A logistic regression model predicting high axillary tumour burden in early breast cancer patients

Purpose. As elective axillary dissection is loosing ground for early breast cancer (BC) patients both in terms of prognostic and therapeutic power, there is a growing interest in predicting patients with (nodal) high tumour burden (HTB), especially after a positive sentinel node biopsy (SNB) because they would really benefit from further axillary intervention either by complete lymph-node dissection or axillary radiation therapy. Methods/patients. Based on an analysis of 1254 BC patients in whom complete axillary clearance was performed, we devised a logistic regression (LR) model to predict those with HTB, as defined by the presence of three or more involved nodes with macrometastasis. This was accomplished through prior selection of every variable associated with HTB at univariate analysis. Results. Only those variables shown as significant at the multivariate analysis were finally considered, namely tumour size, lymphovascular invasion and histological grade. A probability table was then built to calculate the chances of HTB from a cross-correlation of those three variables. As a suggestion, if we were to follow the rationale previously used in the micrometastasis trials, a threshold of about 10% risk of HTB could be considered under which no further axillary treatment is warranted. Conclusions. Our LR model with its probability table can be used to define a subgroup of early BC patients suitable for axillary conservative procedures, either sparing completion lymph-node dissection or even SNB altogether (AU)

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A logistic regression model predicting high axillary tumour burden in early breast cancer patients.

PURPOSE: As elective axillary dissection is loosing ground for early breast cancer (BC) patients both in terms of prognostic and therapeutic power, there is a growing interest in predicting patients with (nodal) high tumour burden (HTB), especially after a positive sentinel node biopsy (SNB) because they would really benefit from further axillary intervention either by complete lymph-node dissection or axillary radiation therapy. METHODS/PATIENTS: Based on an analysis of 1254 BC patients in whom complete axillary clearance was performed, we devised a logistic regression (LR) model to predict those with HTB, as defined by the presence of three or more involved nodes with macrometastasis. This was accomplished through prior selection of every variable associated with HTB at univariate analysis. RESULTS: Only those variables shown as significant at the multivariate analysis were finally considered, namely tumour size, lymphovascular invasion and histological grade. A probability table was then built to calculate the chances of HTB from a cross-correlation of those three variables. As a suggestion, if we were to follow the rationale previously used in the micrometastasis trials, a threshold of about 10% risk of HTB could be considered under which no further axillary treatment is warranted. CONCLUSIONS: Our LR model with its probability table can be used to define a subgroup of early BC patients suitable for axillary conservative procedures, either sparing completion lymph-node dissection or even SNB altogether.

Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients

Purpose. Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement. Methods/patients. Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required. Results. 1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%. Conclusion. We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients (AU)

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Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients.

PURPOSE: Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement. METHODS/PATIENTS: Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required. RESULTS: 1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%. CONCLUSION: We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients.

Aetiology of community-acquired pneumonia among adults in an H1N1 pandemic year: the role of respiratory viruses.

This study aimed to determine the aetiology of community-acquired pneumonia (CAP) by adding polymerase chain reaction (PCR) to conventional methods and to describe the clinical and laboratory features between patients with bacterial pneumonia (BP) and viral pneumonia (VP). Adults with CAP admitted from November 2009 to October 2010 were included. Demographics, comorbidities, severity and clinical features were recorded. Conventional microbiological methods included blood and sputum cultures, acute and convalescent serologic samples, and antigen urinary detection. New methods included multiplex PCR for Mycoplasma pneumoniae, Legionella pneumophila, Chlamydophila pneumoniae, Bordetella pertussis and 15 respiratory viruses. A total of 169 patients were included. Using conventional methods, we identified a pathogen in 51 % of cases. With PCR, up to 70 % of cases had an aetiological diagnosis. Forty-five patients had BP (34 %), 22 had VP (17 %) and 25 (19 %) had co-infection (BP and VP). Pneumococci and respiratory syncytial virus (RSV) were the most frequently identified pathogens. Procalcitonin (PCT) and C-reactive protein (CRP) median values were significantly higher in BP than in VP patients. Shaking chills, higher CURB score and shock were significantly more frequent in BP. A viral infection was identified in more than one-third of patients with CAP. Clinical and laboratory features could help to differentiate between VP and BP and to guide empirical therapy.

Use of axillary ultrasound, ultrasound-fine needle aspiration biopsy and magnetic resonance imaging in the preoperative triage of breast cancer patients considered for sentinel node biopsy.

We assessed the diagnostic yield of axillary ultrasound, alone or in combination with fine-needle aspiration axillary biopsy and magnetic resonance imaging in patients with invasive breast carcinoma compared with final axillary histology by sentinel node biopsy or by axillary lymph node dissection. From January 2003 to March 2009, 520 axillary ultrasound examinations and 105 axillary magnetic resonance imaging studies were included. Compared with final axillary histology, ultrasound fine-needle aspiration showed positive predictive value of 87%, negative predictive value of 82%, sensitivity of 53% and specificity of 100%. In cases of negative ultrasound, the rate of positive nodes was 17% (micro-metastases excluded). Ultrasound examination of the axilla, combined with fine-needle aspiration as appropriate must be included in the preoperative work-up of patients considered for sentinel node biopsy to definitively establish such an indication while minimizing the risk of false-negative sentinel node. Axillary magnetic resonance imaging did not improve the preoperative work-up.

Pseudomonas aeruginosa in patients hospitalised for COPD exacerbation: a prospective study.

Risk factors for Pseudomonas aeruginosa (PA) isolation in patients hospitalised for chronic obstructive pulmonary disease (COPD) exacerbation remain controversial. The aim of our study was to determine the incidence and risk factors for PA isolation in sputum at hospital admission in a prospective cohort of patients with acute exacerbation of COPD. We prospectively studied all patients with COPD exacerbation admitted to our hospital between June 2003 and September 2004. Suspected predictors of PA isolation were studied. Spirometry tests and 6-min walking tests were performed 1 month after the patients were discharged. High-resolution computed tomography (HRCT) was performed in a randomised manner in one out of every two patients to quantify the presence and extent of bronchiectasis. Patients were followed up during the following year for hospital re-admissions. A total of 188 patients were included, of whom 31 (16.5%) had PA in sputum at initial admission. The BODE (body mass index, airflow obstruction, dyspnoea, exercise capacity) index (OR 2.18, CI 95% 1.26-3.78; p = 0.005), admissions in the previous year (OR 1.65, CI 95% 1.13-2.43; p = 0.005), systemic steroid treatment (OR 14.7, CI 95% 2.28-94.8; p = 0.01), and previous isolation of PA (OR 23.1, CI 95% 5.7-94.3; p<0.001) were associated with PA isolation. No relationship was seen between bronchiectasis in HRCT and antibiotic use in the previous 3 months. PA in sputum at hospital admission is more frequent in patients with poorer scoring on the BODE index, previous hospital admissions, oral corticosteroids and prior isolation of PA.

Pseudo-Jahn-Teller origin of the low barrier hydrogen bond in N(2)H(7) (+).

The microscopic origin and quantum effects of the low barrier hydrogen bond (LBHB) in the proton-bound ammonia dimer cation N(2)H(7) (+) were studied by means of ab initio and density-functional theory (DFT) methods. These results were analyzed in the framework of vibronic theory and compared to those obtained for the Zundel cation H(5)O(2) (+). All geometry optimizations carried out using wavefunction-based methods [Hartree-Fock, second and fourth order Moller-Plesset theory (MP2 and MP4), and quadratic configuration interaction with singles and doubles excitations (QCISD)] lead to an asymmetrical H(3)N-H(+)cdots, three dots, centeredNH(3) conformation (C(3v) symmetry) with a small energy barrier (1.26 kcalmol in MP4 and QCISD calculations) between both equivalent minima. The value of this barrier is underestimated in DFT calculations particularly at the local density approximation level where geometry optimization leads to a symmetric H(3)Ncdots, three dots, centeredH(+)cdots, three dots, centeredNH(3) structure (D(3d) point group). The instability of the symmetric D(3d) structure is shown to originate from the pseudo-Jahn-Teller mixing of the electronic (1)A(1g) ground state with five low lying excited states of A(2u) symmetry through the asymmetric alpha(2u) vibrational mode. A molecular orbital study of the pseudo-Jahn-Teller coupling has allowed us to discuss the origin of the proton displacement and the LBHB formation in terms of the polarization of the NH(3) molecules and the transfer of electronic charge between the proton and the NH(3) units (rebonding). The parallel study of the H(5)O(2) (+) cation, which presents a symmetric single-well structure, allows us to analyze why these similar molecules behave differently with respect to proton transfer. From the vibronic analysis, a unified view of the Rudle-Pimentel three-center four-electron and charge transfer models of LBHBs is given. Finally, the large difference in the N-N distance in the D(3d) and C(3v) configurations of N(2)H(7) (+) indicates a large anharmonic coupling between alpha(2u)-alpha(1g) modes along the proton-transfer dynamics. This issue was explored by solving numerically the vibrational Schrodinger equation corresponding to the bidimensional E[Q(alpha(2u)),Q(alpha(1g))] energy surface calculated at the MP46-311++G(**) level of theory.

Lipoescultura no tumescente / Non tumescent liposculpture

En este trabajo, debido a los serios cuestionamientos que tenemos con el "dogma" de la "Tumescencia" como requisito para hacer la liposucción convencional, planteamos como alternativa una nueva técnica denominada por nosotros "lipoescultura no tumescente" que se basa en dos principios: 1) uso de solución vasoconstrictora 2A, 2) Técnica de infiltración suprafascial. Nuestro trabajo es de tipo prospectivo y es el producto de 18 meses de observación, análisis y puesta en marcha de una hipótesis que finalmente confirmó nuestras sospechas: reducción muy importante de los riesgos de una lipoescultura, resultados estéticos de mejor calidad y convicción de lo innecesario y poco racional que, a nuestro juicio, resulta la tumescencia en la lipoescultura; por lo tanto creemos que su vigencia está seriamente cuestionada en estos momentos. Sin embargo debemos reconocer la importancia que tuvo en tanto no hubo un cuestionamiento serio y una alternativa razonable (AU)

In this work, due to the serious questions that we have with the "dogma" of "Tumescencia" as a requirement to make the conventional liposuction, we suggest as an alternative a new technique named by us "non tumescent liposcultpture", based in two principles: 1) use of solution 2A, 2) suprafascial infiltration. Our work is prospective and it is the result of 18 months observation, analysis and development of a hypothesis that has finally confirmed our suspicions: very important reduction of the risks of a liposculture, aesthetic results of better quality and the conviction about how unnecessary and not very rational "tumescencia" can be in the liposculture; therefore we believe that its validity is seriously questioned now, however we should recognize the importance that it had as long as there were not serious questions nor a reasonable alternative (AU)

Effect of neuropeptide Y on GnRH-induced LH release from bovine anterior pituitary cell cultures derived from heifers in a follicular, luteal or ovariectomized state.

Objectives were to determine if neuropeptide Y (NPY) had direct effects GnRH induced secretion of LH from the anterior pituitary gland, and if endogenous steroids modulated the effect of NPY. To accomplish these objectives, 15 Hereford heifers were assigned to one of three ovarian status groups: follicular, luteal, or ovariectomized. One animal from each of the three ovarian status groups was slaughtered on each of 5 days and anterior pituitary gland harvested. Anterior pituitary gland cells within ovarian status were equally distributed and randomly assigned to one of three cell culture treatments: no NPY or GnRH (control), 10 nM GnRH, or 100 nM NPY+10 nM GnRH. Anterior pituitary cell cultures were incubated with or without NPY for 4 h and further incubated for an additional 2 h with or without GnRH and supernatant collected for quantification of LH. Treatment of anterior pituitary cell cultures with GnRH or GnRH+NPY did not affect LH release in cultures obtained from follicular (S.E.=5%; P=0.58) or ovariectomized (S.E.=7%; P=0.22) heifers. Both GnRH and GnRH+NPY increased LH release from anterior pituitary cell cultures from heifers in the luteal phase (S.E.=14%; P < or = 0.05) compared to control cultures. Cultures from luteal phase heifers treated with GnRH did not differ from those treated with GnRH+NPY (P=0.34). These data provide evidence to suggest that effects of NPY on LH release may occur primarily at the level of the hypothalamus.

[Lumbar root compression secondary to juxtafacet cysts: review of 10 cases]. / Compresión radicular lumbar secundaria a quistes yuxtafacetarios: revisión de 10 casos.

OBJECT: We report a series of 10 patients with 11 juxtafacet cysts of the lumbar spine treated in our center from 1994 to 2000. METHODS: The clinical histories, radiographic images, surgical protocols and pathological records of the 10 patients diagnosed of lumbar juxtafacet cyst have been analyzed. RESULTS: Six patients were women and four were men. The average age of presentation was 54 years. The most frequent clinical presentation was radicular pain, and motor or sensitive deficits were not very common. Computed tomography and magnetic resonance are essential in establishing the diagnosis. The cysts were located at L4-L5 in eight patients, at L2-L3 in one patient, and at L3-L4 in other patient. Eight patients were treated by means of decompressive laminectomy and excision of the cyst, and the remaining two underwent conservative treatment. Degenerative phenomena adjacent to the juxtafacet cysts are easy to evidence. All the patients were improved of their radicular pain. CONCLUSIONS: Analysing our series, we conclude that the juxtafacet cysts appear more frequently at L4-L5 level in people of advanced age, and produce commonly low back pain and radiculopathy. Although they can be treated initially in a conservative way, in the presence of a progressive sciatic syndrome, surgical management is preferable.

[Ear, nose, and throat manifestations in patients with primary immunodeficiencies]. / Manifestaciones otorrinolaringológicas de los pacientes con immunodeficiencias primarias.

OBJECTIVE: To determine the flowgram for the timely diagnosis of the immunodeficiencies congenital primary, based on the demonstrations otorrinolaringol recurrent chronicles to difficult control, with or without associated systemic diseases. MATERIAL AND METHOD: Retrospective study, descriptive and observational that included patient with diagnostic of primary known immunodeficiency. They were checked the clinical files to know their evolution and medical treatment-surgical. RESULTS: They were found 10 patient with diagnostic of some primary immunodeficiency; this was made based on the infectious symptoms otolaryngal chronic recurrent to difficult control; they were six men and four women between the four and 36 years old. They were found the following immunodeficiencies: one of hyper-IgM, three by IgG, variable common three, a deficit with C3 of the complement, two of IgA more atopia. CONCLUSIONS: The chronicle sinusitis or recurrent and the otitis mean chronicle or recurrent can be the only demonstrations of a patient with primary immunodeficiency. The immunology evaluation must include, at least: hematic biometric completes with differential, seric levels of immunoglobulins, the same as subclass of IgG, C4 and C3 of the complement, response to immunization with proteins (diphtheria and tetanus), and polysaccharide antigens (pneumovax).

[Disseminated nocardiosis in 3 immunocompetent patients]. / Nocardiosis diseminada en tres pacientes inmunocompetentes.

Nocardia asteroide infections, an aerobic actinomycete, have several forms and lungs, skin and brain are the organs most frequently involved. When the infection suspected, special staining methods must be ordered to identify the agent. We report three immunocompetent patients with disseminated nocardiosis, two presenting with nodular lesions of skin and lungs and one presenting with pulmonary involvement and brain abscesses. The importance of clinical suspicion and early diagnosis of nocardiosis is emphasized.

Metastatic tumors to the upper gastrointestinal tract: endoscopic experience.

Metastatic tumors to the upper gastrointestinal tract were identified by esophagogastroduodenoscopy in 14 patients. Malignant melanoma, breast cancer, and lung cancer were the most common primary cancers in four, three, and three patients, respectively. Osteogenic sarcoma, renal cell carcinoma, Meckel cell carcinoma of the skin, and germ-cell tumor were the primary cancer in the remaining four. The esophagus was involved in three patients, the stomach in 13, duodenum in four, and papilla of Vater in one. Upper gastrointestinal bleeding and anemia were the most common presenting features. There was correlation between symptoms and endoscopic findings in all patients. Involvement of gastrointestinal tract at endoscopy was the initial and only evidence of metastases in all patients without evidence of metastases elsewhere, as evidenced by other diagnostic tests in any of these patients. Endoscopic biopsies and/or brush cytology provided histologic diagnosis in all 14 patients. The endoscopic and nonendoscopic literature regarding metastases to the upper gastrointestinal tract is reviewed.

Upper gastrointestinal bleeding from Merkel cell carcinoma.

Merkel cell carcinoma is a rare small cell carcinoma of the dermis with aggressive clinical features and frequent local recurrence. Intra-abdominal spread of the cancer has previously been noted primarily in the liver and retroperitoneal nodes. We report a patient with previously diagnosed Merkel cell carcinoma of the right buttock with metastases to the stomach and duodenum presenting with acute upper gastrointestinal bleeding.

Suppression of T-lymphocyte responses to Entamoeba histolytica antigen by immune sera.

Lymphocytes from patients cured of amebic liver abscesses proliferate and produce gamma interferon upon incubation with soluble Entamoeba histolytica antigen: however, amebic liver abscesses exhibit a relentless progression without treatment. To determine whether suppressive factors are present in sera, we studied T-lymphocyte responses to total soluble E. histolytica antigen by using cells from five patients treated for amebic liver abscesses in the presence of 15 different immune sera and 10 control sera. In the presence of immune sera, E. histolytica antigen-induced lymphocyte proliferation decreased by 63% and production of gamma interferon was reduced by 93.2% (P less than 0.01). Immune sera had no effect on the mitogenic responses of patient lymphocytes to phytohemagglutinin or on the proliferative responses of control lymphocytes to phytohemagglutinin or tetanus toxoid. The suppressive activity of immune sera diminished as the time between therapy for amebic liver abscesses and serum collection increased (P less than 0.05). Suppressive activity did not correlate with the titers of serum anti-amebic antibody and was not affected when serum was absorbed with viable amebic trophozoites. In conclusion, soluble factors present in the sera of amebic liver abscess patients suppressed in vitro lymphocyte responses to E. histolytica antigen and may have contributed to the lack of development of effective in vivo cell-mediated immune responses following the onset of amebic liver abscesses.

Algorithm-directed care by nonphysician practitioners in a pediatric population: Part I. Adherence to algorithm logic and reproducibility of nonphysician practitioner data-gathering behavior.

The ability of quickly trained nonphysician practitioners to care for pediatric patients with upper respiratory tract infections (URIs) was evaluated in 3802 patients. These nonphysician practitioners (Army Pamosists) used an explicit treatment protocol and computerized audit of protocol adherence. Pamosists omitted protocol-suggested plans in 3.7 per cent of cases and ordered unnecessary treatment plans in 1.7 per cent of cases. They did not obtain a suggested MD consultation in 6.2 per cent of the cases. Agreement between Pamosists and pediatricians on data and management decisions (PM-MD study) was then compared with agreement on the same variables between pairs of a group of five pediatricians who saw a separate but comparable group of 103 pediatric URI patients (MD-MD study). The Pamosists demonstrated good (77 to 89 per cent) overall agreement with pediatricians, and the amounts of agreement between Pamosists and pediatricians in the PM-MD study did not generally differ significantly (p greater than 0.05) from the agreement on the same variables between pairs of pediatricians in the MD-MD study.