Which threshold for ER positivity? a retrospective study based on 9639 patients.

BACKGROUND: Guidelines for the use of chemotherapy and endocrine therapy recently recommended that estrogen receptor (ER) status be considered positive if ≥1% of tumor cells demonstrate positive nuclear staining by immunohistochemistry. In clinical practice, a range of thresholds are used; a common one is 10% positivity. Data addressing the optimal threshold with regard to the efficacy of endocrine therapy are lacking. In this study, we compared patient, tumor, treatment and survival differences among breast cancer patients using ER-positivity thresholds of 1% and 10%. METHODS: The study population consisted of patients with primary breast carcinoma treated at our center from January 1990 to December 2011 and whose records included complete data on ER status. Patients were separated into three groups: ≥10% positive staining for ER (ER-positive ≥10%), 1%-9% positive staining for ER (ER-positive 1%-9%) and <1% positive staining (ER-negative). RESULTS: Of 9639 patients included, 80.5% had tumors that were ER-positive ≥10%, 2.6% had tumors that were ER-positive 1%-9% and 16.9% had tumors that were ER-negative. Patients with ER-positive 1%-9% tumors were younger with more advanced disease compared with patients with ER-positive ≥10% tumors. At a median follow-up of 5.1 years, patients with ER-positive 1%-9% tumors had worse survival rates than did patients with ER-positive ≥10% tumors, with and without adjustment for clinical stage and grade. Survival rates did not differ significantly between patients with ER-positive 1%-9% and ER-negative tumors. CONCLUSIONS: Patients with tumors that are ER-positive 1%-9% have clinical and pathologic characteristics different from those with tumors that are ER-positive ≥10%. Similar to patients with ER-negative tumors, those with ER-positive 1%-9% disease do not appear to benefit from endocrine therapy; further study of its clinical benefit in this group is warranted. Also, there is a need to better define which patients of this group belong to basal or luminal subtypes.

Principles for measurement of chemical exposure based on recognition-driven anchoring transitions in liquid crystals.

The competitive binding of a molecule forming a liquid crystal and a targeted analyte to a common molecular receptor presented at a solid surface possessing nanometer-scale topography is used to trigger an easily visualized surface-driven change in the orientation of a micrometer-thick film of liquid crystal. Diffusion of the targeted analyte from atmosphere to surface-immobilized receptor across the micrometer-thick film of liquid crystal is fast (on the order of seconds), and the competitive interaction of the targeted analyte and liquid crystal with the receptor provides a high level of tolerance to nontargeted species (water, ethanol, acetone, and hexanes). Systems that provide parts-per-billion (by volume) sensitivity to either organoamine or organophosphorus compounds are demonstrated, and their use for imaging of spatial gradients in concentration is reported. This approach does not require complex instrumentation and could provide the basis of wearable personalized sensors for measurement of real-time and cumulative exposure to environmental agents.

Implications of sub-specialisation on the waiting times of general surgical clinics.

INTRODUCTION: Controversy around sub-specialisation in a district general hospital (DGH) has been ongoing for years. AIM: To study the effect of colorectal sub-specialisation on general surgical cases. METHODS: A retrospective audit between October 2002 and September 2003, including all referrals to the outpatient clinics of a single consultant surgeon in a DGH. RESULTS: 1,055 patients were seen in outpatient clinics, of which 53% (563) were seen in rapid access colorectal clinics. Overall, 87% (914) of patients were diagnosed to have colorectal pathology. The majority of the colorectal cases were referred using the designated referral forms. There were 427 urgent, 162 soon and 325 routine referrals with colorectal pathology, and 35 urgent, 22 soon and 84 routine referrals with non-colorectal pathology. Median waiting times for urgent, soon and routine referrals were 12, 61 and 91 days, respectively, for patients with colorectal pathology, in comparison with 44, 75 and 397 days for non-colorectal pathology. CONCLUSION: This audit confirms that colorectal sub-specialisation has resulted in a significant delay in the management of patients with non-colorectal diseases. This has major implications within a DGH setting.

Is one-wave follicular growth during the estrous cycle a usual phenomenon in water buffaloes (Bubalus bubalis)?

The pattern of growth and regression of ovarian follicles was monitored once daily for one complete estrous cycle in eight individual water buffaloes by ultrasonographic scanning of the ovaries for an entire interovulatory interval of normal cycle length. One-wave follicular growth was observed in five animals and two-wave follicular growth in three buffaloes during the estrous cycle. The first follicular wave of a two-wave cycle emerged significantly earlier (P < 0.05) than the emergence of the solitary wave of a one-wave cycle. One- and two-wave cycles differed significantly (P < 0.05) with respect to the mean interovulatory interval (21.0 +/- 0.54 days versus 22.7 +/- 0.33 days) and the mean interestrus interval (20.8 +/- 0.58 days versus 22.3 +/- 0.66 days). The overall linear growth rate of the ovulatory follicle was significantly greater (P < 0.01) in a two-wave cycle compared to that of a one-wave cycle (1.17 +/- 0.33 mm/day versus 0.32 +/- 0.01 mm/day). In a one-wave pattern, the growth profile of the solitary dominant follicle was atypical, showing three distinct phases, i.e. growth phase, regression phase and regrowth phase culminating in ovulation. The level of plasma progesterone steadily increased from day 0 of estrous cycle, attained peak level on day 14 and declined thereafter. A slower growth rate of the dominant follicle was observed in the presence of higher plasma progesterone concentration. The present study shows that one-wave follicular growth is a normal phenomenon in suckled water buffaloes.

The role of local steroid injections in an operational field hospital setting.

OBJECTIVES: To assess the safety and effectiveness of administering local steroid injections in an operational field hospital environment. METHOD: A prospective study of patients presenting to the physiotherapy department at the British Military Hospital (BMH) Shaibah, Iraq was undertaken from July 2006 - September 2006. Patients with a condition amenable to local steroid injection and who had not improved with conservative therapy were considered for the study. They then underwent local injection with steroid and local anaesthetic. RESULTS: During this period 12 patients were identified that fitted the criteria for local steroid injection. This represented 7% (12/179) of patients who were seen by the physiotherapy department in either an in or out-patient setting. All patients were injected with local anaesthetic and steroid injection with a single dose of intravenous antibiotic as antimicrobial cover. 10/12 (83.3%) were able to return to their unit within this theatre of operation. The only complication was one case of post injection flare of pain, which settled after 48 hours. CONCLUSION: The use of local steroid injection, as an adjunct to physical therapy, can enable service personnel to remain in the theatre of operations. These patients may have otherwise required aero medical evacuation. We consider the use of a local steroid injection to be a safe and effective intervention in certain patients where conservative measures alone do not work. This study highlights the safety of using steroid injections in an operational field hospital setting. Further large scale studies may help corroborate this conclusion.

Influence of oxidation polymorphism on phenformin kinetics and dynamics.

Plasma and urinary kinetics and responses of blood lactate, pyruvate, and glucose after a single 50-mg phenformin dose were investigated in eight subjects of known debrisoquin oxidation phenotype, four poor metabolizers (PM) and four extensive metabolizers (EM). Higher peak plasma concentrations of phenformin (152.2 +/- 12.7 ng/ml; mean +/- SE) and a greater plasma AUC (779 +/- 99 ng X hr X ml-1) were reached in PM than in EM (99.8 +/- 13.7 ng/ml and 549 +/- 47 ng X hr X ml-1). Although the urinary excretion of unchanged phenformin was greater in PM between 2 and 24 hr after dosing than in EM, excretion of 4-hydroxy-phenformin could not be detected in most samples collected from PM but was present in every sample from EM. Blood lactate concentrations increased dramatically in PM but fell in EM after phenformin. There were no changes in either blood pyruvate or glucose levels. The results may help to explain lactic acidosis in patients given phenformin in the absence of other predisposing factors.

Genetic polymorphism of phenformin 4-hydroxylation.

The ability to oxidize a single 50-mg dose of phenformin to its 4-hydroxy metabolite was determined in 195 individuals. Variations in the urinary ratio of phenformin/4-hydroxyphenformin ranged from 1 to 184. Family studies were consistent with the hypothesis that this variability resulted from a single gene mode of inheritance in which impaired hydroxylation of phenformin appears as an autosomal recessive trait. Both genotype frequencies and the degree of dominance of the extensive metabolizer phenotype over the recessive showed a remarkable resemblance to those described for debrisoquine 4-hydroxylation, which was confirmed by the high degree of correlation (rs=0.785, P less than 0.0001) between the phenformin ratio and the debrisoquine metabolic ratio. Such close agreement between the metabolism of these drugs may indicate that the same genetic control is in operation. Such genetic polymorphism of phenformin hydroxylation may have important implications for therapeutic response and for the possibility of toxic effects in a few individuals.

Clinical experience with expanded polytetrafluoroethylene (Gore-Tex) grafts for femoropopliteal arterial bypass.

Thirty-seven grafts of expanded polytetrafluoroethylene were implanted in 28 patients in whom autogeneous saphenous vein was not available, either for symptoms of severe claudication or limb salvage. The length of follow-up ranges from 8 to 28 months . The patency rate is 86.9 percent for the patients with severe claudication and 71.4 percent in the limb salvage group; the overall patency rate is 81 percent. We believe that expanded polytetrafluoroethylene is a good prosthetic substitute when autogenous vein is unavailable.

Imaging of the infrahyoid neck.

The infrahyoid neck is a complex region of anatomy and pathology. The spatial division of the infrahyoid neck into six discrete spaces is accomplished by three layers of the deep cervical fascia. Once understood, the pathologic processes in this region can be better characterized. Additionally, this article includes the anatomy and pathology of the thyroid and parathyroid glands and the brachial plexus.

Max Thorek: a surgeon for all seasons.

Max Thorek was a leader in the field of surgery during the first half of the twentieth century. His contributions to plastic surgery included both technical advances and the recognition of the psychological import of aesthetic surgery. His technique for reduction mammaplasty (free nipple graft) is still in use today, and his principles of abdominoplasty remain applicable to modern body contour surgery.

Changes in debrisoquine hydroxylation capacity following liver surgery.

Liver transplantation or the surgical construction of portacaval shunts may radically alter an individual's debrisoquine hydroxylation capacity. Good clinical management should encompass a full awareness of such changing needs and problems in patients who undergo hepatic surgery.

The cost-effectiveness of drug regulation: the example of thorough QT/QTc studies.

We analyzed the cost-effectiveness of the International Conference on Harmonisation (ICH) E14 guideline that requires a thorough QT/QTc (TQT) study for all drugs under development. We compared two pharmacoeconomic scenarios: the health effects and costs resulting from implementing ICH E14 ("regulation" scenario) vs. not implementing ICH E14 ("no regulation" scenario). We used a dynamic population model to calculate the cost-effectiveness of ICH E14 for a prototype QT-prolonging antipsychotic drug entering the US and European markets. The incremental cost-effectiveness ratios of regulation vs. no regulation were ~€2.4 million per sudden cardiac death prevented and ~€187,000 per quality-adjusted life year (QALY) gained in users of antipsychotic drugs. The main driver of cost was the requirement for electrocardiogram (ECG) monitoring of users of QTc-prolonging drugs. Even when several of the assumptions in the model were varied, there were no results in favor of regulation. Our study shows that cost-effectiveness analysis of drug regulatory measures is feasible and should be considered before developing such measures.

Evaluation and management of cardiac safety using the electrocardiogram in oncology clinical trials: focus on cardiac repolarization (QTc interval).

Non-antiarrhythmic drugs have been reported to prolong the QTc interval and induce potentially fatal ventricular tachyarrhythmias. An increasing number of drugs that are used for treating malignancies are no exception. Therefore, both oncologists and regulators expect sponsors of oncology drugs to evaluate, during the development of the drugs, their effects on the electrocardiogram (ECG), particularly on the QTc interval. In the case of agents that cannot be administered to healthy volunteers, the primary approach is to carry out an intense ECG evaluation, employing robust ECG recordings, during early-phase clinical trials, together with characterization of the concentration-QTc interval relationship, and follow this up with an appropriate intensity of ECG monitoring in the later phases of development. This article describes the broad principles of these approaches, including recommendations for exclusion criteria (relative to baseline QTc interval and to cardiac comorbidity); it also describes methods for conducting ECG monitoring and a proposed scheme for the management of any QTc-related effects that may emerge.

Regeneration of stevia plant through callus culture.

Stevia rebaudiana Bertoni that conventionally propagated by seed or by cuttings or clump division which has a limitation of quality and quantity seed material. In present study, callus culture technique was tried to achieve rapid plant multiplication for quality seed material. Callus induction and multiplication medium was standardized from nodal as well as leaf sagments. It is possible to maintain callus on Murashige and Skoog medium supplemented with 6-benzyl amino purine and naphthalene acetic acid. Maximum callus induction was obtained on Murashige and Skoog medium incorporated with 6-benzyl amino purine (2.0-3.0 mg/l) and naphthalene acetic acid (2.0 mg/l) treatments. However, Murashige and Skoog medium containing 2.0 mg/l 6-benzyl amino purine+2.0 mg/l naphthalene acetic acid was found to be the best for callus induction. Higher regeneration frequency was noticed with Murashige and Skoog medium supplemented with 2.0 mg/l 6-benzyl amino purine+0.2 mg/l naphthalene acetic acid. Regenerated plants were rooted better on (1/4) Murashige and Skoog strength supplemented with 0.1 mg/l indole-3-butyric acid. The rooted plantlets were hardened successfully in tera care medium with 63 per cent survival rate. The developed protocol can be utilized for mass production of true to type planting material on large scale independent of season, i.e. external environmental conditions.

HPTLC Method for the Simultaneous Estimation of Valsartan and Hydrochlorothiazide in Tablet Dosage Form.

A simple, precise, accurate and rapid high performance thin layer chromatographic method has been developed and validated for the simultaneous estimation of valsartan and hydrochlorothiazide in combined dosage forms. The stationary phase used was precoated silica gel 60F(254). The mobile phase used was a mixture of chloroform: methanol: toluene: glacial acetic acid (6:2:1:0.1 v/v/v/v). The detection of spots were carried out at 260 nm. The method was validated in terms of linearity, accuracy, precision and specificity. The calibration curve was found to be linear between 300 to 800 ng/spot for valsartan and 100 to 600 ng/spot for hydrochlorothiazide. The limit of detection and the limit of quantification for the valsartan were found to be 100 and 300 ng/spot respectively and for hydrochlorothiazide 30 and 100 ng/spot respectively. The proposed method can be successfully used to determine the drug content of marketed formulation.