Combined pathologic-genomic algorithm for early-stage breast cancer improves cost-effective use of the 21-gene recurrence score assay

Background

The 21-gene recurrence score (RS) (Oncotype DX®; Genomic Health, Redwood City, CA) partitions hormone receptor positive, node negative breast cancers into three risk groups for recurrence. The Anne Arundel Medical Center (AAMC) model has previously been shown to accurately predict RS risk categories using standard pathology data. A pathologic-genomic (P-G) algorithm then is presented using the AAMC model and reserving the RS assay only for AAMC intermediate-risk patients.

Patients and methods

A survival analysis was done using a prospectively collected institutional database of newly diagnosed invasive breast cancers that underwent RS assay testing from February 2005 to May 2015. Patients were assigned to risk categories based on the AAMC model. Using Kaplan-Meier methods, 5-year distant recurrence rates (DRR) were evaluated within each risk group and compared between AAMC and RS-defined risk groups. Five-year DRR were calculated for the P-G algorithm and compared with DRR for RS risk groups and the AAMC model's risk groups.

Results

A total of 1268 cases were included. Five-year DRR were similar between the AAMC low-risk group (2.7%, n = 322) and the RS < 18 low-risk group (3.4%, n = 703), as well as between the AAMC high-risk group (22.8%, n = 230) and the RS > 30 high-risk group (23.0%, n = 141). Using the P-G algorithm, more patients were categorized as either low or high risk and the distant metastasis rate was 3.3% for the low-risk group (n = 739) and 24.2% for the high-risk group (n = 272). Using the P-G algorithm, 44% (552/1268) of patients would have avoided RS testing.

Conclusions

AAMC model is capable of predicting 5-year recurrences in high- and low-risk groups similar to RS. Further, using the P-G algorithm, reserving RS for AAMC intermediate cases, results in larger low- and high-risk groups with similar prognostic accuracy. Thus, the P-G algorithm reliably identifies a significant portion of patients unlikely to benefit from RS assay and with improved ability to categorize risk.

Abstract P2-05-13: Negative progesterone receptor is associate early breast cancer relapse, even among good prognosis tumors

Background/objective: A minority of estrogen-receptor (ER) positive breast cancers lack progesterone receptor (PR) expression, but little is known of the clinical meaning of PR negativity (PR-). In the present study we sought to clarify the association between PR- and outcomes of ER+, human-epidermal growth factor (HER2)-negative breast cancers using a large, single institution database.

Methods: We retrospectively analyzed consecutive, non-metastatic, unilateral HER2- invasive breast cancers diagnosed between 2000 and 2011. Records were reviewed for age at diagnosis, disease stage, tumor features, and histologically confirmed recurrence. ER+ and PR+ status was defined as ≥1% immunoreactive cells. We used Kaplan-Meier curves to determine the association between PR- and early (≤5 years) and late (&gt;5 years) disease recurrence, defined as locoregional or distant breast cancer relapse &gt;6 months after diagnosis.

Results: We identified 1,933 patients with TN (n=337) or ER+/HER2- (n=1,596) breast cancer. Patients with ER+/PR- (n=107) vs. ER+/PR+ (n=1,489) tumors did not differ in age or disease stage at diagnosis; however, PR- tumors were more frequently high grade (37.9% vs. 17.8%, p&lt;0.001), with higher median Ki67 indices (20.0% vs. 10.0%, p&lt;0.001). Median ER expression was also lower in PR- as compared to PR+ tumors (80.0% vs. 90.0%, p&lt;0.001).

Over a median follow-up of 84 months, there were 119 early and 54 late locoregional or distant breast cancer relapses. Negative PR was strongly associated with early relapse, with PR- tumors demonstrating a 2.1-fold higher hazard of relapse in the first 5 years as compared to PR+ tumors (95% CI 1.0-4.2)

Hazards of early (&lt;5 years) breast cancer relapse by hormone status. Shown are univariable Cox proportional hazard ratios and 95% confidence intervals among all tumors, and in subsets defined by %ER, node status, Ki67, and grade. All tumors n=1,933High ER (80-100%) n=1,383TN3.9 (2.6-5.6)*--PR 0%2.1 (1.0-4.2)*1.7 (0.6-4.6)PR 1-100%ReferenceReference Node-negative n=1,299Node-positive n=634TN4.3 (2.5-7.5)*3.6 (2.1-6.0)*PR 0%2.7 (1.0-7.0)*1.6 (0.6-4.5)PR 1-100%ReferenceReference Ki67 &lt;14% n=768Ki67 ≥14% n=997TN**2.4 (1.5-3.8)*PR 0%4.1 (1.2-14.1)*1.6 (0.7-3.8)PR 1-100%ReferenceReference Grade 1/2 n=1,337Grade 3 n=564TN3.4 (1.4-7.9)*1.9 (1.2-3.3)*PR 0%2.0 (0.7-5.7)1.2 (0.4-3.5)PR 1-100%ReferenceReference*p&lt;0.05; **too few subjects/events for analysis.

Negative PR remained significantly associated with a higher hazard of early relapse even in node-negative (HR 2.7, 95%CI 1.0-7.0) and low-proliferating tumors (Ki67&lt;14%, HR 4.1, 95%CI 1.2-14.1). There was no significant association between PR- and late breast cancer relapse (HR 0.7, 95%CI 0.2-2.9).

Conclusions: Compared to ER+/PR+ breast cancers, ER+/PR- breast cancers have a significantly greater risk of early recurrence, similar to triple-negative cancers. These results suggest that negative PR expression is importantly and independently associated with early breast cancer prognosis, and may be an indicator of unique tumor biology.

Citation Format: Winner M, Rosman M, Mylander C, Jackson RS, Pozo ME, Wolff AC, Tafra L, Umbricht CB. Negative progesterone receptor is associate early breast cancer relapse, even among good prognosis tumors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-13.

Abstract PD7-03: A model using grade and hormone receptor staining defines groups at low vs. high risk for distant metastasis: Comparison to the 21-gene recurrence score

Background: The 21-gene recurrence score (RS) combines breast cancer (BC) expression of multiple genes into a single number which is prognostic for BC recurrence. We previously showed that a model using standard pathology data (AAMC Risk Groups) has substantial overlap with RS Risk Groups. The present study compared the recurrence rate of AAMC Risk Groups to that of RS-based Risk Groups as defined by the TAILORx trial and OncotypeDX (ODX) assay.

Methods: From a prospective registry of BC treated at MD Anderson Cancer Center (2/2005 – 5/2015), we selected cases tested with ODX. Cases were excluded for: other cancer in the past 5 years, T4 stage, node positivity, missing grade, missing ER%, ER&PR&lt;1% or HER2 positivity. Three methods were used to categorize distant metastatic risk: ODX and TAILORx Risk Groups were defined using RS, and AAMC Risk Groups were defined using grade and ER/PR level (Tables). For each method, the proportion of patients experiencing metastasis was calculated within Risk Groups.

Results: 1296 cases were included, with a mean follow-up of 3.5 years (25% had ≥ 4.9 years of follow-up). 82 cases (6.3%, 95% CI 5.1 – 7.8%) experienced distant metastasis, with a mean time-to-metastasis of 2.7 years. The proportion of patients experiencing distant metastasis was similar between the AAMC Low Risk Group (1.5%) and the TAILORx (3.2%) and ODX (2.4%) Low Risk Groups. The AAMC Low Risk Group was less than half the size of the ODX Low Risk Group. Of the 5 recurrences in the AAMC Low Risk Group, 1 was ODX Low Risk and 4 were ODX Intermediate Risk; 2 had 1% PR staining. Of the 17 recurrences in the ODX Low Risk Group, 1 was AAMC Low Risk and 5 (all grade 3) were AAMC High Risk; 3 had PR staining &lt; 10%. The proportion of patients experiencing distant metastasis was similar between the AAMC High Risk Group (17.4%) and the TAILORx (16.4%) and ODX (18.2%) High Risk Groups. The number of patients in the AAMC High Risk Group was greater than the ODX High Risk Group.

Table 1: Distant Metastasis in Low Risk GroupsAAMC Definition (n=329)TAILORx Definition (n=250)OncotypeDX Definition (n=704)Low Risk DefinitionGrade 1 & PR ≥1%RS &lt; 11RS &lt;18% with Distant Metastasis1.5% (95% CI 0.6–3.7%; n=5)3.2% (95% CI 1.5-6.4%, n=8)2.4% (95% CI 1.5-3.9%, n=17)% in Common with AAMC Low Risk Group100% (329/329)31.7% (80/250)33.3% (235/704)

Table 2: Distant Metastasis in High Risk GroupsAAMC Definition (n=235)TAILORx Definition (n=238)OncotypeDX Definition (n=148)High Risk DefinitionGrade 3 or ER &lt;20%RS &gt; 25RS &gt; 30% with Distant Metastasis17.4% (95% CI 12.9-23.0%, n=41)16.4% (95% CI 12.0-21.8%, n=39)18.2% (95% CI 12.6– 25.6%, n=27)% in Common with AAMC High Risk Group100% (235/235)56.7% (135/238)70.3% (104/148)

Conclusions: AAMC Low and High Risk Groups were prognostic of the likelihood of distant metastasis, and performed similarly to TAILORx and ODX Low and High Risk Groups. If RS were omitted for AAMC Low and High Risk cases, 44% [(329+235)/1296] of cases in the present cohort could have been spared ODX testing. The AAMC Risk Groups, using standard pathology data, can reliably identify a large number of patients unlikely to benefit from ODX testing and thus provide substantial cost savings.

Citation Format: Mylander C, Jackson RS, Rosman M, Fujii T, Le Du F, Raghavendra A, Sinha A, Ueno NT, Tafra L. A model using grade and hormone receptor staining defines groups at low vs. high risk for distant metastasis: Comparison to the 21-gene recurrence score [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD7-03.

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx

OBJECTIVE

The rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC.

METHODS

Data were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, "HPVpath" staging system that combines features of the primary tumor and nodal metastases.

RESULTS

A combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort.

CONCLUSIONS

Three loco-regional "HPVpath" stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Prevalence of Dientamoeba fragilis among patients consulting complementary medicine practitioners in the British Isles

A high prevalence of Dientamoeba fragilis is reported in faecal samples collected from patients attending complementary medicine practitioners in the British Isles. Specimens were collected directly after passing into sodium acetate-acetic acid-formalin (SAF). During two observation periods in 2002-04 and 2005-07, a D fragilis prevalence of 14.6% (n = 543) and 16.9% (n = 421), respectively, was recorded. These results confirm a surprisingly high prevalence of D fragilis among a selected population. Clinical information was only available for half of the patients with D fragilis; 50% of requests with clinical information reported gastrointestinal symptoms. For further work on its pathogenic role and prevalence among patients with gastrointestinal symptoms, immediate collection in SAF should be considered the optimal sampling modality for UK based laboratories.

Otitis media and a neck lump--current diagnostic challenges for Paragonimus-like trematode infections

A 29 year-old Nigerian studying in the UK presented with a neck lump and otitis media. Paragonimus-like trematode eggs were found in the neck lump aspirate. Morphologically these eggs resembled Paragonimus uterobilateralis or Achillurbainia congolensis. We favoured the diagnosis of achillurbainiasis over extrapulmonary paragonimiasis on the basis of clinical features and because we could not amplify DNA sequences using PCR primers specific for Paragonimus species. We discuss current diagnostic challenges for this rare parasitic infection.

Vertebral artery anomaly with atraumatic dissection causing thromboembolic ischemia: a case report

STUDY DESIGN

A case report is presented.

OBJECTIVES

To illustrate a rare cause of atraumatic vertebral artery dissection resulting from anomalous entry of the vessel at the C3 transverse foramen induced by normal physiologic head and neck motion, and to review vertebral artery anatomy and mechanisms whereby it is vulnerable to pathologic compression.

SUMMARY OF BACKGROUND DATA

The vertebral artery usually enters the transverse foramen at C6. Rarely, the artery enters at C5 or C4. Only one prior case with entry at C3 has been reported. That patient experienced recurrent quadriplegia and locked-in syndrome caused by vertebral artery obstruction. A 27-year-old woman with a history of classic migraine experienced neurologic symptoms on three occasions related to physiologic neck and arm movements. Magnetic resonance angiogram was not diagnostic, but standard arteriography demonstrated anomalous vertebral artery entry into the C3 transverse foramen and focal dissection.

METHODS

Pertinent literature and the patient's history, physical examination, and radiologic studies were reviewed.

RESULTS

Standard cervico-cerebral arteriogram demonstrated focal dissection at C4 and thromboembolic complications in distal vertebral and basilar arteries. Initially, diagnosis by magnetic resonance angiogram was elusive. However, arteriography allowed prompt diagnosis followed by anticoagulation with resolution of neurologic symptoms.

CONCLUSIONS

Vertebral artery dissection without trauma is rare, but should be considered when neurologic symptoms accompany physiologic cervical movements. For cases in which vertebrobasilar thromboembolic ischemia is suspected, magnetic resonance angiogram may prove inadequate for demonstrating the causative vascular pathology. Therefore, standard cervico-cerebral arteriography should be performed.

Analysis of posterior spinal wiring in a validated rabbit model

Mamillary and spinous process base wiring did not improve L5-L6 posterolateral fusion rate, stiffness, or strength in a previously established rabbit model. Specimen radiography significantly underestimated fusion rate when compared with manual palpation (37% versus 68%). Fused specimens were significantly stiffer (67.2 N/mm versus 41.1 N/mm) and stronger (177 N versus 121 N) in tension than were nonfused specimens. Deep wound infection, detected only at the time of sacrifice, apparently was more common with internal fixation (43% versus 21%). Noninfected specimens were significantly stiffer (63.3 N/mm versus 43.0 N/mm) and stronger (176 N versus 107 N) than were infected specimens.

The role of melanocortin signalling in the control of body weight: evidence from human and murine genetic models

The peptide products of the pro-opiomelanocortin (POMC) gene have established roles in the control of physiological processes as diverse as adrenal steroidogenesis, skin pigmentation, analgesia and inflammation. In the last 5 years, evidence accumulated from murine and human genetic models of disrupted melanocortin signalling has firmly established a central role for a population of hypothalamic neurons expressing POMC in the control of appetite and body weight. Of the five known melanocortin receptors, the MC4R has been most closely linked to body weight regulation. While a-MSH is active at this receptor and suppresses appetite after central injection, important roles for other POMC-derived products have not been excluded. The development of pharmacological agonists acting on, or mimicking, the hypothalamic melanocortinergic pathway may provide exciting opportunities for the therapy of human obesity.

Intermediate filament, laminin and integrin expression in lacrimal gland acinar cells: comparison of an immortalized cell line to primary cells, and their response to retinoic acid

PURPOSE

The goal of this study was to characterize intermediate filament, integrin and laminin expression by rabbit lacrimal gland acinar cells in culture, to determine whether retinoic acid (RA) alters expression of these proteins and to compare primary cells to an immortalized rabbit lacrimal gland acinar cell line using flow cytometric analysis.

METHODS

Primary cells, maintained in serum free medium, were exposed to 10(-6) M retinoic acid for 24 hours. Immortalized cells were grown in defined medium with Nu-Serum and exposed to retinoic acid. Cells were labeled with monoclonal antibodies to cytokeratins (AE1, AE2, AE3, AE5, CK10/13, CK18), integrins (alpha(3), alpha(6), alpha(V), beta(1), beta(2), beta(3) and beta(4)), laminin, or vimentin and with FITC-conjugated secondary antibodies. Cells were analyzed for antigen expression by flow cytometry and immunocytochemistry.

RESULTS

Primary and immortalized cells expressed type I and type II epithelial cytokeratins (AE1 and AE3), cytokeratin 18, and cytokeratin 3 (AE5) Both cell types were negative to AE2 and CK10/13. Primary and immortalized cells expressed vimentin in culture, with immortalized cells expressing this protein at higher levels. Lacrimal acinar cells appear to synthesize laminin which was detected intracellularly in both cells types. Integrins alpha(6) (CD49f) and alpha(V) (CD51) were expressed by primary and immortalized cells. Expression of integrin alpha(6) was 10-fold higher in immortalized cells compared to primary cells. Retinoic acid increased integrin alpha( V) expression by primary and immortalized cells 1.3-fold and 3-fold, respectively, and caused a slight increase in integrin alpha(6) expression by primary cells. Both cell types also expressed integrins beta( 1), beta(2) and beta(3), but beta(4) was detected only in immortalized cells. Lacrimal acinar cells do not express integrin alpha(3).

CONCLUSIONS

Expression of cytokeratins, laminin and integrins by primary and immortalized cells was similar, suggesting that the immortalized cell line is a good model for the study of lacrimal structure and function. Since retinoic acid up-regulated only integrin alpha(V), but not cytokeratins, these cells appear to be highly differentiated. Flow cytometry is a useful method for analysis of protein expression by lacrimal acinar cells.

The African American church and university partnerships: establishing lasting collaborations

This article highlights the experiences of the Health Wise Church Project, a community outreach initiative between a diverse group of African American churches and a university health education program. The objective of the program was to develop early detection and illness prevention networks among older church members. Not all partnerships results in long-term collaborations, and this article makes a clear distinction between different types of "working together" arrangements. The project discussed in this article presents a four-stage model to illustrate how organizations achieve collaborative partnerships. Involving community partners in the early phase of project planning contributed to the success of the church-university collaboration. This type of shared planning helped to sustain community interest during the project's implementation.

Molecular and cellular regulation of prohormone processing

The processing of prohormones involves cleavage at specific basic amino acids by members of the subtilisin-like serine endoprotease family, followed by trimming of the COOH terminus by carboxypeptidase E. The enzymes are regulated by the intra-organelle ionic environment, through post-translational processing and by interaction with endogenous inhibitors. Much has been learned about their catalytic function and cell biology from in vitro gene transfer experiments using chimeric molecules and by site-directed mutagenesis. Further insight into their molecular properties and physiological function has been gained recently from the study of in vivo mutants.

Obesity and impaired prohormone processing associated with mutations in the human prohormone convertase 1 gene

Human obesity has an inherited component, but in contrast to rodent obesity, precise genetic defects have yet to be defined. A mutation of carboxypeptidase E (CPE), an enzyme active in the processing and sorting of prohormones, causes obesity in the fat/fat mouse. We have previously described a women with extreme childhood obesity (Fig. 1), abnormal glucose homeostasis, hypogonadotrophic hypogonadism, hypocortisolism and elevated plasma proinsulin and pro-opiomelanocortin (POMC) concentrations but a very low insulin level, suggestive of a defective prohormone processing by the endopeptidase, prohormone convertase 1 (PC1; ref. 4). We now report this proband to be a compound heterozygote for mutations in PC1. Gly-->Arg483 prevents processing of proPC1 and leads to its retention in the endoplasmic reticulum (ER). A-->C+4 of the intro-5 donor splice site causes skipping of exon 5 leading to loss of 26 residues, a frameshift and creation of a premature stop codon within the catalytic domain. PC1 acts proximally to CPE in the pathway of post-translational processing of prohormones and neuropeptides. In view of the similarity between the proband and the fat/fat mouse phenotype, we infer that molecular defects in prohormone conversion may represent a generic mechanism for obesity, common to humans and rodents.

Simplified technique to measure mandibular range of motion

The validity and reliability of a simplified technique to measure mandibular range of motion was studied in 10 dentate subjects without symptoms. The simplified technique consisted of marking with a pencil the centric relation and maximum right, left, and protrusive positions and maximum opening. These markings were made on a tongue blade held against the maxillary anterior teeth with the mesioincisal embrasures between the mandibular central incisors used as a reference. Range of motion was also measured with a mandibular kinesiograph as the control. Each method was repeated five times on each subject by each of three investigators. Intraclass correlation coefficient demonstrated a moderate level of agreement between the two techniques and high inter-rater reliability for the three investigators for all positions except maximum left movement. These data support the hypothesis that this simplified technique is a valid and reliable way to measure mandibular range of motion.

Implementing continuous quality improvement in primary care: implications for preventive services

The implementation of CQI must be done in a manner that capitalizes on the challenges of primary care, including the professional autonomy of the physician, the availability of data, issues of cost and efficiency of service, and the expanding role of patient expectations in quality care. Analysis of these factors is based on an ongoing study designed to help community-based primary care practices increase the utilization of prevention and early detection services offered to patients.

Comparison of paired short Synacthen and insulin tolerance tests soon after pituitary surgery

The cortisol responses to hypoglycaemia (insulin tolerance test, ITT) and tetracosactrin (short Synacthen test, SST) were compared after hypophysectomy to evaluate the SST for the assessment of hypothalamo-pituitary-adrenocortical (HPA) axis function in the immediate post-operative period. In 12 patients who were tested a mean of 21 months postoperatively (range 1-96) peak plasma cortisol in the SST correlated with that in the ITT (r = 0.90). Correlation was also seen in 12 patients tested a mean of 9 days (range 4-18) after hypophysectomy (r = 0.73). Basal-peak cortisol increments did not correlate. The peak plasma cortisol response in each test was classified by comparison with a reference value of 550 nmol/L. On this basis there was a notable discrepancy between the ITT and SST results in only one patient who was tested 4 days after hypophysectomy. The close correlation between ITT and SST responses after pituitary surgery extends into the immediate post operative period and indicates that the latter test can be used to screen HPA axis function at this time.

Capgras syndrome in adolescence

Capgras syndrome, the delusion of substitution, has rarely been reported in adolescents. The etiology is unknown, and intense controversy surrounds the debate over the relative importance of biological versus psychological factors. Presented here are two cases of Capgras syndrome in adolescents and a review of the relevant biological, neuropsychological, and psychodynamic literature. The authors suggest that the psychological processes underlying the Capgras delusion are mediated by neuroanatomical connections between various brain areas and hypothesize that the fundamental lesion in Capgras syndrome may be the patient's inability or failure to acknowledge the authenticity of a person they clearly recognize.

Are patients with low serum thyroid stimulating hormone and normal total thyroxine hyperthyroid? Usefulness of 99mTc pertechnetate uptake

The records of 107 patients who had had thyroid 99m Tc pertechnetate uptake measured, were reviewed. In patients with normal serum thyroxine (T4) and thyroid stimulating hormone (TSH), 35 of 36 with normal uptake and three with high uptake were clinically euthyroid. In patients with high serum T4 and low TSH, seven had normal and 29 had high uptake and all were clinically hyperthyroid. In patients with normal serum T4 and low TSH, 10 of 11 with high uptake were clinically hyperthyroid whereas only two of 18 with normal uptake were. The sensitivity, specificity and positive predictive value of pertechnetate uptake measurements were 83%, 94%, and 91%, respectively. The measurement of pertechnetate uptake is a rapid investigation and may help in the interpretation of patients with undetectable serum TSH found in the presence of normal serum T4.

Acute rupture of myxomatous mitral valve presenting as refractory cardiopulmonary arrest

A 59 year old white woman had an out of hospital sudden cardiac arrest. Resuscitation at the scene restored spontaneous pulse, blood pressure and respiration but cardiovascular collapse recurred within 30 minutes of hospital arrival. Medically refractory cardiogenic shock of unclear origin prompted the placement of an intraaortic balloon pump, and hemodynamic stabilization was achieved over several hours. Acute rupture of the chordae tendineae of myxomatous mitral valve was diagnosed as the cause of the cardiac arrest. Mitral valve replacement was performed and the patient made an uneventful recovery. This report describes the first known case of rupture of a myxomatous mitral valve presenting as sudden cardiac death. The differential diagnosis of sudden death in this disorder is reviewed, the role of mechanical circulatory assistance in refractory cardiac arrest is discussed and several interesting hemodynamic aspects of the case are considered.

High-frequency ventilation in the management of tracheal trauma

Two cases of rupture of the trachea were treated by surgical repair. Intraoperative and postoperative ventilation was managed with high-frequency ventilation. This mode of ventilation afforded good intraoperative exposure and support as well as good postoperative ventilation despite pulmonary contusion without requiring inflation of the endotracheal tube cuff against tracheal suture lines. We recommend high-frequency ventilation in the management of tracheobronchial trauma intraoperatively and postoperatively, because it allows good ventilation despite pulmonary contusion without high positive airway pressures and without the necessity for inflation of the endotracheal tube cuff against a tracheal suture line.

Development of a statewide program for surveillance and reporting of hospital-acquired infections

In 1974, a statewide program was begun to improve surveillance of nosocomial infection in Virginia hospitals. Infection control practitioners were trained at the University of Virginia Hospital, Charlottesville, and were encouraged to submit monthly surveillance reports for analysis. In the first three years of the project, 141 students from 65 hospitals within the state attended a two-week basic course, with eight to 10 students per class. Of the 98 Virginia hospitals that sent students, 75 (73%) submitted monthly reports. The consistency of reporting (number of monthly reports received divided by the number of possible reporting months) was 83%. The sensitivity of reported data was estimated in comparative daily prospective surveys to be 69% for participating hospitals, and the specificity was 99%. The crude infection rate for the first 1.1 million patients at risk was 3.3%.

Epidemic kepone poisoning in chemical workers

From March 1974 through July 1975, 76 (56%) of 133 persons who had worked at a pesticide plant that produced Kepone, a chlorinated hydrocarbon insecticide, contracted a previously unrecognized clinical illness characterized by nervousness, tremor, weight loss, opsoclonus, pleuritic and joint pain, and oligospermia. Illness incidence rates for production workers (64%) were significantly higher than for nonproduction personnel (16%). The mean blood Kepone level for workers with illness was 2.53 ppm and for those without disease 0.60 ppm (p less than 0.001). Blood Kepone levels in current workers (mean, 3.12 ppm) were higher than those in former employees (1.22 ppm). Blood Kepone levels for workers in nearby businesses and for residents of a community within 1.6 km of the plant ranged from undetectable to 32.5 ppb. Illness attributable to Kepone was found in two wives of Kepone workers; there was no apparent association between frequency of symptoms and proximity to the plant in the survey of the community population.

Serologic response to revaccination with two rubella vaccines

Three years after receiving rubella vaccine, 1,060 elementary school children living on the island of Maui, Hawaii, were revaccinated with either HPV-77 DE-5 or RA 27/3 rubella vaccine given subcutaneously or intranasally in order to compare the effectiveness of these two vaccines in raising antibody titers. RA 27/3 was the more effective booster vaccine, producing fourfold or greater titer rises in 20.1% of recipients, including 80% of children with hemagglutination-inhibiting antibody titers less than or equal to 1:40 at the time of revaccination, intranasal revaccination was not significantly more effective than subcutaneous revaccination, although it did elicit higher titers in children who responded. Responses differed according to the vaccine that children had received three years earlier. Because antibody titers have persisted in vaccinated children, routine administration of a second dose of rubella vaccine is not currently recommended.

Tickborne oculoglandular tularemia: case report and review of seasonal and vectorial associations in 106 cases

A patient acquired tickborne oculoglandular tularemia in early summer in rural Virginia. Tick exposure may be a clue to the diagnosis of tularemia in the eastern as well as the western United States, especially in summer months. A review of the experience with tularemia in Virginia for the last 13 years shows a bimodal seasonal incidence of tularemia with an associated vector exposure in 77.4% of 106 cases. The majority of cases occurring during winter months have been associated with rabbit exposure, while those in summer months are often associated with tick exposure.

Rubella vaccination: fertility control in a large-scale vaccination program for postpubertal women

Despite nationwide immunization programs, rubella infections during pregnancy continue. To solve this serious health problem direct immunization of women of reproductive age may be required. On a clinic basis, using nonphysician personnel, we vaccinated 404 susceptible women, ages 18 to 33; half were sexually active. Since pregnancy is proscribed for 2 to 3 months following rubella vaccination, a full range of family-planning services and a variety of contraceptive methods were used to ensure sustained fertility control. Sixteen vaccinees presented with possible conceptions in a 3 month follow-up. Of these, only five required treatment: two received diethylstilbestrol, two had menstrual inductions, and one an abortion. Administration of vaccine during a menstrual period was effective in preventing inadvertent vaccination of pregnant women. It was concluded that contraceptive counseling with adequate pregnancy termination backup makes it feasible to give rubella vaccine to highly motivated women.

Repeated germination of sclerotia of Botrytis convoluta to produce successive crops of conidia

Six successive crops of mature conidia were produced at 5 °C by sclerotia of Botrytis convoluta when each sporulation was preceded by a 24-h exposure to near-ultraviolet (n.uv.) radiation. Conidial production during these sporulations was greatest during the second sporulation while the largest number of conidia produced per unit of weight lost during the sporulations occurred during the third sporulation. Sporulation began to decline after the dry weight of the sclerotia had fallen to 32% of its initial level.The improved sporulation that occurred during the second sporulation was more marked at 10 °C than at any other temperature tested. It resulted in a shift in the optimum temperature for sporulation from 5 °C during the first sporulation to 10 °C during the second sporulation.At 5 °C, sclerotia were able to produce at least four crops of conidia after only a single, initial 24-h exposure to n.uv. radiation. The total number of spores produced during these sporulations was 11% below that of sclerotia exposed to n.uv. radiation before each of the four sporulations. When sclerotia were placed at 25 °C for the first sporulation, however, they did not sporulate again at either 5 °C or 25 °C without additional exposure to n.uv. radiation.When conidia and conidiophores of one sporulation were left intact on the sclerotia, they did not produce further crops of conidia under otherwise favorable conditions. The suppression of repeated sporulation was lifted by the removal of the conidia. Removal of the conidiophores as well as the conidia did not further influence the number of conidia produced during the subsequent resporulation.

Environmental factors regulating the production of conidia by sclerotia of Botrytis convoluta

Sclerotia of Botrytis convoluta germinated to produce conidia only when dried, remoistened, and exposed to near-ultraviolet (n.uv.) radiation. An exposure of less than 2 h at an intensity of 340 μW/cm2 was ineffective in inducing spore production. Longer exposures, up to 45 h duration, progressively resulted in greater sporulation. Sensitivity to n.uv. radiation fell when sclerotia were held under moist conditions in darkness for more than 12 h. The development of the loss of sensitivity was retarded for at least 24 h by exposing sclerotia to n.uv. radiation for 30 min at an intensity of 340 μW/cm2. Induction of sporulation by n.uv. radiation was optimal at 20 °C. Initiation of conidiophore formation appears to be optimal at 5 °C. Conidial production was not influenced by holding the sclerotia at either 5 or 15 °C.