The management of polypharmacy in people living with HIV

Antiretroviral therapy (ART) has modified the prognosis of HIV which has evolved into a chronic condition. People living with HIV (PLWH) are living longer presenting an increased number of comorbidities leading to polypharmacy. Literature on the prevalence, associated factors, drug-drug interactions (DDIs), effects on ART-outcomes, geriatric conditions, and nutritional status together with health-interventions aimed to reduce it is presented in this review. A literature search was conducted on the MEDLINE database for all relevant English- and Spanish-language studies since 2006. Studies providing data of interest were identified and ordered in groups: (i) prevalence and associated factors (n = 37), (ii) DDIs (n = 19), (iii) Effects on ART-outcomes (n = 12), (iv) Effects on health conditions (n = 13), and (V) Health-interventions to assess and/or reduce it (n = 9). Polypharmacy occurs in 9-91% of PLWH (2.6-19.5% affected by severe polypharmacy). Main factors associated with polypharmacy are older age, a higher number of comorbidities, frailty, deteriorated renal function, and previous hospitalizations. DDIs were present in 19.15-84% of cases (1.3-12.2% for the most severe types). Mainly involved non-ART drugs were antihypertensives, statins, antithrombotic agents, corticosteroids, divalent cations, and antiacids. Polypharmacy can affect ART selection, adherence, and outcomes and has been related to some geriatric conditions such as falls, frailty, and poor nutritional status. Potentially prescribing issues are present in up to 87.9% of cases according to the STOPP-START and Beers criteria and some pharmacist-led interventions have been shown to reduce it. Considering these findings, polypharmacy should be considered a clinical concern in this population and treatment-optimization programs are needed to reduce its burden.

Correlation and agreement between the Mohindra and cycloplegic retinoscopy techniques in children

PURPOSE

As an objective technique to assess refractive status, retinoscopy is particularly useful in children. The Mohindra technique (RM) is an alternative for those patients not good candidates for cycloplegic retinoscopy (RC). The aim of the present research was to compare both techniques and to determine the correlation and agreement of their measurements.

MATERIAL AND METHODS

A total of 47 boys and girls of ages ranging from 3 to 11 years old were included in the study. Cycloplegic (cyclopentolate 1%) and Mohindra retinoscopy were conducted in both eyes, and refraction was also assessed with an autorefractometre (AR). The results from the three techniques were compared and a correction factor between RM and RC was calculated.

RESULTS

Statistically significant differences were found between RM and RC (median of -0.42 D; p < 0.001) and between RM and AR (median of -0.42 D; p = 0.008), but not between RC and AR (median of 0.00 D; p = 0.758). A strong correlation was found between RM and RC (rho = 0.846; p < 0.001), although the Bland-Altman test revealed a larger difference between these techniques in patients with larger hyperopic refractive errors, with a correction factor of RC = 1.15 RM + 0.42.

CONCLUSIONS

The Mohindra technique may be considered a valid alternative to cycloplegic retinoscopy in patients of young age, with a good correlation between both techniques, albeit less agreement in patients with high hyperopic refractions.

On the efficiency of perovskite solar cells with a back reflector: effect of a hole transport material

Organometal halide perovskites are promising, high-performance absorbers in solar cells. However, the light-harvesting performance of these devices is still limited by excessive charge carrier recombination. Charge carrier management can be improved, taking into account the transport properties of layers surrounding the absorber. In particular, the choice of an appropriate hole-transport material (HTM) could provide a path towards increasing the device performance of perovskite solar cells (PSCs). The Lambertian reflection on the cell's back-surface reflector could increase the power conversion efficiency (PCE) of PSCs as well. Taking into account these facts, we analyse the absorptance and the PCE of a perovskite thin-film solar cell with the Lambertian reflection on the cell's back-surface reflector for various organic and inorganic HTMs. The analysis is done by means of the Monte-Carlo ray tracing simulations complemented by the transfer-matrix method to account for the interference phenomenon in the local generation rate G of carriers in a thin-film multilayer system. This function is employed further in the transport equations to calculate the current-voltage characteristics of the cell. We show that wide band gap HTMs, that possess negligible absorption, increase the photocurrent in the perovskite, passing reflected photons from the back reflector. In contrast, at the same perovskite thickness the PSC gains less photocurrent with narrow band gap HTMs, where an excessive non-radiative recombination takes place. Our analysis demonstrates that the optimal thickness of the solar cell with the typical absorber CH₃NH₃PbI₃ is ∼300 nm, providing the maximal efficiency ∼18.8% for the wide band gap HTM (CuSCN) at the moderate absorber purity (the diffusion length _D ∼ 1 μm).

Treatment Adherence and Clinical Outcomes of Patients with Inflammatory Bowel Disease on Biological Agents During the SARS-CoV-2 Pandemic

BACKGROUND

The outbreak of COVID19 evolved rapidly into a global pandemic, forcing hospitals, including inflammatory bowel disease (IBD) referral units, to change their practices to ensure quality of care.

AIMS

To describe the clinical outcomes and the fulfilment of the treatment schedule of patients with IBD treated with biological agents in a single-center of a red-zone of the pandemic, and to report the patients' perceptions about COVID-19 and the measures adopted at our center.

METHODS

Therapeutic adherence and clinical outcomes were collected for all patients undergoing treatment with intravenous biologicals and subcutaneous biologicals at our center. A telephone survey was also performed to assess these patients' perceptions of the COVID pandemic and the related measures adopted at their IBD unit.

RESULTS

A total of 234 patients were included (117 on intravenous and 117 on subcutaneous biologicals). Only 10% of patients postponed intravenous infusions intentionally and 5% postponed the collection of subcutaneous biologicals at the hospital pharmacy. Only five confirmed COVID-19 cases were registered (2.1%), all of them of mild severity. One hundred and fifty-five patients participated in the survey (77 on intravenous and 78 on subcutaneous drugs). Fear of going to the hospital was the most common reason for postponing biological administrations. Among those on combination therapy, only 7% admitted to have withdrawn immunosuppressants.

CONCLUSIONS

Adherence to intravenous and subcutaneous biological therapies during the pandemic was high in a single-center cohort of IBD patients even though the cumulative incidence of confirmed COVID-19 was low.

Translation and cultural adaptation into Spanish of the Low Vision Quality of Life Questionnaire

OBJECTIVE

The purpose of the present study was to provide a translation into Spanish, as well as a cross-cultural adaptation, of the English version of the Low Vision Quality of Life Questionnaire (LVQOL). There are currently some questionnaires designed to assess vision related quality of life in Spanish, although none of them specifically examines the quality of life of patients with visual disability.

METHOD

The LVQOL consists of 25 items and examines 4 different dimensions: distance vision; mobility and ilumination; adaptation, reading and precision work, and daily life activities. The process of translation and cross-cultural adaptation was conducted following the recommendations of the International Society for Pharmacoeconomics and Outcomes. This included, amongst other variables, a direct translation, a back-translation, and a cognitive debriefing with a small sample of patients with visual impairment. Work was supervised by an expert committee consisting of an ophthalmologist, a psychologist with expertise in Patient Reported Outcomes, and an optician-optometrist with experience in the field of low vision.

RESULTS

A total of 46 phrases were considered for translation of which, 41 (89.1%) had excellent equivalence, 3 (6.5%) moderate equivalence, and 2 poor equivalence. The cognitive debriefing phase showed a high degree of acceptance of the questionnaire by the sample of participants with visual impairment.

CONCLUSIONS

The results obtained suggest that the Spanish version of this tool is understandable for patients with visual impairment. Its properties as a measuring tool will be evaluated in a later study to determine its validity, reliability, and sensitivity to changes.

Long-Term Sequelae of Breast Cancer Surgery

Background

Quality of care is today a major issue in oncology, and much attention is given to research on the outcome of breast cancer care. Too little attention has been devoted in the scientific literature to the consequences of treatment in long-term survivors, and in particular to the possible side effects. The specific aim of this contribution is to present population-based data about the long-term impact of breast cancer care in women who had an incident cancer in 1985/1986.

Patients and Methods

The cases are 476 breast cancers incident in the City of Florence in 1985-86. Women still living 5 years later were invited to have an interview and a physical examination. Lymphedema, peripheral nerve lesions and damage to the shoulder were assessed.

Results

Of the 346 5-year survivors, 238 accepted our invitation: 35.2% of the women reported some early postoperative sequelae, 30.2% had a chronic lymphedema and 18.9% a shoulder deficit. Comparing breast-conserving surgery with radical mastectomy, the risk of chronic lymphedema (OR=1.62; 95% CI: 0.91-2.88) and other lesions was higher for women who had a radical surgery. Women who had a breast-conserving surgery more often reported an early lymphedema (OR=1.60; 95% CI: 0.88-2.88).

Conclusions

The proportion of women who complained of (or manifested at the physical examination) a minor or major disability of the arm in our study was high. The impact of these functional problems in terms of quality of life should also be assessed, but it is our impression that there is need for much greater attention to the issue of long-term survivor sequelae.

Osteogenic Sarcoma of the Breast. A Case Report

A case of primary osteogenic sarcoma of the breast is reported. It should be distinguished from carcinoma with extensive osseous metaplasia. The results of light and electron microscopy including an immunohistochemical study are presented. Immunohistochemical and ultrastructural studies proved that the lesion, in the absence of epithelial differentiation, was a primary osteogenic sarcoma of the breast rather than a carcinoma with extensive osseous metaplasia. Diagnosis may be delayed because the tumor is confused clinically and mammographically with a calcific fibroadenoma.

Risk of Infiltrating Breast Cancer Subsequent to Lobular Carcinoma in Situ

The authors report on a retrospective consecutive multicentric series of 60 cases with histologic evidence of lobular carcinoma in situ (LCIS), followed for an average of 5.3 years. In the course of the follow-up, ipsilateral LCIS or infiltrating carcinoma occurred in 3 or 5 cases, respectively. Two LCIS reoccurrences and all ipsilateral infiltrating carcinomas were observed in 37 patients treated by limited surgery. Contralateral synchronous or metachronous carcinoma was observed in 3 or 2 cases, respectively (intraductal = 3, infiltrating = 2). Three patients died of breast cancer (2 with Ipsilateral, 1 with ipsilateral and contralateral infiltrating carcinoma). The study confirms the higher risk of ipsilateral and contralateral cancer in LCIS patients and warns about the possible hazards of limited surgery in these cases.

Intraductal Breast Carcinoma. Review of a Multicenter Series of 350 Cases

A multicentrer series of 350 intraductal breast cancers (DCIS) is reported. Mammography was the most sensitive test but suspicion arose only at palpation in 13% of cases whereas in 10% of cases biopsy was recommended for a benign lesion and DCIS was an unexpected finding. Mammography, physical examination and cytology must be combined to achieve optimal sensitivity. Systematic biopsy of apparently benign masses would increase DCIS detection rates but the cost-effectiveness of such a policy is questionable. A trend of conservative surgery was evident over time (from 1968-79, 28%; 1985-1989, 50%) but breast irradiation followed only in one fourth of the cases. The local recurrence rate was significantly higher in cases of limited surgery (with or without irradiation) with respect to mastectomy (1.2 vs 0.2 × 100 patient-years at risk). Most recurrences (7 of 8) in the conserved breast were infiltrating, but no recurrence was seen in subclinical DCIS cases. Three patients died of breast cancer after local recurrence in the conserved breast (2 cases) or mastectomy scar (1 case). Eligibility for conservative surgery of DCIS needs to be carefully discussed to avoid under-treatment. Contralateral breast cancer was recorded in 44 cases and the incidence of further metachronous cancer to the other breast was ten times higher than expected in normal breasts. Four patients died of contralateral breast cancer, free of ipsilateral recurrence. A careful follow-up of the contralateral breast in DCIS cases looks as important as surveillance of the conserved breast.

Limitations of CEA Monitoring as a Guide to Second-Look Surgery in Colorectal Cancer Follow-Up

Forty-two patients with localized colorectal cancer (Dukes’ A, B, C stages) were treated with potentially curative surgery and controlled with a follow-up program, which included CEA monitoring, for a period ranging from 12 to 48 months (median 33 months). During this period, we observed recurrent neoplastic disease in 14 patients. A retrospective analysis of the results showed that: 1. patients with a preoperative CEA value > 20 ng/ml have a significantly higher risk of recurrence than the patients with CEA < 20 ng/ml; 2. sensitivity of the CEA test was good for metastatic recurrent disease, fairly good for residual neoplastic disease, but insufficient for local recurrence; 3. test-specificity was poor, as demonstrated by the negative results of four exploratory laparotomies performed exclusively on the basis of increased CEA levels. Since the principal aim of a second-look operation is the cure of local recurrence, this type of surgery cannot be proposed only on the basis of increased CEA levels.

Lack of Prognostic Value of p53 Protein Expression in Node-Negative Breast Cancer

Aims and background

The association of p53 protein accumulation and prognosis in node-negative breast cancer patients has been alternately demonstrated and denied in literature reports, and opinions on the use of p53 expression as an indicator of high risk of recurrence and as a guide for adjuvant therapy are controversial.

Study design

The association of p53 protein accumulation with prognosis was retrospectively evaluated in a series of 221 node-negative breast cancer patients treated with surgery alone and followed up for a minimum of 10 years. p53 accumulation was determined by immunohistochemistry on archive material, and classified into four grades of increasing immunostaining.

Results

No association was observed between p53 and age or pT category, whereas a significant association with nuclear grade was found (P = 0.0014). Univariate and multivariate analysis of 10-yr disease-free and overall survival showed a significant and independent prognostic association for tumor size (pT category) and nuclear grading but not for p53 expression, whatever grade grouping was used.

Conclusions

We did not find any evidence supporting the use of p53 immunostaining in current practice as an independent prognostic indicator or as a discriminant factor for adjuvant treatment of node-negative breast cancer patients.

Prognostic Role of Estrogen Receptor Determination in Breast Cancer

The authors report on 283 primary, non-metastatic, breast cancer cases consecutively referred after surgery and followed-up from a minimum of 10 months to a maximum of 3.5 years. All cases were studied according to the presence of estrogen receptors (ER). ER presence was correlated with age and menstrual status, with ER+ cases more frequent in older patients. No correlation was found between ER and nodal status. Prognosis was evaluated in terms of disease-free survival at 2 years (actuarial method). No correlation between ER and survival was evident for N– cases, whereas a better prognosis was recorded for ER+N+ patients compared to ER-N+, although the difference was not statistically significant. The observed results are compared with recent literature data and agree with other recent reports, which did not confirm the previously undiscussed statement regarding the prognostic role of ER determination. According to these studies and to the present study, the prognostic role of ER determination seems at least questionable and particularly the postoperative adjuvant treatment of ER-N– cases should be reconsidered.

Reasons for Failure of Physical Examination in Breast Cancer Detection (Analysis of 232 False-Negative Cases)

The diagnostic role of physical examination (PE) is evaluated in 1450 cases of breast cancer detected in 34,677 women controlled at the Centro per lo Studio e la Prevenzione Oncologica in the period 1974–1981. In 47 cancer cases, PE findings were normal since the neoplasm was not clinically palpable because of its size and site, and in another 185 cases the clinical diagnosis was benignancy without evidence of suspect signs. Therefore, the overall sensitivity of PE was 84%. PE errors did not involve a therapeutic delay for the patient in 75% of cases in which a biopsy was recommended for clinical benignancy or for suspicion on the basis of other diagnostic methods. The present study confirms that PE has a good diagnostic sensitivity when the examined population is represented by self-referred women, who for the most part are symptomatic, whereas it cannot be considered as the only diagnostic test for early diagnosis in mass screening, since in asymptomatic women a large number of cancers are not clinically palpable. Moreover, PE shows lower sensitivity for small lesions and in younger women. Extensive use of fine needle aspiration cytology and other diagnostic methods in association with PE is therefore recommended to reduce the possibility of errors.

Staging Breast Cancer - Screening for Occult Metastases

The authors report on 1,017 consecutive breast cancer cases without symptomatic metastases staged by means of chest X-ray (CXR), skeletal survey (BXR) and bone scintigraphy (BS). Occult metastases (DM) detection rate was 0.88 %: 0.29 % for lung and 0.59 % for bone DM. The detection rate was correlated with clinical stage: 0.36 % for stage I, 0.20 % for stage II, 0.26 % for stages I and II, and 2.77 % for stage III cases. The sensitivity based on DM cases prevalent or surfacing within 6 months of follow-up was 0.30 for CXR, 0.22 for BXR and 0.55 for BS; specificity was 0.99, 0.98 and 0.90, respectively. The study confirms the possibility of early detection of DM with preoperative staging, but the extremely low detection rates in stage I and II cancers do not advise such a routine procedure. The higher detection rate of DM may suggest adoption of the routine staging procedure in stage III cancers. In these cases, although no evidence is available of a favorable prognostic impact of early detection and treatment of DM, an unnecessary mastectomy could be avoided in about 3 % of cases in the presence of DM detected by the staging procedure.

Clinically Occult Breast Lesions: Criteria of Radiological Diagnosis as a Guide to the Choice of Biopsy Technique

A series of 90 clinically occult operated breast lesions, diagnosed in the course of mammographic mass screening for early detection of breast cancer, is reported. Five radiological patterns of suspect lesions are identified and compared with histological diagnosis of the biopsy. Diagnostic quadrantectomy is suggested for clinically unapparent lesions showing a radiologic pattern which has a high probability of finding a cancer or preneoplastic lesion (severe epitheliosis). Alternative biopsy methods to diagnostic quadrantectomy are recommended for lesions showing other radiological patterns, allowing for a more limited breast tissue excision.

The major allergen of Alternaria alternata (Alt a 1) is expressed in other members of the Pleosporaceae family

There is general consensus regarding the scarce cross-reactivity existing between Alternaria alternata and other allergenic moulds such as Aspergillus fumigatus, Penicillium notatum or Cladosporium herbarum. However, A. alternata has been shown to have a very significant level of allergenic cross-reactivity with other fungi belonging to the Pleosporaceae family. To date, no biological identity or homologies with other proteins have been described for Alt a 1, and it remains unclear whether the major allergen Alt a 1 contributes to the cross-reactivity shown for these moulds. Specific quantification of Alt a 1 in culture filtrates of Stemphylium botryosum, Ulocladium botrytis, Curvularia lunata, Alternaria tenuissima, C. herbarum, Penicillium chrysogenum and Asp. fumigatus, and immunoblotting using culture filtrate extracts from the above-mentioned moulds and rabbit serum anti-recombinant Alt a 1 have shown significant amounts of Alt a 1 in culture filtrates as well as antigenic components ranging from 14 to 20 kDa that strongly react with the specific serum for all taxonomically related species (Pleosporaceae family). No reactions were revealed in culture filtrates of Cladosporium, Penicillium and Aspergillus. These results restrict the cross-reactivity phenomenon due to Alt a 1 to the scope of the taxonomical term of family.

Enzymatic analysis of Blomia tropicalis and Blomia kulagini (Acari: Echimyopodidae) allergenic extracts obtained from different phases of culture growth

The majority of important allergenic extracts from arthropods present enzymatic activity. This activity has been studied particularly in Dermatophagoides house dust mites because of its implication in the stability and immunogenicity of extracts used as tools for the diagnosis and specific treatment of allergic diseases. Extracts from cultures of Blomia tropicalis [van Bronswijk (1973a, b). Acarologia 15:477-489, 490-505] and Blomia kulagini (Zakhvatkin 1936) were used to study enzymatic profiles during three growth periods of the mite population: latency phase, maximum mite concentration during exponential growth, and drop stage. The activities of 19 enzymes were analyzed using the Api Zym system. The results show a large variety of enzymes. Some enzymatic activity was found to be (almost) exclusively attributable to mites. The activity levels of proteases, glycosidases and lipases overlapped with the growth curve. Only phosphatase activity showed no significant change during mite growth when compared with the culture medium. We suggest that the glycosidases (beta-galactosidase, beta-glucuronidase, beta-N-acetylglucosaminidase, alpha-mannosidase and alpha-fucosidase) and proteases (leucine aminopeptidase and trypsin) may constitute suitable parameters for inclusion in the quality control process for the production of allergenic mite extracts, and may help define a new index for conducting environmental controls.

Variability of Alt a 1 expression by different strains of Alternaria alternata

BACKGROUND

While it is well known that there is significant intraspecific variation in the content an potency of Alternaria alternata allergens, little data has been published on intraspecific variability for individual allergens from moulds.

OBJECTIVE

To assess the variability of Alt a 1 expression in different strains of A alternata.

METHODS

Eleven strains of A alternata were cultured in a Czapek broth medium and culture filtrate extracts were obtained. A sensitive two-site enzyme-linked immunosorbent assay was used to measure Alt a 1 concentrations in medium following 3 weeks of culture and in culture filtrate extracts.

RESULTS

Expression of Alt a 1 was highly variable in different strains ofA alternata (coefficient of variation > 135%). A good correlation was found between Alt a 1 concentrations at the beginning of the process and measurements at the end of extract production (r=0.940).

CONCLUSIONS

The high variability of Alt a 1 expression in different A alternata strains makes it necessary to measure Alt a 1 concentrations during the first stage of allergenic extract production in order to be able to choose a suitable strain for producing extracts or purifying Alt a 1.

The management of elderly patients with T1–T2 breast cancer treated with or without radiotherapy

AIM

The aim of the current study is to identify a subgroup of patients with breast cancer who have a low risk of local recurrence after conservative surgery in order to avoid radiotherapy treatment.

METHODS

A group of 472 patients underwent conservative surgery without radiotherapy, and it was compared to a second group of 755 patients with similar characteristics, but who had received radiotherapy treatment (RT) after conservative surgery.

RESULTS

Breast relapse's univariate analysis demonstrated statistical significance for the following factors: radiotherapy treatment, clinical stage, pathological stage, positive axillary nodes and tumour grading. Different results were obtained studying breast relapse. In the no-RT group breast relapse was 10.6% while in the irradiated group it was 3.4%. The breast relapse incidence decreases as the age of the patients increases especially over 75 years of age.

CONCLUSIONS

In conclusion, there is clinical evidence of avoiding adjuvant radiotherapy for patients over 75 years with T1-T2 cancer treated with quadrantectomy with a clear excision margin.

Tubular carcinoma of the breast: outcome and loco-regional recurrence in 307 patients

PURPOSE

The aim of this study is to describe the University of Florence experience in evaluating clinical, pathologic and treatment factors as they are related to the outcome and loco-regional recurrence in patients with tubular breast carcinoma.

MATERIAL AND METHODS

Three hundred and seven patients (median age 56.4 years, range 26-91 years) with histological verified tubular carcinoma of the breast were consecutively treated at University of Florence from 1976 to 2001. All patients were followed for a median of 8.4 years (range 3 months to 20 years). Thirty-seven women underwent mastectomy and 270 underwent breast conserving surgery. Positive axillary nodes were found in 15% of patients. Fifty-two patients did not undergo radiotherapy to whole breast after having breast conserving surgery. Tamoxifen was prescribed in 108 patients and chemotherapy in 21 patients, 15 out of 21 had positive axillary nodes.

RESULTS

Cause specific survival was 99.6, 99.2 and 97.2% at 3, 5 and 10 years. Local recurrence rate was 1.9, 3.6 and 4.7% at 3, 5 and 10 years. Univariate statistical analysis was significant for specific survival and local recurrence for angiolymphatic invasion only (p=0.0004).

CONCLUSIONS

In the absence of axillary disease and angiolymphatic invasion, conserving surgery with adjuvant radiotherapy is effective treatment of disease.

Allergy to sea fishing baits

We report a new case of rhinitis and asthma caused by sea fishing baits. The results showed exposure to Sipunculus nudus (Phylum Sipuncula; order Sipunculida: Sipunculidae) to be the main cause of the allergic symptoms. The intervention of IgE was demonstrated, with the presence of cross-reactions with allergenic extracts from other worm species used as baits, belonging to different orders of Annelida.

Allergenic cross-reactivity between Blomia tropicalis and Blomia kulagini (Acari: Echymiopodidae) extracts from optimized mite cultures

BACKGROUND

At present, data about the cross-reactivity of Blomia spp. comes from studies made among different genera of mites, and no results have been published involving different species of the genus Blomia.

OBJECTIVE

The aim of this study was to find out the level of cross-reactivity between the two main species of Blomia causing allergy, and its implication in the diagnosis of Blomia sensitization.

METHODS

Using extracts from optimal growth phases of Blomia kulagini (Zakhvatkin, 1936) and Blomia tropicalis (van Bronswijk, Cock and Oshima, 1973) as allergenic material, the allergenic cross-reactivity between both house dust mites was evaluated by means of cutaneous tests, specific IgE values, ImmunoCAP-inhibition and SDS-PAGE-IgE-immunoblotting-inhibition.

RESULTS

The results demonstrated that IgE-binding components belonging to both species are very similar from the immunological point of view, showing high correlations between both species when using cutaneous tests (R2=0.915) or specific IgE (R2=0.980). ImmunoCAP-inhibition and SDS-PAGE-IgE-Immunoblotting-inhibition probed with human sera, showed a total inhibition of specific IgE reactions by the heterologous antigens.

CONCLUSION

The results obtained strongly suggest the great resemblance between the allergenic composition of both species.

Analysis of the allergen expression of Blomia tropicalis and Blomia kulagini (Astigmata: Glycyphagidae) cultures

Laboratory cultures of the mites Blomia tropicalis (van Bronswijk, Cock & Oshima) and Blomia kulagini (Zakhvatkin) were used to study the population dynamics of the mites and the kinetics of released allergens during the growth cycle. The analysis of extracts obtained after different incubation periods, by means of immunoblotting, and quantification of the major allergen Blo t 5, allowed definition of three different growth phases, demonstrating that mite cultures during the maximum growth (end of exponential growth curve-beginning maximum growth plateau) contain the largest amount of allergenic components as well as the highest Blo t 5 concentration.

Uncinaria stenocephala: antigenic characterization of larvae and adults worms using sera from naturally infected dogs

An antigenic characterization of the larval (somatic) and adult (somatic and excretory-secretory) antigens of Uncinaria stenocephala was made, employing immunoblotting and immunoblotting-inhibition with 10 selected sera from dogs naturally infected by this hookworm. The results indicated that each one of the three parasitic extracts has different antigenic components. Sixty percent of the dog sera consistently recognised four antigens of 20, 25, 30, and 38kDa of the larval extract and the immunoblotting inhibition showed that these antigens were only observed at the larval stage. All these results indicated that these antigens can be considered as major antigens and they could be useful for the immunodiagnosis of this parasitic infection.

Prognostic factors for lymphedema after primary treatment of breast carcinoma

BACKGROUND

Lymphedema of the arm is a serious consequence of breast carcinoma treatment. Postmastectomy lymphedema of the upper limb usually is related to certain risk factors such as axillary surgery, radiotherapy, obesity, venous outflow obstruction, delayed wound healing, and infection. The objective of the current study was to identify the risk factors for secondary lymphedema after breast carcinoma treatment.

METHODS

A total of 1278 breast carcinoma patients, all of whom were residents of Florence area, Italy at the time of diagnosis and who were operated on by the same surgeon between 1989 and 1997, were included in the current analysis. The circumference of the upper arm was measured and lymphedema was defined as being present when an increase of > 5% of the sum differences between the two arms was found. The observed cumulative probability of lymphedema occurrence was estimated using the Kaplan-Meier method. The Cox proportional hazards models were fitted to assess the relative excess risk of lymphedema and to check for confusing factors. All patients with lymphedema who were living in the Florence area were referred to a specialist for treatment.

RESULTS

Two hundred three cases of lymphedema of the ipsilateral arm were found (15.9%). The right arm was affected in 44.5% of the cases and the left arm in 55.5%. The risk of developing late lymphedema was found to be significantly related to a pathologic T2 classification (hazards ratio [HR] = 1.44; 95% confidence interval [95% CI], 1.06-1.94) and postoperative radiotherapy (HR = 1.35; 95%CI, 1.00-1.83). Patients who had > 30 lymph nodes removed were found to have a borderline increased risk of lymphedema (HR = 1.64; 95% CI, 0.99-2.74). Multivariate analysis identified postoperative radiotherapy (HR = 1.38; 95% CI, 1.02-1.86) and the number of lymph nodes removed (HR = 1.29; 95% CI, 1.04-1.59) to be independent predictors of lymphedema.

CONCLUSIONS

The results of the current study demonstrated that the risk of lymphedema was correlated with the use of postoperative radiotherapy and the number of lymph nodes removed.

Expression of multiple thyroid hormone receptor isoforms in rat femoral and vertebral bone and in bone marrow osteogenic cultures

Thyroid hormones influence both bone formation and bone resorption. Clinical data and animal studies provide evidence of skeletal site heterogeneity (hip vs. spine) of bone responses to thyroid hormones. In vitro studies also demonstrate direct effects of thyroid hormones on cells of the osteoblast lineage. Transcriptional regulation by thyroid hormone is mediated by ligand-dependent transcription factors called thyroid hormone receptors (TRs). Two genes, c-ErbAalpha and c-ErbAbeta, generate at least four TR isoforms in the rat: TRalpha(1), c-erbAalpha(2), TRbeta(1), and TRbeta(2). Although functional TRs have been identified in cells of the osteoblast lineage, it is still not known if TR isoform expression in bone differs depending upon which skeletal site is examined. We have used ribonuclease protection assay and Northern blot analysis to simultaneously examine the expression of TR isoform mRNAs in adult rat femoral and vertebral bone. TRalpha(1), c-erbAalpha(2), and TRbeta(1) are expressed in both femur and vertebra whole bone. Bone marrow cells from both skeletal sites were also cultured under conditions whereby the osteoprogenitors differentiated into osteoblasts and formed a mineralized extracellular matrix. TRalpha(1), c-erbAalpha(2), and TRbeta(1) mRNAs are each expressed in both femoral and vertebral osteoblast cultures. The presence of TRalpha(1), c-erbAalpha(2), and beta(1) proteins was confirmed by Western analysis of nuclear protein extracts from femoral and vertebral cell cultures. These results indicate that the three predominant TR isoforms are highly expressed in bone and osteoblasts from femurs and vertebrae. Whether there are distinct mechanisms of thyroid hormone action mediated by TRalpha(1), c-erbAalpha(2), and TRbeta(1) at these separate skeletal sites remain to be shown.

Danielone, a phytoalexin from papaya fruit

A new phytoalexin was induced and isolated from papaya fruit slices treated with copper salts; its structure was established as 3',5'-dimethoxy-4'-hydroxy-(2-hydroxy)acetophenone. This compound showed high antifungal activity against Colletotrichum gloesporioides, a pathogenic fungus of papaya.

Adjuvant postoperative radiotherapy in rectal cancer: 148 cases treated at Florence University with 8 years median follow-up

BACKGROUND AND PURPOSE

To analyse the outcome, the treatment related side effects, the prognostic significance of clinical parameters in a group of patients with rectal cancer receiving postoperative radiotherapy after radical resection.

MATERIALS AND METHODS

From 1980 to 1990 148 consecutive patients with rectal carcinoma stage B2-B3 or C1-C2-C3 were treated with postoperative radiotherapy after radical surgery. All patients received 50 Gy in 25 sessions in 5 weeks. In 42 a "flash' dose of 5 Gy was also given within 24 h before surgery. Median follow up was 8.1 years.

RESULTS

At 5 years the overall survival was 54%, the determined (cancer specific) survival 61%, the local recurrence-free survival 88%. The influence of stage, histotype, distance from anal margin, type of surgery, number of involved nodes and flash dose were analysed. Overall and determined survival and distant metastasis rate were significantly influenced (P < 0.005) by the pathological stage. Patients with more than 3 involved nodes presented a significantly lower determined survival (P < 0.001) and a higher distant relapse rate (P < 0.005) than those with 3 or less involved nodes. A higher determined survival (P < 0.01) was also found in patients receiving the preoperative "flash'; this group was however unbalanced in respect to the relative number of cases with 3 or less involved nodes. The incidence of major side effects requiring surgery or hospitalization for medical treatment was 35% before 1985 and 12% thereafter. The systematic use of small bowel visualization during simulation and the discontinuation of the flash dose were the main modifications introduced in the second period. As a consequence of the small bowel visualization the size of lateral fields was slightly reduced and some patients were excluded from the treatment.

CONCLUSIONS

Value of postoperative radiotherapy to decrease the incidence of local recurrence was confirmed in this retrospective study; the incidence of side effects was however considerable and did not support the addition of chemotherapy as advised by the NIH consensus meeting. Our policy was therefore moved to preoperative irradiation whose combination with chemotherapy was recently reported to be better tolerated and highly effective.

Accuracy and reliability of frozen section diagnosis in a series of 672 nonpalpable breast lesions

Frozen section (FS) diagnosis was routinely performed in a large series of nonpalpable breast lesions from 1977 through 1991. The original FS diagnoses of 672 patients were classified in four categories (1 = benign lesion, 2 = in situ carcinoma, 3 = invasive carcinoma, 4 = deferred diagnosis) and compared with the diagnoses obtained at review of the permanent paraffin sections to estimate the accuracy of FS. A review of the mammographic pattern of the lesion was also performed. Frozen section diagnostic conclusion was deferred to permanent paraffin sections in only 22 cases (3.3%). Benign or malignant (grouping in situ and invasive carcinomas) FS diagnoses were accurate in 623 of 650 cases (95.8%). Overall, the prevalence of malignant lesions was 44.8% with a benign/malignant ratio of 1.2. The diagnosis was modified on the basis of permanent sections in 27 cases (4.2%) with three false positives and 24 false negatives. Sensitivity and specificity of FS diagnoses were 91.7 and 99.2%, respectively. When the comparison between FS and histologic diagnoses was analyzed according to the mammographic pattern, sensitivity among patients with microcalcifications as the only alteration was lower (88.8%) than among patients with opacities (94.9%). On the basis of these results, FS is to be considered a feasible and reliable diagnostic procedure in nonpalpable breast lesions, particularly in cases excised because of a mammographic opacity that is identifiable on gross examination of the surgical specimen.

Unambiguous 13C NMR assignment of acnistins and absolute configuration of acnistin A

Carbon and proton atoms were fully assigned in this new type of withanolide by HMQC and HMBC experiments. The absolute configuration of acnistin A was determined by X-ray diffraction. Proton and 13C NMR measurements are particularly useful in identifying members of this group of natural products.

Non-palpable lesions of the breast detected by mammography--review of 1182 consecutive histologically confirmed cases

We report on 1182 consecutive histologically confirmed non-palpable breast lesions detected by mammography (infiltrating carcinoma 427, in situ carcinoma 121, benign 634). The proportion of cancer cases varied according to age (< 50 years = 33%; 50-59 years = 46%; > 59 years = 63%), mammographic pattern (regular opacities = 8%, parenchymal distortions = 20%, isolated calcifications = 42%, irregular opacities = 62%, stellate opacities = 73%), and calendar period (1970-1985 = 29%, 1986-1989 = 56%; 1990-1992 = 69%). A sharp decrease of the benign/malignant biopsy ratio was evident after routine fine-needle aspiration cytology (sonography-guided or stereotaxic) was introduced in 1986. The independent significant association of cancer frequency to age, calendar period and mammographic pattern was confirmed by multivariate analysis. A significant trend over time in favour of conservative surgery was also observed for cancer cases (1970-1979 = 6%, 1980-1985 = 41%, 1986-1992 = 83%). Among invasive cancers, node involvement was observed in 11.5% of cases, being associated with tumour size (pT1a = 0%, pT1b = 7%, pT1c = 13%, pT2a = 33%). Five-, ten- and fifteen-year overall survivals of invasive cancers were 98.1, 95.7 and 87.3%, respectively.

Cell kinetics in breast cancer

In breast cancer the study of prognostic factors has been well developed during last years and many biologic and biochemical parameters have been analyzed. Cell kinetics parameters demonstrated the capability to select patients with different risk of evolution of the neoplasia and in some cases treatment protocols are established by means of proliferation rate. The present study deals with the determination of Thymidine Labelling Index in breast tumors mostly T1-T2 with negative lymph nodes. Results demonstrated that the proliferative activity is higher in younger patients, in T2 cancers compared to T1, and in ductal infiltrating forms compared to the other more frequent histotypes. A significant correlation has been observed between TLI and nuclear grade. The preliminary analysis of the prognostic value of TLI has been two performed using an experimental cut off that is able to discriminate groups of patients with overall survival rate of 67% and 88%, depending on the different proliferative activity of the tumor.

Prognostic value of proliferating cell nuclear antigen in lymph node-negative breast cancer patients

BACKGROUND

The prognostic value of proliferating cell nuclear antigen (PCNA) has been demonstrated in recent studies of human tumors including breast cancer.

METHODS

PCNA immunoreactivity was assessed retrospectively in a consecutive series of 173 lymph node-negative primary breast cancer cases. The PCNA grade was determined according to estimated quartiles of nuclear immunostaining, and its association to disease-free and overall survival was studied.

RESULTS

PCNA grade was associated significantly with nuclear grade. On univariate analysis, PCNA grade was associated significantly with both 5-year relapse-free survival rate (Grades 1-2 = 78%; Grades 3-4 = 52%; P = 0.0117) and overall survival. On multivariate analysis, T category and PCNA were associated independently and significantly with both relapse-free and overall survival. Nevertheless, the magnitude of the association of PCNA grade to prognosis was low (relative risk of recurrence in patients with PCNA Grades 3-4 versus Grades 1-2 = 2.13), and only 24% of all relapses or 28.8% of all cancer deaths observed at 5 years occurred in patients with PCNA Grades 3-4.

CONCLUSIONS

The predictive value of the relationship of PCNA grade to prognosis was too low to be of value as an independent prognostic indicator.

Prognostic significance of c-erbB-2 expression in node negative breast cancer

The prognostic value of c-erbB-2 oncogene expression was studied retrospectively in a consecutive series of 230 node negative breast cancers, followed-up for at least 7 years after primary treatment. The expression of c-erbB-2 oncoprotein was determined on formalin-fixed paraffin-embedded tissue, using a monoclonal anti-c-erbB-2 antibody by the avidin-biotin immunoperoxidase method. Positive immunostaining was observed in 20.9% of cases, whereas strong diffuse positivity was recorded only in 8.7% of cases. C-erbB-2 gene product showed no association to T category or nuclear grade. A significant association of c-erbB-2 expression to prognosis was observed only for cases showing a strong diffuse immunostaining, but such an association was no longer statistically significant at multivariate analysis adjusting for other prognostic factors such as T category and nuclear grading. C-erbB-2 expression is of no value to predict the clinical course of node negative patients in the current practice.

Phyllodes tumor of the breast: a multicenter series of 59 cases. Coordinating Center and Writing Committee of FONCAM (National Task Force for Breast Cancer), Italy

A series of 59 phyllodes tumors of the breast was retrospectively reviewed (average follow-up = 3.9 years). Clinical features (age, size of tumor) and diagnostic tests (palpation, mammography, sonography and cytology) were found to be inaccurate in predicting benign (n = 22), borderline (n = 12) or malignant (n = 25) histological type. Limited surgery was associated with a relatively high proportion of local recurrence (enucleation/enucleoresection = 3/5, wide resection = 12/30) compared with mastectomy (2/24). No significant association was observed between the probability of local recurrence and patient's age, histological type or lesion size. Although the study confirms that limited surgery may cure phyllodes tumor, careful follow-up of all patients is needed, since no reliable risk factors for recurrence are available. In malignant cases, axillary node involvement was nil and distant metastases were infrequently observed (3/25). Axillary dissection and search for asymptomatic metastases is not recommended.

Intraductal breast cancer: review of 183 consecutive cases

The aim was to review a series of 183 intraductal breast cancer to define the diagnostic features and therapeutic outcome. Patients' average age was 54 years. Diagnostic procedures employed were clinical examination, mammography in 173 cases and fine-needle aspiration cytology in 98 cases. The sensitivity of clinical examination was 0.61, of mammography 0.74, of fine needle aspiration cytology 0.70. The sensitivity of clinical examination and mammography associated was 0.93. The surgical options adopted were: conservative surgery 80 cases, mastectomy 103 cases. Conservative surgery was followed by breast irradiation in 34 cases. Axillary dissection was performed in 122. 97 cases have been reviewed histologically. 60% of ductal carcinoma in situ (DCIS) were multifocal and 22% multicentric. Local recurrence, all infiltrating, occurred in the same breast after conservative surgery in 8 cases, 3 of which had received postoperative radiotherapy, and in 3 patients after mastectomy. Contralateral breast cancer was recorded in 13 cases, being synchronous in 4 (infiltrating in 3, DCIS in 1) and metachronous in 8 (all infiltrating). 3 patients died of breast cancer. The present series confirms the risk of ipsilateral cancer recurrence after conservative surgery but there are no significant differences relating to mammographic pattern, size, histological type, margin involvement and radiotherapy.

The role of CA 15-3 and MCA monoclonal antibody assays in the detection of primary and recurrent breast cancer

CA 15-3 and MCA assays were tested in 103 operable patients (preoperative determination) and 100 patients with advanced breast cancer. Normal CA 15-3 and MCA values were determined in a series of 68 healthy women. The negative/positive cut-off was set at 28.8 U/ml and 15.5 U/ml respectively for CA 15-3 and MCA (mean value + 2SD). Results were analyzed in the two groups and with respect to T and N pathological categories in the preoperative series. In pT1 (59 pts), pT2 (30 pts), pT3 + pT4 (14 pts), pNO (58 pts), pN1 (45 pts) and overall preoperative series CA 15-3 and MCA sensitivities were respectively 25%, 40%, 57%, 22%, 42%, 30% and 27%, 30%, 35%, 21%, 33%, 26%. In the patients affected by widespread disease, sensitivity was 92% and 80% for CA 15-3 and MCA. Results were significantly different among normal, preoperative and advanced patients (P less than 0.05). Our results suggest that CA 15-3 and MCA levels are correlated with the tumor mass. Nevertheless, the low sensitivity in pT1 and pNO cases indicates that these two assays have no role in the diagnosis of early breast cancer. In the advanced patients, too, the results can be questioned: in the present study, in fact, recurrent cases were characterized by gross disease with multiple site involvement and cannot be considered as an example of early diagnosis of breast cancer recurrence.

Alkaline phosphatases and steroid receptors in human breast cancer

Estrogen receptors (ER), progesterone receptors (PR) and alkaline phosphatases (AP) were measured in 150 tumors from patients who underwent mastectomy for primary breast cancer. The percentage of ER positive samples was inversely related to the AP activity ranging from 88.9% in low activity samples (less than 30 U/mg prot.) down to 30.6% in the high activity ones (greater than 400 U/mg prot.). When considering only ER positive samples, the ER content was inversely related to the AP activity. This could not be demonstrated for PR. Therefore, the authors suggest the hypothesis that in human breast cancer, the AP may play a role in the dephosphorylation of the ER molecule and in the consequent modulation of its binding capability.

Gene expression from the c-erbA alpha/Rev-ErbA alpha genomic locus. Potential regulation of alternative splicing by opposite strand transcription

Alternative splicing of the c-erbA alpha gene transcript generates mRNAs encoding a thyroid hormone (T3) receptor (alpha 1) and a non-T3-binding variant (alpha 2). Also encoded at this genomic locus is Rev-ErbA alpha (Rev), a non-T3-binding member of the T3/steroid hormone receptor family. The DNA strand coding for Rev is opposite of that encoding the c-erbA alpha proteins, such that bidirectional transcription is required to generate the Rev and alpha 2 mRNAs. We have used cycloheximide as a tool for studying the regulation of gene expression from this complex genomic locus. In 235-1 cells cycloheximide treatment increased Rev mRNA levels by 50-100-fold. The effect was detectable after a 1-2-h incubation with 20 micrograms/ml cycloheximide and maximal at 24 h. The cycloheximide-induced increase in Rev gene expression was due to inhibition of protein synthesis since anisomycin caused a similar induction of Rev mRNA. Nuclear run-on assays revealed an approximately 10-fold increase in the transcriptional rate of the Rev gene during cycloheximide treatment. In addition, cycloheximide stabilized the Rev mRNA, as evidenced by half-life determinations in the presence of actinomycin D (5 ng/ml). Thus, labile proteins repress basal Rev gene expression both transcriptionally and post-transcriptionally. Cycloheximide treatment also increased alpha 1 and decreased alpha 2 mRNA levels, with the alpha 1/alpha 2 ratio increasing approximately 10-fold. Interestingly, however, these effects appeared not to be due to changes in rates of transcription or degradation of either mRNA. A likely alternative, given the structure of the c-erbA alpha gene, is that inhibition of protein synthesis resulted in a change in the c-erbA alpha splicing pattern. We hypothesize that this may be causally related to the accumulation of Rev mRNA (or the nascent Rev gene transcript), which could inhibit splicing to alpha 2 by hybridizing to complementary sequences, favoring alpha 1 mRNA production. Since alpha 1 is a T3 receptor whereas alpha 2 is an inhibitor of T3 action, such changes could influence target cell responsiveness to T3.

In situ ductal carcinoma of the breast--analysis of clinical presentation and outcome in 156 consecutive cases

We report on 156 consecutive cases of in situ ductal carcinoma (DCIS) of the breast observed from 1968 to 1988. The relative frequency of DCIS was much higher in screened, with respect to self-referred, women and a significant association of DCIS with younger age was observed. The combined use of mammography and physical examination identified 138 of 156 total DCIS cases as suspicious. Mammography, physical examination or cytology (of nipple discharge or needle aspirate) were the only tests to provide suspicious evidence in 35, 22 and four cases respectively. DCIS was a relatively unexpected surgical finding in 13 apparently benign cases. Different surgical options were recorded in the study period but a temporal trend in favour of conservative surgery was evident. Subsequent ipsilateral or contralateral breast cancer was recorded in seven and six cases respectively. Death from breast cancer occurred in five cases, all of whom had contralateral or subsequent ipsilateral infiltrating cancer. This figure confirms the high curability of DCIS if local control is achieved.

Prognosis of nonpalpable infiltrating carcinoma of the breast

A consecutive series of 185 instances of histologically confirmed nonpalpable infiltrating carcinoma of the breast is presented. Histologic nodal involvement was found in 12 per cent and was dependent on the size of the tumor. Conservative surgical treatment was the predominant method used during the study period. The ten year over-all survival was studied and compared with that of 4,217 instances of palpable carcinoma of the breast observed during the same period. The ten year survival rates were, by far, better for nonpalpable (94 per cent) than for palpable carcinomas (65 per cent). A better prognosis for nonpalpable carcinomas was confirmed also by multivariate analysis (Cox) with adjustment for potential confounders, such as age, stage or nodal involvement. The possible confounding effect of over diagnosis and length or lead time bias is discussed. Although this difference in survival might be partially explained by the aforementioned confounders, the chance of increasing life expectancy and conservative surgical treatment encourages preclinical detection of carcinoma of the breast.

Follow-up of colorectal cancer resected for cure. An experience with CEA, TPA, Ca 19-9 analysis and second-look surgery

Sixty-four consecutive patients who had undergone curative resection for colorectal carcinoma were studied prospectively to evaluate the roles of sequential CEA determinations and independent instrumental follow-up in the early detection of resectable recurrences. Fifty-two of these patients also were submitted to sequential determinations of other tumor antigens: TPA (tissue polypeptide antigen) and Ca 19-9 (colon cancer antigen detected with a monoclonal antibody), for a retrospective evaluation of their utility as markers of recurrent tumors. Twenty-two recurrences were detected in a period ranging from 12 to 72 months (median, 47 months). CEA was the best predictor of recurrence (sensitivity, 90 percent) when compared with the other two markers (TPA sensitivity, 60 percent; Ca 19-9 sensitivity, 20 percent). When compared with the instrumental or biochemical examinations of the follow-up, CEA was still the most sensitive indicator of relapse although the specificity was quite low (78 percent) if minimal significative increases were considered. History and physical examination were more useful than CEA in detecting local recurrences in rectal cancer where the preoperative CEA level was low. A few second-look explorations based solely on small CEA increases failed to demonstrate recurrence or revealed peritoneal carcinomatosis. Selected second-look surgery based on demonstrated recurrences resulted in a resectability rate of 57 percent. A follow-up program based on frequent CEA assays, history, and physical examinations, including rectal, vaginal, and perineal exploration, is proposed. Extensive instrumental investigations should follow when a minimal significative CEA rise is observed, or when history and physical examinations suggest a possible recurrence. Second-look surgery should be evaluated after confirmed or highly suspected diagnosis of recurrence, on the basis of instrumental or clinical examinations.

Polyamine modification in human breast tumors after short treatment with tamoxifen

The authors measured estrogen receptors, and polyamine (putrescine, spermidine and spermine) in breast tumors from patients (n = 23) who had received tamoxifen for a few days (5-10) before surgery. Women undergoing mastectomy without any preoperatory treatment were selected as the control group (n = 44). As already reported about in vitro experiments, the treatment resulted in a significant lowering of the spermidine to spermine ratio. Such a modification was larger in the ER positive tumors then in the ER negative ones and it seems to be related to the regression process of the drug-responsive tumors. On the basis of the experimental data the authors suggest the development of a in vivo tamoxifen-sensitivity test.

Patterns of axillary metastases in breast cancer

Thirty-seven (4.1%) cases of nodal metastases skipping the first level are reported in a consecutive series of 912 breast cancer axillary dissections including 392 N+ cases. First level nodes examination is sufficiently accurate in assessing the quality of nodal status (negative or positive) but not the extent of nodal involvement (number of involved nodes).