The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis.

BACKGROUND: Following neoadjuvant chemotherapy (NAC), the optimal strategies for postmastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after breast-conserving surgery (BCS) are controversial. In this analysis, we evaluate the impact of these radiotherapy (RT) approaches for women with clinically node-positive breast cancer treated with NAC in the National Cancer Database (NCDB). PATIENTS AND METHODS: Women with cT1-3 cN1 M0 breast cancer treated with NAC were divided into four cohorts by surgery [Mastectomy (Mast) versus BCS] and post-chemotherapy pathologic nodal status (ypN0 versus ypN+). Overall survival (OS) was estimated using the Kaplan-Meier method and RT approaches were analyzed using the log-rank test, multivariate Cox models, and propensity score-matched analyses. RESULTS: From 2003 to 2011, 15 315 cases were identified including 3040 Mast-ypN0, 7243 Mast-ypN+, 2070 BCS-ypN0, and 2962 BCS-ypN+ patients. On univariate analysis, PMRT was associated with improved OS for both Mast-ypN0 (P = 0.019) and Mast-ypN+ (P < 0.001) patients. On multivariate analyses adjusted for factors including age, comorbidity score, cT stage, in-breast pathologic complete response, axillary surgery, ypN stage, estrogen receptor status and hormone therapy, PMRT remained independently associated with improved OS among Mast-ypN0 [hazard ratio (HR) = 0.729, 95% confidence interval (CI) 0.566-0.939, P = 0.015] and Mast-ypN+ patients (HR = 0.772, 95% CI 0.689-0.866, P < 0.001). No differences in OS were observed with the addition of RNI to breast RT for BCS-ypN0 or BCS-ypN+ patients. Propensity score-matched analyses demonstrated identical patterns of significance. On subset analysis, OS was improved with PMRT in each pathologic nodal subgroup (ypN0, ypN1, and ypN2-3) (all P < 0.05). CONCLUSIONS: In the largest reported analysis of RT for cN1 patients treated with NAC, PMRT was associated with improved OS for all pathologic nodal subgroups. No OS differences were observed with the addition of RNI to breast RT.

Disparities in disease presentation in the four screenable cancers according to health insurance status.

OBJECTIVES: Current guidelines support the use of screening for early detection in breast, prostate, colorectal and cervical cancer. The purpose of this study was to evaluate whether insurance status predicts for more advanced disease in these four currently screened cancers. STUDY DESIGN: The Surveillance, Epidemiology, and End Results (SEER) database was queried for breast, prostate, colorectal and cervix in patients aged 18-64 years. The database was queried from 2007 to 2011, with 425,614 patients with known insurance status included. METHODS: Multinomial logistic regression was used to evaluate insurance status and cancer presentation. RESULTS: Under multivariate analysis for breast cancer, uninsured patients more often had invasive disease (odds ratio [OR]: 1.55), T- (OR: 2.00), N- (OR: 1.59) stage, and metastatic disease (OR: 3.48), and were more often high-grade (OR: 1.21). For prostate cancer, uninsured patients again presented more commonly with higher T-stage (OR: 1.45), nodal (OR: 2.90) and metastatic (OR: 4.98) disease, in addition to higher prostate-specific antigen (OR: 2.85) and Gleason score (OR: 1.65). Colorectal cancer had similar findings with uninsured individuals presenting with more invasive disease (OR: 1.78), higher T (OR: 1.86), N (OR: 1.22), and M (OR: 1.58) stage, in addition to higher carcinoembryonic antigen levels (OR: 1.66). Similar results were seen for cervical cancer with uninsured having higher T (OR: 2.03), N (OR: 1.21), and M (OR: 1.45) stage. CONCLUSION: In the four cancers detected by screening exams, those without health insurance present with more advanced disease, with higher stage and grade, and more elevated tumour markers.

A Qualitative Exploration of Community-Based Organization Programs, Resources, and Training to Promote Adolescent Sexual Health.

BACKGROUND: Youth development professionals (YDPs) working at community-based organizations (CBOs) can promote adolescent sexual health through programs. This study explored the programs and resources that youth access at CBOs and training YDPs receive. METHODS: Twenty-one semi-structured interviews were conducted with YDPs. Qualitative content analyses were conducted using NVivo. RESULTS: Most YDPs (n = 15, 71.4%) described sexuality-related programs for youth. Some YDPs provided informal information (n = 11, 52.4%) and/or referrals for youth (n = 6, 28.6%). Few YDPs (n = 8, 38.1%) were trained to address adolescent sexuality, but some (n = 10, 47.6%) sought outside resources. CONCLUSIONS: YDPs have a unique opportunity to improve adolescent sexual health and sexuality. Five considerations for organizations that develop programs and training for CBOs are suggested.

Visual hallucinations and racing thoughts on eye closure after minor surgery.

Two hours after minor surgery under local anesthesia, a 67-year-old man developed vivid visual hallucinations that were present only when he closed his eyes. After lasting 4 hours, the hallucinations were succeeded by racing thoughts, lasting 2 hours, and then by illusionary movements of his body. The reaction was attributed to the effect of lidocaine. The case resembles one previously reported.

Oval pupils.

The records of 17 patients whose neurological examination disclosed oval pupils in one or both eyes were reviewed. Sixteen of the 17 had serious cerebrovascular illnesses--hypertensive cerebral hemorrhage (five patients), ruptured saccular aneurysm (five patients), epidural hemorrhage (one patient), bilateral cerebral infarction (two patients), brainstem strokes (two patients), and cerebral anoxia (one patient). One patient was recovering from an oculomotor palsy. Oval pupils usually represent a transient, unstable phase in progressive injury to the oculomotor complex and less frequently a transient phase of recovery.

Capsular infarcts: the underlying vascular lesions.

In ten patients, 11 infarcts involving mainly the internal capsule have been examined pathologically. Serial sections of the involved basal ganglia were studied in ten infarcts and only a gross dissection was made in the other. The implicated penetrating arteries were traced throughout their length and obstructive vascular lesions were found in nine instances. In two of the nine there was an atheromatous plaque with a superimposed thrombus, in four an atheromatous plaque had caused severe stenosis, in one a destructive arterial process lipohyalinosis had occurred, in one case the nature of the obstruction remained "uncertained," and in one the penetrating arteries were obstructed at their orifices by an atheroma in the superior division of the middle cerebral artery. In two cases the vessels were patent, suggesting embolism. The atheromas consisted almost exclusively of a conglomerate of fat-filled macrophages. The clinical correlate was a pure motor hemiplegia or hemiparesis involving the face, arm, and leg without sensory deficit, homonymous hemianopia, receptive aphasia, or apractognosia. Confusion was prominent in one patient.

Ataxic hemiparesis. A pathologic study.

Three stroke patients showed weakness and pyramidal signs on one side combined with a cerebellar-like ataxia on the same side. Pathologic study in each case showed an old infarct cavity in the basis pontis at the level of the junction of the upper one third and lower two thirds on the side opposite the neurologic deficit. The basilar artery was patent and the infarcts were probably the result of occlusion of penetrating arteries. This study demonstrates that a lesion of the basis pontis may be associated with a contralateral ataxia that is cerebellar in character. The designation ataxic hemiparesis is suggested for the syndrome.

Disorientation for place.

The study of a patient with remarkable disorientation for place associated with an acute nondominant parietooccipital lesion raised the general question of a relationship between disorientation for place and topographical disorientation. The literature does not address this matter. The clinical findings of one case in particular are presented here in detail. Another six patients had been seen with a disproportionate disorientation for place; in each there was an acute insult to the nondominant hemisphere. Based on these cases, there is preliminary evidence of a possible relationship.

Transient global amnesia. Precipitating activities and other observations.

Impressed with the number of patients whose spells of transient global amnesia were triggered by special circumstances, I have reviewed 78 such cases. Precipitating events were reported in 26 of 85 spells: eight occurred during highly emotional experiences; seven, during sexual intercourse; six, while the patient was in pain; two, while a trigeminal ganglion was being stimulated; and three, during a dip in the cold Atlantic Ocean. These observations suggest an electrophysiologic disturbance. The characteristics of the amnesia, the organization of memory, and behavior during spells were also considered.

Trigeminal sensory neuropathy.

The etiology of trigeminal sensory neuropathy remains obscure. In a recent case, a relationship to herpes simplex virus might be inferred. A woman, aged 63 years, had at least ten episodes of "cold sore," always at the same site on her upper lip. After a typical prodromal burning, she expected a cold sore to appear, but a trigeminal sensory neuropathy began instead, starting at the site where the cold sores had always appeared.

The 'herald hemiparesis' of basilar artery occlusion.

In thrombosis of the basilar artery, not infrequently a hemiparesis is present at an early stage, when brain-stem signs may be absent or few, slight or equivocal. It is natural to suspect that such a hemiparesis signifies localization in a cerebral hemisphere, but unexpectedly in a few hours bilateral hemiplegia appears associated with coma or a locked-in syndrome, indicating basilar artery occlusion. I would term this disarming hemiparesis the "herald hemiparesis" of basilar artery occlusion. If the true nature of the condition is recognized early, the use of heparin and other measures may forestall disaster.

Lacunar infarct of the tegmentum of the lower lateral pons.

A stroke with a somewhat unusual neurologic formula was correlated with a small linear high-intensity T2 focus in the lateral tegmentum of the lower third of the pons. The clinical features included dysarthria, staggering gait, incoordination of handwriting, right facial weakness, nystagmus, ocular overshoot, right appendicular ataxia, and left-sided dissociated sensory loss for pain and temperature. Lacunar lesions of the tegmentum in the region of the pontomedullary junction, while not uncommon, have not been studied pathologically and have not been reported in the magnetic resonance imaging literature, to my knowledge.

'Catatonia' due to disulfiram toxicity.

In an alcoholic patient, catatonia developed while he was receiving disulfiram (Antabuse). Resolution of the question whether his state was classically catatonic required a detailed review of the literature on the subject. The conclusion reached is that the original definition still holds for psychiatric illness, but application of the term to neurological and metabolic states has often been based on imprecise criteria and failure to consider akinetic mutism and extrapyramidal motor disturbances as factors. The action of disulfiram as an inhibitor of dopamine beta hydroxylase provides a possible mechanism for the cerebral toxic effect, but nonetheless the various interpretations remain largely speculative.

Acute cerebellar infarction in the PICA territory.

Although old or recent infarcts of a cerebellar hemisphere in the territories of the posterior inferior (PICA), superior, or anterior inferior cerebellar arteries are commonplace autopsy findings, in no case have corresponding clinical symptoms been clearly identified. We have studied three cases, two clinocaopthologically and one clinicosurgically, in which an acute infarct involving only the cerebellum lay in the PICA territory distal to the branches to the medulla oblongata. The clinical manifestations consisted of rotatory dizziness intensified by motion, nausea, vomiting, imbalance, and nystagmus. In two cases, the clinical diagnosis had been a benign labyrinthine disorder. Recognition of a syndrome corresponding to cerebellar infarction in the PICA territory is important insofar as it assists in the differential diagnosis of dizziness. It becomes of crucial importance when cerebellar infarction is the prelude to cerebellar swelling and brain stem conpression leading to coma and death unless surgically relieved.

Cerebral atheromatous embolism following carotid sinus pressure.

Complications of carotid sinus pressure, which are rare, include cardiac arrhythmias and cerebrovascular accidents. A 79-year-old man experienced a flaccid right hemiplegia one minute after left carotid sinus pressure. At necropsy, an atheromatous embolus occluded the left middle cerebral artery, resulting in hemorrhagic infarction in its vascular territory. Atheromatous embolism following carotid sinus pressure has not been previously documented. Most sudden stroke deficits following carotid sinus pressure are probably caused by this mechanism.

Sensorimotor stroke due to thalamocapsular ischemia.

A 61-year-old hypertensive diabetic man awoke with a numb, heavy right arm and leg; symptoms progressed within 30 hours to a dense right hemisensory syndrome involving head, face, trunk, arm, and leg, accompanied by a right hemiparesis, involving tongue, face, arm, and leg with extensor plantar response, leaving him barely able to move the arm and leg against gravity. No impairment in alertness, memory, language, praxic, or visual functions was evident at any time. Improvement in motor function began in 24 hours and progressed to walking status by discharge on day 23. Eight days passed before the sensory deficit showed improvement, and it was still prominent at discharge. Autopsy three months later showed a 4 X 2 X 4-mm lacune in the ventral posterior nucleus of the left thalamus, with a zone of pallor on stained microscopic sections extending into the immediately adjacent posterior limb of the internal capsule. This case appears to be unique in that a sensorimotor stroke has been produced by a confirmed thalamocapsular infarct.

Clinical and radiologic remission in reticulum cell sarcoma of the brain.

Two patients with cerebral reticulum cell sarcoma (CRCS) are reported in whom neurologic abnormalities and radiologic (computerized tomographic [CT] scan) evidence of tumor remitted. In one patient, remission followed craniectomy and corticosteroid therapy and lasted for eight months. In the other patient, at least four remissions occurred over a span of seven years, each in conjunction with the administration of corticosteroids. Corticosteroids may favorably alter the biologic activity of tumor tissue in some cases of CRCS, predisposing to clinical remission and disappearance of tumor on CT scan.

Hydrocephalus as a cause of disturbances of gait in the elderly.

To investigate the possible role of symptomatic normal-pressure hydrocephalus (NPH) in unexplained walking difficulties of the elderly, we used CT to measure lateral ventricular size. We compared data in 50 patients over the age of 60 with a disturbance of gait and 80 control subjects of similar age who walked well and were mentally sound. Forty-six of the 50 gait patients (92%) had a ventricular span of more than 12 mm, whereas only 5 of the 80 controls (6.3%) had ventricles of that size. There was a narrow zone of overlap. Seventeen of the gait patients later improved after surgical shunting or test withdrawal of lumbar CSF. These findings demonstrate that hydrocephalus is an important cause of disturbances of walking in the elderly. The validity of the study, the clinical picture in NPH, and the nature of NPH are discussed.

Hunger and the temporal lobe.

A boy experienced two episodes of intracerebral hemorrhage in the region of the right anterior temporal lobe. On both occasions, the bleeding was ushered in by an exclamation of intense hunger. The patient provides further evidence for the temporal lobe localization of the sensation of hunger. We describe a model of the neural system subserving feeding that incorporates the cortical locus of hunger.

Hypomanic symptoms caused by herpes simplex encephalitis.

This is a case report of a brief episode of rather typical hypomanic symptoms in the acute phase of presumed herpes simplex encephalitis in a young woman. I infer that the hypomanic episode was triggered from the anterior inferomedial temporal lobe or limbic system, the presumed cerebral substrate of the emotions in general, and review the literature relating to the occurrence of hypomania associated with structural disease of the nervous system.