To provide recommendations on the follow-up and management of patients with breast cancer who have completed primary therapy with curative intent.
To update the 2006 guideline of the American Society ...of Clinical Oncology (ASCO), a systematic review of the literature published from March 2006 through March 2012 was completed using MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed the evidence to determine whether the recommendations were in need of updating.
There were 14 new publications that met inclusion criteria: nine systematic reviews (three included meta-analyses) and five randomized controlled trials. After its review and analysis of the evidence, the Update Committee concluded that no revisions to the existing ASCO recommendations were warranted.
Regular history, physical examination, and mammography are recommended for breast cancer follow-up. Physical examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For women who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. The use of complete blood counts, chemistry panels, bone scans, chest radiographs, liver ultrasounds, pelvic ultrasounds, computed tomography scans, (18)Ffluorodeoxyglucose-positron emission tomography scans, magnetic resonance imaging, and/or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination.
The treatment of peripheral artery disease with percutaneous transluminal angioplasty is limited by the occurrence of vessel recoil and restenosis. Drug-coated angioplasty balloons deliver ...antiproliferative agents directly to the artery, potentially improving vessel patency by reducing restenosis.
In this single-blind, randomized trial conducted at 54 sites, we assigned, in a 2:1 ratio, 476 patients with symptomatic intermittent claudication or ischemic pain while at rest and angiographically significant atherosclerotic lesions to angioplasty with a paclitaxel-coated balloon or to standard angioplasty. The primary efficacy end point was primary patency of the target lesion at 12 months (defined as freedom from binary restenosis or from the need for target-lesion revascularization). The primary safety end point was a composite of freedom from perioperative death from any cause and freedom at 12 months from limb-related death (i.e., death from a medical complication related to a limb), amputation, and reintervention.
The two groups were well matched at baseline; 42.9% of the patients had diabetes, and 34.7% were current smokers. At 12 months, the rate of primary patency among patients who had undergone angioplasty with the drug-coated balloon was superior to that among patients who had undergone conventional angioplasty (65.2% vs. 52.6%, P=0.02). The proportion of patients free from primary safety events was 83.9% with the drug-coated balloon and 79.0% with standard angioplasty (P=0.005 for noninferiority). There were no significant between-group differences in functional outcomes or in the rates of death, amputation, thrombosis, or reintervention.
Among patients with symptomatic femoropopliteal peripheral artery disease, percutaneous transluminal angioplasty with a paclitaxel-coated balloon resulted in a rate of primary patency at 12 months that was higher than the rate with angioplasty with a standard balloon. The drug-coated balloon was noninferior to the standard balloon with respect to safety. (Funded by Lutonix-Bard; LEVANT 2 ClinicalTrials.gov number, NCT01412541.).
Silver nanoparticles (AgNPs) are currently being very widely used in industry, mainly because of their anti-bacterial properties, with applications in many areas. Once released into the environment, ...the mobility, bioavailability, and toxicity of AgNPs in any ecosystem are dominated by colloidal stability. There have been studies on the stability or the aggregation of various nanoparticles (NPs) under a range of environmental conditions, but there is little information on fully characterised AgNPs in media used in (eco)toxicity studies. In this study, monodisperse 7, 10 and 20
nm citrate-stabilised AgNPs were synthesised, characterised and then fractionated and sized by flow field-flow fractionation (FFF) and measured with dynamic light scattering (DLS) in different dilutions of the media recommended by OECD for
Daphnia magna (water flea) toxicity testing. Stability of NPs was assessed over 24
h, and less so over 21 days, similar time periods to the OECD acute and chronic toxicity tests for
D. magna. All particles aggregated quickly in the media with high ionic strength (media1), resulting in a loss of colour from the solution. The size of particles could be measured by DLS in most cases after 24
h, although a fractogram by FFF could not be obtained due to aggregation and polydispersity of the sample. After diluting the media by a factor of 2, 5 or 10, aggregation was reduced, although the smallest NPs were unstable under all media conditions. Media diluted up to 10-fold in the absence of AgNPs did not induce any loss of mobility or fecundity in
D. magna. These results confirm that standard OECD media causes aggregation of AgNPs, which result in changes in organism exposure levels and the nature of the exposed particles compared to exposure to fully dispersed particles. Setting aside questions of dose metrics, significant and substantial reduction in concentration over exposure period suggests that literature data are in the main improperly interpreted and nanoparticles are likely to have far greater biological effects than suggested thus far by poorly controlled exposures. We recommend that the standard OECD media is diluted by a factor of ca. 10 for use with these NPs and this test media, which reduces AgNP aggregation without affecting the viability of the text organism.
More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This ...practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe.
We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate.
SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use.
MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.
Combining experiment with theory reveals the role of self‐assembly and complexation in metal‐ion transfer through the water–oil interface. The coordinating metal salt Eu(NO3)3 was extracted from ...water into oil by a lipophilic neutral amphiphile. Molecular dynamics simulations were coupled to experimental spectroscopic and X‐ray scattering techniques to investigate how local coordination interactions between the metal ion and ligands in the organic phase combine with long‐range interactions to produce spontaneous changes in the solvent microstructure. Extraction of the Eu3+–3(NO3−) ion pairs involves incorporation of the “hard” metal complex into the core of “soft” aggregates. This seeds the formation of reverse micelles that draw the water and “free” amphiphile into nanoscale hydrophilic domains. The reverse micelles interact through attractive van der Waals interactions and coalesce into rod‐shaped polynuclear EuIII‐containing aggregates with metal centers bridged by nitrate. These preorganized hydrophilic domains, containing high densities of O‐donor ligands and anions, provide improved EuIII solvation environments that help drive interfacial transfer, as is reflected by the increasing EuIII partitioning ratios (oil/aqueous) despite the organic phase approaching saturation. For the first time, this multiscale approach links metal‐ion coordination with nanoscale structure to reveal the free‐energy balance that drives the phase transfer of neutral metal salts.
Working at the interface: Combining experiment with theory reveals the role of self‐assembly and complexation in metal‐ion transfer through the water–oil interface. The coordinating metal salt Eu(NO3)3 was extracted from water into oil by a lipophilic neutral amphiphile (see figure).
Mature B lymphocytes are crucial components of adaptive immunity, a system essential for the evolutionary fitness of mammals. Adaptive lymphocyte function requires an initially naïve cell to ...proliferate extensively and its progeny to have the capacity to assume a variety of fates. These include either terminal differentiation (the long-lived plasma cell) or metastable transcriptional reprogramming (germinal center and memory B cells). In this review, we focus principally on the regulation of differentiation and functional diversification of the "B2" subset. An overview is combined with an account of more recent advances, including initial work on mechanisms that eliminate DNA methylation and potential links between intracellular metabolites and chromatin editing.
The opioid epidemic has resulted from myriad causes and will not be solved by any simple solution. Consequent to a staggering increase in opioid-related deaths in the USA, various governmental inputs ...and stakeholder strategies have been proposed and implemented with varying success. This article summarizes the history of opioid use and explores the causes for the present day epidemic. Recent trends in opioid-related data demonstrate an almost fourfold increase in overdose deaths from 1999 to 2008. Tragically, opioids claimed over 64,000 lives just last year. Some solutions have undergone legislation, including the limitation of numbers of opioids postsurgery, as well as growing national prevalence of enhanced recovery after surgery protocols which focus on reduced postoperative opioid consumption and shortened hospital stays. Stricter prescribing practices and prescription monitoring programs have been instituted in the recent past. Improvement in abuse deterrent strategies which is a major focus of the Food and Drug Administration (FDA) for all opioid preparations will likely play an important role by increasing the safety of these medications. Future potential strategies such as additional legislative policies, public awareness, and physician education are also detailed in this review.
The need for ceramic composites is increasing over a vast range of industrial applications, including energy and nuclear technology (structural materials for fission and fusion applications); space ...(thermal shields) or chemical sectors. Current finite element (FE) models are not able to reproduce the aleatory nature of crack generation and propagation through materials and interfaces. To tackle the shortcomings of FE models, a nonlocal bond‐based peridynamics model implemented in the Abaqus FE code has been updated to reproduce the behavior of interfaces between ceramic materials. Two‐ and three‐dimensional simulations have been used to simulate three‐point bend tests for a range of ceramic composites and compared with experiments available in the literature. The model reproduced most of the experimental failure loads, as well as correctly reproducing the failure modes and crack patterns. In particular, the model was able to predict two mechanisms for interface failure, cohesive failure, in which the two materials separate exactly at the interface, and cohesive failure of the substrate, in which a thin layer of the weaker material remains attached to the stronger material and a crack propagates in the weaker material, rather than at the interface. Both failure modes are experimentally observed and still difficult to reproduce with currently available FE simulations.
Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive technology that guides endoscopic tools to pulmonary lesions. ENB has been evaluated primarily in small, single-center studies; ...thus, the diagnostic yield in a generalizable setting is unknown.
NAVIGATE is a prospective, multicenter, cohort study that evaluated ENB using the superDimension navigation system (Medtronic, Minneapolis, Minnesota). In this United States cohort analysis, 1215 consecutive subjects were enrolled at 29 academic and community sites from April 2015 to August 2016.
The median lesion size was 20.0 mm. Fluoroscopy was used in 91% of cases (lesions visible in 60%) and radial endobronchial ultrasound in 57%. The median ENB planning time was 5 minutes; the ENB-specific procedure time was 25 minutes. Among 1157 subjects undergoing ENB-guided biopsy, 94% (1092 of 1157) had navigation completed and tissue obtained. Follow-up was completed in 99% of subjects at 1 month and 80% at 12 months. The 12-month diagnostic yield was 73%. Pathology results of the ENB-aided tissue samples showed malignancy in 44% (484 of 1092). Sensitivity, specificity, positive predictive value, and negative predictive value for malignancy were 69%, 100%, 100%, and 56%, respectively. ENB-related Common Terminology Criteria for Adverse Events grade 2 or higher pneumothoraces (requiring admission or chest tube placement) occurred in 2.9%. The ENB-related Common Terminology Criteria for Adverse Events grade 2 or higher bronchopulmonary hemorrhage and grade 4 or higher respiratory failure rates were 1.5% and 0.7%, respectively.
NAVIGATE shows that an ENB-aided diagnosis can be obtained in approximately three-quarters of evaluable patients across a generalizable cohort based on prospective 12-month follow-up in a pragmatic setting with a low procedural complication rate.
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