Gynecological-endocrinological aspects in women carriers of BRCA1/2 gene mutations.

Women carriers of mutations in the genes BRCA1 and BRCA2 coding for tumor suppressor proteins are at high risk of developing breast and ovarian cancers. Hereditary breast and ovarian cancers due to BRCA pathogenic mutations occur at earlier ages: mean age 43 years at diagnosis of breast cancer for BRCA1 mutations; onset of ovarian cancer up to 10-21% by age 50 years. Preventive strategies are then defined in the reproductive years. The National Comprehensive Cancer Network (NCCN) guidelines define that BRCA1/2 genetic testing should begin with the affected cancer individual (BRCA1/2 full sequencing); then, family members should be tested for the specific gene mutation found. A woman known to be a carrier needs a strict specific surveillance strategy to achieve early diagnosis. The NCCN proposes breast imageneological surveillance beginning at age 25 years; ovarian surveillance beginning at age 30-35 years. Concomitantly, risk-reducing strategies should be analyzed: surgical or pharmacological. When prophylactic bilateral salpingo-oophorectomy is performed before menopause, estrogen replacement therapy could be required. For BRCA, we review the risks of cancer in mutations carriers, criteria for genetic testing, surveillance and risk-reduction strategies, and the safety of prescribing hormone therapy when needed.

Stroke team remote evaluation using a digital observation camera in Arizona: the initial mayo clinic experience trial.

BACKGROUND AND PURPOSE: Telemedicine techniques can be used to address the rural-metropolitan disparity in acute stroke care. The Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use, improved data collection, low risk of complications, low technical complications, and favorable assessment times. The main objective of the STRokE DOC Arizona TIME (The Initial Mayo Clinic Experience) trial was to determine the feasibility of establishing, de novo, a single-hub, multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol. METHODS: Methods included prospective, single-hub, 2-spoke, randomized, blinded, controlled trial of a 2-way, site-independent, audiovisual telemedicine system designed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis. The primary outcome measure was whether the decision to give thrombolysis was correct. Secondary outcomes were rate of thrombolytic use, 90-day functional outcomes, incidence of intracerebral hemorrhages, and technical observations. RESULTS: From December 2007 to October 2008, 54 patients were assessed, 27 of whom were randomized to each arm. Mean National Institutes of Health Stroke Scale score at presentation was 7.3 (SD 6.2) points. No consultations were aborted; however, technical problems (74%) were prevalent in the telemedicine arm. Overall, the correct treatment decision was established in 87% of the consultations. Both modalities, telephone (89% correct) and telemedicine (85% correct), performed well. Intravenous thrombolytic treatment was used in 30% of the telemedicine and telephone consultations. Good functional outcomes at 90 days were not significantly different. There were no statistically significant differences in mortality (4% in telemedicine and 11% in telephone) or rates of intracerebral hemorrhage (4% in telemedicine and 0% in telephone). CONCLUSIONS: It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub, multispoke rural hospital telestroke research network in Arizona. The trial was not designed to have sufficient power to detect a difference between the 2 consultative modes: telemedicine and telephone-only. Whether by telemedicine or telephone consultative modalities, there were appropriate treatment decisions, high rates of thrombolysis use, improved data collection, low rates of intracerebral hemorrhage, and equally favorable time requirements. The learning curve was steep for the hub and spoke personnel of the new telestroke network, as reflected by frequent technical problems. Overall, the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise.

The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine.

A rural-urban disparity exists in acute stroke management practices in Arizona. A proposed solution is a statewide acute stroke care plan centered on stroke telemedicine. Our purpose was to evaluate the emergency stroke resources available at and care provided by remote Arizona hospitals and to formulate a 5-year stroke telemedicine plan for Arizona rural residents. We used the Arizona Hospital and Healthcare Association Web site to identify all eligible institutions. Consenting personnel were mailed the survey on behalf of the Arizona Department of Health Services. To construct the 5-year telemedicine plan, we used survey data as well as our previously designed stroke telemedicine research trial. We estimated the resources, the geographic coverage, and the operating costs. Thirty-five hospitals met survey eligibility criteria; however, 24/35 (69%) hospitals completed the survey. Only one hospital had neurologists on call 24/7. Hospitals thrombolysed 2%-4% of all stroke patients annually. Ninety percent of the hospitals were interested in participating in a statewide telemedicine initiative. The stroke telemedicine plan divided Arizona into two regions, each with a one-hub to three-spoke ratio. The budget was estimated to be U.S. $8,141,217.10 for 5 years. Remote communities of Arizona were underserviced with regard to the availability of neurologists and the delivery of emergency stroke care. The majority of the remote emergency departments were interested in participating as spoke sites in a statewide stroke telemedicine initiative. Telemedicine may be an effective method to provide expert care to stroke patients located in rural areas.

Stroke telemedicine.

Stroke telemedicine is a consultative modality that facilitates care of patients with acute stroke at underserviced hospitals by specialists at stroke centers. The design and implementation of a hub-and-spoke telestroke network are complex. This review describes the technology that makes stroke telemedicine possible, the members that should be included in a telestroke team, the hub-and-spoke characteristics of a telestroke network, and the format of a typical consultation. Common obstacles to the practice of telestroke medicine are explored, such as medicolegal, economic, and market issues. An example of a state-based telestroke network is thoroughly described, and established international telestroke networks are presented and compared. The opportunities for future advances in telestroke practice, research, and education are considered.

Competitive adsorption of proteins: key of the relationship between substratum surface properties and adhesion of epithelial cells.

The adhesion of Hep G2 cells was investigated using different substrata (commercial substrata, polystyrene modified by oxygen or ammonia plasma discharge), the surface properties of which were characterized (surface chemical composition, water contact angle, zeta potential). Some substrata were pre-conditioned with solutions of extracellular matrix (ECM) protein (collagen, laminin, fibronectin), solutions of albumin or polylysin, fetal calf serum or culture medium. The culture medium contained the surfactant Pluronic F68; cycloheximide was added in certain tests to inhibit protein synthesis. Cells spread within 1.5 h provided ECM proteins were present at the surface. Adsorption of ECM proteins was subject to competition with adsorption of Pluronic F68. When the substratum was exposed simultaneously to ECM protein and Pluronic F68, either by pre-conditioning or through protein cell secretion, a weaker substratum hydrophobicity favored adsorption of the proteins and subsequent cell adhesion. On the other hand, when ECM proteins were pre-adsorbed, they were not displaced by Pluronic F68 and cell adhesion was not influenced by substratum hydrophobicity. When ECM proteins were present, no difference was observed between substrata of similar hydrophobicity carrying positive or negative charges, respectively. In absence of ECM proteins, the presence of cationic sites at the substratum surface (NH3 plasma treatment, adsorption of polylysine) allowed cell attachment but no spreading within 1.5 h.