Clinicopathologic features,patterns of recurrence,and survival among women with triple‐negative breast cancer in the National Comprehensive Cancer Network

BACKGROUND:

The objective of this study was to describe clinicopathologic features, patterns of recurrence, and survival according to breast cancer subtype with a focus on triple‐negative tumors.

METHODS:

In total, 15,204 women were evaluated who presented to National Comprehensive Cancer Network centers with stage I through III breast cancer between January 2000 and December 2006. Tumors were classified as positive for estrogen receptor (ER) and/or progesterone receptor (PR) (hormone receptor [HR]‐positive) and negative for human epidermal growth factor receptor 2 (HER2); positive for HER2 and any ER or PR status (HER2‐positive); or negative for ER, PR, and HER2 (triple‐negative).

RESULTS:

Subtype distribution was triple‐negative in 17% of women (n = 2569), HER2‐positive in 17% of women (n = 2602), and HR‐positive/HER2‐negative in 66% of women (n = 10,033). The triple‐negative subtype was more frequent in African Americans compared with Caucasians (adjusted odds ratio, 1.98; P < .0001). Premenopausal women, but not postmenopausal women, with high body mass index had an increased likelihood of having the triple‐negative subtype (P = .02). Women with triple‐negative cancers were less likely to present on the basis of an abnormal screening mammogram (29% vs 48%; P < .0001) and were more likely to present with higher tumor classification, but they were less likely to have lymph node involvement. Relative to HR‐positive/HER2‐negative tumors, triple‐negative tumors were associated with a greater risk of brain or lung metastases; and women with triple‐negative tumors had worse breast cancer‐specific and overall survival, even after adjusting for age, disease stage, race, tumor grade, and receipt of adjuvant chemotherapy (overall survival: adjusted hazard ratio, 2.72; 95% confidence interval, 2.39‐3.10; P < .0001). The difference in the risk of death by subtype was most dramatic within the first 2 years after diagnosis (overall survival for 0‐2 years: OR, 6.10; 95% confidence interval, 4.81‐7.74).

CONCLUSIONS:

Triple‐negative tumors were associated with unique risk factors and worse outcomes compared with HR‐positive/HER2‐negative tumors. Cancer 2012. © 2012 American Cancer Society.     

Antimicrobials in dermatologic surgery: Facts and controversies

The two main uses of antimicrobials in dermatologic surgery include prophylaxis for bacteremia and prevention of localized surgical skin infection (LSSI). Bacteremia can result in hematogenous surgical infections such as infective endocarditis and prosthetic joint infection. Comprehensive guidelines from the American Heart Society (AHA), American Dental Association (ADA), and the American Academy of Orthopedic Surgeons (AAOS) have significantly reduced the number of patients in which prophylaxis is indicated for hematogenous surgical infection. The use of antimicrobials for localized surgical skin infection in dermatology is controversial. Although the overall trend in the literature supports the decreased use of antimicrobials in dermatologic surgery as a whole, it is important to know which situations still warrant antibiotics. This contribution will address the updated guidelines of the AHA, ADA, and AAOS, evidence-based techniques to decrease localized surgical skin infections, and situations in which antibiotics should be considered during dermatologic surgery.     

Fractures among long‐term survivors of childhood cancer

BACKGROUND:

Although reductions in bone mineral density are well documented among children during treatment for cancer and among childhood cancer survivors, little is known about the long‐term risk of fracture. The objective of this study was to ascertain the prevalence of and risk factors for fractures among individuals participating in the Childhood Cancer Survivor Study (CCSS).

METHODS:

Analyses included 7414 ≥5‐year survivors of childhood cancer diagnosed between 1970 and 1986 who completed the 2007 CCSS follow‐up questionnaire and a comparison group of 2374 siblings. Generalized linear models stratified by sex were used to compare the prevalence of reported fractures between survivors and siblings.

RESULTS:

The median ages at follow‐up among survivors and siblings were 36.2 years (range, 21.2‐58.8 years) and 38.1 years (range, 18.4‐62.6 years), respectively, with a median 22.7 years of follow‐up after cancer diagnosis for survivors. Approximately 35% of survivors and 39% of siblings reported ≥1 fracture during their lifetime. The prevalence of fractures was lower among survivors than among siblings, both in males (prevalence ratio, 0.87; 95% confidence interval, 0.81‐0.94; P < .001) and females (prevalence ratio, 0.94; 95% confidence interval, 0.86‐1.04; P = .22). In multivariable analyses, increasing age at follow‐up, white race, methotrexate treatment, and balance difficulties were associated with increased prevalence of fractures among female survivors (P = .015). Among males, only smoking history and white race were associated with an increased prevalence of fracture (P < .001).

CONCLUSIONS:

Findings from this study indicated that the prevalence of fractures among adult survivors did not increase compared with that of siblings. Additional studies of bone health among aging female cancer survivors may be warranted. Cancer 2012. © 2012 American Cancer Society.     

A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes

OBJECTIVES: To study the feasibility and effectiveness of a discharge planning intervention.
DESIGN: Quasi-experimental pre–post study design.
SETTING: General medicine wards at three hospitals: an academic medical center, a community teaching hospital, and a community-based nonteaching hospital.
PARTICIPANTS: All patients aged 65 and older admitted to the hospitalist services.
INTERVENTION: The intervention toolkit had five core elements: admission form with geriatric cues, facsimile to the primary care provider, interdisciplinary worksheet to identify barriers to discharge, pharmacist–physician collaborative medication reconciliation, and predischarge planning appointments.
MEASUREMENTS: Thirty-day readmission and return to emergency department rates and patient satisfaction with discharge. Odds ratios were determined, and site effects were examined accordig to interaction terms and Breslow Day statistics.
RESULTS: Two hundred thirty-seven patients were followed during the preintervention period, and 185 were exposed to the intervention. Patients characteristics were similar across the two time periods. The proportion of patients with high-quality transitions home, measured according to Coleman's Care Transition Measures, increased from 68% to 89% (odds ratio (OR)=3.49, 95% confidence interval (CI)=2.06–5.92). Return to the emergency department within 3 days of discharge was lower in the intervention period (10% vs 3%, OR=0.25, 95% CI=0.10–0.62). At 30 days, there was a lower rate of readmission (22% vs 14%, OR=0.59, 95% CI=0.34–0.97) and fewer visits to the emergency department (21% vs 14%, OR=0.61, 95% CI=0.36–1.03) ( P =.06).
CONCLUSION: When hospitalized elderly patients are treated with consideration of their specific needs, healthcare outcomes can be improved.     

Influence of visual cues on gait in Parkinson's disease: contribution to attention or sensory dependence?

Sensory cueing is used for a long time to improve gait in patients with Parkinson's disease. This has been established for visual cues such as stripes on floor and for rhythmic auditory cues. Concerning visual cueing two main mechanisms of action have been suggested and may be suitable depending on the instruction given to the patients. Stripes placed on the walking surface may draw attention to the stepping process if patients are talked to put their feet on the stripes. In another paradigm, the stripes on floor are just used to enhance the optical flow and the motion of the stripes is essential to improve gait. These findings are not found in normal controls suggesting that patients with Parkinson's disease are more dependent on dynamic visual cues for gait control than controls. Several common characteristics exist between attention and sensory contribution in gait control. First, their potential beneficial effect may be contre-balanced by a negative influence: visual information may be helpful for gait in patients or may disrupt locomotion and induce freezing (for example passing a door). Attention focused on gait allows a partial correction of the troubles by intentional modulation of the stride length but a dual task flowing attention away produces deterioration. Another point is that both strategies are probably used by the central nervous system to compensate deficits: visual dependence to compensate an impaired kinesthetic feed-back and attentional processing to alleviate automaticity in locomotion and so, to by-pass the deficit of internal cueing.     

The diagnosis of chronic axonal polyneuropathy: the poorly understood chronic polyradiculoneuritides

Chronic inflammatory demyelinating polyradiculoneuropathy is an autoimmune disease that target myelin sheats of peripheral nerves. Its diagnosis is often difficult to make, and a number of cases are probably not identified because of the clinical and electrophysiological heterogeneity. Typical cases associate progressive or relapsing-remitting motor and sensory deficit with increased CSF protein content and electrophysiological features of demyelination. In some cases electrophysiological studies fail to show evidence of demyelination, conventional electrophysiological diagnostic criteria are not filled yet the patient may respond to immunomodulatory treatments. In such cases, presence of clinical characteristics suggestive of CIDP (that means not compatible with a length-dependent axonal process) are critical justifying fully investigations including sural nerve biopsy. The main clinical characteristic are: a symmetric proximal and distal motor weakness predominantly affecting the lower limbs, a diffuse areflexia, a sensory deficit characterized by a preferential involvement of large fibers, an evolution which may be either chronic progressive or recurrent. Usual therapeutic agents (corticosteroids, intravenous immunoglobulins, plasma exchanges) seem to have the same efficacy whatever the electrophysiologic profile.