Metabolic syndrome and breast cancer risk.

BACKGROUND: Limited data are available on metabolic syndrome and its relation to breast cancer risk in Egypt. We aimed to study metabolic syndrome and its individual components as risk of breast cancer. METHODS: This case-control study recruited 112 breast cancer cases and 112 age-matched controls from Assiut University. In addition to demographic, clinical, and anthropoemetric characteristics, blood samples were collected from both study groups to evaluate metabolic syndrome and its individual components. RESULTS: Mean age of breast cancer cases and control groups was 46.10 ± 4.34 and 45.66 ± 4.68 years, respectively. According to Joint Interim Statement (JIS) criteria for clinical diagnosis of metabolic syndrome, the overall prevalence of metabolic syndrome in all participants was 42.9%, and prevalence in breast cancer cases and control group was 57.14% and 28.6%, respectively, OR 33.33, 95% CI (1.91-5.81). BMI was more likely to be higher in breast cancer patients with a linear trend, p < 0.001. For individual components of metabolic syndrome, breast cancer cases were more likely to have high fasting blood glucose level, systolic and/or diastolic blood pressure, high triglycerides level, and low HDL-C as compared to the control group. CONCLUSION: Metabolic syndrome and its components were found to be associated with the risk of breast cancer. We believe that prevention or reversal of metabolic syndrome by raising community awareness for lifestyle changes could be an effective way in minimizing the toll of the disease.

Factors associated with the use of anesthetic drug infusion in patients with status epilepticus and their relation to outcome: a prospective study.

Status epilepticus (SE) is one of the most dreadful neurological emergencies; unfortunately, studies targeting SE are still inadequate. This study aims to identify factors associated with the use of CIVAD in patients presenting with status epilepticus and detect those impact the clinical outcome. A prospective study involving 144 episodes of SE in 144 patients. Patients were categorized according to whether or not they received CIVAD. Subjects underwent clinical assessment, brain imaging, and EEG. The consciousness level was assessed using the Glasgow coma scale (GCS) and the Full outline of responsiveness (FOUR) scale. SE severity score (STESS) and Epidemiology-based mortality score (EMSE) were used as scales for outcome prediction. Continuous IV anesthetic drug infusion was initiated in 36% of patients (+ CIVAD). Such groups showed a significantly worse initial level of consciousness (< 0.001), an unstable course of seizure evolution (0.009), and all of them showed abnormal EEG patterns. A significantly higher number of patients (+ CIVAD) developed complications (< 0.001), had higher outcome prediction scores (< 0.001), and mortality rates (< 0.001) compared to those who did not need CIVAD (- CIVAD). Mortality was associated with acute symptomatic etiology and higher total doses of propofol. Among the study population, mortality among patients who received CIVAD was associated with acute symptomatic SE and prolonged propofol infusion rather than any clinical parameters or predictor scores.

Rapid Detection of Coronavirus (COVID-19) Using Microwave Immunosensor Cavity Resonator.

This paper presents a rapid diagnostic device for the detection of the pandemic coronavirus (COVID-19) using a micro-immunosensor cavity resonator. Coronavirus has been declared an international public health crisis, so it is important to design quick diagnostic methods for the detection of infected cases, especially in rural areas, to limit the spread of the virus. Herein, a proof-of-concept is presented for a portable laboratory device for the detection of the SARS-CoV-2 virus using electromagnetic biosensors. This device is a microwave cavity resonator (MCR) composed of a sensor operating at industrial, scientific and medical (ISM) 2.45 GHz inserted in 3D housing. The changes of electrical properties of measured serum samples after passing the sensor surface are presented. The three change parameters of the sensor are resonating frequency value, amplitude and phase of the reflection coefficient |S11|. This immune-sensor offers a portable, rapid and accurate diagnostic method for the SARS-CoV-2 virus, which can enable on-site diagnosis of infection. Medical validation for the device is performed through biostatistical analysis using the ROC (Receiver Operating Characteristic) method. The predictive accuracy of the device is 63.3% and 60.6% for reflection and phase, respectively. The device has advantages of low cost, low size and weight and rapid response. It does need a trained technician to operate it since a software program operates automatically. The device can be used at ports' quarantine units, hospitals, etc.

Gene expression analysis of invasive breast carcinoma yields differential patterns in luminal subtypes of breast cancer.

Breast cancer is a heterogeneous disease, and new biomarkers are needed for more accurate classification and prediction of prognosis. The goal of this study is to assess the expression of breast cancer classification genes, to identify new molecular signatures in different intrinsic subtypes of breast cancer and to correlate their expression with different clinical variables. The study included 84 female patients newly diagnosed with non-metastatic breast cancer at the outpatient clinic at the National Cancer Institute, Cairo University, Egypt. Detection of 17 breast cancer classification genes was done using RT-PCR in tumor and normal tissues. Estrogen receptor (ER), progesterone receptor (PR), HER2, and Ki67 expression were assessed using IHC assay for intrinsic subtyping. Combined expression of FOXA1 and GATA3 was statistically higher in luminal subtypes in comparison to non-luminal subtypes. In Luminal A subtype; GRB7, EGFR, PTGS2, ID1, and KRT5 were significantly downregulated. FOXA1 and GATA3 were significantly upregulated in luminal B subtype, where EGFR and PTGS2 were significantly downregulated. While ESR1, EGFR, KRT5 and PTGS2 showed significantly low expression in tumor tissue in Her2 enriched subtype, TFF3 was significantly downregulated in triple negative subtype. GATA3 and FOXA1 expression exhibited significant correlation with tumor grade. Furthermore, GATA3, FOXA1, ESR1, and ID1 were also correlated significantly with staging of the tumor. Combined expression of ESR1, FOXA1 and GATA3 represents a molecular signature of luminal subtypes. Long term follow-up is needed to investigate the prognostic effect of breast cancer classification genes found in this study.

Characteristics and outcome in an Egyptian Cohort with status epilepticus.

OBJECTIVES: Status epilepticus (SE) is an important cause of mortality worldwide. Information regarding associations of mortality outcome in Egypt is limited. The main objective of this study was to describe the clinical characteristics and factors associated with mortality of patients with SE admitted to Cairo University Hospitals. METHODS: A prospective observational hospital-based study was conducted from January 2017 to June 2018. Patients with SE aged ≥12 years old were followed with documentation of outcome on discharge as survival versus death. RESULTS: The study cohort included 144 SE patients. The majority of episodes (96.5%) were with prominent motor features, while nonconvulsive SE occurred in 3.5%. There was a clear semiology evolution in 22.9% of episodes, 56.3% had unchanging semiology (e.g., just convulsive or just nonconvulsive) and the semiology evolution could not be discerned in 20.8%. In relation to treatment, the majority of cases were responsive (46.5%), whereas 43.1% were refractory and only 10.4% were super-refractory SE. Apart from seven patients who were referred to other hospitals, 99 patients survived whereas 38 (26.4%) died. After regression analysis, only absence of a history of epilepsy, semiology evolution and mechanical ventilator use were associated with mortality increasing its odds by 3.7, 5, 111 times, respectively. CONCLUSION: Absence of a history of epilepsy, SE semiology evolution, and mechanical ventilator use was found to be associated with mortality outcome among Egyptian patients with SE.

Association of the Trough, Peak/Trough Ratio of Imatinib, Pyridine-N-Oxide Imatinib and ABCG2 SNPs 34 G>A and SLCO1B3 334 T>G With Imatinib Response in Egyptian Chronic Myeloid Leukemia Patients.

Imatinib mesylate (IM) is highly efficacious in the treatment of chronic myeloid leukemia (CML). Therapeutic drug monitoring and pharmacogenetic screening are affirmed for better management of IM therapy. The goal of this study was to gain a greater mechanistic understanding of the factors controlling variability in IM level and its relation to the response. One hundred and two patients with CML at chronic phase were recruited in this study. Blood samples were withdrawn at least 30 days after drug administration, and trough and peak concentrations of imatinib, N-des-methyl imatinib, and pyridine-N-oxide imatinib were determined by HPLC/MS/MS. Genetic polymorphism of the genes ABCG2 SNPs 34 G>A and 421C >A; ABCB1 SNPs 2677 G>A/T, 1236 C>T, 3435 C>T; SLCO1B3 SNPs 334 T>G and CYP3A5 were studied using PCR-RFLP technique. Our study presented significant higher trough IM (1,281 ± 578 ng/ml), lower Peak/Trough ratio, clearance (Cl), and elimination rate constant, ke, among patients who achieved favorable responses (N = 64) than those for patients who suffered unfavorable response (N = 37). The P/T ratio was the only significant independent factor affecting response, as the P/T ratio increased by one, the risk of unfavorable response increased by more than double as compared to favorable response with 95% CI (1.28-3.92, P = 00.005). Moreover, like the results of IM, the trough concentration of Pyridine-N-oxide imatinib was significantly higher (P = 0.01) and its P/T ratio was significantly lower (P = 0.008) in patients achieved favorable response than those without. The wild GG genotype of the ABCG2.34 G>A gene was associated with favorable response (P = 0.01), lower Cl, Ke and high plasma IM trough level than both (AA+GA) genotypes. ABCG2.421C >A (CC) genotype had a significantly higher plasma peak of IM, N-des-methyl imatinib and higher Css. The GG and TG alleles of the SLCO1B3.334 T>G gene were significantly correlated to favorable response, while the wild allele TT was linked to unfavorable response (P = 0.03). In conclusion, the trough and P/ T ratio for both IM and Pyridine-N-oxide imatinib, in addition to Polymorphism of ABCG2 SNPs 34 G>A and SLCO1B3.334 T>G gene, is a good predictor for response of IM in CML Egyptian patients.

Microsatellite Instability and Life Style Factors in Sporadic Colorectal Cancer.

BACKGROUND: Colorectal cancer (CRC) in Egypt is a relatively high young onset disease. As a form of heterogeneous cancer, there is interplay between genetic and environmental factors. We aimed at probing the association of life style factors and Microsatellite Instability (MSI) status that could provide more insights on carcinogenic process of CRC. METHODS: One hundred incident sporadic CRC patients were involved. Information on risk factors of CRC was obtained and microsatellite instability status was predicted through evaluation of MMR protein expression via immunohistochemistry (IHC). RESULTS: Median age was 47.50 years, females represented 54.0% and 36% of patients were Microsatellite Instability High (MSI-H). Most patients with right sided colon cancer (78.3%) were MSI-H while mostly stable or low MSS/MSI-L for left-sided colon and rectum (78.6%, 74.3% respectively, p<0.001). Patients with low physical activity had higher risk of MSS/MSI-L than those with moderate or high activity p =0.026. Patients with BMI greater than 30 Kg/m2 had higher MSS/MSI-L (75.5%) than those with BMI between 25-30 Kg/m2 (60.6%) and those with normal BMI.

External validation of STESS and EMSE as outcome prediction scores in an Egyptian cohort with status epilepticus.

PURPOSE: There is a lack of data concerning the performance of the outcome prediction scores in patients with status epilepticus (SE) in developing countries. The aim of this study was to compare the predictive performances of the status epilepticus severity score (STESS) and the epidemiology-based mortality score in status epilepticus (EMSE) and adaptation of such scoring system to be compatible with the nature of society. METHOD: This is a prospective study, conducted in Egypt from the period of January 2017 to June 2018. The main outcome measure was survival versus death, on hospital discharge. The cutoff point with the best sensitivity and specificity to predict mortality was determined through a receiver operating characteristic (ROC) curve. RESULTS: Among the 144 patients with SE with a mean age of 39.3 ±â€¯19.5 years recruited into the study, 38 patients (26.3%) died in the hospital with the survival of 99 patients while 7 patients (4.9%) were referred to other centers with an unknown outcome. Although EMSE had a bit larger area under the curve (AUC) (0.846) than STESS-3 (AUC 0.824), STESS-3 had the best performance as in-hospital death prediction score as it has a higher negative predictive value (94.6%) than that of EMSE (90.9%) in order not to miss high-risk patients. CONCLUSION: In the Egyptian population, STESS and EMSE are useful tools in predicting mortality outcome of SE. The STESS performed significantly better than EMSEE combinations as a mortality prediction score.

Neuroendocrine tumors of the lung: A five-year retrospective experience of Egyptian NCI (2010-2014).

BACKGROUND: The spectrum of lung neuroendocrine tumors (NETs) encompasses low grade typical carcinoid (TC), intermediate grade atypical carcionid (AC) and high grade, both large cell neuroendocrine carcinoma (LCNEC) and small cell lung cancer (SCLC), with extreme differences in management and survival. OBJECTIVE: To study clinicopathologic and prognostic factors affecting survival of lung NETs. PATIENTS AND METHODS: This is a retrospective study evaluating 35 patients with primary lung NETs treated at National Cancer Institute of Egypt (NCI-E) between January 2010 and December 2014. Pathological diagnosis depended on definite morphology and positivity to at least one of the neuroendocrine markers by immunohistochemistry. RESULTS: The mean age of the patients was 53 ±â€¯11.2 years with male predominance. Performance status (PS) I was encountered in 48.6%. SCLC was the prevalent histology in 68.6%, followed by LCNEC & TC in 20 & 11.4%, respectively. Curative surgery was employed in 100 & 57% of TC & LCNEC patients, respectively. Stage IV was anticipated in 87.5 & 43% of SCLC & LCNEC, respectively. For the entire cohort, the median event-free survival (EFS) and overall survival (OS) were 8.0 and 13.7 months, respectively, whereas the 3-year EFS and OS were 17.8 & 20%, respectively. SCLC patients showed significantly the worst OS compared to other NETs (p = 0.001). Patients who presented with stage IV and PS > I demonstrated significantly shorter OS than those with locoregional and PS I (p = 0.00001 &p = 0.002, respectively). CONCLUSIONS: SCLC subtype, stage IV and initial PS > I are poor prognostic factors for lung NETs associated with shorter survival. This conclusion needs to be confirmed by larger studies.

Inter-observer reproducibility of the Royal College system for reporting thyroid cytology: Experience of the Egyptian National Cancer Institute.

PURPOSE: To assess the inter-observer agreement between 3 cytopathologists of thyroid FNAC using Royal College of Pathology reporting system. PATIENTS AND METHODS: The study is a retrospective one conducted on 204 cases retrieved from the archives of the Cytology Unit, Pathology Department, National Cancer Institute, Cairo University during the time period from January 2016 to December 2016. Cases were diagnosed separately by 3 cytopathologists using the Royal College of Pathology classification system (RCPath), where Thy1, nondiagnostic; Thy2, nonneoplastic; Thy3a, atypical, Thy3f, follicular lesion; Thy4, suspicious of malignancy; and Thy5, malignant. Kappa statistics were used where combination of the agreement between the 3 observers simultaneously was done. RESULTS: There was a good overall agreement between the three observers regarding all categories (kappa statistics was 0.679). Perfect agreement was reported for Thy5 category (κ = 0.874), good agreement was observed for Thy1 and Thy2 (κ = 0.784 and 0.719, respectively). For Thy3a, Thy 3f and Thy 4, a moderate agreement was reported (κ = 0.407, 0.446 and 0.453 respectively). Combination of surgical categories (Thy3f, Thy4, and Thy5) achieved a good agreement (κ = 0.701) as well as for non-surgical categories (Thy1, Thy2, and Thy3a) (κ = 0.712). CONCLUSION: RCPath reporting system for thyroid FNAC is clinically applicable and can be used for differentiation between benign cases needing observation and follow up on one hand, and malignant cases requiring surgical intervention on the other. The least inter-observer agreement (moderate agreement) was detected for Thy3a, Thy3f and Thy4 categories, necessitating multidisciplinary team meeting before any clinical decision.

Interictal cardiac repolarization abnormalities in people with epilepsy.

BACKGROUND AND OBJECTIVE: The occurrence of cardiac electrical abnormalities such as repolarization disorders in patients with epilepsy was previously documented and may, in part, clarify the mechanism of sudden unexpected death in those patients. The aim of this study was to investigate the frequency of cardiac repolarization disorders among patients with epilepsy and whether specific demographic- or disease-related features were associated with their occurrence. SUBJECTS AND METHODS: This cross-sectional study was carried out on 1000 subjects with epilepsy who were compared with age- and sex-matched 2500 subjects without epilepsy. Clinical assessment, which included careful history taking and examination, was carried out for all participants in addition to resting 12-lead electrocardiogram (ECG) recording. Electrocardiograms were reviewed by experienced cardiologists. Electrocardiogram intervals were measured, and morphological abnormalities were identified using standard guidelines. RESULTS: Repolarization abnormalities were found in 142 (14.2%) patients with epilepsy. A statistically significant elevation in percentage of corrected QT interval (QTc) prolongation (both severe and borderline) among patients with epilepsy compared with controls was documented (8.4% vs 2%, P<0.001). Epilepsy increased the likelihood of hosting prolonged QTc more than 4 times (95% confidence interval: 3.175-6.515; odds ratio: 4.548; P<0.001). Affected patients were significantly older (95% confidence interval: 1.012-1.044; odds ratio: 1.027; P=0.001), and the abnormality was significantly more prevalent among those with poor seizure control (95% confidence interval: 1.103-2.966; odds ratio: 1.809; P=0.019). On the other hand, early repolarization (ER) pattern and Brugada type ECG pattern (BP) were significantly more prevalent in subjects without epilepsy. CONCLUSIONS: Corrected QT interval prolongation (both severe and borderline) was more prevalent among patients with epilepsy, especially if uncontrolled or elderly. Electrocardiogram should be established as a part of the diagnostic workup of epilepsy in order to identify such electrocardiographic abnormality.

The Dana Farber Consortium Protocol for the Treatment of Adolescents and Young Adults With Acute Lymphoblastic Leukemia: A Single Institution Experience in Saudi Arabia.

BACKGROUND: Recent retrospective analyses and phase II trials have shown differential outcomes in adolescents and young adults when treated with pediatric compared with adult protocols. The aim of this study was to evaluate the efficacy and toxicity of the Dana Farber Consortium Protocol (DFCP) in Saudi young adults diagnosed with de novo acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: In this retrospective study we included 38 patients with de novo ALL who presented to King Abdulla Medical City in the period from June 2010 to March 2015 and received the DFCP (Princess Margret modified version). RESULTS: A total of 38 patients were included with a median age of 19 years. Two patients died during induction treatment, and 35 of 38 patients achieved complete remission (92.1%). With a median follow-up period of 22 months, at 1 and 3 years, leukemia-free survival was 80% and 68%, respectively, and overall survival was 88% and 72%, respectively. Age younger than 21 years showed a significant association with longer survival. Toxicities included febrile neutropenia in all patients during induction, typhilitis in 8/38 (21%), pneumonia in 10/38 (26%), and pancreatitis in 5/38 patients (13%), 3/38 (7.8%) during induction and 2/38 (5.2%) during intensification. Osteonecrosis affected 3/38 patients (7.8%), and was detected during screening in 2/38 (5.2%) of these patients. There were no fractures or surgical interventions, and no venous thromboembolism was recorded. CONCLUSION: Although it might be feasible to use pediatric-inspired protocols in this age group, toxicity cannot be overlooked, and the application of these protocols might require modification of drug doses or schedules relative to those used for younger children. Moreover, additional surveillance and supportive measures should be implemented to maximize benefits while minimizing toxicity.

Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography?

OBJECTIVE:: To assess the feasibility of using the MRI breast imaging reporting and data system (BI-RADS) lexicon morphology descriptors to characterize enhancing breast lesions identified on contrast-enhanced spectral mammography (CESM). METHODS:: The study is a retrospective analysis of the morphology descriptors of 261 enhancing breast lesions identified on CESM in 239 patients. We presented the morphological categorization of the included lesions into focus, mass and non-mass. Further classifications included (1) the multiplicity for "focus" category, (2) the shape, margin and internal enhancement for "mass" category and (3) the distribution and internal enhancement for "non-mass" category. Each morphology descriptor was evaluated individually (irrespective of all other descriptors) by calculating its sensitivity, specificity, positive-predictive value (PPV) and negative-predictive value (NPV) and likelihood ratios (LRs). RESULTS:: The study included 68/261 (26.1%) benign lesions and 193/261 (73.9%) malignant lesions. Intensely enhancing foci, whether single (7/12, 58.3%) or multiple (2/12, 16.7%), were malignant. Descriptors of "irregular"-shape (PPV: 92.4%) and "non-circumscribed" margin (odds ratio: 55.2, LR positive: 4.77; p-value: <0.001) were more compatible with malignancy. Internal mass enhancement patterns showed a very low specificity (58.0%) and NPV (40.0%). Non-mass enhancement (NME) was detected in 81/261 lesions. Asymmetrical NME in 81% (n = 52/81) lesions was malignant lesions and internal enhancement patterns indicative of malignancy were the heterogeneous and clumped ones. CONCLUSION:: We can apply the MRI morphology descriptors to characterize lesions on CESM, but with few expectations. In many situations, irregular-shaped, non-circumscribed masses and NME with focal, ductal or segmental distribution and heterogeneous or clumped enhancement are the most suggestive descriptors of malignant pathologies. ADVANCES IN KNOWLEDGE:: (1) The MRI BI-RADS lexicon morphology descriptors can be applied in the characterization of enhancing lesions on CESM with a few exceptions. (2) Multiple bilateral intensely enhancing foci should not be included under the normal background parenchymal enhancement unless they are proved to be benign by biopsy. (3) Mass lesion features that indicated malignancy were irregular-shaped, spiculated and irregular margins and heterogeneous internal enhancement patterns. The rim enhancement pattern should not be considered as a descriptor of malignant lesions unless CESM is coupled with an ultrasound examination.

The Liver MicroRNA Expression Profiles Associated With Chronic Hepatitis C Virus (HCV) Genotype-4 Infection: A Preliminary Study.

BACKGROUND: MicroRNAs (miRNAs) have been repeatedly shown to play important roles in liver pathologies, including hepatitis, liver cirrhosis, and liver cancer. Egypt has the highest hepatitis C virus (HCV) infection rate worldwide, predominantly involving genotype-4. OBJECTIVES: In this study, we attempted to characterize the miRNA profile of the poorly studied genotype 4 of HCV in chronically infected Egyptian patients to obtain a better understanding of the disease and its complications and help in the design of better management protocols. PATIENTS AND METHODS: We analyzed the expression levels of a selected panel of 94 miRNAs in fresh liver biopsies collected from 50 Egyptian patients diagnosed with chronic HCV infection using quantitative real-time polymerase chain reaction (PCR) assay. Non-parametric tests were used to analyze the expression level of each miRNA and association with the clinicopathological features of enrolled patients in this study. RESULTS: Our results revealed differential expression levels of the analyzed miRNAs compared to the normal controls. Twenty-seven miRNAs (including miR-105, miR-147, miR-149-3p, and miR-196b) showed up-regulation, while 17 miRNAs (including miR-21, miR-122, miR-199a-3p, and miR-223) showed down-regulation. An inverse correlation was observed between levels of miR-95, miR-130a, and miR-142-5p with the blood albumin level. Increased expression levels of seven miRNAs (miR-29c, miR-30c, miR-126, miR-145, miR-199a, miR-199a-3p, and miR-222) were observed with severe chronic hepatic inflammation. Several deregulated miRNAs found in this study have been previously linked to chronic liver inflammation and the risk of hepatocellular carcinoma (HCC) development. CONCLUSIONS: The identified expression profiles of some examined miRNAs might offer important points to consider for the treatment of naive patients and the management of chronically infected HCV patients in Egypt and around the world.

Contrast-enhanced spectral mammography: Impact of the qualitative morphology descriptors on the diagnosis of breast lesions.

OBJECTIVE: To analyze the morphology and enhancement characteristics of breast lesions on contrast-enhanced spectral mammography (CESM) and to assess their impact on the differentiation between benign and malignant lesions. MATERIALS AND METHOD: This ethics committee approved study included 168 consecutive patients with 211 breast lesions over 18 months. Lesions classified as non-enhancing and enhancing and then the latter group was subdivided into mass and non-mass. Mass lesions descriptors included: shape, margins, pattern and degree of internal enhancement. Non-mass lesions descriptors included: distribution, pattern and degree of internal enhancement. The impact of each descriptor on diagnosis individually assessed using Chi test and the validity compared in both benign and malignant lesions. The overall performance of CESM were also calculated. RESULTS: The study included 102 benign (48.3%) and 109 malignant (51.7%) lesions. Enhancement was encountered in 145/211 (68.7%) lesions. They further classified into enhancing mass (99/145, 68.3%) and non-mass lesions (46/145, 31.7%). Contrast uptake was significantly more frequent in malignant breast lesions (p value ≤ 0.001). Irregular mass lesions with intense and heterogeneous enhancement patterns correlated with a malignant pathology (p value ≤ 0.001). CESM showed an overall sensitivity of 88.99% and specificity of 83.33%. The positive and negative likelihood ratios were 5.34 and 0.13 respectively. CONCLUSION: The assessment of the morphology and enhancement characteristics of breast lesions on CESM enhances the performance of digital mammography in the differentiation between benign and malignant breast lesions.

Efficacy and safety of dexmedetomidine added to caudal bupivacaine in pediatric major abdominal cancer surgery.

BACKGROUND: Caudal analgesia has been prolonged by the addition of various adjuvants. Dexmedetomidine is a highly selective alpha-2 agonist with sedative and analgesic properties. OBJECTIVE: To investigate the effect of addition of dexmedetomidine to 0.25% bupivacaine for caudal analgesia in children undergoing major abdominal cancer surgery. STUDY DESIGN: A randomized double-blind trial. SETTING: Academic medical center. METHODS: Forty pediatric patients, aged 3 - 12 years, weighting 10 - 40 kg, and of American Society of Anesthesiologists (ASA) physical status I and II scheduled for major abdominal cancer surgeries under general anesthesia combined with caudal analgesia were enrolled. They were randomly allocated into 2 groups: Group I (BD): (n = 20) received 1 mL/kg bupivacaine 0.25% with dexmedetomidine 1 µg/kg and group II (B): (n = 20) received 1 mL/kg bupivacaine 0.25%. Heart rate (HR), mean arterial pressure (MAP), and oxygen saturation (SPO2) were recorded for 120 minutes. Pain was assessed immediately postoperative and at hours 2, 4, 6, 12, 18, and 24 of postoperative period by Face, Legs, Activity, Cry and Consolability (FLACC) score. Time to first request for analgesia and total analgesic consumption in the first 24 hours were recorded. The level of sedation was recorded using Ramsay's sedation scale [Intravenous acetaminophen 15mg/kg (perfalgan, Squibb)]. Adverse effects were recorded and treated. RESULTS: There was significant reduction in FLACC score in group BD at 2, 4, 6, and 12 hours postoperatively compared to group B. At the eighteenth and twenty-fourth hour there was no significant difference. Time of the first rescue analgesic requirement was significantly prolonged in group BD compared to group B. The mean total consumption of rescue analgesia in the 24 hours of the postoperative period was significantly decreased in group BD (405.00 ± 215.03) mg when compared with group B (810.35 ± 200.93) mg. LIMITATIONS: This study is limited by its small sample size. CONCLUSION: Addition of dexmedetomidine (1 µg/kg) to caudal bupivacaine 0.25% (1 mL/kg) in pediatric major abdominal cancer surgeries achieved significant postoperative pain relief for up to 19 hours, with less use of postoperative analgesics, and prolonged duration of arousable sedation. Hemodynamic changes were statistically significant, yet of no clinical significance.

Dexmedetomidine as an adjunctive analgesic with bupivacaine in paravertebral analgesia for breast cancer surgery.

BACKGROUND: There is little systematic research on the efficacy and tolerability of the addition of adjunctive analgesic agents in paravertebral analgesia. The addition of adjunctive analgesics, such as fentanyl and clonidine, to local anesthetics has been shown to enhance the quality and duration of sensory neural blockades, and decrease the dose of local anesthetic and supplemental analgesia. OBJECTIVES: Investigation of the safety and the analgesic efficacy of adding 1 µg/kg dexmedetomidine to bupivacaine 0.25% in thoracic paravertebral blocks (PVB) in patients undergoing modified radical mastectomy. STUDY DESIGN: A randomized, double-blind trial. SETTING: Academic medical center. METHODS: Sixty American Society of Anesthesiologists physical status -I - III patients were randomly assigned to receive thoracicPVB with either 20 mL of bupivacaine 0.25% (Group B, n = 30), or 20 mL of bupivacaine 0.25% + 1 µg/kg dexmedetomidine (Group BD, n= 30). Assessment parameters included hemodynamics, sedation score, pain severity, time of first analgesics request, total analgesic consumption, and side effects in the first 48 hours. RESULTS: There was a significant reduction in pulse rate and diastolic blood pressure starting at 30 minutes in both groups, but more evidenced in group BD (P < 0.001). Intraoperative Systolic blood pressure showed a significant reduction at 30 minutes in both groups (P < 0.001) then returned to baseline level at 120 minutes in both groups. There was a significant increase in pulse rate starting 2 hours postoperative until 48 hours postoperatively in group B but only after 12 hours until 48 hours in group BD (P < 0.001). The time of the first rescue analgesic requirement was significantly prolonged in the group BD (8.16 ± 42 hours) in comparison to group B (6.48 ± 5.24 hours) (P = 0.04). The mean total consumption of intravenous tramadol rescue analgesia in the postanesthesia care unit in the firtst 48 hours postoperatively was significantly decreased in group BD (150.19 ± 76.98 mg) compared to group B (194.44 ± 63.91 mg) (P = 0.03). No significant serious adverse effects were recorded during the study. LIMITATIONS: This study is limited by its sample size. CONCLUSION: The addition of dexmedetomidine 1 µg/kg to bupivacaine 0.25% in thoracic PVB in patients undergoing modified radical mastectomy improves the quality and the duration of analgesia and also provides an analgesic sparing effect with no serious side effects.

On the significance of fuzzification of the N and m in cancer staging.

The tumor, node, metastasis (TNM) staging system has been regarded as one of the most widely used staging systems for solid cancer. The "T" is assigned a value according to the primary tumor size, whereas the "N" and "M" are dependent on the number of regional lymph nodes and the presence of distant metastasis, respectively. The current TNM model classifies stages into five crisp classes. This is unrealistic since the drastic modification in treatment that is based on a change in one class may be based on a slight shift around the class boundary. Moreover, the system considers any tumor that has distant metastasis as stage 4, disregarding the metastatic lesion concentration and size. We had handled the problem of T staging in previous studies using fuzzy logic. In this study, we focus on the fuzzification of N and M staging for more accurate and realistic modeling which may, in turn, lead to better treatment and medical decisions.

Age at diagnosis in women with non-metastatic breast cancer: Is it related to prognosis?

OBJECTIVE: Primary objective was to verify whether breast cancer patients aged less than 40 years at diagnosis have poorer prognosis than older patients. Secondary to assess prognostic factors influencing disease free survival. METHODS: 941 women were diagnosed with non-metastatic breast cancer at NCI, Cairo in 2003. Epidemiologic, clinico-pathological characteristics, treatment modalities and disease free survival were compared among the two age groups. Prognostic factors were evaluated for association with disease-free survival. RESULTS: One hundred-eighty-one patients (19.2%) were younger than 40 years and 760 (80.8%) were older. Older women presented with higher rates of comorbidities and younger women presented with more hormone non-responsive tumors. Young women presented with larger tumors pT4=13.8% compared to 8.6% in older women, yet not significant. Young women were treated with more conservative surgery, more adjuvant chemotherapy and radiotherapy while older women with more radical mastectomies and more hormonal treatment. Recurrence rates were significantly higher among young women 44.2% compared to 34.5% in older women. Five year disease free survival in young women was 38.9% ± 4.6% compared to 48.6% ± 2.5% with adjusted hazard ratio of 1.22 95% CI (0.91-1.64), p=0.19. Multivariate analyses identified positive axillary lymph nodes (pN2-pN3), larger tumor size (pT3-pT4), hypertension, lobular carcinoma type and lack of adjuvant systemic treatment as independent factors associated with poor DFS. CONCLUSION: Young women were not found to have poorer prognosis, yet they presented with more ER negative tumors. Most of women presented with advanced stage and young women had higher recurrence rates.

Role of Ki67 in predicting resistance to adjuvant tamoxifen in postmenopausal breast cancer patients.

INTRODUCTION: Breast cancer (BC) is a major health problem in Egypt and worldwide. Its prognosis depends not only on tumor stage but also on tumor biology. AIM: To correlate the expression of Ki67 with the clinical outcomes of early hormone-receptor positive postmenopausal BC patients who are receiving tamoxifen. METHODS: This cohort study included 70 patients. They were followed up for a minimum of 2 years. Ki67 was assessed on paraffin-embedded blocks using immunohistochemistry methods. RESULTS: The median Ki67 value was 22.5% (IQR, 10%-50%). Ki67 was significantly higher in patients with HER2 positive tumors compared to HER2 negative tumors. After a median follow up period of 53 months, 22 patients (31%) developed disease recurrence either loco-regional or distant in 5.7% and 30%, respectively. Recurrent patients had significantly higher tumor stage, nodal stage and Ki67 values compared to non-recurrent cases. The 2-, 3- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 100% & 91%, 98% & 84% and 77% & 59%, respectively. DFS was significantly worse with higher TNM stage, lower ER expression and higher Ki67 values. OS was significantly worse in patients with Ki67 values ≥ 30%. Ki67 ≥ 30% was an independent predictor of recurrence, poor DFS and OS. CONCLUSION: High Ki67 expression is predictive of poor prognosis and of resistance to adjuvant tamoxifen therapy in postmenopausal BC. We recommend considering Ki67 as one of the risk factors that guide adjuvant treatment decisions.