Psychometric properties of Persian version of irritable bowel syndrome- behavioral responses questionnaire (IBS-BRQ).

Aim: This study aimed to determine the psychometric properties of Persian version of Irritable Bowel Syndrome-Behavioral Responses Questionnaire (IBS-BRQ). Background: In addition to somatic symptoms and complaints, patients with irritable bowel syndrome have specific dysfunctional behaviors that lead to disease persistence and functional disturbance. Methods: Participants included 170 patients with irritable bowel syndrome, who were diagnosed based on ROM-IV criteria and selected from patients referring to the Gastrointestinal Disorders Clinic, as well as 100 persons from the general population in Isfahan in 2020. Both groups completed the 26-item Irritable Bowel Syndrome-Behavioral Responses Questionnaire (IBS-BRQ). Also, questionnaires including the Irritable Bowel Syndrome Symptom Severity Scale (IBS-SSS), Irritable Bowel Syndrome-Quality of Life IBS-QOL, Illness Perception Questionnaire (IPQ-R), Irritable Bowel Syndrome-Patient Satisfaction (IBS-SAT), Hope Scale, Interpersonal Forgiveness Inventory (IFI), and Dysfunctional Attitude Scale- 26-item (DAS-26) were completed to determine the validity of IBS-BRQ. Tests of internal consistency, principal components analyses (PCAs), differentiation analysis, and correlation were used to determine its reliability, along with criterion and construct validity. Results: IBS-BRQ was valid and reliable in both groups with a high degree of internal consistency. Cronbach's alpha was obtained in the sample of patients with IBS and the total sample of participants 0.87 and 0.95 respectively. This scale differentiated significantly between IBS patients and non-patients (p<.001). The criterion validity was high as evidenced by a high correlation with DAS-26 (r=0.53, p<0.001), IBS-QOL (r=0.76, p<0.001), IBS-SSS (r=0.44, p<0.001), IPQ-R (r=0.56, p<0.001), and reverse correlation with IFI (r=-0.031, p<0.001), IBS-SAT (r=-0.23, p<0.001), and HOPE (r=-0.49, p<0.001). Conclusion: The Persian version of the IBS-BRQ proved to be a well-defined behavioral response measure in IBS patients with high validity and reliability, making it a suitable measure to be used in future IBS clinical research in Iran.

A two-echelon location routing problem considering sustainability and hybrid open and closed routes under uncertainty.

Location-routing is an extremely important problem in supply chain management. In the location-routing problem, decisions are made about the location of facilities such as distribution centers as well as the set of vehicle routes. Today, organizations seek to reduce the transportation cost by outsourcing leading to a particular kind of transportation problems known as open routing. However, the increasing attention to environment have led to paying more attention to environmental issues and reducing the environmental impacts of logistics activities. To this end, in this paper, both open and closed routes were simultaneously addressed by developing a multi-objective mixed integer linear programming model that included three economic, environmental, and social responsibility aspects. The three objective functions of the proposed model encompass the minimization of total costs and greenhouse gas emissions, and the maximization of employment rate and economic development. Also, in this study, a different type of routing was considered in each echelon. A small-sized problem instance was solved using the Augmented Epsilon Constraint (AEC) method with the CPLEX Optimizer Solver for the validation of the proposed model. Moreover, the sensitivity analysis was performed to investigate the effect of changing main parameters on the values of the objective function. Due to the NP-Hardness of the problem, two efficient metaheuristic algorithms of Non-dominated Sorting Genetic Algorithm (NSGA-II) and Multi-Objective Stochastic Fractal Search (MOSFS) were exploited to solve the medium and large size problems. The performance of the algorithms was compared on the basis of six different well-known indexes of Time, MID, RAS, Diversity, Spacing, and SNS. According to the obtained results, the performance of the MOSFS algorithm was %20, %9, %11.22, %10.03, and %19.06 higher than the performance of the NSGA-II on the basis of SNS, RAS, MID, Diversity, and Time indexes, respectively. On the other hand, the NSGA-II performance was %6.3 higher than the MOSFS performance in terms of Spacing index.

Lymphoscintigraphy in the Time of COVID-19: Effect of Molybdenum-99 Shortage on Feasibility of Sentinel Node Mapping.

Background: In the current study, we reported our experience on sentinel node mapping of breast cancer patients during the extreme shortage of Mo99-Tc99m generators using Tc-99m phytate. Methods and Results: During the period from March 7, 2019, to April 18, 2020, due to disruption of molybdenum supply chain, we used low specific activity Tc-99m pertechnetate elute (0.5-2 mCi of 99mTcO4 in 5 mL) for each kit preparation. Two or three intradermal periareolar injections were done for each patient (0.02-0.1 mCi/0.2 mL for each injection). Immediately following injection, dynamic lymphoscintigraphy was done. Surgery was done the same day of injection and the axillary sentinel node was sought using a gamma probe. Overall, 35 patients were included in the study. The specific activity of the Tc-99m elute (in 5 mL) used for kit preparation was 2 mCi/10 mg in four, 1.5 mCi/10 mg in eight, 1.25 mCi/10 mg in eight, 1 mCi/10 mg in three, 0.75 mCi/10 mg in five, and 0.5 mCi/10 mg of 99mTc-Phytate in seven patients. For the first four groups of patients, we used two 0.2 mL injections, while in the latter two groups, three 0.2 mL injections were used. At least one sentinel node was detected in all patients but three in whom axilla was involved. Conclusion: Sentinel node biopsy can be achieved with low specific activity of Tc-99m elute at the time of Mo99-Tc-99m generator shortage. If special personal protection is used, sentinel node mapping can be done in nuclear medicine departments with excellent results despite the COVID-19 pandemic and disruption of generator shipment.

Idiopathic granulomatous mastitis: Management and predictors of recurrence in 474 patients.

Idiopathic Granulomatous Mastitis (IGM) is an uncommon inflammatory disease of the breast, with similar presentations as breast cancer and a relatively high recurrence rate. We reviewed the demographics, clinical presentations, and treatment modalities of a large cohort of patients in Iran. Most of the patients had history of pregnancy and breastfeeding. The most common clinical finding was pain and a palpable mass, respectively. Most of the patients received medical treatment, and about half of the patients had surgery. The recurrence rate was 24.8%, and breast skin lesions were associated with a significantly higher odds of recurrence.

Novel Biomarkers Aim at Detecting Metastatic Sentinel Lymph Nodes in Breast Cancer

Background: Intra-operative molecular diagnostic assays are currently used for the detection of lymph node metastases. The objective of this study was to find new biomarkers to improve diagnostic accuracy in the detection of metastatic axillary lymph nodes in breast cancer patients. Methods: We applied an absolute quantitative real-time reverse transcription-PCR to quantitate the expression of CK19, KLK11, and CLEC3A mRNAs in 79 FFPE sentinel lymph nodes (SLNs) from 35 breast cancer patients. The CK19 was confirmed as a standard biomarker, and the level of expression of selected new markers, KLK11 and CLEC3A, was evaluated in pathologically negative and positive SLNs by using absolute quantitative real-time PCR. Results: The overall concordance of the CK19 gene with pathological results was 92.4% (less than 250 copies) in negative SLNs and 85% in positive SLNs (more than 250 copies). The sensitivity and specificity of CK19, which were detected by real-time PCR, was 85% and 46%, respectively. Our results revealed that lower CLEC3A was associated with more lymph node involvement. We could set a cut-off point for CLEC3A with the sensitivity of 78% and specificity of 60%. Also, the mean KLK11 had a statistically significant reverse correlation with tumor grade (p = 0.017). Higher CK19 levels were related to more tumor invasion (p < 0.0001). Conclusion: Regarding the findings, CLEC3A along with CK19 can be used as a promising marker with high sensitivity and specificity for the detection of metastatic SLN.

Measurement of the serum levels of serum troponins I and T, albumin and C-Reactive protein in chronic hemodialysis patients and their relationship with left ventricular hypertrophy and heart failure.

BACKGROUND: Hemodialysis patients are at high risk for cardiovascular diseases. The prognostic value of cardiac troponins, albumin and CRP in hemodialysis patients and their association with cardiac diseases has been proven. The aim of this study was to investigate the relationship between these factors and heart failure and left ventricular hypertrophy in hemodialysis patients in Sanandaj city. METHODS: A total of 90 hemodialysis patients referred to hemodialysis ward of Tohid Medical Center of Sanandaj were enrolled in the study. After receiving the required information from patients and recording them in questionnaire, blood samples were taken from them and were sen to Lab for Measurement. Finally, the data were analyzed using SPSS software and Spearman correlation coefficient for independent variables and Chi square test and correlation coefficient of Choprovert's for independent qualitative variable. RESULTS: In the case of LVH, 23.3% of patients were with normal thickness, 38.9% had mild LVH, 30% had moderate LVH and 7.8% had severe LVH. The mean serum albumin level in patients was 3.8 g/dl, CRP 9.4 mg/dL, and troponins I and T were 0.4 and 685.06 ng/dL, respectively. There was a statistically significant relationship between cardiac I and T troponins levels and CRP levels in patients with chronic hemodialysis (P < 0.05. There was a significant relationship between serum albumin level, troponins I, T and CRP with left ventricular hypertrophy in chronic hemodialysis patients (P < 0.05). CONCLUSION: Serum levels of I and T troponins, albumin, as well as CRP, are related to heart failure and left ventricular hypertrophy in hemodialysis patients, and this can be used by physicians to determine the patient's ability and risk of disease Cardiovascular diseases.

Sustainable location and route planning with GIS for waste sorting centers, case study: Kerman, Iran.

One of the important issues in the world is the significant growth of waste production, including waste that is not biodegradable in nature. According to the Kerman Municipality, 440 tonnes of municipal waste is collected daily in Kerman consisting of five major parts of paper, plastic, metal, glass, and wet waste. The major problems of municipal solid waste disposal are soil erosion, air pollution, and greenhouse gas emissions. The most important factors related to recycling are waste sorting and the relevant environmental conditions. This study aims to create a sustainable approach by locating the optimal sites to reduce environmental pollution, decrease costs, and improve the service system to the society. Optimal locations for establishing the collecting and sorting centers in the city are specified by the use of geographic information system software, based on criteria consisting of population density, road network, distance to health centers, distance to disposal center, waste sorting culture, land space, and land cost, which were weighted by an analytical hierarchy process. It was noteworthy that the criterion "waste sorting culture", which has a foundation in human sciences and sociology, has been considered by experts in this study to be of the highest importance among other criteria at locating sorting centers. Subsequently, using a symmetric capacitated vehicle routing problem, the number and capacity of each vehicle are determined to serve the specified locations according to the economic, social, and environmental constraints.

Assessment of Ultrasound / Radio-guided Occult Lesion Localization in Non-palpable Breast Lesions.

OBJECTIVES: Controversy exists about the localization of non-palpable breast lesions. In many countries, the gold standard for the diagnosis of these lesions is needle localization due to its accuracy. This study sought to compare the ultrasound- and radio-guided occult lesion localization (ROLL) as a simple method with the conventional procedures in terms of their diagnostic power. METHODS: This study was conducted on 94 patients with non-palpable breast lesions detected by ultrasonography and localized by the combination of ultrasonography and using radiopharmaceuticals. One to ten hours prior to surgery, 0.1-0.2 ml (equivalent to 0.5-1 mCi) of Tc-99m-phytate was injected to the lesion under the guidance of ultrasonography. Then, the lesion was localized using a hand-held gamma probe, and excision of the lesion was performed according to its radioactivity signal. Data analysis was performed using SPSS, version 16. RESULTS: Benign and malignant pathologic results were observed in 77 (81.9%) and 17(18.1%) of the patients, respectively, and the mean volume of the excised tissue was 26.29±27 mm³. 79 patients had a solitary lesion (84%), 55 in the left breast (58.5%) and 39 in superolateral quadrant (41.5%). The mean size of the lesions was 15.7 mm in diameter (ranging from 4 to 34 mm). Additionally, there was a need to secondary surgery in 3 (3.2%) patients and inappropriate localization in 6 (6.4%) patients (subcutaneous or intra-ductal spread of radiodrug). CONCLUSION: Combination of ultrasound- and radio-guided localization methods for localizing non-palpable breast lesions is a simple and acceptable method for localization with no significant complications. For radio-drug spread and subsequent excessive excised tissue volume, subcutaneous and intra-ductal lesions are not suitable indication for ROLL.

EGFR Expression in Patients with Esophageal Squamous Cell Carcinoma and its Association with Pathologic Response to Preoperative Chemoradiotherapy: A Study in Northeastern Iran.

INTRODUCTION: Esophageal squamous cell carcinoma (ESCC) accounts for 80% of all esophageal cancers worldwide. It is the most common histological type of esophageal carcinoma in low-resource countries. ESCC is prevalent in Asian countries, accounting for more than 95% of esophageal cancers. The epidermal growth factor receptor (EGFR) is involved in cancer development, as its gene is often mutated and/or amplified in cancer cells. According to recent statistics, esophageal cancer is the eighth most common cancer in Iran. METHODS: In this retrospective study, we assessed EGFR overexpression, using immunohistochemistry (IHC) in 68 patients with ESCC, undergoing neoadjuvant chemoradiotherapy and esophagectomy in 2011-2014. The treatment protocol included external beam radiotherapy (40 Gy), concomitant with cisplatin 20mg/m2 and 5- fluorouracil (5-FU) 1000 mg/m2 for 4 consecutive days during the first and fourth weeks of treatment. To compare the two groups (EGFR positive and negative) in terms of complete pathologic response, Chi-square test was performed using SPSS version 16. RESULTS: The median age of the patients was 59 years (range: 27-70 years), with a female-to-male ratio of 1.06. Overall, 70% of the subjects showed EGFR overexpression. Complete pathologic response to neoadjuvant treatment was significantly higher in EGFR-positive patients (40% vs. 15.8%, P = 0.05). In all cases, 1- and 3-year overall survival rates were 86.6% ± 4.1 and 48% ± 6.9, respectively. The 1- and 3-year disease free survival rates were calculated as 71.8% ± 5.4 and 44.3% ± 6.5, respectively. The overall survival rate was relatively higher in cases with EGFR overexpression, although the difference was not statistically significant (5-year survival rate: 47.9 ± 8.2 vs. 30.9 ± 13, P = 0.23). CONCLUSION: EGFR overexpression was reported in the majority of patients with ESCC in northeastern Iran. Moreover, EGFR overexpression was significantly associated with complete pathologic response.

A clinical trial of neoadjuvant concurrent chemoradiotherapy followed by resection for esophageal carcinoma.

BACKGROUND: Esophageal carcinoma is a common malignancy in the North East of Iran. Combined modality treatments have been adopted to improve survival in patients with esophageal carcinoma. In this trial, we evaluated the efficacy and toxicity of a preoperative concurrent chemoradiotherapy protocol in the patients with locally advanced esophageal carcinoma. MATERIALS AND METHODS: Between 2006 and 2011, eligible patients with locally advanced esophageal carcinoma underwent concurrent radiotherapy and chemotherapy and 3-4 weeks later, esophagectomy. Pathologic response, overall survival rate, toxicity, and feasibility were evaluated. RESULTS: One hundred ninety-seven patients with a median age of 59 (range: 27-70) entered the protocol. One hundred ninety-four cases (98.5%) had esophageal squamous cell carcinoma. Grades 3-4 of toxicity in patients undergoing neoadjuvant chemoradotherapy were as follows: Neutropenia in 21% and esophagitis in 2.5% of cases. There were 11 (5.6%) early death probably due to the treatment-related toxicities. One hundred twenty-seven patients underwent surgery with postsurgical mortality of 11%. In these cases, the complete pathological response was shown in 38 cases (29.9%) with a 5-year overall survival rates of 48.2% and median overall survival of 44 months (95% confidence interval, 24.46-63.54). CONCLUSION: The pathological response rate and the overall survival rate are promising in patients who completed the protocol as receiving at least one cycle of chemotherapy. However, the treatment toxicities were relatively high.

Can methylene blue dye be used as an alternative to patent blue dye to find the sentinel lymph node in breast cancer surgery?

BACKGROUND: Sentinel lymph node biopsy (SLNB) is standard care to evaluate axillary involvement in early breast cancer. It has fewer complications than complete lymph node dissection; however, using blue dye in SLNB is controversial. We have evaluated the detection rate and local complications associated with methylene blue dye (MBD) used in SLNB in early breast cancer patients and compared these results to patent blue dye (PBD). MATERIALS AND METHODS: In a cohort prospective study, 312 patients with early breast cancer without axillary lymph node involvement were divided into two groups according to dye type. All of the patients received radiotracer and one type of blue dye. We filled out a checklist for the patients that contained demographic data, size of tumor, stage, detection of sentinel lymph node, and complications and then analyzed the data. RESULTS: Demographic and histopathologic characteristics were not significantly different in both groups. Mean (standard deviation [SD]) tumor size in all patients was 2.4 (0.8) cm. Detection rate in the MBD group was 77.5% with dye alone and 94.2% with dye and radioisotope; and in the PBD group it was 80.1% and 92.9% respectively (P > 0.05). We had blue discoloration of the skin in 23.7% in the PBD and 14.1% in the MBD group (P < 0.05) local inflammation was detected in one patient in the PBD and five in the MBD group (P < 0.05). Skin necrosis and systemic complications were not observed. CONCLUSION: Methylene blue has an acceptable detection rate, which may be a good alternative in SLNB. Complication such as blue discoloration of the skin was also lower with MBD.

Diagnostic value of 99mTc-bombesin scintigraphy for differentiation of malignant from benign breast lesions.

OBJECTIVE: In this study, we evaluated the diagnostic accuracy of (99m)Tc-bombesin scintigraphy for differentiation of benign from malignant palpable breast lesions. (99m)Tc-Bombesin is a tracer with high affinity for gastrin-releasing peptide receptor, which is overexpressed on a variety of human tumors including breast carcinoma. MATERIALS AND METHODS: We examined 33 consecutive women who were referred to our center with suspicious palpable breast lesions but had no definitive diagnosis in other imaging procedures. A volume of 370-444 MBq of (99m)Tc-bombesin was injected and dynamic 1-min images were taken for 20 min immediately after injection in anterior view. Thereafter, two static images in anterior and prone-lateral views were taken for 5 min. Finally, single-photon emission computed tomography images were taken for each patient. Definitive diagnosis was based on biopsy and histopathological evaluation. RESULTS: The scan findings were positive in 19 patients and negative in 11 on visual assessment of the planar and single-photon emission computed tomography images. Pathologic examination confirmed breast carcinoma in 12 patients with positive scans and benign pathology for 18 patients. The overall sensitivity, specificity, negative and positive predictive values, and accuracy of this radiotracer for diagnosis of breast cancer were 100, 66.1, 100, 63, and 76%, respectively. Semiquantitative analysis improved the specificity of the visual assessment from 66 to 84%. CONCLUSION: Our study showed that (99m)Tc-bombesin scintigraphy has a high sensitivity and negative predictive value for detecting malignant breast lesions, but the specificity and positive predictive value of this radiotracer for differentiation of malignant breast abnormalities from benign ones are relatively low.

Efficacy of high-energy collimator for sentinel node lymphoscintigraphy of early breast cancer patients.

INTRODUCTION: Lymphoscintigraphy is an important part of sentinel node mapping in breast cancer patients. Sometimes star shaped artefacts due to septal penetration can be problematic during imaging. In the current study, we evaluated the possibility of high energy (HE) collimators use for lymphoscintigraphy. PATIENTS AND METHODS: Twenty patients with early breast carcinoma were included. Thirty minutes after radiotracer injection (99mTc-antimony sulphide colloid), anterior and lateral images were acquired using a dual head gamma camera equipped with a parallel hole low energy high resolution (LEHR) collimator on one head and HE collimator on another head. All images were reviewed by two nuclear medicine specialists regarding detectability and number of axillary sentinel nodes and presence of star artefact. RESULTS: All images taken by LEHR collimators showed star artefact of the injection site. No image taken by HE collimator showed this effect. In two patients the sentinel node was visible only by HE collimator. Tumour location in both of these patients was in the upper lateral quadrant and both had history of excisional biopsy. In two patients additional sentinel node was visible adjacent to the first one only on the LEHR images. CONCLUSIONS: HE collimators can be used for sentinel lymph node mapping and lymphoscintigraphy of the breast cancer patients. This collimator can almost eliminate star-shaped artefacts due to septal penetration which can be advantageous in some cases. However, to separate two adjacent sentinel nodes from each other LEHR collimators perform better.

Expression of A1 and A3 adenosine receptors in human breast tumors.

BACKGROUND: Adenosine receptors (A1, A2A, A2B, A3) play an important role in the regulation of growth, proliferation and death of cancer and normal cells. We recently showed the expression profile of A2A and A2B receptors in normal and tumor breast tissues. In the present study, we used semiquantitative RT-PCR to measure the A1 and A3 gene expression levels in normal and tumor breast tissues. METHODS: Breast tumors (n = 18) and non-neoplastic mammary tissues (n = 10) were collected and histologically confirmed to be neoplastic or non-neoplastic, respectively. Total RNA was extracted and reverse transcribed into cDNA, and PCR was performed under optimized condition for each receptor subtype. Amplification of beta-actin mRNA served as control for RT-PCR. The PCR products were separated on 1.7% agarose gels. The intensity of the bands was quantitated with ImageJ software after normalization against beta-actin expression. RESULTS: All breast tumor and normal tissue specimens expressed A1 and A3 adenosine receptor transcripts. However, we observed that the expression level of the A3 receptor in tumor tissues was 1.27-fold that of normal tissues, whereas there was no significant difference between the expression levels of A1 in normal and tumor tissues. CONCLUSIONS: Interestingly, the results of the present study indicate that breast tumors exhibit a higher level of A3 transcripts (than normal tissues) and support the possible key role of A3 adenosine receptor in tumor development. However, further studies based on real-time quantitative RT-PCR are needed to identify the exact gene expression levels.

Prevalence of occult metastases in axillary sentinel lymph nodes of breast carcinoma.

Recently, sentinel lymph node biopsy (SLNB) has been accepted as a standard method of assessment of axillary lymph nodes in breast cancer patients with no clinical lymphadenopathy. There is no standard pathologic method to evaluate sentinel lymph nodes. The purpose of this study is to evaluate the frequency of occult lymph node metastasis in sentinel lymph nodes via serial sectioning and immunohistochemical study with cytokeratin and its relationship with other clinicopathologic factors. Paraffin-embedded blocks of axillary sentinel lymph nodes of breast cancer patients, biopsied in 2005-2009 and reported as negative, were reviewed with 3 µm sections, H and E staining and immunohistochemical study with an epithelial cytokeratin marker. Clinicopathologic data and relapse, if occurred was recorded and its relationship with occult metastasis was statistically analyzed. Sixty-eight sentinel pathology blocks of 66 patients (65 women and one man, median age 49 years) were investigated. Four cases (5.8%) of occult metastases were found, one by HE staining, and three cases with IHC (1 micrometastasis, 2 isolated tumor cells). Accuracy of reported cases was 94.1% upon re-examination. Sixty-four patients were followed after surgery and adjuvant therapy (range: 6-38 months, median: 21 months). No relapse was reported. There was no significant statistical relationship between occult metastasis and disease-free survival. Although 4 cases (5.8%) of sentinel lymph nodes were positive in the complementary study, with a median follow-up of 21 months, we found no difference in disease-free survival between these patients and others. To show a significant, however small, difference, one needs further research with a greater number of patients and longer follow-up.

Comparison between one day and two days protocols for sentinel node mapping of breast cancer patients.

Sentinel node biopsy can decrease the morbidity of breast cancer treatment significantly by sparing many patients of axillary lymph node dissection and resulting arm lymphedema. Despite widespread use of sentinel node mapping for breast cancer patients almost all aspects of this procedure are controversial; such as: type of the radiotracer, eligibility, time of injection, etc. One of these controversial issues is the efficacy of 2 days protocol (injection of the tracer on one day and sentinel node mapping and surgery on the following day). The main reason to perform 2 days protocol is the ease of operation room scheduling the patient does not need to complete injection and imaging in the nuclear medicine department. Despite widespread use of 2 days protocol for sentinel node mapping, very few studies have specifically evaluated this protocol in comparison to 1 day protocol and also the false negative rate which is the better index of sentinel node mapping success. Most of the above studies used tracers with large particle size such as (99m)Tc-sulfur colloid. Tracers with small particle size can theoretically be washed out from the real sentinel nodes and move to the second echelon nodes, so some recommended using large particle size radiotracers for the 2 days protocol. In this study, we compared the false negative rate of sentinel node mapping between 1 and 2 days protocols using intradermal injection of (99m)Tc-antimony sulfide colloid ((99m)Tc-SbSC) which has very small particle size. Eighty patients with early stage breast cancer (clinical stages of I and II) were evaluated. The diagnosis of the breast cancer was established by either excisional or core needle biopsy. The patients didn't take any chemotherapeutic drug before surgery and were divided into two groups: 1 day (Group I) and 2 days (Group II) protocols (45 in Group I and 35 in Group II). For Group I, periareolar intradermal injections of 0.5Bq/0.2mL (99m)Tc-SbSC were applied for patients without previous excisional biopsy. For patients with excisional biopsy two intradermal injections of 0.5Bq/0.2mL (99m)Tc-SbSC were used on both sides of the incision line. All injections were followed by gentle massage for 1min. For Group II, the same injection techniques were used but the dose of the tracer was doubled. Anterior, and lateral spot views were acquired 30min after the injection (5min/image, 128Χ128 matrix) using a dual head gamma camera (E.CAM Siemens) and parallel hole low energy high resolution collimator. The operation was performed 4h (for Group I) or 20h (for Group II) post radiotracer injection. All patients received 2mL patent blue V dye in a subdermal and periareolar fashion, 2min after general anesthesia. A surgical gamma probe (EUROPROBE, France) was used for harvesting the sentinel lymph nodes during surgery. As sentinel node was defined any blue node or any node with an ex vivo radioisotope count of twofold or greater than the axillary background. After completion of sentinel node biopsy, all patients underwent standard axillary lymph node dissection. The study was approved by our local ethical committee and all patients gave their informed consent before inclusion into the study. Quantitative data were expressed as mean±SD. For comparison between groups, independent sample student's t-test for quantitative variables, and chi-square or Fisher's exact tests for categorical variables were used. P-values less than 0.05 were considered statistically significant. SPSS version 11.5 was used for statistical analyses. The patients characteristics are shown in Table I. These general characteristics were not significantly different between the study groups (P>0.05). Detection rate was 100% for both Groups. The median number of sentinel nodes in both Groups was one sentinel node. The mean number of detected sentinel nodes during surgery was not statistically different between groups (1.28±0.7 and 1.32±0.6 for Group I and II respectively). One false negative sentinel node case with positive axillary nodes after dissection was found in both groups. This amounts to 6.25% and 6.66% false negative rate for Group I and II patients respectively. During surgery mean count rate at the injection site was 243123±22134 and 29430±2125 for Groups I and II, respectively. Mean count rate at the sentinel nodes was 4345±457 and 2375±356 for Groups I and II, respectively. Although the mean count rate at the injection site and the sentinel nodes were both higher in Group I of the study compared to Group II (P<0.0001 for both), the mean ratio of sentinel to injection site was statistically higher in Group II (P<0.0001). The 2 days protocol allows that the required lymphoscintigraphy imaging (including delayed views) can be performed before and during operation without any time limits. Most studies have reported similar to ours detection or false negative rates for both protocols. Our study showed comparable mean number of harvested sentinel nodes by the two protocols which is against the hypothesis of moving the tracer to other sentinel nodes by time. Others had similar results. The count rate of the sentinel nodes during surgery was statistically acceptable. Similar results have been reported by others too. Although we didn't evaluate radiation exposure in our study, this was acceptable in other studies and Buscombe et al showed a maximum effective dose of 2.6µSv/MBq for these patients and even assuming this highest value the patient exposure was very low compared to many other procedures. In conclusion, two days protocol gives the sentinel node biopsy team considerable flexibility and lymphoscintigrpahy imaging can be completed before surgery. Finding of the axillary sentinel node during surgery is also being easier. False negative rates as well as the detection rate for one day and two days protocols are comparable.

Effect of adding levamisole on seroconversion response to hepatitis B virus vaccination in hemodialysis patients: a single-center experience.

INTRODUCTION: Hepatitis B virus (HBV) infection is much more common in hemodialysis patients than the general population. Up to half of hemodialysis patients do not have adequate protective HBV antibodies after HBV vaccination. We studied the effects of adding levamisole, as an immunomodulator and adjuvant agent, on seroconversion response to HBV vaccination in hemodialysis patients. MATERIALS AND METHODS: Thirty-six hemodialysis patients were divided into 2 groups. The first group received 40 microg of HBV vaccine intramuscularly at 0, 1, and 6 months plus 100 mg of oral levamisole per day for 12 days. The second group received the same amount and method of vaccine and placebo. Serum antibody levels were measured in each group after 0, 2, and 4 months after the last dose of vaccination. RESULTS: Anti-HBV antibody level in the patients who received levamisole was lower than that in the control group. Antibody levels in the levamisole group at 0, 2, and 4 months after the last dose of vaccination were 44.4%, 77.8%, and 77.7%, respectively. In the control group, response rates at 0, 2, and 4 months were 55.6%, 72.2%, and 77.8% respectively (P = .04, P = .12, and P = .08, respectively). CONCLUSIONS: Anti-HBV antibody level was significantly lower immediately after HBV vaccination when it was accompanied by levamisole administration. However, no significant differences were observed between the two groups at 2 and 4 months. Further evaluation is recommended to assess the effect of adding levamisole on Hepatitis B surface antibody titer in hemodialysis patients.

Factors influencing the time of sentinel node visualization in breast cancer patients using intradermal injection of the radiotracer.

BACKGROUND: The objective of our study was to determine the important factors that have influence on the time of sentinel node visualization using intradermal injection of (99m)Tc-antimony sulfide colloid. METHODS: Two hundred fifty consecutive patients with the diagnosis of early-stage breast cancer were evaluated. Anterior and lateral views were acquired in various intervals after intradermal injection of the tracer until 180 minutes or visualization of the sentinel node. The effect of several variables on the time of sentinel node visualization was evaluated by univariate and multivariate analyses. RESULTS: The time of sentinel node visualization was significantly correlated with age, body mass index (BMI), and interval between biopsy and sentinel node mapping. Standardized beta values for these variables were .1, .3, -.55 respectively. CONCLUSIONS: Older age and higher BMI can result in slow sentinel node visualization. Longer interval between biopsy and sentinel node mapping can be associated with rapid sentinel node detection.