Hypertension and Afro-descendant ethnicity: a bad interaction for lupus nephritis treated with cyclophosphamide?

Hypertension and ethnicity are important prognostic factors in evolution of lupus nephritis. A cohort of 75 patients with lupus nephritis treated with cyclophosphamide was conducted to investigate the evolution of creatinine levels between Caucasians and Afro-descendants. A multiple linear model was used to evaluate the combined effects of ethnicity and hypertension over delta creatinine controlling confounders. Sample characteristics were: 85% females; mean (±SD) age of 33.6 ± 12.0 years; 77% Caucasians; 40% hypertensive at renal biopsy; 91% WHO class IV; mean basal creatinine: 1.5 ± 1.3 mg/dL; mean final creatinine: 2.1 ± 2.5 mg/dL; 40% anaemia; proteinuria: 5.4 ± 4.8 g/day. Comparing Caucasians and Afro-descendants, it was found: 28.1% versus 72.2% for hypertension ( P = 0.002); 31.6% versus 66.7% for anaemia ( P = 0.018); 5.9 ± 5.0 versus 3.8 ± 4.0. g/day ( P = 0.02) for proteinuria. Other comparisons including basal creatinine did not reach statistical significance. Comparing outcomes between Caucasians and Afro-descendants, it was found: 10.5% versus 22.2% for doubling of creatinine ( P = 0.24); 0.41 ± 2.03 versus 1.05 ± 2.41 for delta creatinine ( P = 0.29); 8.8% versus 22.2% for haemodialysis ( P = 0.21) and 3.5% versus 5.6% for death ( P = 0.99). Analysing delta creatinine with multiple linear regression showed that hypertension had a significant overall effect ( b = 0.80; SE = 0.32; P = 0.015), ethnicity alone was not significant ( b = 0.35; SE = 0.29; P = 0.228); however, the effect of hypertension on delta creatinine was more intense among Afro-descendants than among Caucasians (interaction term b = — 0.83; SE = 0.37; P = 0.027). Afro-descendants lupus patients experience worst prognosis of renal function probably due to the effect of hypertension and not ethnicity per se. Lupus (2007) 16, 724—730.

Histopathological grading of breast ductal carcinoma in situ: validation of a web-based survey through intra-observer reproducibility analysis

BACKGROUND

Histopathological grading diagnosis of ductal carcinoma in situ (DCIS) of the breast may be very difficult even for experts, and it is important for therapeutic decisions. The challenge may be due to the inaccurate and/or subjective application of the diagnosis criteria. The aim of this study was to investigate the intra-observer agreement between a traditional method and a developed web-based questionnaire for scoring breast DCIS.

METHODS

A cross-sectional study was carried out to evaluate the diagnostic agreement of an electronic questionnaire and its point scoring system with the subjective reading of digital images for 3 different DCIS grading systems: Holland, Van Nuys and modified Black nuclear grade system. Three pathologists analyzed the same set of digitized images from 43 DCIS cases using two different web-based programs. In the first phase, they accessed a website with a newly created questionnaire and scoring system developed to allow the determination of the histological grade of the cases. After at least 6 months, the pathologists read again the same images, but without the help of the questionnaire, indicating subjectively the diagnoses. The intra-observer agreement analysis was employed to validate this innovative web-based survey.

RESULTS

Overall, diagnostic reproducibility was similar for all histologic grading classification systems, with kappa values of 0.57 ± 0.10, 0.67 ± 0.09 and 0.67 ± 0.09 for Holland, Van Nuys classification and modified Black nuclear grade system respectively. Only two 2-step diagnostic disagreements were found, one for Holland and another for Van Nuys. Both cases were superestimated by the web-based survey.

CONCLUSION

The diagnostic agreement between the web-based questionnaire and a traditional method, both using digital images, is moderate to good for Holland, Van Nuys and modified Black nuclear grade system. The use of a scoring point system does not appear to pose a major risk of presenting large (2-step) diagnostic disagreements. These findings indicate that the use of this point scoring system in this web-based survey to grade objectively DCIS lesions is a useful diagnostic tool.

P5-09-01: Breast Cancer Annual Screening Program Núcleo Mama Porto Alegre (NMPOA): Imaging Results after Seven Years

Introduction: The NMPOA cohort started in 2004 with the purpose of testing a breast screening model for underserved women in limited resource countries. In the city of Porto Alegre (South Brazil with 1.5 million population), breast cancer incidence rate is 127/100.000 (Brazilian NCI,2010) with increasing mortality due to 45% of Stage III and IV and no public health care early detection program, it was mandatory to test the feasibility of an organized screening program for women with very low income and level of education (64% under 6 years of schooling). In this scenario, there was always a concern of over diagnosis that will increase costs (more biopsies and surgeries) and under diagnosis by the radiologists involved in the program. We present here the results of all breast biopsies performed in this period, and its correlation with the attributed BI-RADS classification in order to optimize care and costs. Also, this study has a long term proposal and other results have been published concerned to the baseline profile of the population (Cancer Epidemiol Biomarkers Prev. 2010 Oct;19(10):2673–9. Epub 2010 Aug 17).

Methods:Since April 2004, 5592 women from 40 to 69 years were enrolled in the program and underwent to clinical breast exam and annual mammography screening at NMPOA. Initially, lesions were classified as B1, B2 or B0. After complementary views or exams, B0 was classified as B3, B4 (A, B or C) or B5. B4 and B5 were considered positive tests and immediately submitted to biopsy (open surgical or ultrasound guided core biopsy). B3 was followed according to recommended in BI-RADS fourth edition, and subsequently classified as benign (annual follow up) or suspicious findings (biopsy performed). The evaluation included histological analysis of breast biopsy specimens by two independent pathologists. Predictive positive value (PPV), predictive negative value (PNV) and accuracy (Acc) were calculated.

A model to optimize health care assistance for women with breast cancer: The Núcleo Mama Porto Alegre Project

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Background: The promptness of breast cancer (BC) diagnosis and treatment is cornerstone in reducing the disease's mortality. In Brazil, the main problem to achieve this is lack of access to the insufficient referral centers, which in turn are not used to perform early diagnosis and treatment. To address this problem in our city, we created the Núcleo Mama Porto Alegre (NMPOA) model, through a partnership among the private, public and third sectors. The cohort is composed by 9,218 women, of which 4,500 are in the 40–69 age group and have annual clinical examination and mammography (MMG) at NMPOA, and the remainder (<40 and >=70) have clinical follow-up at primary care facilities. All clinical visits, exams and treatment are conducted in the NMPOA center. Our aim is to demonstrate the effectiveness of a model for underserved population to shorten the time between 1st medical appointment and the start of BC treatment. Methods: We analyzed all BC cases diagnosed up to now. We evaluated 3 time periods of the patient's care: median time (MT) between the medical appointment and MMG, MT between MMG and biopsy, and MT between biopsy and the first treatment as indicated: definitive surgery, neoadjuvant chemo- or hormone therapy. Results: 48 cases were evaluated. Clinical staging were the following: stage 0: 16.6%; I: 37.5%; IIA: 18.8%; IIB: 12.5%; IIIA: 10.4%; and IV: 4.1%. MT between the first visit and MMG was 0 days; between MMG and biopsy, 3 days; and between biopsy and first treatment, 23 days. Conclusions: Our model shows much faster results than the usual delay time in Brazil (4–6 months between first visit and treatment). A nationwide BC screening program in Brazil must be implemented with efficient infrastructure and well trained personnel in order to rapid investigate breast lesions, assuring quick access to treatment and therefore diminishing BC mortality.

No significant financial relationships to disclose.

A model to optimize public health care and downstage breast cancer in limited-resource populations in southern Brazil. (Porto Alegre Breast Health Intervention Cohort)

Background

Breast cancer (BC) is a major public health problem, with rising incidence in many regions of the globe. Although mortality has recently dropped in developed countries, death rates are still increasing in some developing countries, as seen in Brazil. Among the reasons for this phenomenon are the lack of structured screening programs, a long waiting period between diagnosis and treatment, and lack of access to health services for a large proportion of the Brazilian population.

Methods and design

Since 2004, an intervention study in a cohort of women in Southern Brazil, denominated Porto Alegre Breast Health Intervention Cohort, is being conducted in order to test the effectiveness and cost-effectiveness of a model for BC early detection and treatment. In this study, over 4,000 women from underserved communities aged 40 to 69 years are being screened annually with mammography and clinical breast examination performed by a multidisciplinary team, which also involves nutritional counseling and genetic cancer risk assessment. Risk factors for BC development are also being evaluated. Active search of participants by lay community health workers is one of the major features of our program. The accrual of new participants was concluded in 2006 and the study will last for 10 years. The main goal of the study is to demonstrate significant downstaging of BC in an underserved population through proper screening, attaining a higher rate of early-stage BC diagnoses than usually seen in women diagnosed in the Brazilian Public Health System. Preliminary results show a very high BC incidence in this population (117 cases per 100,000 women per year), despite a low prevalence of classical risk factors.

Discussion

This study will allow us to test a model of BC early diagnosis and treatment and evaluate its cost-effectiveness in a developing country where the mortality associated with this disease is very high. Also, it might contribute to the evaluation of risk factors in a population with a different ethnic background from that studied in developed countries. If our model is proven effective, it may be replicated in other parts of the globe where BC is also a major public health problem.

Evaluation of clinical significance of basal-like subtype of breast cancer identified by immunohistochemistry

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Background: At present time, prognostic evaluation of initial breast cancer is mostly based on patients’ clinical and tumoral histological features. Recently, molecular subtypes of invasive breast cancer were recognized through DNA microarray profiling studies. This new classification can potentially improve the prognostic evaluation but this technology is still not widely available. The possibility of identifying the molecular subtypes through simpler and cheaper methods is promising. The identification of basal-like breast cancer (BLBC) is particularly important because it has a poor outcome and fewer treatment options available. Additionally, Epidermal Growth Factor Receptor (EGFR) expression seems to be more frequent in this subtype. Methods: A retrospective cohort of 112 consecutive patients with pathologic stage I or II primary breast carcinomas, treated in the same institution between 1995 and 2000, was studied. Histological and clinical features as well as clinical outcome and survival were reviewed. Immunohistochemical analysis was carried out in representative blocks of tumors with antibodies against Estrogen Receptor (ER), Human Epidermal Growth Receptor - type 2 (HER2), CK5/6 and EGFR. The primary endpoint was to determine the prevalence of BLBC (ER and HER2-negative and CK 5/6 and/or EGFR-positive) in this population. Results: 13 of 112 tumors (11,6 %) were BLBC. Their mean age was 49 years; 77 % were stage II and 100 % were invasive ductal carcinomas. There was no prognostic difference between BLBC and the subtypes luminal (ER-positive and HER2-negative); HER2-overexpressing (HER2-positive) and undetermined (four markers negative) relating to disease-free and overall survival. This is probably related to limited number of patients in this study and good prognosis of initial-stage patients. 11 of 112 cases (10%) were positive for EGFR. EGFR-positive tumors tended to be ER- negative (23 % vs 5 %; p=0,01). Conclusions: Our results suggest that it is possible to identify BLBC by immunohistochemical analysis of ER, HER2, CK 5/6 and EGFR. Besides, EGFR expression seems to be more frequent in ER-negative tumors, which suggest EGFR-targeted drugs may benefit this population.

No significant financial relationships to disclose.

Clinical Relevance of Low Levels of Preformed Alloantibodies Detected by Flow Cytometry in the First Year Post–Kidney Transplantation

OBJECTIVE

To determine the prevalence of transplants performed with a false-negative cytotoxicity cross-match and to analyze the clinical relevance of alloantibodies (Ab) detected only by flow cytometry (flow).

METHODS

We studied 66 patients undergoing kidney transplantation from a cadaveric donor. All patients had a simultaneous negative T+AHG+DTT and B+DTT. Pretransplant sera were retrospectively analyzed by flow cytometry according to an Emory University protocol: (1) T+ and B-: Ab anti-class I; (2) T- and B+: anti-class II; (3) T+B+: anti-class I + II. Chi-square, Fisher exact, Student t test, and Kaplan Meier analyses were employed with significance assigned at P < or = .05.

RESULTS

The overall incidence of false-negative cytotoxicity was 33.3% (22/66), namely, 6.1% (n = 4) anti-class I; 9.1% (n = 6) anti-class II; and 18.2% (n = 12) anti-class I + II. Primary nonfunctioning grafts occurred in 6.8% (3/44) and 13.6% (3/22) negative and positive flow patients (two anti-class I + II and one class II; P = .39). The incidence of graft loss in the first year was respectively, 13.6% (6/44) and 18.2% (4/22; two anti-class II and two anti-class I + II; P = .72). Compared to flow-negative grafts, creatinine levels were significantly higher among flow-positive patients at 8 and 12 weeks. One-year graft survivals were 86.4% among negative versus 81.8% for the positive group (P = .67).

CONCLUSIONS

We observed that 33% of kidney transplant recipients had low levels of alloantibodies detected only by flow. This single factor was associated with the worst graft function in the first trimester with a suggestion of a higher risk for non-functioning graft.

Cryoablation of benign breast tumors: evolution of technique and technology

We report on improvements in cryoprobe design and techniques of cryoablation as a minimally invasive alternative to open surgery for the treatment of benign breast tumors. In the study, which was conducted in 12 centers, 124 lesions in 102 patients were monitored for a period of 12 months after cryoablation. Two different treatment techniques were used: Double HI FREEZE and Tailored Freeze. In patients treated with the Tailored Freeze technique significantly better results were recorded 12 months after the procedure: the median reduction in tumor volume was 91%, 73% of all tumors treated were nonpalpable, 84% of lesions less than 2.5 cm in maximum diameter were nonpalpable, and none of the 31 mammograms performed yielded abnormal findings. Patient satisfaction was good to excellent in 92% of the patients. The safety profile of this technique was excellent; all complications were minor. Evolution of cryoablation freezing techniques, coupled with improvements in cryoprobe design, has resulted in significant improvements in both safety and effectiveness.

Memory facilitation by naloxone is due to release of dopaminergic and beta-adrenergic systems from tonic inhibition

The post-training IP administration of naloxone (0.8 mg/kg) facilitates memory consolidation of the habituation of a rearing response to a tone in rats. Amphetamine (1.0 - 2.5 mg/kg or nicotine (0.2 - 0.5 mg/kg), and amphetamine (2.5 mg/kg) plus nicotine (0.5 mg/kg) have no effect. The higher doses of amphetamine or nicotine, however, when given together with a dose of naloxone which is ineffective alone (0.2 mg/kg), markedly enhance consolidation. Haloperidol (0.5 mg/kg), propranolol (0.5 mg/kg), and phenoxybenzamine (2.0 mg/kg) have no effect on their own; whereas tolazoline (2.0 mg/kg) impairs consolidation. The effect of naloxone (0.8 mg/kg) is antagonized by haloperidol and by propranolol, but not by phenoxybenzamine or tolazoline. The results suggest that naloxone causes memory facilitation through the release of central dopaminergic and beta-adrenergic mechanisms from a tonic inhibitory influence of endogenous opiate peptide systems.