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Abstract: Background: The aim of this study was to evaluate the prognostic significance of the basal cell–like molecular breast cancer subtype with respect to locoregional recurrence and distant metastasis in African American women treated for breast cancer. Methods: A retrospective analysis was performed of the tumor registry database for all African American women diagnosed and treated for breast cancer from 1998 to 2005 who had assessable data for all 3 markers: estrogen, progesterone, and Her-2/neu. Results: A total of 372 patients were included in our study sample. Of these, 22 (6.1%) had locoregional recurrence, 35 (9.8%) had distant metastasis, and 301 (84.1%) had no evidence of breast tumor recurrence. The median follow-up time was 36 months. Compared with the other molecular subtypes the basal cell–like subtype showed a statistically significant association to distant metastasis: 15 (42.9%) vs 13 (37.1%), 4 (11.4%), and 3 (8.6%) (P < .001), respectively, for luminal A, Her-2/neu, and luminal B subtypes. The basal cell–like subtype was an independent predictor of distant metastasis (odds ratio, 5.8; 95% confidence interval, 1.5–22.0, P = .009). The molecular subtypes showed no statistically significant difference with respect to locoregional treatment administered and tumor stage at time of diagnosis. Conclusions: The basal cell–like molecular breast cancer subtype is an independent predictor of distant metastasis in African American women. [Copyright &y& Elsevier]

Objective: To describe the 1-year experience of a unique postgraduate medical education program set in Eritrea, a recently war-torn country., Design: The Partnership for Eritrea, a cooperative between The George Washington University Medical Center, Physicians for Peace, and the Eritrean Ministry of Health, formed a surgical residency program, launched January 2, 2008, in Asmara, Eritrea, to train native Eritrean surgeons. No prior residency program (to our knowledge) had existed in Eritrea., Setting: Eritrea, a country in the Horn of Africa., Patients: Five Eritrean physicians participated in the surgical residency., Main Outcome Measures: The number of operations performed, length of stay, antibiotic use, and intravenous fluid use., Results: The number of operations increased and resource use decreased because of improved and standardized clinical management., Conclusions: The Partnership for Eritrea established a general surgical residency program that improved clinical care in a resource-poor country that previously had lacked postgraduate training. The program experience suggests a model that can be reproduced in other developing countries.

Objective: To analyze whether the local-regional surgical treatments (breast-conserving therapy, mastectomy) resulted in different overall survival, distant metastasis-free survival, and locoregional recurrence-free survival rates for the various molecular breast cancer subtypes., Summary Background Data: Molecular gene expression profiling has been proposed as a new classification and prognostication system for breast cancer. Current recommendation for local-regional treatment of breast cancer is based on traditional clinicopathologic variables., Methods: Retrospective analysis of 372 breast cancer cases with assessable immunohistochemical data for ER, PR, and Her-2/neu receptor status, diagnosed from 1998 to 2005. Molecular subtypes analyzed were luminal A, luminal B, basal like, and Her-2/neu., Results: No substantial difference was noted in overall survival, and locoregional recurrence rate between the local-regional treatment modalities as a function of the molecular breast cancer subtypes. The basal cell-like subtype was an independent predictor of a poorer overall survival (hazard ratio [HR] = 2.52, 95% confidence interval [CI] 1.28-4.97, P < 0.01) and a shorter distant metastasis-free survival time (HR = 3.61, 95% CI 1.27-10.2, P < 0.01), and showed a tendency toward statistical significance as an independent predictor of locoregional recurrence (HR = 3.57, 95% CI 0.93-13.6, P = 0.06)., Conclusions: The basal cell-like subtype is associated with a worse prognosis, a higher incidence of distant metastasis, and may be more prone to local recurrence when managed with breast-conserving therapy.

Background: Breast cancer is currently regarded as a heterogeneous disease classified into various molecular subtypes using gene expression analysis. These molecular subtypes include: basal cell-like, Her-2/neu, luminal A, and luminal B., Objectives: To analyze the prevalence and clinicopathologic associations for molecular breast cancer subtypes in premenopausal and postmenopausal African-American women., Design: A retrospective analysis of all African-American women diagnosed with breast cancer from 1998 to 2005, who had assessable data for ER, PR, and Her-2/neu status. Molecular subtype classification was done based on immunohistochemical surrogates for ER, PR, and Her-2/neu status obtained from Howard University tumor registry for each patient. The molecular subtypes were defined as: luminal A (ER+ and/or PR+, HER2-), luminal B (ER+ and/or PR+, HER2+), basal-like (ER-, PR-, HER2-), and Her-2/neu (ER-, PR-, and HER2+)., Outcome Measures: We analyzed the prevalence of molecular breast cancer subtypes in a population of African-American women and determined their associations with patient demographics and clinicopathologic variables: node status, tumor size, histological grade, p53 mutation status, and breast cancer-specific survival., Results: The luminal A subtype was the most prevalent in our study sample (55.4%) compared with (11.8%) luminal B, (21.2%) basal cell-like, and (11.6%) Her-2/neu subtypes. The molecular subtypes did not differ by menopausal status. However, when stratified into age-specific groups, the basal cell-like subtype (57.1%) was the most prevalent in the age group <35 y compared with luminal A, luminal B, and Her-2/neu subtypes at 25.0%, 14.3%, and 3.6%, respectively. The basal cell-like subtype also showed an age-specific bimodal distribution with a peak in the <35 y and 51 to 65 y age groups. The basal cell-like and the Her-2/neu subtypes showed an increased association with clinicopathologic variables portending a more aggressive clinical course when compared with luminal A subtype. A paradoxical inverse relationship between the expression of p53 and Bcl-2 protooncoprotein was noted in the molecular subtypes. Breast cancer-specific survival differed significantly among the molecular subtypes (P < 0.04), with the basal cell-like and Her-2/neu subtypes having the poorest outcome., Conclusions: The high prevalence of the basal cell-like subtype in the young premenopausal African-American women aged <35 y could be a contributory factor to the poorer prognosis of breast cancer observed in this cohort of patients.

Introduction: Breast cancer is currently viewed as a heterogeneous disease made up of various subtypes, with distinct differences in prognosis. Our goal was to study the distribution and to characterize the clinical and biological factors that influence the behavior and clinical management of the different molecular breast cancer subtypes in premenopausal African-American women., Methods: A retrospective analysis of Howard University Hospital tumor registry, for all premenopausal African-American women aged less than 50 years, diagnosed with breast cancer from 1998-2005, was performed., Results: The luminal A subtype was the most prevalent (50.0%), vs basal-cell-like (23.2%), luminal B (14.1%), and HER-2/neu (12.7%). However when stratified by age groups, results showed that in the age group <35 years the basal-cell-like subtype was the most prevalent (55.6%), vs 25.9%, 14.8%, and 5.6% for luminal A, luminal B, and HER-2/neu subtypes, respectively (P < .000). P53 mutation was more prevalent in the basal-cell-like subtype compared to luminal A (48.0% vs 18.6%, P < .01). The expression of the Bcl-2 gene differed by subtype, with the luminal A and luminal B subtypes more likely to overexpress the Bcl-2 gene (89.1% luminal A, 80.0% luminal B vs 47.6% basal-cell-like and 40.0% HER-2/neu, P < .000). Though not statistically significant, HER-2/neu and basal-cell-like subtypes had the shortest survival time (P < .31)., Conclusion: The high prevalence of the basal-cell-like subtype in young premenopausal African-American women aged <35 years may contribute to the poorer prognosis observed in this cohort of African-American women.

Objective: To compare aminoglycoside pharmacokinetics in African-Americans with normal renal function with published adult population values., Design: An Institutional Review Board approved concurrent study., Setting: The study was conducted at Howard University Hospital, Washington DC., Subjects: All subjects had serum creatinine levels of 1.5mg/dl or less and were receiving aminoglycoside for suspected or documented Gram-negative infection, had no obvious underlying disease condition that could influence aminoglycoside pharmacokinetics and were aged 18 years or older., Main Outcome Measures: Volume of distribution (Vd), half-life (t1/2), elimination rate constant (Ke) and total body clearance (Cl) were calculated using a one-compartment, open, linear pharmacokinetic model. Using an unpaired Student's t-test, the pharmacokinetic values of our patients were compared with general population values., Interventions: Patients receiving aminoglycosides were identified by the pharmacist through the hospital's standard antibiotic order sheet. Twenty-five patients were enrolled after they met the inclusion criteria. Pharmacists made recommendations for dose change as part of standard of care when inappropriate doses were ordered. In collaboration with medical and nursing staff, the amount and time of dose administration, and steady-state peak and trough serum drug levels were stringently measured, documented on a data collection form and used to calculate pharmacokinetic values for our patients. The form was also used to document demographic information., Results: The following values were obtained: Vd 0.27+/-0.15 litres/kg, t(1/2) 1.93+/-1.38h, Ke 0.31+/-0.134/h (gentamicin), Ke 0.22 +/- 0.10/h (tobramycin), Cl 103.95+/-62.98ml/kg/h (gentamicin) and Cl 118.96+/-84.83ml/kg/h (tobramycin). These values are not significantly different from general population values. Following a mean tobramycin or gentamicin dose of 1.32+/-0.32mg/kg ideal body weight (IBW)/ dose or 1.11+/-0.33 mg/kg actual body weight (ABW)/ dose every 8h, patients achieved a mean peak and trough serum drug levels of 6.6+/-3.86mg/litre and 1.03+/-0.68mg/litre, respectively. Wide interpatient pharmacokinetic variability was also observed., Conclusions: We conclude that aminoglycoside pharmacokinetics in African-Americans seem to be consistent with the published general population values. Thus, initiating aminoglycoside regimens using population dosing guidelines appears to be appropriate. However, due to the observed wide interpatient pharmacokinetic variability, individualized dosing is required with very close monitoring, to avoid or minimize toxicity.

Objective: To determine the frequency with which early adequate peak serum concentrations (6-12 mg/ litre) can be achieved following a 4 mg/kg loading dose of gentamicin or tobramycin in post-operative septic shock patients., Method: Eleven post-operative septic shock patients were grouped into (i) a control group (n=7) who received the conventional gentamicin or tobramycin dosing regimen of 2 mg/kg loading dose followed by a maintenance dose of approximately 1.5mg/kg (peak and trough levels were measured after the third dose), and (ii) a study group (n = 4) who received a tobramycin or gentamicin 4 mg/kg loading dose, followed by 30 min, 3 h and 16 h serum drug level measurements. Pharmacokinetic parameters were calculated using a one-compartmental model. Differences in both groups were determined using Student's t-test., Results: Pharmacokinetic parameters in both groups showed no statistically significant difference. The dose from which peak levels were drawn was significantly higher in the study group (4 mg/kg vs. 1.66 mg/kg; P = 0.001), which also resulted in higher but adequate peak serum concentrations (8.9+/-2.2 vs. 4.8+/-1.8 mg/litre). In the study group, linear regression analysis showed significant relationships between dose and peak concentrations and volume of distribution and peak concentrations (r = 0.96, P= 0.01 and r= -0.96, P= 0.01, respectively)., Conclusion: One hundred per cent of the post-operative septic shock patients achieved target peak serum concentrations (mean 8.9+/-2.2 mg/litre) following a 4 mg/kg tobramycin or gentamicin loading dose. An expanded Vd (0.46+/-0.13 litres/kg) was also observed.

Leading causes of consumer product-related ocular trauma have not been well described. To delineate these causes in a nationally representative sample, data collected by the US Consumer Product Safety Commission (USCPSC) were reviewed. Data were obtained from the National Electronic Injury Surveillance System (NEISS), a national probability sample survey conducted by USCPSC that continuously monitors consumer product-related injuries treated in hospital emergency rooms across the United States. These data formulated the product summary report for the calendar year 1991. The sampling frame for the NEISS consisted of hospitals listed on the Center for Health Statistics Master Inventory File stratified geographically by size of hospital and number of emergency-room visits. During the calendar year 1991, there were a nationally estimated 298,852 consumer product-related eye injuries treated in hospital emergency rooms. Appoximately 500 different products were implicated in these injuries, with the leading cause being contact lenses (hard and soft), accounting for an estimated 26,490 emergency-room visits. This is followed by welding equipment (12,771 visits), hair curlers/curling irons (5946 visits), and workshop power grinders (5476 visits). Consumer products account for a sizable number of ocular injuries requiring treatment in hospital emergency rooms. Research on outcomes and prevention strategies of the injuries is warranted.

The most common cause of pneumoperitoneum is iatrogenic postsurgical free air that enters the abdominal cavity during laparotomy. In these patients, pneumoperitoneum usually resolves within the first week of surgery and laparoscopic procedures. In patients who have not had recent laparotomy or laparoscopy, pneumoperitoneum indicates rupture of an intra-abdominal viscus in about 90 per cent of the time. Perforated gastric and duodenal ulcers account for the greatest number of these cases. The other 10 per cent are due to a variety of nonsurgical causes that can often be treated by supportive and non-operative measures. Lack of clinical awareness about these small but significant subset of patients who present with spontaneous benign pneumoperitoneum is a source of needless laparotomies that can at times lead to serious postoperative complications. Benign pneumoperitoneum can be categorized according to the source of the gas as suggested by Gantt. The thoracic cavity is by far the most common source, followed by the GI and female genital tracts and a host of other miscellaneous causes. We report here six patients who presented to Howard University Hospital with nonsurgical pneumoperitoneum. Four of these patients underwent negative laparotomies and one died postoperatively. The most common causes of benign pneumoperitoneum are discussed and a review of the literature is presented.

A patient with actinomyces infection of the posterior neck was diagnosed by fine-needle aspiration biopsy. The lesion presented as a recurrent, firm, and indurated mass that was clinically diagnosed as adenitis and cellulitis and was thought to be a lymphoma 6 months after the onset of his illness. Smears and cell block sections of the aspirate showed characteristic colonies ("sulfur granules") of actinomyces. Subsequent regional lymph node biopsy revealed reactive lymphoid hyperplasia.

Eighty-three cases of tracheopleuropulmonary injuries complicating enteral tube feeding are analyzed to identify the patterns of injury, and precipitating factors and ways to avoid them. Six new cases observed by the authors and 77 other cases cited in British literature between 1976 and 1987 are presented. In recent years, reports of this complication have been increasing, apparently in a geometrical progression: 8%, 18%, and 74% were reported between 1976 to 1979, 1980 to 1983, and 1984 to 1987, respectively. Sixty-one percent occurred in patients aged 60 years or older. Most of the patients (84%) were seriously ill, which compounded their complications. Seventy-four percent of all injuries were committed by house staff; the narrow bore tube with guide wire was used in 77% of cases. Less than reliable methods were used to confirm tube position in most instances. The presence of cuffed endotracheal tubes did not offer protection. The patients on mechanical ventilation tended to deteriorate if they developed a pneumothorax once the malpositioned tubes were removed. Of the cases reviewed for this report, 18 deaths occurred; 72% being directly related to the tube injuries. Lack of awareness, inadequate confirmatory methods, and insufficient supervision accounted for most of these preventable complications. Educating house/nursing staff in the use of the new tubes, closer supervision, and the application of equal measures of care and caution as employed in other invasive and potentially dangerous procedures are recommended to avoid disastrous outcome.