HER-2/neu (c-erbB-2) evaluation in primary breast carcinoma by fluorescent in situ hybridization and immunohistochemistry with special focus on intratumor heterogeneity and comparison of invasive and in situ components.

We have studied the intratumor HER-2/neu heterogeneity in 78 consecutive and population-based primary invasive breast carcinomas. Within the invasive component, heterogeneity was detected in only 1 of 78 tumors. In 48 tumors (62%), we found both in situ and invasive components in analyzed tissue sections. Twelve of these 48 tumors had a difference of at least 2 arbitrary units in the in situ compared with the invasive part of the tumor with regard to the HER-2/neu status analyzed by HercepTest (immunohistochemistry). Eight of these 12 tumors were reanalyzed with fluorescent in situ hybridization and immunohistochemistry with and without a new Automated Cellular Imaging System. In this limited material, immunohistochemistry in combination with the Automated Cellular Imaging System seemed to have a better correlation with fluorescent in situ hybridization than immunostaining analyzed manually. In conclusion, HER-2/neu expression is not seldom heterogeneous in invasive compared with in situ components within a tumor. This finding should be considered in the choice of evaluation method. To avoid heterogeneity as a confounding factor in HER-2/neu analyses, detection methods such as immunohistochemistry and fluorescent in situ hybridization, which can provide evaluation in a preserved tissue architecture, should be used. Perhaps the intratumor HER-2/neu heterogeneity can explain some of the unexpected failures of trastuzumab therapy.     

The consensus is clearly needed for the definition of stress hyperglycaemia in acute myocardial infarction.

We enjoyed reading the article of Bauters et al.¹ about newrelation of stress hyperglycaemia with left ventricular remodelling.Stress hyperglycaemia has been proved to be the independentprognostic marker of worse outcome     

Video-enhanced visualization of the larynx and intubation with the Bullard laryngoscope — equipment report

PURPOSE: A simple technical solution is presented to provide video transmission from the tip of a Bullard laryngoscope to a bedside video display, while the operator is still able to look through the viewing ocular of the Bullard laryngoscope during tracheal intubation. EQUIPMENT: This is achieved by insertion of an ultrathin fibreoptic video-endoscopic system into the working channel of the Bullard laryngoscope. Thereby the view from the distal blade tip is transmitted to a bedside monitor, without interfering with the use of the Bullards laryngoscope's original eyepiece. The presented technical solution allows video transmission without considerable additional weight normally associated with attaching video endoscopy cameras, light and camera cables to endoscopic devices. Thus, the Bullard laryngoscope remains lightweight and easy to maneuver. A screw-threaded adapter with a side-port is proposed to prevent displacement of the fibreoptic cable while still allowing application of oxygen. CONCLUSION: Experience and skills with tracheal intubation using the presented video-enhanced Bullard laryngoscope can be achieved in the originally intended way, while the supervisor or attending viewers can follow the tracheal intubation procedure on the video display.     

Influence of Gas Composition on Recurrence of Atelectasis after a Reexpansion Maneuver during General Anesthesia

Background: Atelectasis, an important cause of impaired gas exchange during general anesthesia, may be eliminated by a vital capacity maneuver. However, it is not clear whether such a maneuver will have a sustained effect. The aim of this study was to determine the impact of gas composition on reappearance of atelectasis and impairment of gas exchange after a vital capacity maneuver.

Methods: A consecutive sample of 12 adults with healthy lungs who were scheduled for elective surgery were studied. Thirty minutes after induction of anesthesia with fentanyl and propofol, the lungs were hyperinflated manually up to an airway pressure of 40 cmH2 O. FI sub O2 was either kept at 0.4 (group 1, n = 6) or changed to 1.0 (group 2, n = 6) during the recruitment maneuver. Atelectasis was assessed by computed tomography. The amount of dense areas was measured at end-expiration in a transverse plane at the base of the lungs. The ventilation-perfusion distributions (V with dot A/Q with dot) were estimated with the multiple inert gas elimination technique. The static compliance of the total respiratory system (Crs) was measured with the flow interruption technique.

Results: In group 1 (FIO2 = 0.4), the recruitment maneuver virtually eliminated atelectasis for at least 40 min, reduced shunt (V with dot A/Q with dot < 0.005), and increased at the same time the relative perfusion to poorly ventilated lung units (0.005 < V with dot A/Q with dot < 0.1; mean values are given). The arterial oxygen tension (PaO2) increased from 137 mmHg (18.3 kPa) to 163 mmHg (21.7 kPa; before and 40 min after recruitment, respectively; P = 0.028). In contrast to these findings, atelectasis recurred within 5 min after recruitment in group 2 (FIO2 = 1.0). Comparing the values before and 40 min after recruitment, all parameters of V with dot A/Q with dot were unchanged. In both groups, Crs increased from 57.1/55.0 ml *symbol* cmH2 O sup -1 (group 1/group 2) before to 70.1/67.4 ml *symbol* cmH2 O sup -1 after the recruitment maneuver. Crs showed as low decrease thereafter (40 min after recruitment: 61.4/60.0 ml *symbol* cmH2 O sup -1), with no difference between the two groups.     

Resting metabolic rate and the influence of the pretesting environment.

We examined the effect of pretesting environment on measurement of resting metabolic rate (RMR). RMR was measured in 18 older (66.1 +/- 1.4 y) individuals after an overnight stay in the Clinical Research Center (ie, inpatient) and after subjects transported themselves to the laboratory (ie, outpatient). Similar measurements were also performed after an 8-wk endurance-training program. RMR was higher (P less than 0.01) before exercise training in subjects who transported themselves to the laboratory (ie, outpatients; 4.9 +/- 0.13 kJ/min) than in inpatients (4.6 +/- 0.13 kJ/min) and after exercise training in outpatients (5.4 +/- 0.08 kJ/min) vs inpatients (5.0 +/- 0.13 kJ/min). Training increased RMR under both inpatient (10%; P less than 0.01) and outpatient (11%; P less than 0.01) conditions. We conclude that RMR is higher when measured under outpatient conditions in older volunteers. Therefore, when daily energy requirements based on the assessment of RMR are being estimated, the pretesting environment should be considered. However, the exercise-training-induced increase in RMR can be detected by using either an inpatient or an outpatient protocol.