Potential Benefits of Pre-emptive PGx Testing in Male Breast Cancer Patients.

The objective is to report a case of recurrent breast cancer in a poor CYP2D6 metabolizer male patient on tamoxifen, and how pharmacogenomic (PGx) testing can play an important role in selecting appropriate adjuvant endocrine therapy. The case examined here is a 60-year-old white male diagnosed with recurrence of breast cancer. The patient was prescribed tamoxifen four years prior as adjuvant endocrine therapy after initial treatment with surgery. PGx testing ordered at the time of recurrence revealed patient is a poor metabolizer of CYP2D6, which may decrease the efficacy of tamoxifen. The results prompted a change in therapy to an aromatase inhibitor (AI). This case illustrates the potential benefits of preemptive PGx testing in a male breast cancer patient to assist in selecting appropriate adjuvant therapy based on how the patient metabolizes medications. In addition, PGx testing encourages patient involvement by emphasizing the association of genetics in determining treatment. The ultimate goal in performing these tests is to individualize treatment to improve safety and efficacy while minimizing adverse drug reactions.

Presence of Mast Cells and Mast Cell Degranulation in Scalp Biopsies of Telogen Effluvium.

BACKGROUND: Telogen effluvium (TE) is a type of acquired, diffuse alopecia that occurs due to an abnormal shift of scalp hair follicles from anagen to telogen, leading to premature shedding of hair. Previous studies have suggested the existence of a neuroimmunologic "brain-hair follicle" axis, in which mast cells have been implicated as an important link between the nervous system and immunologic system. OBJECTIVE: The current study sought to investigate the role of mast cell presence and mast cell degranulation in the pathogenesis of TE. MATERIALS AND METHODS: Mast cells were counted using Giemsa and tryptase immunohistochemical stains in scalp biopsy specimens with the pathologic diagnosis of TE (TE, n = 10), alopecia areata (AA, n = 7), and androgenic alopecia (ANDRO, n = 9). RESULTS: We found significant (P < 0.001) group-level differences between the mean mast cell counts per high-power fields for each type of alopecia studied. Tukey post hoc analysis showed the mean mast cell count for TE to be significantly larger than AA for both Giemsa (P = 0.002) and tryptase (P = 0.006); significantly larger than ANDRO for both Giemsa (P < 0.001) and tryptase (P < 0.001); and significantly larger when compared to normal scalp skin for both Giemsa (P < 0.001) and tryptase (P < 0.001). No significant difference of mean mast cell counts was observed for AA compared to ANDRO for Giemsa (P = 0.373) or tryptase (P = 0.598) stains. CONCLUSION: Our findings suggest that mast cells could play a role in mediating stress-induced hair loss seen in TE.

Patients' preference for migraine preventive therapy.

OBJECTIVE: Preventive treatment is an important part of migraine therapy. When prescribing medication, physicians should understand patients' treatment preferences and select drugs that most closely meet their patients' needs. Understanding the factors that influence patients' preference increases physicians' ability to select appropriate migraine therapy. However, unlike acute migraine treatment, patients' preferences for migraine preventive treatment have never been studied. METHODS: We enrolled 250 patients who attended the Jefferson Headache Center and Sao Paulo Headache Center and had a primary headache diagnosis. Patients' age, gender, body mass index (BMI), headache diagnosis, headache frequency, duration, and intensity, headache disability (by MIDAS), and current preventive treatments were ascertained. Patients were asked to rate 7 aspects of headache prevention (efficacy, speed of onset, out-of-pocket expenses, adverse events, formulation of therapy, type of treatment, and frequency of dosing) in order of importance (1-7). Each patient also evaluated 12 different clinical scenarios, each one containing a simulation of 2 hypothetical headache preventive treatments, wherein patients could choose Product A, Product B, or neither. Patients were informed of each product's efficacy data (50%, 75%, or 100% headache elimination), adverse event profile (weight gain, concentration difficulty, and/or fatigue), and dosing frequency (once every 3 months, once per day, or twice per day). RESULTS: Most patients were Caucasian. Mean BMI was 26.55 +/- 5.34, range (17-45). Mean history of headache was 20.93 years. Fifty patients (40%) had 45 or more headache days in the past 3 months. Mean headache intensity score (0-10 scale) was 5.7 +/- 1.8. Patients were on various preventive treatments, including beta-blockers (48 [41%]), calcium-channel blockers (19 [16%]), antidepressants (52 [44%]), antiepileptics (46 [39%]), neurotoxins (16 [14%]), vitamins/herbal therapies (28 [24%]), and nonmedicinal therapy (38 [32%]). Of the 7 aspects of migraine prevention that patients were asked to rate, 72% rated effectiveness the most important aspect. Twelve percent rated speed of onset most important, 6% rated absence of adverse events most important, 3% rated formulation of therapy most important, 3% rated out-of-pocket expenses most important, and 2% rated type of treatment (prescription/vitamin) most important. None rated frequency of dosing as the most important factor. In the area of preventive treatment scenarios, patients were more likely to choose treatments with higher efficacy rates, fewer adverse events and less frequent dosing schedule. Patients indicated that they preferred the treatment options with higher efficacy rates even if side effects were present and a more frequent dosing schedule was necessary. CONCLUSION: Patients' preference regarding migraine prevention is very important in headache management. Patients rated efficacy the most important aspect in preventive therapy and preferred treatment options with higher efficacy rates. Future studies are needed for a better understanding of patients' preference for migraine prevention.

Contact dermatitis in tobacco farmworkers.

Occupational skin disease is highly prevalent among agricultural workers. Tobacco cultivation and harvest are particularly hazardous for farmworkers. We report 5 migrant Latino farmworkers in North Carolina with contact dermatitis related to tobacco work. These cases show a characteristic distribution of contact dermatitis; the flexural and medial surfaces of the upper extremities were affected in each case, whereas most cases showed some involvement of the torso and axilla. This pattern most likely reflects a common occupational practice of holding the tobacco leaves under the arm and pressed against the body during harvesting.