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Introduction. ER, PR, and HER2 are routinely available in breast cancer specimens. The purpose of this study is to contrast breast cancer-specific survival for the eight ER/PR/HER2 subtypes with survival of an immunohistochemical surrogate for the molecular subtype based on the ER/PR/HER2 subtypes and tumor grade. Methods. We identified 123,780 cases of stages 1–3 primary female invasive breast cancer from California Cancer Registry. The surrogate classification was derived using ER/PR/HER2 and tumor grade. Kaplan-Meier survival analysis and Cox proportional hazards modeling were used to assess differences in survival and risk of mortality for the ER/PR/HER2 subtypes and surrogate classification within each stage. Results. The luminal B/HER2− surrogate classification had a higher risk of mortality than the luminal B/HER2+ for all stages of disease. There was no difference in risk of mortality between the ER+/PR+/HER2− and ER+/PR+/HER2+ in stage 3. With one exception in stage 3, the ER-negative subtypes all had an increased risk of mortality when compared with the ER-positive subtypes. Conclusions. Assessment of survival using ER/PR/HER2 illustrates the heterogeneity of HER2+ subtypes. The surrogate classification provides clear separation in survival and adjusted mortality but underestimates the wide variability within the subtypes that make up the classification.

To assess the effect of marital status and the role of race/ethnicity on breast cancer specific mortality in women with triple negative breast cancer (TNBC). The study utilized the California Cancer Registry to identify 22,812 cases of first primary female TNBC. Unadjusted Kaplan-Meier breast cancer specific survival was computed. Cox Proportional Hazards modeling was used to compute the adjusted risk of breast cancer specific mortality for women who were single, separated, divorced, and widowed when compared with women who were married. Models were adjusted for age, stage, tumor grade, SES, and treatment with surgery, chemotherapy, hormone therapy, and radiation therapy. Hazard ratios (HR) and 95% confidence intervals (CI) were reported. Separated (HR: 1.45; 95% CI: 1.14-2.01) and widowed (HR: 1.39; 95%CI: 1.23-1.57) white women had a higher risk of mortality than white married women whereas single and divorced white women had the same risk of mortality. For Asian/Pacific Islanders (API), only single (HR: 1.55; 95% CI: 1.17-2.06) and divorced (HR:1.81; 95% CI:1.26-2.60) women had a higher risk of mortality than married women. Marital status had no influence on risk of mortality for either black or Hispanic women. The risk of mortality associated with marital status is dependent on race/ethnicity. Only white and API women with TNBC have a marital advantage.

Purpose The purpose of this study was to assess differences in breast cancer-specific mortality within tumors of the same size when breast cancer was defined using the three tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Methods We identified 104,499 cases of node-negative primary female invasive breast cancer from the California Cancer Registry. Tumor size was categorized as T1a, T1b, T1c, T2, and T3. Breast cancer was defined using ER, PR, and HER2. Kaplan–Meier Survival analysis was conducted and Cox Regression was used to compute the adjusted risk of mortality for the ER+/PR+/HER2+, ER−/PR−/HER2− (TNBC), and ER−/PR−/HER2+ (HER2-overexpressing) subtypes when compared with the ER+/PR+/HER2−. Separate models were computed for each tumor size. Results Unadjusted survival analysis showed that for all tumor sizes, the ER+/PR+ subtypes regardless of HER status have better breast cancer-specific survival than ER−/PR− subtypes. Subtype was not an important factor for risk of mortality for T1a tumors. The ER+/PR+/HER2+ subtype was only a risk for mortality in T1b tumors that were unadjusted for treatment. For all other tumor sizes, the ER+/PR+/HER2+ had the same mortality as the ER+/PR+/HER2− subtype regardless of adjustment for treatment. The HER2-overexpressing subtype had a higher risk of mortality than the ER+/PR+/HER2− subtype except for T1b tumors that were adjusted for treatment. For all tumor sizes, the TNBC had higher hazard ratios than all other subtypes. Conclusions T1a tumors have the same risk of mortality regardless of ER/PR/HER2 subtype, and ER and PR negativity plays a stronger role in survival than HER2 positivity for tumors of all size.

Background Racial disparities in breast cancer survival have been well documented. This study examines the association of race/ethnicity and socioeconomic status (SES) on breast cancer-specific mortality in a large population of women with invasive breast cancer. Methods We identified 179,143 cases of stages 1–3 first primary female invasive breast cancer from the California Cancer Registry from January, 2000 through December, 2010. Cox regression, adjusted for age, year of diagnosis, grade, and ER/PR/HER2 subtype, was used to assess the association of race/ethnicity on breast cancer-specific mortality within strata of stage and SES. Hazard ratios (HR) and 95% confidence intervals were reported. Results Stage 1: There was no increased risk of mortality for any race/ethnicity when compared with whites within all SES strata. Stage 2: Hispanics (HR = 0.85; 0.75, 0.97) in the lowest SES category had a reduced risk of mortality.. Blacks had the same risk of mortality as whites in the lowest SES category but an increased risk of mortality in the intermediate (HR = 1.66; 1.34, 2.06) and highest (HR = 1.41; 1.15, 1.73) SES categories. Stage 3: Hispanics (HR = 0.74; 0.64, 0.85) and APIs (HR = 0.64; 0.50, 0.82) in the lowest SES category had a reduced risk while blacks had similar mortality as whites. Blacks had an increased risk of mortality in the intermediate (HR = 1.52; 1.20, 1.92) and highest (HR = 1.53; 1.22, 1.92) SES categories. Conclusions When analysis of breast cancer-specific mortality is adjusted for age and year of diagnosis, ER/PR/HER2 subtype, and tumor grade and cases compared within stage and SES strata, much of the black/white disparity disappears. SES plays a prominent role in breast cancer-specific mortality but it does not fully explain the racial/ethnic disparities and continued research in genetic, societal, and lifestyle factors is warranted.

Purpose The ER-/PR-/HER2- or triple-negative (TNBC) subtype is more prevalent among women who are young, black, Hispanic, and of lower SES. The purpose of this study is to determine if young age and low SES are associated with TNBC within four mutually exclusive race/ethnicities. Methods The study identified 19,283 cases of TNBC and 89,089 of ER+/PR+/HER2- from the California Cancer Registry. Logistic regression analyses were conducted separately for whites, blacks, Hispanics, and Asian/Pacific Islanders (API) to compute the adjusted odds ratios (OR) for age and SES for the TNBC versus the ER+/PR+/HER2- subtype. Results White (OR=1.37;1.23-1.53) and Hispanic and women (OR=1.35;1.17-1.56) 30–39 had increased odds of the TNBC when compared with women 50–59 of the same race/ethnicity. Black women under 40 had the same odds, and black women 40–49 had lower odds of the TNBC as black women 50–59. White, black, and Hispanic women 70 and older had decreased or the same odds of the TNBC as 50 to 59-year-old women. API women had a similar risk of TNBC at all ages. Lower SES was associated with increased risk of TNBC only for white and Hispanic women. The odds of TNBC were no worse for API women with lower SES than API women with higher SES. SES was not statistically significant for black women. Conclusions When assessing the odds of TNBC within a single race/ethnicity, young age and low SES are risk factors only for white and Hispanic women, but not for black and API women.

Purpose This study compared the demographic and clinicopathologic characteristics and risk of mortality between the triple positive (TP) and ER+/PR+/HER2− breast cancer subtypes. Methods Cases of first primary female invasive TP and ER+/PR+/HER2− breast cancer were obtained from the California Cancer Registry. Logistic regression analysis was used to compare differences in factors associated with the TP versus the ER+/PR+/HER2− subtype. Cox regression was used to compute the adjusted risk of breast cancer-specific mortality of the TP versus ER+/PR+/HER2−. Results The odds of TP versus ER+/PR+/HER2− were higher with advanced stage, high grade, low SES, ≤ 45 years of age (OR 1.48; CI 1.40–1.55), black (OR 1.11; CI 1.02–1.21), Asian/Pacific Islander (OR 1.15; CI 1.09–1.22), and uninsured (OR 1.42; CI 1.15–1.73). Unadjusted survival analysis indicated worse survival for the TP when compared with the ER+/PR+/HER2− subtype. However, adjusted risk of mortality for the TP subtype was not statistically significantly worse than the ER+/PR+/HER2− subtype. Conclusions Young age, advanced stage and grade, low SES, black and API race, and lack of health insurance are more common in the TP subtype than in the ER+/PR+/HER2− subtype. However the risk of mortality between these two subtypes is similar.

Background The 2007 St Gallen international expert consensus statement describes three risk categories and provides recommendations for treatment of early breast cancer. The set of recommendations on how to best treat primary breast cancer is recognized and used by clinicians worldwide. We now examine the variability of five-year survival of the 2007 St Gallen Risk Classifications utilizing the ER/PR/HER2 subtypes. Methods Using the population-based California Cancer Registry, 114,786 incident cases of Stages 1-3 invasive breast cancer diagnosed between 2000 and 2006 were identified. Cases were assigned to Low, Intermediate, or High Risk categories. Five-year-relative survival was computed for the three St Gallen risk categories and for the ER/PR/HER2 subtypes for further differentiation. Results and Discussion There were 9,124 (13%) cases classified as Low Risk, 44,234 (65%) cases as Intermediate Risk, and 14,340 (21%) as High Risk. Within the Intermediate Risk group, 33,735 (76%) were node-negative (Intermediate Risk 2) and 10,499 (24%) were node-positive (Intermediate Risk 3). For the High Risk group, 6,149 (43%) had 1 to 3 positive axillary lymph nodes (High Risk 4) and 8,191 (57%) had four or more positive lymph nodes (High Risk 5). Using five-year relative survival as the principal criterion, we found the following: a) There was very little difference between the Low Risk and Intermediate Risk categories; b) Use of the ER/PR/HER2 subtypes within the Intermediate and High Risk categories separated each into a group with better five-year survival (ER-positive) and a group with worse survival (ER-negative), irrespective of HER2-status; c) The heterogeneity of the High Risk category was most evident when one examined the ER/PR/HER2 subtypes with four or more positive axillary lymph nodes; (d) HER2-positivity did not always translate to worse survival, as noted when one compared the triple positive subtype (ER+/PR+/HER2+) to the triple negative subtype (ER-/PR-/HER2-); and (e) ER-negativity appeared to be a stronger predictor of poor survival than HER2-positivity. Conclusion The use of ER/PR/HER2 subtype highlights the marked heterogeneity of the Intermediate and High Risk categories of the 2007 St Gallen statements. The use of ER/PR/HER2 subtypes and correlation with molecular classification of breast cancer is recommended.

Purpose Nonventilator hospital‐acquired pneumonia (NV‐HAP) is an underreported and unstudied disease, with potential for measurable outcomes, fiscal savings, and improvement in quality of life. The purpose of our study was to (a) identify the incidence of NV‐HAP in a convenience sample of U.S. hospitals and (b) determine the effectiveness of reliably delivered basic oral nursing care in reducing NV‐HAP. Design A descriptive, quasi‐experimental study using retrospective comparative outcomes to determine (a) the incidence of NV‐HAP and (b) the effectiveness of enhanced basic oral nursing care versus usual care to prevent NV‐HAP after introduction of a basic oral nursing care initiative. Methods We used the International Statistical Classification of Diseases and Related Problems (ICD‐9) codes for pneumonia not present on admission and verified NV‐HAP diagnosis using the U.S. Centers for Disease Control and Prevention diagnostic criteria. We completed an evidence‐based gap analysis and designed a site‐specific oral care initiative designed to reduce NV‐HAP. The intervention process was guided by the Influencer Model™ (see Figure ) and participatory action research. Findings We found a substantial amount of unreported NV‐HAP. After we initiated our oral care protocols, the rate of NV‐HAP per 100 patient days decreased from 0.49 to 0.3 (38.8%). The overall number of cases of NV‐HAP was reduced by 37% during the 12‐month intervention period. The avoidance of NV‐HAP cases resulted in an estimated 8 lives saved,$1.72 million cost avoided, and 500 extra hospital days averted. The extra cost for therapeutic oral care equipment was $ 117,600 during the 12‐month intervention period. Cost savings resulting from avoided NV‐HAP was$1.72 million. Return on investment for the organization was $ 1.6 million in avoided costs. Conclusions NV‐HAP should be elevated to the same level of concern, attention, and effort as prevention of ventilator‐associated pneumonia in hospitals. Clinical Relevance Nursing needs to lead the way in the design and implementation of policies that allow for adequate time, proper oral care supplies, ease of access to supplies, clear procedures, and outcome monitoring ensuring that patients are protected from NV‐HAP.

Background The alignment of the lower extremity has important implications in the development of knee arthritis. The effect of incremental rotations of the limb on common parameters of alignment has not been studied. The purpose of the study was to (1) determine the standardized neutral position measurements of alignment and (2) determine the effect of rotation on commonly used measurements of alignment. Methods Eighty-seven full length CT angiography studies (49 males and 38 females, average age 66 years old) were included. Three-dimensional models were created using a rendering software program and placed on a virtual plane. An image of the extremity was obtained. Thirty scans were randomly selected, and those models were rotated in 3° intervals around the longitudinal axis and additional images were obtained. Results In the neutral position, the mechanical lateral distal femoral articular angle (mLDFA) was 85.6 ± 2.3°, medial proximal tibial angle (MPTA) was 86.1 ± 2.8°, and mechanical tibiofemoral angle (mTFA) was −0.7 ± 3.1°. Females had a more valgus alignment with a mTFA of 0.5 ± 2.9° while males had a more varus alignment with a mTFA of −1.7 ± 2.9°. The anatomic tibiofemoral angle (aTFA) was 4.8 ± 2.6°, the anatomic lateral distal femoral angle (aLDFA) measured 80.2 ± 2.2°, and the anatomical-mechanical angle (AMA) was 5.4 ± 0.7°. The prevalence of constitutional varus was 18%. The effect of rotation on the rotated scans led to statistically significant differences relative to the 0° measurement for all measurements. These effects may be small, and their clinical importance is unknown. Conclusions This study provides new information on standardized measures of lower extremity alignment and the relationship between discreet axial rotations of the entire lower extremity and these parameters.

Background: Previous studies of conversion of failed ankle arthrodesis to total ankle arthroplasty showed failure in patients with an absent distal fibula, and more recently that has been considered a contraindication. However, these conclusions were based on limited case series with older prosthetic designs, and the potential for successful conversion in this challenging patient population remains unclear. This retrospective study examines the midterm follow-up of 21 patients treated for a conversion of failed ankle arthrodesis by a single surgeon using a standard technique with a single prosthesis, with a focus on the treatment of 5 patients with a deficient distal fibula. Methods: Between May 2010 and August 2019, 27 patients underwent conversion using a prosthesis with an intramedullary tibial component, 21 of which were available for the study. Six patients had a deficient distal fibula, and 5 were available for follow-up. Our primary outcome measure was having a total ankle arthroplasty in place. Secondary outcomes were evaluated postoperatively with a visual analog scale, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, a satisfaction survey, and radiographic assessment of the arthroplasty and any concomitant hindfoot fusions. Results: Mean follow-up for all patients was 7.6 (2.6-11.8) years, with follow-up of the deficient fibula group of 8.2 (4.9-11.8) years. Complications included malleolar fracture with or without subsequent surgery (n = 5), varus deformity (n = 1), and wound dehiscence or infection (n = 2). At final follow-up, all patients, including the 5 with a deficient distal fibula, had an intact ankle arthroplasty, although 3 with intact fibulas had undergone prosthetic revision. Postoperative dorsiflexion was 4.5 ± 5.1 degrees and plantarflexion 20.9 ± 13.37 degrees. There were no pseudarthroses in the 11 patients with concomitant hindfoot arthrodesis. Mean (±SD) VAS score was 4.4 ± 3.0 and AOFAS score was 71.2 ± 21.7. Sixty-seven percent reported that they were satisfied or very satisfied, with 16% dissatisfied or very dissatisfied. One of the deficient fibula patients was very dissatisfied. Seventy-six percent had no limitations with activities of daily living and two-thirds of those had no limitations at all. Conclusion: Consistent with previous studies, we find that total ankle arthroplasty can be a satisfactory salvage procedure for patients with a failed ankle arthrodesis. Unlike previous reports, we observed high prosthetic retention in patients with a deficient fibula, although pain relief and range of motion outcomes were mixed, and some patients required revision surgery. These findings should be interpreted in light of the intrinsic limitations of a small sample size, lack of preoperative comparison data, and incomplete follow-up in the deficient fibula group. Level of Evidence: Level IV, clinical research. Visual Abstract This is a visual representation of the abstract.