Is Oncotype DX testing informative for breast cancers with low ER expression? A retrospective review from a biomarker testing referral center.

PURPOSE: It remains unclear whether patients with HER2-negative, low-estrogen receptor (ER-low)-positive early breast cancer (BC) benefit from Oncotype DX® (ODX) testing. METHODS: We conducted a retrospective review of cases referred for ODX testing over a seven-year period from a breast biomarker testing referral center (n = 854). For each case, we recorded the ODX Recurrence Score (RS) along with percentage of ER nuclear positivity and staining intensity on immunohistochemistry. Our criteria for ER-low was defined as ≤10% cells with nuclear positivity and/or weak intensity of staining. Slides from all ER-low cases were reviewed and the reported ODX ER gene scores were recorded. We randomly selected a comparator group of 56 patients with ER > 10% positivity and non-weak staining intensity (ER-high). RESULTS: We identified 27 cases (3.2%) that met our criteria for ER-low. Of these, 92.6% had a high RS (>25), and 7.4% had a RS of 25. All cases with ≤10% ER nuclear positivity had a high RS. Most ER-low cases (85.2%) had ODX quantitative ER gene scores in the negative range, whereas all (100%) ER-high cases had positive ER gene scores. CONCLUSION: ODX does not appear to add significant additional information to inform treatment decisions for most patients with ER-low BC. Incorporating weak ER staining intensity in addition to low percentage of nuclear positivity identifies about twice as many ER-low patients, although with reduced specificity for high RS. Our study supports the contention that most ER-low early BC should be regarded similarly to ER-negative BC.

ALDH1A3 promotes invasion and metastasis in triple-negative breast cancer by regulating the plasminogen activation pathway.

Aldehyde dehydrogenase 1A3 (ALDH1A3) is a cancer stem cell marker that promotes metastasis. Triple-negative breast cancer (TNBC) progression has been linked to ALDH1A3-induced gene expression changes. To investigate the mechanism of ALDH1A3-mediated breast cancer metastasis, we assessed the effect of ALDH1A3 on the expression of proteases and the regulators of proteases that degrade the extracellular matrix, a process that is essential for invasion and metastasis. This revealed that ALDH1A3 regulates the plasminogen activation pathway; it increased the levels and activity of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA). This resulted in a corresponding increase in the activity of serine protease plasmin, the enzymatic product of tPA and uPA. The ALDH1A3 product all-trans-retinoic acid similarly increased tPA and plasmin activity. The increased invasion of TNBC cells by ALDH1A3 was plasminogen-dependent. In patient tumours, ALDH1A3 and tPA are co-expressed and their combined expression correlated with the TNBC subtype, high tumour grade and recurrent metastatic disease. Knockdown of tPA in TNBC cells inhibited plasmin generation and lymph node metastasis. These results identify the ALDH1A3-tPA-plasmin axis as a key contributor to breast cancer progression.

Cutaneous Breast Cancer Metastasis Is Effectively Treated With Intralesional Interleukin-2 and Imiquimod: A Case Report and Brief Literature Review.

Breast cancer is the most common non-cutaneous cancer affecting women worldwide and is a major cause of cancer-related morbidity and mortality in females. While many women are diagnosed with early-stage disease, a subset of women may present with isolated cutaneous metastases or recurrent locoregional cutaneous metastatic disease. There is a paucity of evidence for effective treatments for cutaneous breast cancer metastases. Herein, we present a case of hormone receptor negative, HER2 positive cutaneous breast cancer metastasis treated with intralesional IL-2 and topical imiquimod, which was well tolerated with only minor low grade side effects. We also present a brief literature review of immunotherapy for cutaneous breast cancer metastasis to frame the discussion around using minimally invasive local therapies for this disease. Together, this limited data suggests that intralesional IL-2 and imiquimod may be considered as a safe option when treating a patient with cutaneous breast cancer metastases.

Independent primary cutaneous and mammary apocrine carcinomas with neuroendocrine differentiation: Report of a case and literature review.

Cutaneous apocrine carcinomas share common features with their counterparts in the breast; hence, metastatic mammary carcinoma must be excluded before such lesions can be designated primary cutaneous neoplasms. Primary tumors from either source rarely exhibit neuroendocrine differentiation. We report a case of a 72-year-old female with a painless 1.2-cm scalp nodule. An incisional biopsy revealed dermal involvement by an invasive apocrine carcinoma juxtaposed to a benign apocrine cystic lesion. Immunohistochemically, the carcinoma expressed neuroendocrine proteins including synaptophysin, chromogranin, and CD56. A primary cutaneous apocrine carcinoma with neuroendocrine differentiation was favored, but additional investigations to exclude breast origin were recommended. These revealed a 1.1-cm nodule in the right breast, which proved to be an invasive ductal carcinoma, morphologically and immunophenotypically similar to the scalp lesion. This confounded the case, yet factors militating against metastatic breast carcinoma to skin included (a) the small size of the mammary tumor, (b) absence of other metastatic disease, and (c) juxtaposition of the scalp carcinoma to a putative benign precursor. Molecular studies were undertaken to resolve the diagnostic quandary. Single nucleotide polymorphism microarray analysis revealed distinct patterns of chromosomal copy number alterations in the two tumors, supporting the concept of synchronous and unusual primary neoplasms.

S100A10 Has a Critical Regulatory Function in Mammary Tumor Growth and Metastasis: Insights Using MMTV-PyMT Oncomice and Clinical Patient Sample Analysis.

S100A10 (p11) is a plasminogen receptor that regulates cellular plasmin generation by cancer cells. In the current study, we used the MMTV-PyMT mouse breast cancer model, patient tumor microarray, and immunohistochemical (IHC) analysis to investigate the role of p11 in oncogenesis. The genetic deletion of p11 resulted in significantly decreased tumor onset, growth rate, and spontaneous pulmonary metastatic burden in the PyMT/p11-KO (knock-out) mice. This phenotype was accompanied by substantial reduction in Ki67 positivity, macrophage infiltration, decreased vascular density in the primary tumors, and decrease in invasive carcinoma and pulmonary metastasis. Surprisingly, IHC analysis of wild-type MMTV-PyMT mice failed to detect p11 expression in the tumors or metastatic tumor cells and loss of p11 did not decrease plasmin generation in the PyMT tumors and cells. Furthermore, tumor cells expressing p11 displayed dramatically reduced lung metastasis when injected into p11-depleted mice, further strengthening the stromal role of p11 in tumor growth and metastasis. Transcriptome analysis of the PyMT tumors from p11-KO mice showed marked reduction in genes such as Areg, Muc1, and S100a8 involved in breast cancer development, progression, and inflammation. The PyMT/p11-KO tumors displayed a remarkable increase in inflammatory cytokines such as interleukin (Il)-6, Il-10, and interferon (Ifn)-γ. Gene expression profiling and IHC of primary breast cancer samples showed that p11 mRNA and protein levels were significantly higher in tumor tissues compared to normal mammary tissue. P11 mRNA expression was significantly associated with poor patient prognosis and significantly elevated in high grade, triple negative (TN) tumors, and tumors with high proliferative index. This is the first study examining the crucial role of p11 in breast tumor development and metastasis, thus emphasizing its potential as a diagnostic and prognostic biomarker in breast cancer.

Prolactin and androgen R1881 induce pro-survival carboxypeptidase-D and EDD E3 ligase in triple-negative and HER2+ breast cancer.

Plasma membrane carboxypeptidase-D (CPD) hydrolyzes C-terminal arginine (Arg) from extracellular substrates, and Arg is converted into nitric oxide (NO) in the cell. CPD is upregulated by prolactin (PRL) and androgens in breast cancer (BCa) cells, increasing NO production to promote cell survival. EDD E3 ubiquitin ligase, upregulated by PRL/androgens, is implicated in TORC1 signaling. This study investigated CPD and EDD in triple-negative (TNBC) and HER2+ BCa. Kaplan-Meier analysis showed a negative correlation between CPD or EDD mRNA expression in TNBC patients and relapse-free survival. Immunohistochemistry showed that benign and malignant breast tissues stained abundantly for the PRL receptor (PRLR) and androgen receptor (AR). CPD and EDD staining were elevated in TNBC and HER2+ tumors as compared to benign tissues. In TNBC/HER2+ cell lines, CPD and EDD protein expression were upregulated by PRL or synthetic androgen methyltrienolone (R1881) at 3-6 h. PRL/R1881-induced CPD in TNBC and HER2+ cells increased intracellular NO production, which was abolished by PRLR antagonist ∆1-9-G129R-hPRL and AR antagonist flutamide. In turn, treatment with NO increased viability and decreased apoptosis in Arg-deprived TNBC cells. Cell viability and apoptosis were also affected in HER2+ cells with CPD knockdown. Lastly, EDD knockdown decreased PRL/R1881-induced phosphorylation of initiation factor 4E binding protein-1 and decreased 4E release in TNBC cells. In summary, PRL/R1881-induced CPD promotes TNBC/HER2+ cell survival through production of NO, and EDD promotes TNBC cell survival by TORC1 activation. This study implicates CPD and EDD as useful therapeutic targets for TNBC/HER2+ tumors, and suggests that PRLR and AR blockade are also beneficial to these patients.

Multiple Cultures and Extended Incubation for Upper Extremity Revision Arthroplasty Affect Clinical Care: A Cohort Study.

Skin flora organisms (SFOs) isolated from 1 to 2 tissue samples during shoulder and elbow revision arthroplasty are difficult to distinguish as contamination or infection. We examined the change in clinical care after implementation of an Arthroplasty Infection Protocol by increasing the number of intraoperative samples held for 10-day incubation to a minimum of 5. METHODS: Infection was defined as ≥3 cultures growing the same SFO or any one culture growing any other virulent organism. SFOs growing in 1 to 2 samples were defined as skin flora contaminant. All cases were compared with pre-Arthroplasty Infection Protocol institution standard to determine changes in microbiological diagnosis and resultant antibiotic treatment. RESULTS: Forty cases fulfilled the inclusion criteria: 50% of these were culture negative, and 35% grew Propionibacteria. When compared with the standard of obtaining one sample, this protocol altered the microbiological diagnosis and subsequent antibiotic treatment in 45% of cases (95% confidence interval 29% to 62%). This protocol had a predictive value of joint sterility in 95% of culture-negative cases (95% confidence interval 74% to 99%). DISCUSSION: The addition of 5 or more samples held for 10-day incubation reliably differentiated between joint infection, contamination, and sterility, which changed the course of care in 45% of surgical cases.

Prolactin-inducible EDD E3 ubiquitin ligase promotes TORC1 signalling, anti-apoptotic protein expression, and drug resistance in breast cancer cells.

Previously, we identified a prolactin (PRL)-inducible gene encoding EDD E3 ubiquitin ligase in human breast cancer (BCa) cells. We reported that EDD binds the mTOR (TORC1)-associated α4 phosphoprotein-PP2Ac protein phosphatase complex that regulates initiation of translation and cell cycle progression, and that EDD targets PP2Ac for proteasomal degradation. The present study showed that EDD immunostaining was low in benign human breast tissues, but increased progressively in ductal carcinoma in-situ, low-grade, and high-grade BCa, and in triple-negative BCa (TNBC). EDD mRNA and protein levels varied in human BCa cell lines. In high-EDD expressing MCF-7 and T47D cells, siRNA knockdown of EDD arrested cells in the G2-phase of the cell cycle, decreased cell viability, and increased apoptosis. EDD siRNA-induced apoptosis in MCF-7 cells correlated with significantly increased levels of pro-apoptotic Bim and Bak mRNAs and proteins (P < 0.05, n = 3-6), and increased levels of pro-apoptotic Bax and MOAP-1 proteins (P < 0.001, n = 3-6), leading to increased cleavage of caspase-7 and caspase substrate poly-ADP-ribose polymerase-1 (PARP-1), as compared to control cells. Loss of EDD in MCF-7 cells decreased PRL-induced phosphorylation of eukaryotic initiation factor 4E-binding protein-1, a mediator of TORC1 signaling, resulting in decreased binding of 4E to γ-aminophenyl-m7GTP agarose in Cap-binding assays. In low-EDD expressing MDA-MB-436 TNBC cell line, gain of EDD following pCMV-Tag2B.EDD transfection increased cell resistance to chemotherapeutic drugs cisplatin and doxorubicin, TORC1 inhibitor rapamycin, and TORC1/TORC2 inhibitor INK128, as compared to controls. In contrast, loss of EDD in MCF-7 cells increased cell sensitivity to cisplatin, doxorubicin, rapamycin, and selective estrogen receptor modulator tamoxifen. In summary, EDD levels increase with BCa progression in vivo. PRL-inducible EDD in BCa cells promotes TORC1 signaling, anti-apoptotic protein expression, and drug resistance in vitro. These findings implicate EDD as a potential therapeutic target and support PRL receptor blockade as an additional therapy for BCa.

Identification of infectious species after resection of soft-tissue sarcomas.

BACKGROUND: Pathogenic species in deep tissue infections after soft-tissue sarcoma (STS) resection is largely unstudied, particularly the role of anaerobic bacteria, risks factors for those pathogens, and the time course of infection presentation. METHODS: Retrospective analysis of 64 patients requiring operative debridement for deep tissue infection after STS resection was undertaken to identify infectious species and study risk factors for anaerobic infections. Kaplan-Meier methods examined the time course of infection presentation. RESULTS: STS subtypes were most commonly pleomorphic STS, myxofibrosarcoma, and undifferentiated STS. Staphylococcus aureus was the most common organism isolated (56%). Twenty (31%) infections were positive for ≥1 anaerobic organism. Twelve gram-positive and 10 gram-negative aerobic organisms were isolated. Most (90%) anaerobic-containing infections were polymicrobial, vs 52% of purely aerobic infections. No significant risk factors for anaerobic infections were identified. Median time from tumor resection until debridement was significantly greater for anaerobic infections (54.5 days) than for purely aerobic infections (29.5 days; P = 0.004), a difference so pronounced that using "presentation after 53 days" as a proxy for the presence of anaerobic pathogens had an accuracy of 81%. CONCLUSIONS: Because polymicrobial and anaerobic bacterial infections are common, we strongly support antibiotic use with anaerobic coverage at debridement, particularly for infections presenting later.

Prolactin/androgen-inducible carboxypeptidase-D increases with nitrotyrosine and Ki67 for breast cancer progression in vivo, and upregulates progression markers VEGF-C and Runx2 in vitro.

PURPOSE: Carboxypeptidase-D (CPD) cleaves C-terminal arginine (Arg) to produce nitric oxide (NO). Upregulation of CPD and NO by 17ß-estradiol, prolactin (PRL), and androgen increases survival of human breast cancer (BCa) cells in vitro. To demonstrate similar events in vivo, CPD, nitrotyrosine (NT, hallmark of NO action), androgen receptor (AR), prolactin receptor (PRLR), and phospho-Stat5a (for activated PRLR) levels were evaluated in benign and malignant human breast tissues, and correlated with cell proliferation (Ki67) and BCa progression (Cullin-3) biomarkers. METHODS: Paraffin-embedded breast tissues were analyzed by immunohistochemistry (IHC). BCa progression markers in human MCF-7 and T47D BCa cell lines treated with NO donor SIN-1 or PRL, ±CPD inhibitors were analyzed by RT-qPCR and immunoblotting. RESULTS: IHC showed progressive increases in CPD, NT, Ki67, and Cullin-3 from low levels in benign tissues to high levels in ductal carcinoma in situ, low-grade, high-grade, and triple-negative BCa. CPD and NT staining were closely associated, implicating CPD in NO production. Phospho-Stat5a increased significantly from benign to high-grade BCa and was mostly nuclear. AR and PRLR were abundant in benign breast and BCa, including triple-negative tumors. SIN-1 and PRL increased VEGF-C and Runx2, but not Cullin-3, in BCa cell lines. PRL induction of VEGF-C and Runx2 was inhibited partly by CPD inhibitors, implicating NO, produced by PRL-regulated CPD, in BCa progression. CONCLUSIONS: The CPD-Arg-NO pathway contributes to BCa progression in vitro and in vivo. PRL/androgen activation of the pathway support combined AR and PRLR blockade as an additional therapy for BCa.

Well-differentiated invasive breast cancers with equivocal HER2 immunohistochemistry: what is the yield of routine reflex in-situ hybridization testing?

AIMS: The 2013 American Society of Clinical Oncology and the College of American Pathologists (ASCO/CAP) HER2 guidelines recommend testing all invasive breast cancers for HER2, typically with immunohistochemistry (IHC) followed by in-situ hybridization (ISH) when IHC is equivocal. As well-differentiated breast cancers are rarely HER2-positive, we assessed the value of routine reflex HER2 ISH testing for this subset of breast cancers. METHODS AND RESULTS: We collected HER2 IHC 2+ cases and fluorescence in-situ hybridization (FISH) data from primary breast cancers with well-differentiated tumour types (grade 1 ductal carcinomas, classic lobular carcinomas, tubular, cribriform and pure mucinous carcinomas) at our centre from 2010 to 2015. Haematoxylin and eosin (H&E) and IHC slides were reviewed to confirm tumour type, grade and IHC score based on ASCO/CAP 2013 guidelines and their recent revisions. Of 4633 invasive carcinomas, 1133 had a well-differentiated tumour type; 177 of these were HER2 IHC equivocal, three of which were low-level amplified by FISH (0.3% of all well-differentiated tumours). One amplified case was classic invasive lobular carcinoma and two were invasive ductal carcinomas, grade 1. One amplified case had chromosome 17 monosomy, and one was rescored as HER2 IHC 1+ upon review. 'Basolateral' staining was noted in one amplified case and in 65 of 174 (37.4%) non-amplified cases. This incomplete membranous staining pattern was observed in the majority of invasive ductal carcinomas that were rescored as 1+ according to the revised 2013 guidelines. CONCLUSIONS: The rate of HER2 amplification among well-differentiated breast cancers is very low. Basolateral staining in well-differentiated tumours may be overinterpreted as HER2 IHC 2+, but is rarely associated with HER2 amplification.

Risk Factors for Complications during Outpatient Parenteral Antimicrobial Therapy for Adult Orthopedic and Neurosurgical Infections.

OBJECTIVES: Outpatient parenteral antimicrobial therapy (OPAT) is an effective way of treating infections, but complications are common. We identified patient characteristics and OPAT treatment factors associated with increased risk of OPAT-related complications. METHODS: We used a retrospective cohort design that assessed 337 adult patients treated with OPAT for orthopedic and neurosurgical infections between August 1, 2008 and May 30, 2010. Independent variables included demographics, infection characteristics, lead time factors, OPAT treatment factors, and comorbid conditions. Multivariable log-binomial regression was used to estimate the risk of OPAT complications. RESULTS: The mean patient age was 55 years (range 19-87), 86% had an orthopedic infection, and 44% were treated with intravenous vancomycin. OPAT complications were seen in 45% (152/337) of the cohort. Risk ratios for OPAT complications were 1.9 (95% confidence interval 1.4-2.5) in patients having no primary care provider, 1.7 (95% confidence interval 1.3-2.1) for those treated with vancomycin. CONCLUSIONS: Identifying specific patient characteristics and OPAT treatment factors could facilitate OPAT process improvements to reduce the risk of OPAT complications for vulnerable patients.

Best practices for centers of excellence in addressing periprosthetic joint infection.

Periprosthetic joint infection is a rare and devastating complication. Management of this complication often requires a multidisciplinary approach similar to that used for the care of patients with cancer. Several studies have reported better outcomes following total joint arthroplasties performed at specialized hospitals than those performed at general hospitals. Specialized institutions use care pathways that aid the multidisciplinary team in decision making. During the recent Musculoskeletal Infection symposium, specific issues were discussed with regard to the treatment of periprosthetic joint infection, including medical optimization, systematic approaches to infection management, and the importance of establishing registries to aid in the creation of Centers of Excellence. A Center of Excellence in periprosthetic infection could provide better overall outcomes with lower financial, physical, and emotional costs to patients.

Incidence of Pneumocystis jirovecii pneumonia after temozolomide for CNS malignancies without prophylaxis.

AIMS: Prophylaxis against Pneumocystis jiroveci pneumonia (PJP) is currently recommended for patients receiving chemoradiation with temozolomide for newly diagnosed glioblastoma multiforme. At our institution, PJP prophylaxis during temozolomide treatment has not been routinely given because of the paucity of supporting data. We investigated the rate of PJP infections in our patients. PATIENTS & METHODS: We conducted a retrospective chart review of 240 brain tumor patients treated between 1999 and 2012 with temozolomide and no PJP prophylaxis, 127 of which received concurrent chemoradiation. RESULTS: One in 240 patients (0.4%; 95% CI: 0.01-2.00; median total dose: 7375 mg/m(2); interquartile range: 1300) were diagnosed with PJP. CONCLUSION: There was a <1% rate of PJP for brain tumor patients treated with temozolomide until progression without PJP prophylaxis.

Posterior fixation without debridement for vertebral body osteomyelitis and discitis.

OBJECT: The authors evaluated the efficacy of posterior instrumentation for the management of spontaneous spinal infections. Standard surgical management of spontaneous spinal infection is based on debridement of the infected tissue. However, this can be very challenging as most of these patients are medically debilitated and the surgical debridement requires a more aggressive approach to the spine either anteriorly or via an expanded posterior approach. The authors present their results using an alternative treatment method of posterior-only neuro-decompression and stabilization without formal debridement of anterior tissue for treating spontaneous spinal infection. METHODS: Fifteen consecutive patients were treated surgically by 2 of the authors. All patients had osteomyelitis and discitis and were treated postoperatively with intravenous antibiotics for at least 6 weeks. The indications for surgery were failed medical management, progressive deformity with ongoing persistent spinal infection, or neurological deficit. Patients with simple epidural abscess without bony instability were treated with laminectomy and were not included in this series. Fourteen patients were treated with posterior-only decompression and long-segment rigid fixation, without formal debridement of the infected area. One patient was treated with staged anterior and posterior surgery due to delay in treatment related to medical comorbidities. The authors examined as their outcome the ambulatory status and recurrence of deep infection requiring additional surgery or medical treatment. RESULTS: Of the initial 15 patients, 10 (66%) had a minimum 2-year follow-up and 14 patients had at least 1 year of followup. There were no recurrent spinal infections. There were 3 unplanned reoperations (1 for loss of fixation, 1 for early superficial wound infection, and 1 for epidural hematoma). Nine (60%) of 15 patients were nonambulatory at presentation. At final followup, 8 of 15 patients were independently ambulatory, 6 required an assistive device, and 1 remained nonambulatory. CONCLUSIONS: Long-segment fixation, without formal debridement, resulted in resolution of spinal infection in all cases and in significant neurological recovery in almost all cases. This surgical technique, when combined with aggressive antibiotic therapy and a multidisciplinary team approach, is an effective way of managing serious spinal infections in a challenging patient population.

Decadal increase in seagrass biomass and temperature at the CARICOMP site in Bocas del Toro, Panama

The Caribbean Coastal Marine Productivity Program (CARICOMP) was launched in 1993 to study regional long-term interactions between land and sea, taking standardized measurements of productivity and biomass of mangroves, coral reefs and seagrasses. Since 1999 continuous measurements of seagrass (Thalassia testudinum) parameters as well as environmental data have been recorded in Caribbean Panama. Replicate stations were selected near the Smithsonian Tropical Research Institute in Bocas del Toro. Sediment cores and quadrants were placed there to estimate biomass and productivity, respectively. Mean values for productivity, standing crop, turnover rate, total dry biomass, and Leaf Area Index were 1.74gDW/m²/d, 66.6gDW/m², 2.62%/d, 1 481 gDW/m², and 4.65, respectively. Total dry biomass (shoots, rhizomes and roots) and LAI of T. testudinum increased significantly during the study period. Mean values for total rainfall, Secchi disk depth, sea surface temperature, and salinity were 3 498mm, 8.24m, 28.79°C, and 32.26psu, respectively. Sea surface temperature was the only environmental variable with a statistically significant change, increasing from 1999 to 2010. Correlation between sea surface temperature and T. testudinum parameters (total biomass and LAI) were both positive and significant. Human population has increased dramatically over the last ten years in Bocas del Toro region, increasing pressure (deforestation, runoff, wastewater) over coastal ecosystems (seagrasses, mangroves, coral reefs). Change in the abundance of T. testudinum may be linked to ocean warming, as a consequence to satisfy plant’s metabolic requirements, although other local factors need to be analyzed (reduced grazing and increased eutrophication). A further warming of the ocean could have a negative effect on T. testudinum population, increasing respiratory demands and microbial metabolism.

El Programa de Productividad Costera Marina del Caribe (CARICOMP) fue iniciado en 1993 para estudiar interacciones regionales a largo plazo entre la tierra y el mar, tomando mediciones estandarizadas de productividad y biomasa de manglares, arrecifes de coral y pastos marinos. Desde 1999 mediciones continuas de parámetros de pasto marino (Thalassia testudinum) así como datos ambientales han sido registrados para el Caribe de Panamá. Réplicas de estaciones fueron seleccionadas cerca del Instituto Smithsonian de Investigaciones Tropicales en Bocas del Toro. Núcleos de sedimento y cuadrantes fueron colocados para estimar biomasa y productividad, respectivamente. Valores promedio de productividad, biomasa foliar, tasa de recambio, biomasa total seca e Índice de Área Foliar fueron 1.74gDW/m²/d, 66.6gDW/m², 2.62%/d, 1 481 gDW/m², y 4.65, respectivamente. La biomasa total seca (haces, rizomas y raíces) e Índice de Área Foliar de T. testudinum incrementaron significativamente durante el periodo de estudio. Valores promedio de lluvia total, profundidad de disco de Secchi, temperatura superficial del mar y salinidad fueron 3 498mm, 8.24m, 28.79°C, y 32.26psu, respectivamente. La temperatura superficial del mar fue la única variable ambiental con un incremento estadísticamente significativo, de 1999 a 2010. La correlación entre la temperatura superficial del mar y los parámetros de T. testudinum (biomasa total y LAI) fueron tanto positivos como significativos. La población humana ha crecido dramáticamente durante los últimos diez años en la región de Bocas del Toro, incrementando la presión (deforestación, escorrentía, aguas negras) sobre los ecosistemas costeros (pastos marinos, manglares, arrecifes coralinos). Cambios en la abundancia de T. testudinum pueden estar ligados al calentamiento oceánico, como una consecuencia para satisfacer los requerimientos metabólicos de la planta, aunque es necesario analizar otros factores locales (reducción del pastoreo e incremento en la eutrofización). Un mayor calentamiento del océano puede tener efectos negativos en la población de T. testudinum, incrementando las demandas respiratorias y el metabolismo microbiano.

Multiple cultures and extended incubation for hip and knee arthroplasty revision: impact on clinical care.

The impact on patient care of introducing a protocol of obtaining 5 or more intra-operative separate tissue biopsies that were cultured for 10 days was assessed for hip and knee arthroplasty revision. The charts of seventy-three patients undergoing 77 cases of revision arthroplasty were reviewed one year post-operatively. When compared to the prior standard of obtaining only one intra-operative culture, the protocol changed the microbiological diagnosis in 26/77 cases (34%, 95% Confidence Interval (CI): 23-45%) and antibiotic treatment in 23/77 cases (30%, 95% CI: 20-41%). In addition, the protocol had a predictive value of joint sterility in culture negative cases of 95% (95% CI: 85-99%). This data demonstrated the new protocol significantly changed patient care, and suggests that 1 or 2 cultures are insufficient. Adopting a similar protocol should be considered by surgeons and institutions as a new minimum standard for management of prosthetic joint infections.

Decadal increase in seagrass biomass and temperature at the CARICOMP site in Bocas del Toro, Panama.

The Caribbean Coastal Marine Productivity Program (CARICOMP) was launched in 1993 to study regional long-term interactions between land and sea, taking standardized measurements of productivity and biomass of mangroves, coral reefs and seagrasses. Since 1999 continuous measurements of seagrass (Thalassia testudinum) parameters as well as environmental data have been recorded in Caribbean Panama. Replicate stations were selected near the Smithsonian Tropical Research Institute in Bocas del Toro. Sediment cores and quadrants were placed there to estimate biomass and productivity, respectively. Mean values for productivity, standing crop, turnover rate, total dry biomass, and Leaf Area Index were 1.74 gDW/m2/d, 66.6 gDW/m2, 2.62%/d, 1481 gDW/m2, and 4.65, respectively. Total dry biomass (shoots, rhizomes and roots) and LAI of T. testudinum increased significantly during the study period. Mean values for total rainfall, Secchi disk depth, sea surface temperature, and salinity were 3498 mm, 8.24 m, 28.79 degrees C, and 32.26 psu, respectively. Sea surface temperature was the only environmental variable with a statistically significant change, increasing from 1999 to 2010. Correlation between sea surface temperature and 7 testudinum parameters (total biomass and LAI) were both positive and significant. Human population has increased dramatically over the last ten years in Bocas del Toro region, increasing pressure (deforestation, runoff, wastewater) over coastal ecosystems (seagrasses, mangroves, coral reefs). Change in the abundance of 7 testudinum may be linked to ocean warming, as a consequence to satisfy plant's metabolic requirements, although other local factors need to be analyzed (reduced grazing and increased eutrophication). A further warming of the ocean could have a negative effect on T. testudinum population, increasing respiratory demands and microbial metabolism.

Loss of expression of DNA mismatch repair proteins is rare in pancreatic and small intestinal neuroendocrine tumors.

CONTEXT: Two recent studies have identified a high rate of microsatellite instability (MSI) in pancreatic neuroendocrine tumors (pNETs). Microsatellite instability is rare in small intestinal neuroendocrine tumors (NETs). It is unclear why there is discordance in the frequency of MSI in the 2 studies of pNETs and why this mechanism is comparatively rare in small intestinal tumors. Loss of expression of DNA mismatch repair (MMR) proteins, which is known to correlate strongly with MSI, is not well studied in pancreatic or small intestinal NETs. OBJECTIVE: To determine if there is loss of expression of MMR protein expression in pancreatic or small intestinal NETs. DESIGN: Sixty-nine patients (31 male, 38 female; mean age, 59.2 years) were identified who had a resection for a primary pancreatic (n  =  35) or primary small intestinal (n  =  34) NET during an 18-year period. Immunohistochemical stains for MLH1, MSH2, MSH6, and PMS2 were applied to archived tissue from all cases. All pNETs with adequate tissue (n  =  32) were also assessed by MSI analysis. RESULTS: There was preserved expression of MLH1, MSH2, MSH6, and PMS2 in all 35 pNETs. Of 32 pNETs tested by polymerase chain reaction, 28 were microsatellite stable and DNA did not amplify in 4. In 34 small intestinal NETs, 2 cases had indeterminate MLH1 and 1 case had indeterminate PMS2 expression. The remainder had intact MMR protein expression. CONCLUSION: Defects in DNA MMR proteins are rare in pancreatic and small intestinal NETs, raising doubt that MSI plays a significant role in the pathogenesis of these tumors.