Molecular classification and biomarkers of clinical outcome in breast ductal carcinoma in situ: Analysis of TBCRC 038 and RAHBT cohorts

Ductal carcinoma in situ (DCIS) is the most common precursor of invasive breast cancer (IBC), with variable propensity for progression. We perform multiscale, integrated molecular profiling of DCIS with clinical outcomes by analyzing 774 DCIS samples from 542 patients with 7.3 years median follow-up from the Translational Breast Cancer Research Consortium 038 study and the Resource of Archival Breast Tissue cohorts. We identify 812 genes associated with ipsilateral recurrence within 5 years from treatment and develop a classifier that predicts DCIS or IBC recurrence in both cohorts. Pathways associated with recurrence include proliferation, immune response, and metabolism. Distinct stromal expression patterns and immune cell compositions are identified. Our multiscale approach employed in situ methods to generate a spatially resolved atlas of breast precancers, where complementary modalities can be directly compared and correlated with conventional pathology findings, disease states, and clinical outcome.

Isoforms of Wilms' tumor suppressor gene (WT1) have distinct effects on mammary epithelial cells

The role of WT1 (Wilm's tumor suppressor gene) in breast cancer is controversial, with evidence for both tumor-promoting and tumor-suppressing activities. In order to address this question, we expressed different WT1 isoforms in the mammary epithelial cell line H16N-2, which does not express endogenous WT1. Cells were stably transfected with either WT1 (-Ex5/-KTS) or WT1 (+Ex5/+KTS) under the control of the inducible metallothionein promoter. Induction of WT1 (-Ex5/-KTS) upregulated p21, causing a slowing of proliferation and a G2-phase cell cycle arrest. In artificial basement membrane, the WT1 (-Ex5/-KTS) isoform promoted the appearance of highly organized acinar cellular aggregates. In contrast, WT1 (+Ex5/+KTS) had no effect on p21 or proliferation, but rather caused an epithelial-mesenchymal transition and a redistribution of E-cadherin from the cell membrane to the cytoplasm. This isoform also causes the cellular aggregates growing in artificial basement membrane to appear significantly less organized than control cells. Thus, different WT1 isoforms have distinct effects in this cell line, suggesting that depending on the ratio of WT1 isoform expression in mammary epithelial cells, WT1 could function to either promote or suppress a transformed phenotype.

Sources and magnitude of job stress among physicians

Research has suggested that physicians' jobs are more stressful than many other types of work, but sources of job stress for physicians have rarely been measured systematically. Interview data from 204 young physicians (57 women, 147 men) were used to construct four scales of sources of job stress: patient relationships, business/financial issues, time pressures, and competence concerns. The latter is a stronger source of stress for doctors in early practice. Sources and intensity of job stressors do not vary significantly by gender, but medical practice problems are more stressful in nonprofit than in for-profit practices. Early-career doctors appeared to experience only moderate levels of stress, and stressors were not related to impaired mental health.

The dorsal antiglide plate in the treatment of Danis-Weber type-B fractures of the distal fibula

The results of 93 of 107 consecutive antiglide plate internal fixations of Danis-Weber Type-B fractures of the distal fibula are reported with a follow-up period of just over one year. Using the ankle evaluation scale of Weber, 66.7% excellent, 27.9% good, and only 5.4% poor results were found. The method of dorsal antiglide plate fixation is possible in most of the frequent Type-B ankle fractures. Stabilization is better with the antiglide plate, especially in older patients with osteoporotic bone. Because of these advantages and the biomechanically sound technique, the antiglide plate is recommended for stabilization of the Danis-Weber Type-B fracture of the distal fibula.

Delayed intramedullary nailing after failed external fixation of the tibia

Thirteen patients (11 males, two females) with 16 tibia fractures (three segmental) were initially treated with external fixation and secondarily had delayed intramedullary nailing after fixator removal. There were six closed injuries and two Grade I, five Grade II, one Grade IIIA, and two Grade IIIB open soft-tissue injuries. The average patient age was 40 years (range, 19-84 years). The external fixator was removed at an average of 12 weeks (range, three to 25 weeks) for malreductions in six case, atrophic segmental fractures in two, and atrophic/unstable fracture patterns in five. Intramedullary nailing was performed at an average of 13 days (range, five to 30 days) after fixator removal. There were 12 reamed nails and one self-broaching nail. Preoperative antibiotics averaged eight days, and postoperative averaged 11 days. All patients healed with bridging callus; full weight bearing occurred at an average of 2.7 months. Follow-up evaluation averaged 22.5 months. Weight bearing began within the first three weeks in 12 of 13 patients. Results were rated as excellent in eight and good in five. There were no complications related to infection or non-union. Delayed intramedullary nailing, after excluding potential high-risk patients, is an option for the treatment of tibia fractures that have failed treatment with external fixation. However, it is not recommended as a routine procedure.

Composite wiring of metacarpal and phalangeal fractures

Composite wiring techniques using various configurations of Kirschner pins and stainless steel wire sutures have been applied to the treatment of 63 fractures of the long bones of the hand. The secure fixation achieved allowed active motion within 1 week of operation. Thirty-three metacarpal fractures achieved a final mean total active motion of 256 degrees (standard deviation 13.4) (normal total active motion -260 degrees). Twenty-one phalangeal fractures achieved a mean total active motion of 215 degrees (standard deviation, 46 degrees). There were no instances of infection, malunion, nonunion, loss of reduction, or tendon rupture in the 63 fractures that were treated.

The Le(a+b+) phenotype in Polynesians

The presence of the rare Lewis phenotype Le(a+b+) is reported in various Polynesian groups, including Maoris, Samoans, Cook Islanders, Nuieans and Tokelau Islanders. The phenotype was found in Polynesians of all blood groups and the frequency was significantly increased in group 0 persons. The phenotype was not significantly associated with H reactivity in group A donors and showed no correlation with age or sex.

Anterior approach and stabilization of the disrupted sacroiliac joint

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.

Blood groups and other genetic markers in New Zealand Europeans and Maoris

Genetic data on the frequency of various red-cell antigens and enzymes as well as polymorphic protein markers from New Zealand European and Maori populations are outlined. Despite widespread intermarriage between races in New Zealand there was, in nearly all systems tested, a significant difference in the frequency of genetic markers.

Internal fixation of a capitellar fracture using Herbert screws. A case report

Fractures of the capitellum can involve a significant portion of the articular surface, rendering the elbow joint unstable. In this situation it is desirable to reduce and internally fix the capitellar fragment, because this restores the articular surface and augments joint stability. A 35-year-old woman sustained a posterolateral dislocation of the left elbow associated with a capitellar fracture. Fixation of the capitellar fragment with Herbert screws stabilized the joint, allowed anatomic reduction, and gave good fixation. Active motion was possible at three weeks. When the patient was evaluated at one year, the fracture had united and there was no evidence of avascular necrosis.

Operative treatment of displaced talus fractures

The talus is a bone with unique biomechanical features and vascular supply. Displaced fractures of the talus, therefore, frequently create problems of proper management. Forty-one severe talar fractures were treated operatively. The incidence of avascular necrosis was relatively low in this series (16%), and all of these were of Type III and IV fractures of the Marti-Weber classification. Type IV fractures were successfully treated by arthrodesis per primam, and suggested that fusion may be the indicated method of treatment in these severe injuries. Fusion of the tibiotalar joint has been used to encourage revascularization and to preserve the important function of the subtalar joint. In all other fracture types with dislocation, anatomic reduction is performed to restore joint congruity and encourage maintenance of talar dome viability. Painstaking postoperative management is important for the complete restoration of function.

Silastic condylar arthroplasty

Interpositional Silastic condylar arthroplasty of the first carpometacarpal joint was used in 40 patients with disabling arthritis. Limiting bone resection at the base of the thumb improves prosthetic stability. Pain was lessened and function improved in most cases. Technical modifications and their rationale are discussed.

The syndrome of idiopathic osteolysis. Classification, review, and case report

Idiopathic osteolysis is characterised by a spontaneous onset without previous causative factors, followed by rapid destruction and resorption of the involved bones. This process can result in severe deformities with joint subluxation and instability. In certain forms an associated malignant nephropathy may develop. A case report is presented which illustrates the destructive nature of the process.

The operative treatment of scapular fractures

Fractures of the scapula occur mainly from direct trauma involving considerable violence and associated injuries of the shoulder and thorax are common. In most cases early functional treatment gives good or excellent results. Operative treatment may, however, be indicated, especially with displaced intra-articular fractures, fractures of the glenoid rim associated with humeral head subluxation, or unstable fractures of the scapular neck. Between 1967 and 1981, we treated 37 such fractures by open reduction and stable osteosynthesis. We were able to follow up 33 cases (89%), of which 21 (64%) had complete functional recovery. The other 12 had varying degrees of pain, loss of mobility, and weakness. Overall, however, 79% of the patients had good to excellent results.

Factors associated with poor results following arthroscopic subcutaneous lateral retinacular release

Forty-eight patients who underwent 55 arthroscopic subcutaneous lateral retinacular releases with an average follow-up period of 15 months were examined. Advancing age, postoperative hemarthrosis, incomplete release, incomplete quadriceps rehabilitation, and severe ligamentous laxity are factors that may contribute to a poor result following this procedure. In patient selection the increased risk of poor results in patients older than 30 years of age and in those with generalized ligamentous laxity must be considered. During surgery, release of the tight lateral tether is essential to produce a positive "tilt" sign, signifying complete release. Although postoperative hemarthrosis is usually associated with immediate morbidity, it can ultimately lead to poor results. Incomplete or incorrect quadriceps rehabilitation is almost always associated with a compromised result.

Gasoline immersion injury

Chemical burns and pulmonary complications are the most common problems encountered in the patient immersed in gasoline. Our patient demonstrated a 46-percent total-body-surface area, partial-thickness chemical burn. Although he did not develop bronchitis or pneumonitis, he did display persistent atelectasis, laryngeal edema, and subsequent upper airway obstruction. This had not previously been reported in gasoline inhalation injuries. Hydrocarbon hepatitis secondary to the vascular endothelial damage is apparently a reversible lesion with no reported long-term sequelae. Gasoline immersion injuries may be a series multisystem injury and require the burn surgeon to take a multisystem approach to its diagnosis and treatment.