Missed opportunities: clinical antecedents in the diagnosis of advanced breast cancer.

BACKGROUND: Locally advanced breast cancer (LABC) often requires complex treatment, and the prognosis is typically poor. We hypothesize that LABC patients engage the healthcare system with a variant pattern as compared with patients diagnosed with early stage disease. METHODS: We identified all newly diagnosed breast cancer patients between 2005 and 2009 at Kings County Hospital (KCH), focusing upon established patients. All provider encounters during 2 years before diagnosis were retrieved from the medical record. Patients were stratified to two groups: early breast cancer (n = 87) and LABC (n = 44). Encounters were classified by type of clinic and whether a clinical breast examination or breast imaging study was performed. RESULTS: The early group made more total contacts with the healthcare system than LABC group, 10.4 and 7.4, respectively. Both groups demonstrated statistically equivalent rates of contact with subspecialty and acute providers. Early patients demonstrated greater usage of primary care services, 4.6 compared with 3.0 visits among LABC patients. The early cohort demonstrated increased rates of breast imaging and examinations overall as well as an increased rate of breast examination within primary care clinics. DISCUSSION: Delayed breast cancer diagnosis is influenced by patterns of healthcare utilization and the effectiveness of primary care services. LABC patients are less likely to visit primary care clinics despite frequent contacts with the healthcare system and as such are less likely to receive basic diagnostic procedures, including clinical breast examination and mammography. Renewed attention to these primary care activities should detect many LABC patients at an earlier stage.

Traumatic stress symptoms and breast cancer: the role of childhood abuse.

OBJECTIVE: The present study investigated relations between reported childhood abuse and recent traumatic stress symptoms in women newly diagnosed with breast cancer (n=330). METHODS: As part of a larger ongoing study, patients from eight public and private hospitals were referred by their physicians and completed the Childhood Trauma Questionnaire (CTQ), and the Impact of Events Scale-breast cancer (IES), which measured breast cancer-related intrusive and avoidant symptoms. RESULTS: Emotional abuse, physical abuse, and sexual abuse were correlated with intrusive symptoms. Cancer-related avoidant symptoms approached significance in their relation to emotional and sexual abuse. Multivariate analysis, controlling for age and time since diagnosis, revealed that childhood emotional abuse was an independent predictor of breast cancer-related intrusive symptoms, but that childhood physical abuse and sexual abuse were not significant predictors. CONCLUSIONS: Childhood emotional, physical, and sexual abuse were associated with breast cancer-related intrusive symptoms. Emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. Results suggest that a cancer diagnosis may trigger cognitive and emotional responses that relate to patients' prior trauma experiences. PRACTICE IMPLICATIONS: Physicians and psychologists treating women with breast cancer should be aware that a history of childhood abuse may exacerbate patients' cancer-related intrusive symptoms. Interventions for women affected by both childhood abuse and breast cancer may be most effective when they address both stressors and associated emotional responses. Findings highlight the importance of additional research to explore links between prior trauma and distress following a cancer diagnosis stress.

Regeneration of lithium aluminum hydride.

Lithium aluminum hydride (LiAlH(4)) is a promising compound for hydrogen storage, with a high gravimetric and volumetric hydrogen density and a low decomposition temperature. Similar to other metastable hydrides, LiAlH(4) does not form by direct hydrogenation at reasonable hydrogen pressures; therefore, there is considerable interest in developing new routes to regenerate the material from the dehydrogenated products LiH and Al. Here we demonstrate a low-energy route to regenerate LiAlH(4) from LiH and Ti-catalyzed Al. The initial hydrogenation occurs in a tetrahydrofuran slurry and forms the adduct LiAlH(4).4THF. The thermodynamics of this reversible reaction were investigated by measuring pressure-composition isotherms, and the free energy was found to be small and slightly negative (DeltaG = -1.1 kJ/mol H(2)), suggesting an equilibrium hydrogen pressure of just under 1 bar at 300 K. We also demonstrate that the adduct LiAlH(4).4THF can be desolvated at low temperature to yield crystalline LiAlH(4).

Understanding the role of Ti in reversible hydrogen storage as sodium alanate: a combined experimental and density functional theoretical approach.

We report the results of an experimental and theoretical study of hydrogen storage in sodium alanate (NaAlH(4)). Reversible hydrogen storage in this material is dependent on the presence of 2-4% Ti dopant. Our combined study shows that the role of Ti may be linked entirely to Ti-containing active catalytic sites in the metallic Al phase present in the dehydrogenated NaAlH(4). The EXAFS data presented here show that dehydrogenated samples contain a highly disordered distribution of Ti-Al distances with no long-range order beyond the second coordination sphere. We have used density functional theory techniques to calculate the chemical potential of possible Ti arrangements on an Al(001) surface for Ti coverages ranging from 0.125 to 0.5 monolayer (ML) and have identified those that can chemisorb molecular hydrogen via spontaneous or only moderately activated pathways. The chemisorption process exhibits a characteristic nodal symmetry property for the low-barrier sites: the incipient doped surface-H(2) adduct's highest occupied molecular orbital (HOMO) incorporates the sigma antibonding molecular orbital of hydrogen, allowing the transfer of charge density from the surface to dissociate the molecular hydrogen. This work also proposes a plausible mechanism for the transport of an aluminum hydride species back into the NaH lattice that is supported by Car-Parrinello molecular dynamics (CPMD) simulations of the stability and mobility of aluminum clusters (alanes) on Al(001). As an experimental validation of the proposed role of titanium and the subsequent diffusion of alanes, we demonstrate experimentally that AlH(3) reacts with NaH to form NaAlH(4) without any requirement of a catalyst or hydrogen overpressure.

Decomposition kinetics of the AlH3 polymorphs.

Aluminum hydride polymorphs (alpha-AlH3, beta-AlH3, and gamma-AlH3) were prepared by organometallic synthesis. Hydrogen capacities approaching 10 wt % at desorption temperatures less than 100 degrees C have been demonstrated with freshly prepared AlH3. The temperature-dependent rate constants were determined by measuring the isothermal hydrogen evolution between 60 degrees C and 140 degrees C. Fractional decomposition curves showed good fits using both the second and third-order Avrami-Erofeyev equations, indicating that the decomposition kinetics are controlled by nucleation and growth of the aluminum phase in two and three dimensions. The large activation energies measured for the AlH3 polymorphs suggest that the decomposition occurs via an activated complex mechanism with complexes consisting of approximately nine AlH3 molecules (1-2 unit cells for alpha-AlH3).

Measurements of the acid-binding capacity of ingredients used in pig diets.

: Some feed ingredients bind more acid in the stomach than others and for this reason may be best omitted from pig starter foods if gastric acidity is to be promoted. The objective of this study was to measure the acid-binding capacity (ABC) of ingredients commonly used in pig starter foods. Ingredients were categorised as follows: (i) milk products (n = 6), (ii) cereals (n = 10), (iii) root and pulp products (n = 5), (iv) vegetable proteins (n = 11), (v) meat and fish meal (n = 2), (vi) medication (n = 3), (vii) amino acids (n = 4), (viii) minerals (n = 16), (ix) acid salts (n = 4), (x) acids (n = 10). A 0.5 g sample of food was suspended in 50 ml distilled de-ionised water with continuous stirring. This suspension was titrated with 0.1 mol/L HCl or 0.1 mol/L NaOH so that approximately 10 additions of titrant was required to reach pH 3.0. The pH readings after each addition were recorded following equilibration for three minutes. ABC was calculated as the amount of acid in milliequivalents (meq) required to lower the pH of 1 kg food to (a) pH 4.0 (ABC-4) and (b) pH 3.0 (ABC-3). Categories of food had significantly different (P < 0.01) ABC values. Mean ABC-4 and ABC-3 values of the ten categories were: (i) 623 (s.d. 367.0) and 936 (s.d. 460.2), (ii) 142 (s.d. 79.2) and 324 (s.d. 146.4), (iii) 368 (s.d. 65.3) and 804 (s.d. 126.7), (iv) 381 (s.d. 186.1) and 746 (s.d. 227.0), (v) 749 (s.d. 211.6) and 1508 (s.d. 360.8), (vi) 120 (s.d. 95.6) and 261 (s.d. 163.2), (vii) 177 (s.d. 60.7) and 1078 (s.d. 359.0), (viii) 5064 (s.d. 5525.1) and 7051 (s.d. 5911.6), (ix) 5057 (s.d. 1336.6) and 8945 (s.d. 2654.1) and (x) -5883 (s.d. 4220.5) and -2591 (s.d. 2245.4) meq HCl per kg, respectively. Within category, ABC-3 and ABC- 4 values were highly correlated: R2 values of 0.80 and greater for food categories i, iv, v, vi, vii and viii. The correlation between predicted and observed ABC values of 34 mixed diets was 0.83 for ABC-4 and 0.71 for ABC-3. It was concluded that complete diets with low ABC values may be formulated through careful selection of ingredients. The final pH to which ABC is measured should matter little as ABC-3 and ABC-4 are highly correlated.

Use of a state-wide administrative database in assessing a regional trauma system: the New York City experience.

BACKGROUND: A successful regional trauma care system should concentrate severely injured patients within trauma centers, and should improve severity-adjusted outcomes. We compared injured patients' outcomes in New York City's level 1 trauma centers and nontrauma centers. STUDY DESIGN: We analyzed 1998-2000 New York Statewide Planning and Cooperative Research System (SPARCS) data for 103,725 adult discharges from 70 New York City hospitals (15 level I trauma centers), using ICD-9CM codes 800-950. Their 227 DRG's were aggregated into 7 clinical injury classes. A severity index was extracted from each refined DRG, and deaths, age, and gender were analyzed. Regression analysis predicted death from age, gender, severity index, and trauma center discharge, with separate analyses of the three largest clinical classes, and estimated excess mortality because of trauma center discharge. RESULTS: Level 1 trauma centers discharged 48.2% of injured patients, with higher mean annual discharges per hospital (1,046 discharges per TC vs. 437 per NTC, p < 0.001). Trauma centers discharged more than half the central nervous system, general/gastrointestinal, cardiothoracic, and vascular injuries. Trauma center patients were 12.5 years younger than NTC patients (p < 0.0005), and were disproportionately men (64.7% TC vs. 47.2% NTC, p < 0.0005). For the entire patient cohort, and for central nervous system, orthopaedic and general/gastrointestinal injuries, severity, age, and gender adjusted mortality risk was significantly greater at trauma centers than nontrauma centers. CONCLUSIONS: New York City's trauma system concentrates injured patients in trauma centers on the basis of injury class rather than severity, but does not produce improved adjusted mortality outcomes for injured patients.