Prinzmetal's angina and emotions: A neglected psychosomatic entity.

Prinzmetal's angina, a form of angina precipitated by vasoconstriction or spasm, appears to be a somatic phenomenon, but there is evidence, from research and case reports, of a major psychological component. In this study, individuals with Prinzmetal's angina were interviewed to determine the nature of their interpersonal relationships and their intrapsychic state at the time of onset of their chest pain. In addition, short developmental histories were obtained. The authors found that onset of chest pain was related to experiencing intense affect, and multiple levels of interpersonal and intrapsychic conflict, with strong conscious and unconscious, emotional and ideational links to previous traumas.

Evaluation of a displacement assay with tamoxifen as prognostic indicator in breast-cancer patients with estrogen-receptor-positive tumors.

A displacement assay with tamoxifen, based on the relative binding affinity of tamoxifen and estradiol for the estrogen receptor (ER), was proposed in 1990 as prognostic indicator for breast-cancer patients. Validation of its predictive results in relation to the outcome of 73 patients with ER+ tumors is analyzed. ER, progesterone receptor (PgR) determinations and other conventional prognostic factors in relation to the displacement assay, were considered. Displacement assay results allowed ER+ tumors to be grouped as displaceable (D) or weakly displaceable (WD), with the implication that D tumors should respond better to tamoxifen (Tam) administration. Survival and disease-free interval curves showed highly significant differences between patients with ER+ D and ER+ WD tumors. For survival, including all tumor stages, 73.9% of patients were alive at 9 years after surgery in the group with D tumors and 37.0% in the group with WD tumors (p < 0.005); relative contribution of the different stages is analyzed. Addition of axillary-node number increased the prognostic significance of displacement categories for survival and disease-free interval. PgR determination as another ER functional expression failed to show significant differences for survival and disease-free interval between ER+ PgR+ and ER+ PgR- tumors. Thus, results from the displacement assay and from PgR determinations reflect 2 independent ER functional expressions. Displacement assay data appear as reliable prognostic indicators of breast-cancer outcome, and contribute to more appropriate treatment decisions in this pathology.

[New concepts on hormone dependence in breast cancer]. / Nuevos conceptos sobre hormonodependencia en el cáncer de mama.

The type of hormone dependence in mammary neoplasias is usually defined by the presence or absence of estrogen and progesterone receptors. At present, new advances in the knowledge related to the functionality of these receptors are changing our previous concepts. Estrogen receptors classified as negative by biochemical or immunocytochemical methods because of deletions or mutations in their ligand-binding domain, are still able to regulate the expression of genes related to cellular proliferation. Receptors defined as positive, may present other defective domains with disappearance or distortion of their transcriptional function. As a result, regulation of the cellular proliferative process is distorted and the tumoral growth seems autonomous, as if the receptors were absent. The modular organization of the receptor molecule allows a relative functional independence of the constitutive domains. Functional assays to evaluate receptor behavior under different experimental or clinical situations are necessary. A displacement assay with tamoxifen, for studying the relative binding affinity of tamoxifen and estradiol for the estrogen receptor contributes to a more appropriate use of this antiestrogen in mammary oncology. Conformational changes and mutations in one or several of these genomic molecules may after the transcriptional message with repercussion on cellular proliferation. In this way, antiprogestinic agents can show progestin agonistic effects when combined with cAMP analogues; on the other hand, opposite effects on cellular growth by cAMP analogues can be observed according to the type of hormone dependency (autonomous or dependent) of the tumors. Modulation of steroid receptor transcriptional activity is also achieved through non-transcriptional proteins associated to the receptor molecule. These proteins are then potential targets for the pharmacological regulation of the transcription message. Resistance to antihormone treatments in breast cancer is a dominant feature in the evolution of this malignancy. It cannot be attributed to the presence or absence of steroid receptors when only defined by their quantitative variations.

Clinical assessment of the 1987 American College of Rheumatology criteria for rheumatoid arthritis.

The 1987 American College of Rheumatology (ACR) criteria for the classification of rheumatoid arthritis (RA) were clinically assessed. These criteria do not include findings of synovial fluid (SF) analysis and require no exclusion criteria. We have studied sequential patients with arthritis seen in four rheumatology centers in the Philadelphia area. Classifications by the ACR criteria were compared with our clinical diagnoses. Two hundred ninety eight patients were evaluated, 113 with RA and 185 with other diagnoses. Classifications as RA by the ACR criteria corresponded to our clinical diagnosis in 95% of the cases, corroborating the high sensitivity previously reported. However, we found a lower specificity (73%) than that reported (89%). False positive classifications as RA were found in 71% of patients with psoriatic arthritis, 48% of patients with SLE, and 31% of patients with gout. The specificity could be improved to 89% by excluding disorders with obvious distinguishing extraarticular features such as psoriasis or by SF findings of monosodium urate crystals. Awareness of these possible sources of confusion will further increase the teaching and epidemiologic value of these useful simplified criteria.

Evolución de pacientes con mejor pronóstico en cáncer de mama / Evolution of patients with best prognosis in breast cancer

En una serie de 23 pacientes seguidas durante 4 y 5 años, se pudo constatar una alta correlación entre aquellas con tumores RE+ desplazables y la evolución favorables de su enfermedad (11 de 12 casos - 91 por ciento), así como una correlación entre los tumores RE+ poco desplazables y la evolución desfavorable de la enfermedad (3 de 4 casos - 75 por ciento). Este último grupo se homologa con los tumores RE - cuya evolución fue desfavorable. En esta serie, los tumores RE+ de las pacientes con evolución favorable, presentaron valores de RPg mayores de los RE (10 de 12 casos - 83 por ciento). En las pacientes con tumores RE+ la evolución desfavorable, los valores de RPg no fueron mayores que RE (3 de 4 casos - 75 por ciento). Los estudios anatomo-patológicos indicaron que los tumores RE+ desplazables presentaron mayor proporción de células más diferenciadas que el grupo de tumores RE. Los otros indicadores histológicos examinados: necrosis, desmoplasia, invasión linfocitaria, no mostraron correlación con grado de dependencia hormonal ni con la prueba de desplazamiento por Tam

Evolución de pacientes con mejor pronóstico en cáncer de mama / Evolution of patients with best prognosis in breast cancer

En una serie de 23 pacientes seguidas durante 4 y 5 años, se pudo constatar una alta correlación entre aquellas con tumores RE+ desplazables y la evolución favorables de su enfermedad (11 de 12 casos - 91 por ciento), así como una correlación entre los tumores RE+ poco desplazables y la evolución desfavorable de la enfermedad (3 de 4 casos - 75 por ciento). Este último grupo se homologa con los tumores RE - cuya evolución fue desfavorable. En esta serie, los tumores RE+ de las pacientes con evolución favorable, presentaron valores de RPg mayores de los RE (10 de 12 casos - 83 por ciento). En las pacientes con tumores RE+ la evolución desfavorable, los valores de RPg no fueron mayores que RE (3 de 4 casos - 75 por ciento). Los estudios anatomo-patológicos indicaron que los tumores RE+ desplazables presentaron mayor proporción de células más diferenciadas que el grupo de tumores RE. Los otros indicadores histológicos examinados: necrosis, desmoplasia, invasión linfocitaria, no mostraron correlación con grado de dependencia hormonal ni con la prueba de desplazamiento por Tam

Treatment of the eosinophilia-myalgia syndrome.

The eosinophilia-myalgia syndrome (EMS) is a unique entity associated with products that contain L-tryptophan (L-trp). Studies of the underlying etiopathogenic processes are underway. EMS is a distinct syndrome, but shares features with eosinophilic fasciitis and other variants of systemic sclerosis. A wide spectrum of clinical manifestations has been described, but there is no consensus regarding treatment. We report the clinical and laboratory features of 12 patients. All were treated with nonsteroidal antiinflammatory drugs (NSAIDs) and analgesics with transient or minimal effect. Two received D-penicillamine (DP) and colchicine, with minimal improvement; one had no response to azathioprine (AZA). Eleven received corticosteroids and had improvement of general symptoms, arthralgias, arthritis, myalgias, skin changes, eosinophilia, and leukocytosis. Nevertheless, all but the latter two findings recurred when corticosteroids were tapered. Seven patients who were unresponsive to the former treatments received low-dose pulse oral methotrexate. Six exhibited continued improvement after a mean follow-up of 4.5 months, with good drug tolerance. Corticosteroids were tapered and, in some instances, discontinued without relapse or complications. One patient improved but later died of aspiration pneumonia. We conclude that methotrexate (MTX) is a therapeutic alternative for patients with severe or refractory EMS.

Peripheral arthrocentesis in the work-up of acute low back pain.

Involvement of the axial skeleton in acute gouty arthritis has rarely been reported. Without the presence of peripheral tophi or history of gout, this diagnosis is often not considered. A patient is described with acute low back pain and for whom a diagnosis of acute axial gout was suggested after arthrocentesis of an asymptomatic peripheral joint yielded monosodium urate crystals. Treatment with colchicine led to prompt resolution of the gouty flare. Demonstration of urate crystals in this manner may encourage the clinician to attempt a trial therapy for acute gout, or at least to add gout to the differential diagnosis of acute back pain.

Increased risk for cancer of the breast due to previous medication.

Fifteen patients presenting one or more risk factors for cancer of the breast, who also received medication with prolactin-stimulating effects, were selected. The medication was by hormone derivatives or by non-hormone drugs used for processes other than oncologic . In all cases the medication was for long periods, three or more years, with the exception of one case, where the correlation with the unfavourable evolution of the cancer process was more evident. In patients presenting the classic risk factors for cancer of the breast, it is recommended to avoid the prescription of drugs having a prolactin-stimulating effect. The association of both circumstances (risk factors and prolactin-stimulating medication) is considered as an increased risk for cancer of the breast.

PIP: 15 patients presenting 1 or more risk factors for breast cancer who were also receiving medication with prolactin-stimulating effects were selected for study. The medication was hormone derivatives or nonhormonal drugs used for other than oncologic processes. In all cases, the medication was taken over a long period, 3 or more years, with the exception of 1 patient where the correlation with the unfavorable evolution of cancer was evident. In patients presenting the classic risk factors for breast cancer, it is recommended that drugs with a prolactin-stimulating effect be avoided. The association of both circumstances (risk factors and prolactin-stimulating medication) is considered an increased risk for breast cancer. (author's modified)

Correlation of single and serial CEA determinations with the clinical evolution of cancer patients.

The correlation between CEA results and the clinical evolution of 56 patients with breast and colorectal cancer, was studied. In mammary cancer (41 patients) there was a correspondence of 75% between single initial CEA values and clinical state at the time of the determination. For colorectal cancer patients the correspondence was 80%. A follow up of the patients during 4 years permitted the evaluation of serial CEA results in the prognosis of the disease. Two or more consecutive CEA results with the same significance (increased or normal) correlated better than single values with the clinical evolution of the disease (93% of correspondence). Normal values in patients with active disease were indicative of favourable prognosis; the appearance of single values above normal but below three times the upper normal limit, do not justify changes in the installed therapy. Two or more consecutive increased results are indicative of present or future deterioration of the patient. Cases of non-correspondence between consecutive serial. CEA results and clinical evolution of the patient are considered as "real false results" (7%). Serial CEA determination resulted very useful in the follow up of the oncological patient in the frame of other laboratory and diagnostic means, as a part of the periodic clinical control.