Luminal A Versus B After Choosing Wisely: Does Lymph Node Surgery Affect Oncologic Outcomes?

BACKGROUND: In 2016, the Choosing Wisely campaign recommended against routine sentinel lymph node biopsy (SLNB) in women ≥ 70 years old diagnosed with early-stage hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer. No distinction is made between luminal A and luminal B phenotypes, despite luminal B being considered more aggressive. This study evaluates the effect of SLNB on oncologic outcomes in HER2- luminal B versus luminal A breast cancer. PATIENTS AND METHODS: We performed an IRB-approved, single institution, retrospective cohort study from 2010 to 2020 of women aged ≥ 70 years with clinically node negative, HR+ breast cancer undergoing definitive surgical treatment. Luminal status was defined by gene expression panel testing, Ki67%, and/or pathologic grading. Primary endpoints included locoregional recurrence (LRR), disease free survival (DFS), and overall survival (OS). RESULTS: SLNB did not correlate with significant differences in LRR in luminal A (p = 0.92) or luminal B (p = 0.96) disease. SLNB correlated with improved DFS (p < 0.01) and OS (p < 0.001) in luminal A disease, but not in luminal B disease (DFS p = 0.73; OS p = 0.36). On multivariate analysis, age (HR = 1.17; p < 0.01) and tumor size (HR = 1.03; p < 0.05) were associated with DFS, while SLNB was not (p = 0.71). Luminal status (HR = 0.52, p < 0.05), age (HR = 1.15, p < 0.01), and comorbidities (HR = 1.35, p < 0.05) were associated with OS, but not SLNB (p = 0.71). CONCLUSIONS: Our results suggest that SLNB may be safely omitted in patients aged ≥ 70 years with luminal B disease given similar LRR in luminal A disease. Our findings suggest that DFS and OS are driven by tumor biology, patient age, and comorbidities rather than receipt of SLNB.

Concordant care in sentinel lymph node omission following Choosing Wisely® recommendations at a comprehensive cancer center.

BACKGROUND: In 2016, the SSO and ABIM released a Choosing Wisely® guideline stating SLNB can be safely omitted in women ≥70 with HR â€‹+ â€‹HER-invasive breast cancer. No study evaluating concordance of care with this guideline has been performed within a comprehensive cancer center. METHODS: From 2005 to 2020, there were 382 patients with cT1-2N0 invasive carcinoma ER+/PR+ and HER2-identified as having undergone SLNB. These patients were then separated into two groups; those in the pre-guideline concordance cohort (2005-2015) and those in the post-guideline concordance (2016-2020) cohort. Axillary management concordance was trended over time. RESULTS: 382 patients from 2005 to 2020 with HR â€‹+ â€‹HER- IBC were identified. No difference was seen in SLNB pre-versus post-guidelines (p â€‹= â€‹0.35). Increased concordance was noted as age increased (p â€‹= â€‹0.0068) and adjuvant radiation therapy exclusion (p â€‹< â€‹0.0001) post-guideline release. Concordance improved over the years post-guideline release (R2 â€‹= â€‹0.45). CONCLUSIONS: Surgical guideline adoption occurs over time but may also be affected by outside decisions and factors. Further study into patterns of guideline adoption may facilitate improving adherence to guidelines.

Prevalence and factors associated with probable obstructive sleep apnea among patients with hypertension in two primary care clinics in Miri, Sarawak, Malaysia.

PURPOSE: Obstructive sleep apnea (OSA) has been increasingly recognized as an important factor contributing to medical morbidity and mortality. It was reported that more than half of the population with hypertension had OSA. Limited studies have been done on assessing OSA in hypertensive patients. This study aimed to determine the prevalence, socio-demographic characteristics, and factors associated with probable OSA in hypertensive patients in primary care clinics in Sarawak. METHODS: A cross-sectional study was carried out using a systematic random sampling method in hypertensive patients who attended two government primary care clinics in Sarawak. The STOP-Bang questionnaire was used to screen for OSA, and social-demographic data was captured with a questionnaire. Multiple logistic regressions were used to examine the determinants of the OSA. RESULTS: A total of 410 patients were enrolled in this study. The mean age of study population patients was 56.4 years, with more than half being female. The mean blood pressure was 136/82. The prevalence of probable OSA among patients with hypertension was 54.4%. According to multiple logistic regression analyses, smoking (odds ratio [OR] 14.37, 95% confidence interval [CI] 3.335-61.947), retirees (OR 3.20, 95% CI 1.675-6.113), and being Chinese (OR 2.21, 95% CI 1.262-3.863) had a significant positive association with probable OSA. CONCLUSIONS: Because of the high prevalence of probable OSA among patients with hypertension, primary care physicians should be more vigilant in identifying hypertensive patients with OSA risk. Early detection and intervention would reduce disease complications and healthcare costs.

The effect of 25-hydroxyvitamin D on insulin sensitivity in obesity: is it mediated via adiponectin?

There has been substantial recent interest in using vitamin D to improve insulin sensitivity and preventing/delaying diabetes in those at risk. There is little consensus on the physiological mechanisms and whether the association is direct or indirect through enhanced production of insulin-sensitising chemicals, including adiponectin. We examined cross-sectional associations between serum 25-hydroxyvitamin D (25(OH)D) and insulin sensitivity (Matsuda index), parathyroid hormone (PTH), waist circumference, body mass index (BMI), triglycerides (TG), total and high molecular weight (HMW) adiponectin, HMW : total adiponectin ratio (HMW : total adiponectin), and total cholesterol : HDL cholesterol ratio (TC:HDL cholesterol) in 137 Caucasian adults of mean age 43.3 ± 8.3 years and BMI 38.8 ± 6.9 kg/m(2). Total adiponectin (standardised ß = 0.446; p < 0.001), waist circumference (standardised ß = -0.216; p < 0.05), BMI (standardised ß = -0.212; p < 0.05), and age (standardised ß = -0.298; p < 0.001) were independently associated with insulin sensitivity. Serum 25(OH)D (standardised ß = 0.114; p = 0.164) was not associated with insulin sensitivity, total or HMW adiponectin, HMW : total adiponectin, or lipids. Our results provide the novel finding that 25(OH)D is not associated with HMW adiponectin or HMW : total adiponectin in nondiabetic, obese adults and support the lack of association between 25(OH)D and lipids noted by others in similar groups of patients.

The socio-economic and cultural impacts of the Pan Borneo Highway on Indigenous and local communities in Sabah, Malaysian Borneo.

Road and highway development can provide multiple benefits to society, but without careful planning, this development can result in negative social and environmental impacts. The 1,200 km Pan Borneo Highway project (PBH) in Sabah, Malaysian Borneo, is constructing new highways and up-grading 2-lane roads to 4-lane highways. We assessed the potential impact of the PBH on communities using three width scenarios of 50m, 75m and 100m for planned highway alignments, and identified potentially impacted dwellings and community lands. We estimated that 65-93 villages will be impacted, and that 1,712-7,093 dwellings and 3,420-6,695 ha of community lands (e.g. paddy, oil palm smallholdings and rubber) may be lost to the PBH. Due to land tenure technicalities, many affected households may not get compensation for the loss of their homes and lands. The PBH will disproportionally impact Sabah's Indigenous Peoples, with the Kadazandusun most affected. For this study to be constructive, we provide a low impact alternative alignment for a part of the PBH; discuss the socio-economic and cultural impacts of the PBH, and offer some perspectives on current planning procedures in Sabah to support more sustainable and equitable development.

miR-128 Regulates Genes Associated with Inflammation and Fibrosis of Rat Kidney Cells In Vitro.

microRNAs (miRNAs) regulate diverse cellular functions and signaling pathways via inhibiting the expression of their target genes. Given that miR-128 mediates mitogen-activated protein kinase signaling and production of reactive oxygen species and pro-inflammatory chemokines in various types of cells and tissues, and that miR-128 is differentially expressed in aged and diseased kidneys, we hypothesized that miR-128 may play key roles in kidney inflammation. Hence, in this study, we evaluated the biological effects of miR-128 in normal rat kidney (NRK) cells in vitro. Our results revealed that overexpression of miR-128 enhanced expression of genes associated with inflammation, pro-inflammatory cytokines and fibrosis in NRK cells. The recent reports showing that expression of miR-128 is increased in liver and lung fibrosis, together with the findings in this study, suggest that miR-128 may be a pro-fibrotic miRNA that regulates fibrosis in various tissues. Anat Rec, 301:913-921, 2018. © 2017 Wiley Periodicals, Inc.

Long-term efficacy of metformin therapy in nonobese individuals with type 2 diabetes.

OBJECTIVE: The U.K. Prospective Diabetes Study (UKPDS) has demonstrated that metformin is as effective as sulfonylureas in obese subjects and is associated with less weight gain, fewer hypoglycemic episodes, and better cardiovascular outcomes. It is hence the pharmacological therapy of choice in this subgroup. However, a gap in our present knowledge is the long-term response to metformin in nonobese individuals. In this study, we compared metformin therapy in normal, overweight, and obese individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS: A database of patients treated at a referral center in Sydney, Australia, were analyzed. Patients with type 2 diabetes and complete HbA(1c) (A1C) data and treated with metformin or sulfonylurea monotherapy for at least three visits before receiving dual oral therapy were included (n = 644). Analysis by BMI and the type of oral agent was performed. Individuals were categorized as normal, overweight, or obese (BMI <25, 25-29.9, and >/=30 kg/m(2), respectively). RESULTS: There were no differences between the initial, follow-up, and last A1C between the three metformin-treated groups. The duration of successful glycemic control with metformin monotherapy in the normal and overweight individuals and their incidences of diabetes-related complications for the entire duration of follow-up were not inferior to those of the obese individuals. The nonobese patients performed better regardless of the type of oral hypoglycemic agent used. CONCLUSIONS: We conclude that metformin is at least as efficacious in normal and overweight individuals as it is in those who are obese. Our study provides evidence-based data to support metformin use in nonobese individuals with type 2 diabetes.

Silver nanoparticles disrupt germline stem cell maintenance in the Drosophila testis.

Silver nanoparticles (AgNPs), one of the most popular nanomaterials, are commonly used in consumer products and biomedical devices, despite their potential toxicity. Recently, AgNP exposure was reported to be associated with male reproductive toxicity in mammalian models. However, there is still a limited understanding of the effects of AgNPs on spermatogenesis. The fruit fly Drosophila testis is an excellent in vivo model to elucidate the mechanisms underlying AgNP-induced defects in spermatogenesis, as germ lineages can be easily identified and imaged. In this study, we evaluated AgNP-mediated toxicity on spermatogenesis by feeding Drosophila with AgNPs at various concentrations. We first observed a dose-dependent uptake of AgNPs in vivo. Concomitantly, AgNP exposure caused a significant decrease in the viability and delay in the development of Drosophila in a dose-dependent manner. Furthermore, AgNP-treated male flies showed a reduction in fecundity, and the resulting testes contained a decreased number of germline stem cells (GSCs) compared to controls. Interestingly, testes exposed to AgNPs exhibited a dramatic increase in reactive oxygen species levels and showed precocious GSC differentiation. Taken together, our study suggests that AgNP exposure may increase ROS levels in the Drosophila testis, leading to a reduction of GSC number by promoting premature GSC differentiation.

Rapid toxicity screening of gasification ashes.

The solid residues including bottom ashes and fly ashes produced by waste gasification technology could be reused as secondary raw materials. However, the applications and utilizations of these ashes are very often restricted by their toxicity. Therefore, toxicity screening of ash is the primary condition for reusing the ash. In this manuscript, we establish a standard for rapid screening of gasification ashes on the basis of in vitro and in vivo testing, and henceforth guide the proper disposal of the ashes. We used three different test models comprising human cell lines (liver and lung cells), Drosophila melanogaster and Daphnia magna to examine the toxicity of six different types of ashes. For each ash, different leachate concentrations were used to examine the toxicity, with C0 being the original extracted leachate concentration, while C/C0 being subsequent diluted concentrations. The IC50 for each leachate was also quantified for use as an index to classify toxicity levels. The results demonstrated that the toxicity evaluation of different types of ashes using different models is consistent with each other. As the different models show consistent qualitative results, we chose one or two of the models (liver cells or lung cells models) as the standard for rapid toxicity screening of gasification ashes. We may classify the gasification ashes into three categories according to the IC50, 24h value on liver cells or lung cells models, namely "toxic level I" (IC50, 24h>C/C0=0.5), "toxic level II" (C/C0=0.05

Nanotoxicity: An Interplay of Oxidative Stress, Inflammation and Cell Death.

Nanoparticles are emerging as a useful tool for a wide variety of biomedical, consumer and instrumental applications that include drug delivery systems, biosensors and environmental sensors. In particular, nanoparticles have been shown to offer greater specificity with enhanced bioavailability and less detrimental side effects as compared to the existing conventional therapies in nanomedicine. Hence, bionanotechnology has been receiving immense attention in recent years. However, despite the extensive use of nanoparticles today, there is still a limited understanding of nanoparticle-mediated toxicity. Both in vivo and in vitro studies have shown that nanoparticles are closely associated with toxicity by increasing intracellular reactive oxygen species (ROS) levels and/or the levels of pro-inflammatory mediators. The homeostatic redox state of the host becomes disrupted upon ROS induction by nanoparticles. Nanoparticles are also known to up-regulate the transcription of various pro-inflammatory genes, including tumor necrosis factor-α and IL (interleukins)-1, IL-6 and IL-8, by activating nuclear factor-kappa B (NF-κB) signaling. These sequential molecular and cellular events are known to cause oxidative stress, followed by severe cellular genotoxicity and then programmed cell death. However, the exact molecular mechanisms underlying nanotoxicity are not fully understood. This lack of knowledge is a significant impediment in the use of nanoparticles in vivo. In this review, we will provide an assessment of signaling pathways that are involved in the nanoparticle- induced oxidative stress and propose possible strategies to circumvent nanotoxicity.

Drosophila melanogaster as a model organism to study nanotoxicity.

Drosophila melanogaster has been used as an in vivo model organism for the study of genetics and development since 100 years ago. Recently, the fruit fly Drosophila was also developed as an in vivo model organism for toxicology studies, in particular, the field of nanotoxicity. The incorporation of nanomaterials into consumer and biomedical products is a cause for concern as nanomaterials are often associated with toxicity in many in vitro studies. In vivo animal studies of the toxicity of nanomaterials with rodents and other mammals are, however, limited due to high operational cost and ethical objections. Hence, Drosophila, a genetically tractable organism with distinct developmental stages and short life cycle, serves as an ideal organism to study nanomaterial-mediated toxicity. This review discusses the basic biology of Drosophila, the toxicity of nanomaterials, as well as how the Drosophila model can be used to study the toxicity of various types of nanomaterials.

Clathrin-mediated endocytosis of gold nanoparticles in vitro.

Gold nanoparticles (AuNPs) have potential biomedical and scientific applications. In this study, we evaluated the uptake and internalization of FBS-coated 20 nm AuNPs into lung fibroblasts and liver cells by different microscopy techniques. AuNP aggregates were observed inside MRC5 lung fibroblasts and Chang liver cells under light microscopy, especially after enhancement with automegallography. Clusters of AuNPs were observed to be adsorbed on the cell surface by scanning electron microscopy. Ultrathin sections showed that AuNPs were mainly enclosed within cytoplasmic vesicles when viewed under transmission electron microscopy. We also investigated the mechanism of uptake for AuNPs, using endocytosis inhibitors and quantification of Au with inductively coupled plasma mass spectrometry. Cells treated with concanavalin A and chlorpromazine showed significant decrease of Au uptake in MRC5 lung fibroblasts and Chang liver cells, respectively, implying that the uptake of AuNPs was facilitated by clathrin-mediated endocytosis. It would therefore appear that uptake of 20 nm AuNPs in both cell types with different tissues of origin, was dependent upon clathrin-mediated endocytosis.

Barriers to effective management of osteoporosis in moderate and minimal trauma fractures: a prospective study.

Osteoporosis management is suboptimal even for high-risk people with a history of prior fracture. There is also evidence that individuals with moderate trauma fracture have a lower bone density and are at higher risk of subsequent fracture. This study aimed to define factors influencing the management of individuals at risk for osteoporosis and to examine the risk profiles of individuals with minimal and moderate trauma fractures. Consecutive fracture patients (n =218) treated in the outpatient fracture clinic in St Vincent's Hospital, Sydney, over a 15-month period (February 2002-July 2003) were interviewed. Fracture risk factors, prior investigation and treatment for osteoporosis were collected and participants were contacted after 3 months to ascertain follow-up. Risk factors for osteoporosis including family history, low dietary calcium and conditions associated with bone loss were similar between low- and moderate-trauma groups and between sexes. Even though half of participants had had a prior fracture, only 34% had a bone density scan and 16% were on anti-resorptive treatment. There was a minimal (6%) increase in the rates of investigation and treatment at the 3-month follow-up, and less in the moderate trauma group and males. Independent predictors for being investigated for osteoporosis were: age over 50, prior fracture and female gender, while predictors for treatment were: age over 50 and having been investigated. This study has confirmed low rates of investigation and treatment even in individuals who have already suffered a prior fracture, and especially in those <50 and in males. People with moderate and minimal trauma fractures had similar risk factors for osteoporosis, including a similarly high proportion of prior fractures. These findings support the concept that people with moderate trauma fractures are at higher subsequent fracture risk, yet are neither investigated nor treated. This study highlights the need for further exploration of barriers to osteoporosis management.