A Prognostic Model Based on Residual Cancer Burden and Tumor-Infiltrating Lymphocytes on Residual Disease after Neoadjuvant Therapy in HER2+ Breast Cancer

PURPOSE

We aim to evaluate the prognostic significance of tumor-infiltrating lymphocyte on residual disease (RD-TIL) in HER2+ patients with breast cancer who failed to achieve pathologic complete response (pCR) after anti-HER2+ chemotherapy (CT)-based neoadjuvant treatment (NAT). We assessed the feasibility of combining the prognostic information provided by residual cancer burden (RCB) and RD-TILs into a composite score (RCB+TIL).

EXPERIMENTAL DESIGN

HER2+ patients with breast cancer treated with CT+anti-HER2-based NAT at three institutions were retrospectively included. RCB and TIL levels were evaluated on hematoxylin and eosin-stained slides from surgical samples according to available recommendations. Overall survival (OS) was used as an outcome measure.

RESULTS

A total of 295 patients were included, of whom 195 had RD. RCB was significantly associated with OS. Higher RD-TILs were significantly associated with poorer OS as compared with lower RD-TILs (15% cutoff). In multivariate analysis, both RCB and RD-TIL maintained their independent prognostic value. A combined score, RCB+TIL, was calculated from the estimated coefficient of RD-TILs and the RCB index in a bivariate logistic model for OS. The RCB+TIL score was significantly associated with OS. The C-index for OS of the RCB+TIL score was numerically higher than that of RCB and significantly higher than that of RD-TILs.

CONCLUSIONS

We have reported an independent prognostic impact of RD-TILs after anti-HER2+CT NAT, which might underlie an imbalance of the RD microenvironment towards immunosuppressive features. We provided a new composite prognostic score based on RCB+TIL, which was significantly associated with OS and proved to be more informative than the isolated evaluation of RCB and RD-TILs.

Case report: Primary Ewing sarcoma of the ureter, an exceptional finding of unique manifestation of disease

Ewing sarcoma (ES) is the second most common malignant bone tumor in children and has also been described in adults with highly aggressive behavior. ES belongs to the small round blue cell tumor family and presents the distinctive translocation of FET-ETS family genes (85% with EWSR1), generating gene fusions. Extraskeletal ES mainly occurs in soft tissues; the urogenital tract is rarely affected, and ureteral localization is an exceptional event with only 4 cases described in the literature. Here we report the first Italian case of primary ES of the ureter, a 24-year-old young man with lower back pain and a narrowed left ureteral lumen on CT scan. ES of the urogenital tract is an almost unique condition with a nonspecific clinical presentation and a challenging diagnosis for pathologists. We encourage awareness of these exceptional events in the differential diagnosis of ureteral lesions in young patients.

1075 THE EFFECTIVENESS OF INTERVENTIONS TO REDUCE ADVERSE OUTCOMES AMONG OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE

Background

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

Method

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and grey literature was searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed and an algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied to outcomes.

Results

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate.

Conclusion

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The evidence for the effectiveness of ED interventions for older adults is limited. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended.

An improved study of HCO+ and He system: Interaction potential, collisional relaxation, and pressure broadening

In light of its ubiquitous presence in the interstellar gas, the chemistry and reactivity of the HCO⁺ ion requires special attention. The availability of up-to-date collisional data between this ion and the most abundant perturbing species in the interstellar medium is a critical resource in order to derive reliable values of its molecular abundance from astronomical observations. This work intends to provide improved scattering parameters for the HCO⁺ and He collisional system. We have tested the accuracy of explicitly correlated coupled-cluster methods for mapping the short- and long-range multi-dimensional potential energy surface of atom-ion systems. A validation of the methodology employed for the calculation of the potential well has been obtained from the comparison with experimentally derived bound-state spectroscopic parameters. Finally, by solving the close-coupling scattering equations, we have derived the pressure broadening and shift coefficients for the first six rotational transitions of HCO⁺ as well as inelastic state-to-state transition rates up to j = 5 in the 5-100 K temperature interval.

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic

CLINICAL SCENARIO

A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful.

MANAGEMENT QUESTION

What are the psychological impacts of SJS/TEN on this man's life?

BACKGROUND

SJS and TEN have devastating outcomes for those affected.

OBJECTIVES

To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario.

METHODS

Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age.

RESULTS

Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression.

DISCUSSION AND RECOMMENDATION

The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

Laboratory measurements and astronomical search for cyanomethanimine

CONTEXT

C-cyanomethanimine (HNCHCN), existing in the two Z and E isomeric forms, is a key prebiotic molecule, but, so far, only the E isomer has been detected toward the massive star-forming region. Sagittarius B2(N) using transitions in the radio wavelength domain.

AIMS

With the aim of detecting HNCHCN in Sun-like-star forming regions, the laboratory investigation of its rotational spectrum has been extended to the millimeter-/submillimeter-wave (mm-/submm-) spectral window in which several unbiased spectral surveys have been already carried out.

METHODS

High-resolution laboratory measurements of the rotational spectrum of C-cyanomethanimine were carried out in the 100-420 GHz range using a frequency-modulation absorption spectrometer. We then searched for the C-cyanomethanimine spectral features in the mm-wave range using the high-sensitivity and unbiased spectral surveys obtained with the IRAM 30-m antenna in the ASAI context, the earliest stages of star formation from starless to evolved Class I objects being sampled.

RESULTS

For both the Z and E isomers, the spectroscopic work has led to an improved and extended knowledge of the spectroscopic parameters, thus providing accurate predictions of the rotational signatures up to ~700 GHz. So far, no C-cyanomethanimine emission has been detected toward the ASAI targets, and upper limits of the column density of ~ 10¹¹-10¹² cm^-2 could only be derived. Consequently, the C-cyanomethanimine abundances have to be less than a few 10^-10 for starless and hot-corinos. A less stringent constraint, ≤ 10^-9, is obtained for shocks sites.

CONCLUSIONS

The combination of the upper limits of the abundances of C-cyanomethanimine together with accurate laboratory frequencies up to ~ 700 GHz poses the basis for future higher sensitivity searches around Sun-like-star forming regions. For compact (typically less than 1″) and chemically enriched sources such as hot-corinos, the use of interferometers as NOEMA and ALMA in their extended configurations are clearly needed.

Millimeter-Wave Spectroscopy of HCCCP in Excited Vibrational States

The rotational spectra of the unstable HCCCP molecule have been investigated in the millimeter-wave region for the main excited vibrational states which lie below 1000 cm(-1), namely nu(4) (C&bond;C stretch), nu(5) (HCC bend), nu(6) (CCC bend), nu(7) (CCP bend), 2nu(6), 2nu(7), 3nu(7), 4nu(7), nu(5) + nu(7), and nu(6) + nu(7). l-type resonance effects have been taken into account in the analysis of the spectra, so that the values of the anharmonicity constants x(L(66)), x(L(77)), x(L(57)), and x(L(67)) could be determined. The anharmonic interactions which couple the nu(4) state with nu(6) + nu(7), 2nu(6), and 4nu(7) have been also considered, yielding the unperturbed value of the alpha(4) vibration-rotation coupling constant. Copyright 2001 Academic Press.

Nuclear Quadrupole Tensors for (35)Cl and (37)Cl in cis-1-chloro-2-fluoroethylene Obtained by Detection of Perturbation-Allowed DeltaJ = 2 and DeltaJ = 3 Transitions

The nuclear quadrupole hyperfine structure in rotational transitions of cis-1-chloro-2-fluoroethylene was measured for both (35)Cl and (37)Cl containing isotopomers in the millimeter-wave region. Near degeneracies of the 9(3,7) and 10(2,9) levels of (35)ClHC&dbond;CFH and of the 19(9,10/11) and 17(10,7/8) levels of (37)ClHC&dbond;CFH cause strong perturbations of the hyperfine patterns and give rise to perturbation-allowed DeltaJ = 2 and DeltaJ = 3 transitions. Lamb-dip measurements of such perturbed hyperfine patterns and of forbidden DeltaJ = +2 and perturbation-enhanced DeltaJ = 0 transitions of (35)ClHC&dbond;CFH provided an accurate determination of chi(ab), the off-diagonal element of the inertial nuclear quadrupole tensor. For (37)ClHC&dbond;CFH, chi(ab) was determined for the first time thanks to the observation of perturbed hyperfine patterns and of forbidden DeltaJ = +3 and DeltaJ = -2 transitions. Additional measurements of hyperfine structures led to improved values for the diagonal elements of the chi tensor of both (35)Cl and (37)Cl. Moreover, the complete inertial nuclear quadrupole tensor was evaluated from the field gradient at the chlorine nucleus computed by using the Multi-Configuration Self-Consistent Field (MCSCF) approach and employing basis sets of triple-zeta quality: very good agreement with the experiment was obtained. Copyright 2000 Academic Press.

Lamb-Dip Millimeter-Wave and High-Resolution Far Infrared Spectra of HCCF

The ground state rotational spectrum of fluoroacetylene was measured in the millimeter-wave and FIR regions up to 1280 GHz and J = 65. Very accurate values of the rotational and centrifugal distortion constants were determined and in particular a more reliable value of H0 = 2.0 10(-4) Hz has been obtained compared to that previously determined of -0.30 Hz. HCCF was prepared in a dc glow discharge in presence of 1,3,5-trifluorobenzene. Copyright 1998 Academic Press.

Nuclear Quadrupole Coupling in 1,1,1-Trichloroethane: Inertial and Principal Tensors for 35Cl and 37Cl

The hyperfine structure in the J = 1 <-- 0 and J = 2 <-- 1 transitions of 35Cl3CCH3 and 35Cl237ClCCH3 was resolved by utilizing the sub-Doppler resolution of a pulsed supersonic beam, cavity Fourier transform microwave (FTMW) spectrometer. The complete inertial and principal quadrupole tensors of the chlorine nuclei are determined. The symmetric top treatment for 35Cl3CCH3 and the asymmetric top treatment for 35Cl237ClCCH3 are found to yield identical results for the principal tensor components of the 35Cl nucleus. The quadrupole asymmetry parameter eta for the chlorine nuclei in 1,1,1-trichloroethane is small, which indicates nearly cylindrical symmetry of the field gradient. Nevertheless, there is evidence for some deviation of the z symmetry axis of the field gradient from the direction of the C-Cl bond. Copyright 1998 Academic Press.

Centrifugal Distortion Analysis of the Millimeter-Wave Spectrum of 1,1,1,2-Tetrafluoroethane

Copyright

Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables

OBJECTIVE

To determine if the spread of Clostridium difficile-associated diarrhea is related to the use of electronic thermometers in an acute hospital and a chronic healthcare facility.

DESIGN

After finding that a significant percentage (20.8%) of electronic rectal thermometer handles were contaminated with C difficile, all electronic thermometers were replaced with disposables. A before/after trial was conducted to determine if the change to disposable thermometers would reduce the incidence of C difficile-associated diarrhea.

SETTING

The study took place in a 343-bed acute hospital and a 538-bed skilled nursing facility.

PATIENTS

All patients who underwent routine microbiological evaluation for nosocomially acquired diarrhea over a 1-year period were included in the study. Nosocomial diarrhea was defined as 3 or more loose stools per day for 2 consecutive days and/or abdominal findings such as pain, distension, and ileus occurring 3 or more days after admission.

RESULTS

During the 6-month postintervention period, the incidence of C difficile-associated diarrhea was reduced from 2.71/1,000 patient days to 1.76/1,000 patient days in the acute hospital and from 0.41/1,000 patient days to 0.11/1,000 patient days in the skilled nursing facility. The protective effect of the intervention was statistically significant for both facilities.

CONCLUSIONS

Replacement of electronic thermometers with single-use disposables significantly reduced the incidence of C difficile-associated diarrhea in both acute care and skilled nursing care facilities. Data suggest that the rectal route may be important in the transmission of C difficile in these settings.

Comparison of the acute hemodynamic effects of ibopamine and dopamine in chronic congestive heart failure

The acute hemodynamic effects of ibopamine (SB-7505), the 3,4-diisobutyryl ester of N-methyldopamine which can be administered orally, were compared with those of dopamine. Ten male patients aged 54 years on average, with chronic congestive heart failure in NYHA (New York Heart Association) classes II-IV were studied. Eight of them were suffering from idiopathic congestive cardiomyopathy and two from ischemic cardiopathy. Baseline hemodynamic parameters were recorded within 24 h after withdrawal of previous treatment, the patients being kept on digitalis only. The investigation was carried out for a period of 3 days running. On day 1 of treatment one group of 5 patients were given dopamine at increasing doses of 2, 4 and 6 micrograms/kg/min. Their hemodynamic parameters were assessed 15 min after each dose and 15 and 60 min after withdrawal of the drug. Ibopamine was then administered orally in single doses of 50 mg on day 2 and 100 mg on day 3. The hemodynamic parameters were evaluated at 30, 60, 90, 120, 180, 360 and 480 min after administration. On day 1, another group of 5 patients were given 50 mg ibopamine, on day 2, 100 mg ibopamine and on day 3, dopamine. Hemodynamic data in this group of patients were evaluated at the same times mentioned above. The hemodynamic effects of ibopamine 100 mg are very similar to those obtained with 4 micrograms/kg/min dopamine. Indeed, the effects of both drugs on the cardiac index, right atrial pressure, peripheral and pulmonary vascular resistance do not differ significantly from each other.(ABSTRACT TRUNCATED AT 250 WORDS)

[Beneficial effects of disopyramide on left ventricular outflow obstruction in a case of hypertrophic obstructive cardiomyopathy]

The Authors describe a patient with hypertrophic cardiomyopathy (HCM), severe left ventricular outflow tract obstruction and lack of response to beta-blockers or verapamil. Intravenous infusion of disopyramide resulted in a virtual disappearance of the LV pressure gradient, reduction of the systolic anterior motion of the mitral valve and slowing of the LV isovolumetric relaxation. One month after maintenance therapy with oral disopyramide a decrease of the anginal episodes and an improvement of the exercise tolerance were noted. Thus disopyramide, probably because of its negative inotropic action, is useful in the management of patients with HCM when LV outflow obstruction is the main cause of the clinical-hemodynamic findings.