The estrogen receptor negative-progesterone receptor positive breast carcinoma is a biological entity and not a technical artifact

The ER-/PR+ breast tumor may be the result of a false ER negative result. The aim of this study was to investigate whether there is a difference in patient and tumor characteristics of the ER-/PR+ phenotype in an Asian setting. A total of 2629 breast cancer patients were categorized on the basis of their age, ethnicity, tumor hormonal receptor phenotype, grade and histological type. There were 1230 (46.8%) ER+/PR+, 306 (11.6%) ER+/PR-, 122 (4.6%) ER-/PR+ and 972 (37%) ER-/PR-. ER-/PR+ tumors were 2.5 times more likely to be younger than 50 years at diagnosis (OR: 2.52; 95% CI: 1.72-3.67). Compared to ER+/PR+ tumors, the ER-/ PR+ phenotype was twice more likely to be associated with grade 3 tumors (OR:2.02; 95%CI: 1.00-4.10). In contrast, compared to ER-/PR- tumors, the ER-/PR+ phenotype was 90% less likely to be associated with a grade 3 tumor (OR: 0.12; 95%CI:0.05-0.26), and more likely to have invasive lobular than invasive ductal histology (OR: 3.66; 95%CI: 1.47-9.11). These results show that the ER-/PR+ phenotype occurs in a younger age group and is associated with intermediate histopathological characteristics compared to ER+/PR+ and ER-/PR- tumors. This may imply that it is a distinct entity and not a technical artifact.     

Biliary obstruction after cholecystectomy: diagnosis with quantitative cholescintigraphy

Fifty patients with recurrent post-cholecystectomy pain underwent hepatobiliary scintigraphy. Time-activity curves were generated from regions of interest over the liver, bile duct, duodenum, and bowel. Patients were divided into obstructed and unobstructed groups with endoscopic retrograde cholangiopancreatography criteria. Measurements from the liver, duodenum, and bowel curves contributed little to the analysis. The washout phase of the bile duct curve showed intermittent emptying in both obstructed and unobstructed groups. Less than one-third of peak activity remained in both groups at 90 minutes. Retention fell more rapidly in the later portion of the sequence in patients with obstruction. Quantification was essential, since differences were subtle and could not be appreciated visually. In the absence of hepatocellular disease, the most reliable criterion was the time at which maximal bile duct activity occurred. A cutoff level of 29 minutes or more was used in the diagnosis of obstruction. A sensitivity of 93% with an adequate specificity of 64% and an overall accuracy of 80% was achieved in the prediction of obstruction.     

Can old people on oral anticoagulants be safely managed as out-patients?

Of 62 patients (mean age 75, range 65-92 years) referred to an out-patient anticoagulant clinic specifically for those aged 65 years or more, treatment was considered unsafe in only one patient and was discontinued. Minor bleeding which did not require a significant change in management was recorded on 25 (7%) of 381 clinic visits and one major haemorrhage occurred requiring emergency hospital admission. Anticoagulation was maintained within the therapeutic range on 284 (75%) visits. The results confirm that with appropriate out-patient care and supervision, the risks of oral anticoagulant therapy in the elderly need be no greater than in younger patients.     

Changing presentation of myocardial infarction with increasing old age

The symptoms associated with acute myocardial infarction in a series of 777 elderly hospitalized patients are reviewed. Their ages ranged from 65 to 100, with a mean of 76.0 years. The spectrum of presentation changed significantly with increasing age. Chest pain or discomfort were less frequently reported, although present in the majority of patients up to 85 years. Syncope, stroke, and acute confusion became more common and were often the sole presenting symptom. Shortness of breath, although the most frequently reported symptom in the absence of chest pain, was equally common at all ages. Thus, in patients aged 85 years or over, "atypical" presentation of myocardial infarction became the rule, and in the very old the clinician must be prepared to screen for the diagnosis in most acutely ill patients.