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National comprehensive cancer network guidelines recommend delivery of adjuvant chemotherapy in node-negative triple-negative breast cancer (TNBC) if the tumor is 1 cm and consideration of adjuvant chemotherapy for T1b but not T1a disease. These recommendations are based upon sparse data on the role of adjuvant chemotherapy in T1a and T1b node-negative TNBC. Our objective was to clarify the benefits of chemotherapy for patients with T1N0 TNBC, stratified by tumor size.We performed a retrospective analysis of survival outcomes of TNBC patients at two academic institutions in the United States from 1999 to 2018. Primary tumor size, histology, and nodal status were based upon surgical pathology. The Kaplan-Meier plot and 5-year unadjusted survival probability were evaluated.Among 282 T1N0 TNBC cases, the status of adjuvant chemotherapy was known for 258. Mean follow-up was 5.3 years. Adjuvant chemotherapy was delivered to 30.5% of T1a, 64.7% T1b, and 83.9% T1c (p 0.0001). On multivariable analysis, factors associated with delivery of adjuvant chemotherapy were tumor size and grade 3 disease. Improved overall survival was associated with use of chemotherapy in patients with T1c disease (93.2% vs. 75.2% p = 0.008) but not T1a (100% vs. 100% p = 0.3778) or T1b (100% vs. 95.8% p = 0.2362) disease.Our data support current guidelines indicating benefit from adjuvant chemotherapy in node-negative TNBC associated with T1c tumors but excellent outcomes were observed in the cases of T1a and T1b disease, regardless of whether adjuvant chemotherapy was delivered.

Purpose Breast cancer survivors take vitamins and supplements to bolster their general health and to decrease the risk of cancer recurrence. Healthcare providers are frequently unaware of their patients non-prescription supplement use. The aim of this study was to study the type and the documentation of patients’ dietary supplements and vitamins in the electronic medical record (EMR). Methods 50/51 female breast cancer survivors seen over a 7 week period consented to the study. Mean age was 70 and mean years since diagnosis was 13.9. Informed consent and documentation of supplement and vitamin use was obtained by the nurse practitioner the day before the visit. Study data were collected and managed using REDCap electronic data capture tools hosted at Weill Cornell Medicine. Results Of the 50 study patients, 90% were taking one or more vitamins and/or supplements (mean = 2.4, range = 1–9). The most common were Vitamin D, calcium, and vitamin C. Reasons for vitamin and supplement use included the recommendation by their physician or friend and prevention of bone loss or catching a cold. Five patients mentioned immunity or prevention of COVID-19. The patient reported list was compared with the medication list used by multiple providers in the electronic medical record (EMR). None of the 50 study patients had an accurate list of their vitamins and supplements in the EMR. Conclusion 90% of the breast cancer survivors in our study were taking dietary supplements for a variety of reasons. None had an accurate list in the EMR. We strongly recommend more attention to accurate and easily accessed vitamin and supplement recording by providers.

Animal models have demonstrated the critical role of bone marrow-derived VEGFR1(+) hematopoietic progenitor cells (HPCs) and VEGFR2(+) endothelial progenitor cells (EPCs) in metastatic progression. We explored whether these cells could predict relapse and response in breast cancer (BC) patients. One hundred and thirty-two patients with stages 1-4 BC were enrolled on 2 studies. Circulating CD45(+)/CD34(+)/VEGFR1(+) HPCs and CD45(dim)/CD133(+)/VEGFR2(+) EPCs were assessed from peripheral blood mononuclear cells using flow cytometry. Changes in HPCs and EPCs were analyzed in (1) patients without overt disease that relapsed and (2) metastatic patients according to response by RECIST. At study entry, 102 patients were without evidence of disease and 30 patients had metastatic BC. Seven patients without evidence of BC by exam, labs, and imaging developed recurrence while on study. Median HPC/ml (range) increased from 645.8 (23.5-1,914) to 2,899 (1,176-37,336), P = 0.016, followed by an increase in median EPC/ml from 21.3 (4.7-42.5) to 94.7 (28.2-201.3), P = 0.016, prior to clinical relapse. In metastatic patients with progressive disease, median HPC/ml increased from 1,696 (10-16,470) to 5,124 (374-77,605), P = 0.0009, and median EPC/ml increased from 26 (0-560) to 71 (0-615) prior to progression, P = 0.10. In patients with responding disease, median HPC/ml decreased from 6,147 (912-85,070) to 633 (47-18,065), P = 0.05, and EPC/ml decreased from 46 (0-197) to 23 (0-105), P = 0.41, at response. There were no significant changes in these cells over time in patients with stable disease. Circulating bone marrow-derived HPCs and EPCs predict relapse and disease progression in BC patients.

Transcranial Doppler (TCD) ultrasonography to demonstrate cerebral circulatory arrest (CCA) is a confirmatory test for brain death (BD). The primary aim of this retrospective study was to evaluate the practical utility of TCD to confirm BD when clinical diagnosis was not feasible due to confounding factors. Secondary aims were to evaluate the reasons for inability of TCD to confirm BD and to assess the outcome of patients not brain dead according to the TCD criteria. TCD waveforms and medical records of all the patients examined to confirm suspected BD between 2001 and 2007, where clinical diagnosis was not possible, were analyzed. BD was diagnosed based on CCA criteria recommended by the Task Force Group on cerebral death of the Neurosonology Research Group of the World Federation of Neurology. Final outcome of patients and the use of other ancillary tests were noted. Ninety patients (61 males), aged 40 ± 21 (range 3–84) years underwent TCD examination for confirmation of suspected BD. TCD confirmed BD in 51 (57%) patients and was inconclusive in 38 (43%), with no flow signals on the first examination in 7 (8%) patients and the waveform patterns in 31 (35%) being inconsistent with BD. Fourteen of the 19 patients who had CCA pattern in at least one artery but did not meet all the criteria for BD were subsequently found brain dead according to SPECT/clinical criteria or suffered cardiovascular death. Using the conventional criteria, TCD confirmed BD in a large proportion, of patients where clinical diagnosis could not be made. The presence of CCA pattern in one or more major cerebral artery may be prognostic of unfavorable outcome, even when BD criteria are not satisfied.

The objective of this study was to describe changes in cerebral autoregulation after severe pediatric traumatic brain injury (TBI). Two cerebral autoregulation tests were performed during the first 10 days after severe TBI in children

Tumor growth and metastasis is dependent on the formation and assembly of new blood vessels, a process known as neo-angiogenesis. Both pre-existing and circulating vascular cells have been shown to contribute to the assembly of tumor neo-vessels in specific tumors. Mobilization of endothelial progenitor cells (EPCs) from the bone marrow constitutes a crucial step in the formation of de novo blood vessels, and levels of peripheral blood EPCs have been shown to be increased in certain malignant states. However, the role of circulating EPCs in breast cancer is largely unknown. We recruited twenty-five patients with biopsy-proven invasive breast cancer at Weill Cornell Breast Center to participate in a pilot study investigating the correlation of circulating EPCs to extent of disease and initiation of chemotherapy. For each patient, a baseline sample was drawn before systemic treatment, and for seventeen of those patients, a second sample was taken after the first round of chemotherapy. Levels of peripheral blood EPCs, as defined by co-expression of CD133 and VEGFR2, were quantified by flow cytometry. Breast cancer patients with stage III & IV disease had statistically higher levels of circulating EPCs than did patients with stage I & II disease (median = 165,000 EPCs/5 x 10(6)MNCs vs. median = 6,920 EPCs/5 x 10(6)MNCs, respectively, P < 0.0001). In addition, in late-stage patients, levels of EPCs demonstrated a statistically significant drop after initiation of chemotherapy (median = 162,500 EPCs/5 x 10(6)MNCs [pre] vs. median = 117,500 EPCs/5 x 10(6)MNCs [post], P = 0.01). These results suggest that circulating EPCs may serve as a potential tumor biomarker in breast cancer and that EPCs may represent a plausible target for future therapeutic intervention.

To determine if chronic gastritis (CG) is associated with gastric dysrhythmia or delayed solid emptying in children with dyspepsia, 22 patients (7-15 years of age) with dyspepsia and normal gross endoscopies were studied. Antral biopsies were evaluated for chronic gastritis, and immunohistology was performed to determine densities of CD3+, CD20+, CD25+, and tryptase-positive cells. Electrogastrography (EGG) and gastric scintiscan evaluation were performed within 2-7 days of endoscopy. CG and increased immune cell densities were not associated with altered gastric emptying. Mean CD3+ cell counts were positively correlated with the percentage normal slow waves, and patients with a normal EGG had increased CD3+ cell density. In children with dyspepsia, chronic antral inflammation in the setting of a normal gross endoscopy is not associated with EGG abnormalities or delayed solid emptying. Chronic gastritis and gastric dysrhythmia may simply be two separate and distinct mechanisms resulting in the clinical entity of dyspepsia.

The effects of anesthetic management on blood flow to the optic nerve have not been well-studied. The ophthalmic artery provides the majority of the blood supply to the optic nerve via several smaller branches. Retinal blood flow has been shown to react to carbon dioxide (CO(2)) similar to intracranial vessels, but insufficient data exist for the ophthalmic artery. The purpose of this study is to examine the CO(2)-reactivity of the ophthalmic artery.Eight healthy awake subjects aged 28 to 50 yr were tested for CO(2)-reactivity in the ophthalmic artery using transcranial Doppler (TCD) insonation of blood flow velocity (V(op)), while simultaneously recording the V(op) of the middle cerebral artery (V(mca)) as an internal control. V(op) and V(mca) recordings were made under hypocapnic, normocapnic and hypercapnic conditions.The CO(2)-reactivity slope of V(mca) was 3.27% per mmHg PaCO(2). From normocapnia to hypercapnia, V(op) did not change significantly (mean +/- SD, 18 +/- 4 cm*sec(-1) to 18 +/- 6 cm*sec(-1)), (end-tidal CO(2), etCO(2), = 43 +/- 5 mmHg to 53 +/- 4 mmHg, respectively). In contrast, V(op) increased significantly under hypocapnic conditions (etCO(2) = 26 +/- 4 mmHg) to 25 +/- 5 cm*sec(-1) (P0.05). The CO(2)-reactivity slope of V(op) from normocapnia to hypocapnia was 2.57% per mmHg.This study demonstrates that V(op) increases with hypocapnia, but is unaffected by hypercapnia. The anastomoses of the ophthalmic artery with the external carotid artery, which displays a relatively fixed resistance, may account for these findings.