeks. The incidence of retinitis of prematurity, respiratory complications, and days spent in the hospital decreased with greater gestational age.

CONCLUSIONS

An active plan of management for all gestations of > 23.9 weeks seems appropriate.