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.

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.

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.

Prompt responses to the administration of ethanol in the treatment of the alcohol withdrawal syndrome (AWS).

OBJECTIVE: To report the beneficial effect of the administration of ethanol in the treatment of the alcohol withdrawal syndrome (AWS). METHODS: In 3 instances of the AWS in subjects who used alcohol in socially acceptable amounts, ethanol was administered in one case intravenously, and in 2 cases orally. RESULTS: Symptoms were dramatically relieved in 20, 10 and 5 minutes, respectively. INTERPRETATION: 1. This study suggests the greater use of ethanol in the treatment of AWS. 2. Withdrawal symptoms occurred in subjects who drank only 30 to 60 mL of whiskey daily. 3. Withdrawal manifestations may take up to 10 weeks to clear. 4. The violent reaction of patients to being restrained physically in their management, the restraint reaction, may find its analogy in Watson's intolerable restraint reaction in infants.

Neuroanatomic evidence to explain why bilateral internuclear ophthalmoplegia may result from occlusion of a unilateral pontine branch artery.

Microscopic study of serial sections of the pons in two autopsy cases without known neurologic disease showed that the terminal portion of paramedian tegmental pontine arteries may divide to supply the region of the medial longitudinal fasciculus bilaterally. This finding provides the basis for the occurrence of bilateral internuclear ophthalmoplegia with unilateral basilar branch artery occlusion.

Early arrest of mental and motor development associated with bilateral hippocampal anoxic damage.

BACKGROUND: Clinical-pathological study of the case of a woman with amentia from birth. CASE HISTORY: A 45-year-old woman was institutionalized since the age of two and showed no change in 43 years. She did not stand, walk, talk, use her hands or comprehend. She was placed in a chair each day. She lacked control of bladder and bowel. She showed no mental capability. CASE PATHOLOGY: The brain weighed 1250 gm and was normally developed. There were two anoxic-ischemic regions of damage. The hippocampus showed extensive damage bilaterally and the cerebellum showed watershed infarction bilaterally. CONCLUSION: A perinatal anoxic-ischemic episode is suspected. Hippocampal damage was the only finding that might explain the failure of mental and motor development. If this hypothesis is correct, the function of the human hippocampus is broader than currently accepted.

Outcome of surgery for vascular access in patients commencing haemodialysis.

OBJECTIVE: assessment of surgical vascular access procedures for haemodialysis. DESIGN: retrospective cohort audit. MATERIALS AND METHODS: secondary patency was calculated from surgery until access failure, death, transplant, conversion to peritoneal dialysis, or loss to follow-up. All surgical procedures including immediate failures and failures to mature fistulae were included but not radiological interventions. RESULTS: four hundred and forty-five operations were undertaken in 197 patients over 87 months comprising 273 access creations and 172 revisions. Median follow-up was 26 months with a mortality of 9.4 deaths per 100 patient-years including eight perioperative deaths. Autogenous access was created in 147 (75%) patients with 142 based on the radial artery whilst 50 prosthetic grafts including 46 PTFE grafts and 40 forearm loops were placed. Patients receiving grafts were more likely to be older, female and die in follow-up. Grafts had higher patencies of 89, 75 and 68% at 1, 2 and 4 years, respectively compared to 69, 63 and 55% for autogenous access. This difference was significant (p=0.049) when the effects of the presence of diabetes and peripheral arterial disease were accounted for but more frequent revisions were required. The final access placed was autogenous in 110 (56%) and prosthetic in 87 (44%) patients. CONCLUSIONS: in our surgical unit, there was high secondary patency including for prosthetic grafts, high autogenous utilisation and relatively infrequent reintervention.

Reversal of normal pressure hydrocephalus symptoms by subdural collections.

BACKGROUND: The pathogenesis of symptoms in normal pressure hydrocephalus (NPH) is unclear. One theory is that in the presence of enlarged lateral ventricles, the ventricular fluid exerts increased force on the ventricular walls, the cerebrospinal fluid pressure remaining normal. This is in accordance with Pascal's principle of F = PxA. It has not been possible to obtain direct evidence for this view. METHOD: The opportunity to gain insight into the matter arose when it was observed that two patients with symptomatic NPH were relieved of their symptoms when they developed bilateral subdural collections, one after head trauma, the other after ventriculo-peritoneal shunting for NPH. RESULT: In each case, concomitant with the subdural collections and the reversal of symptoms, the ventricular system became smaller. In the first patient, symptoms returned when the subdural collections were resorbed. In the second patient, symptoms returned when the subdural collections became excessive. CONCLUSION: Although documentation was less thorough than desired, it was concluded that relief of symptoms was related to the decrease in the ventricular size rather than lowering of the intraventricular pressure, thus providing evidence for operation of the principle F = PxA as the mechanism of symptoms in NPH.

If there were no free will.

Electrophysiological findings in humans who are performing voluntary acts, indicate that the intention to act, follows brain activity rather than preceding it. This has implications for voluntary behavior and the doctrine of free will. This essay reviews the fields of human behavior, including medicine, in which this new thesis might have far-reaching significance.

Combined endovascular and open surgery for four-vessel cerebrovascular occlusive disease.

PURPOSE: To report a case of bilateral simultaneous percutaneous transluminal angioplasty and stenting of the intracranial vertebral arteries prior to staged bilateral carotid endarterectomy. CASE REPORT: A 68-year-old man presented with a 3-month history of recurrent, intermittent left-sided weakness and diplopia. Imaging defined bilateral 80% to 99% internal carotid artery stenoses and >90% stenoses of both distal vertebral arteries at the level of the foramen magnum. Bilateral intracranial vertebral artery stenting was performed, followed by staged carotid endarterectomies. No complications occurred, and the patient recovered uneventfully from all 3 procedures. He remains symptom- and event-free 20 months later. CONCLUSIONS: Our initial success in this case indicates a role for percutaneous transluminal angioplasty and stenting as an alternative to open surgery for intracranial vertebral artery stenosis.

Alien hand phenomena: a review with the addition of six personal cases.

This is a comprehensive literature review of the motor abnormalities that have come to be included under the designation of Alien Hand Phenomena (AHP). Some of the disorders are dyspractic in nature - intermanual conflict, mirror movements, interference etc., while others - groping, grasping with inability to release, utilization etc. are frontal lobe reflexes. AHP are mainly associated with two pathological processes: 1) Infarction or hemorrhage in the territory of the anterior cerebral arteries; and 2) Corticobasal degeneration. Included in the review is a description of AHP in six personal cases of corticobasal degeneration. The summary includes a short discussion of the possible anatomy of 'free will' based on AHP.

Hysteria: a delusional state.

This paper explores the hypothesis that hysterical symptoms may best be regarded as the product of delusional thinking. Hysteria has generally been interpreted as a process quite distinct from other psychiatric disorders. An attempt is made to bring it within more conventional bounds.

Prevalence and outcome of activated protein C resistance in patients after peripheral arterial bypass grafts.

The association of activated protein C resistance with peripheral arterial bypass graft patency was assessed. A retrospective cohort study of consecutive first-time femoro-popliteal or femoro-distal bypasses performed in patients living within the boundaries of the Area Health Service was performed. Of 242 patients eligible for inclusion, 73 had died, nine refused to participate and 40 were lost to follow-up. Activated protein C resistance was present in nine (7.5%) of the 120 patients tested. In the study group, smoking at the time of surgery, female gender and the use of prosthetic grafts were significantly associated with graft failure on univariate Cox regression analysis, but activated protein C resistance was not. After accounting for confounders, there was a trend (P = 0.098) for activated protein C resistance to be associated with graft failure (OR 2.90, 95% CL 0.82-10.3). Patients who died or who were lost to follow-up had significantly earlier operation dates than those who remained alive or tested for activated protein C resistance. However, there was also a highly significant (P = 0.006) trend for activated protein C resistance in patients who had undergone surgery closer to the end of the study period. Six of the nine patients with activated protein C resistance underwent surgery in the last 10 months of the review period and only three activated protein C resistance patients had a graft patent for more than 8 months. The prevalence of activated protein C resistance in patients undergoing peripheral arterial bypass grafting is greater than in the general population. There was a trend for activated protein C resistance to be associated with graft failure. A significantly higher proportion of patients with activated protein C resistance was found with more recently performed surgery. The observed results could be accounted for by excess mortality in patients with activated protein C resistance. This hypothesis requires testing prospectively.

Phantom erection after amputation of penis. Case description and review of the relevant literature on phantoms.

BACKGROUND: Perception of a phantom limb is frequent after an amputation of an upper or lower extremity. Phantom penis is reported infrequently. METHOD: Case description and literature review. RESULT: The phenomenon of phantom penis followed total penectomy. Several aspects were unusual, particularly the existence with phantom only in the erect state, and associated recrudescence of a preoperative painful ulcer. General features of limb phantoms after amputation are reviewed including a résumé of recent studies of cortical reorganization. The phantom process is analyzed looking for clues to the nature of the underlying neural organization. The puzzle of phantom pain is briefly touched on. CONCLUSION: The development of the phantom is attributed to activity in the deafferented parietal sensory cortex.

Late-life (migrainous) scintillating zigzags without headache: one person's 27-year experience.

BACKGROUND: Episodes of typical scintillating zigzags similar to the visual aura of migraine may occur without headache, especially after the age of 50. There is no record of one individual's long-term experience. PRESENT MATERIAL: This paper is a personal account of all 41 episodes of scintillating zigzags that occurred between the ages of 59 and 85. Observations were made on several aspects of the visual event itself--evolution, pattern, scotoma, coloration, duration, lateralization, etc. The chronological distribution of spells, circumstances of occurrence, time of day, the season, etc were noted. The study was observational in nature. Documentation of this experience could be of value clinically and scientifically. RESULTS: The spells occurred irregularly, unrelated to season, time of day, activity at onset, diet, and temperamental state. The characteristic appearance was a flickering zigzag line that began centrally and migrated to the periphery. The display, which was stereotyped, was achromatic. The average duration was 15 minutes. Both visual fields were equally involved, never at the same time. The details of the scintillating zigzag line are actually complex and an account of the observations of others and of the author is included here.