Phyllodes Tumor

Findings: Mammogram shows a lobular hyper dense mass with partially circumscribed and partially obscured margins. No calcifications visible

Meaning : leaf-like in Greek, phyllodes tumors demonstrate papillary growth of epithelial lined stroma
Key point: Large rapidly growing circumscribed mass without calcifications
Mammography :Phyllodes tumors appear as a dense, round or oval masses with circumscribed or lobulated borders on mammography. Indistinct margins favor malignant transformation. Calcifications are rare but when present are coarse.
Ultrasonography: demonstrates an oval, round, or lobulated hypoechoic mass. Cystic spaces favor malignancy. Increased vascularity can be common .

T1W1/T2W1 :Phyllodes tumors appear heterogeneously hypointense on T1WI with slit like areas of increased T2WI representing fluid. Enhancement is typically rapid and suspicious kinetics can be observed in approximately 33% of cases.
Differential Diagnosis:
Typically occurring in younger women, fibroadenomas also appear as oval or lobulated mass but have dense, coarse calcifications, homogeneous echogenicity, and more moderate enhancement characteristics.
While there is some overlap with phyllodes tumors demonstrating malignant transformation, breast carcinoma is more likely to demonstrate indistinct margins. Pleomorphic calcifications also favor carcinoma.
Primary sarcoma of the breast is distinguished from phyllodes tumors by the absence of epithelial components. The clinical course of primary sarcoma of the breast is similar to malignant phyllodes tumors.

Ultrasound shows an irregularly shaped mass with heterogeneous echogenicity and ill-defined borders.

Treatment: is by surgical excision with greater than 1 cm margins. Mastectomy may be required for large tumors. Axillary node dissection is usually unnecessary. With respect to adjuvant therapy, radiation reduces local recurrence. Chemotherapy has demonstrated no benefit.

US Braced For Fights With Pakistanis

President Obama insisted that the assault force hunting down Osama bin Laden last week be large enough to fight its way out of Pakistan if confronted by hostile local police officers and troops, senior administration and military officials said Monday.

In revealing additional details about planning for the mission, senior officials also said that two teams of specialists were on standby: One to bury Bin Laden if he was killed, and a second composed of lawyers, interrogators and translators in case he was captured alive. That team was set to meet aboard a Navy ship, most likely the aircraft carrier Carl Vinson in the North Arabian Sea.
Mr. Obama’s decision to increase the size of the force sent into Pakistan shows that he was willing to risk a military confrontation with a close ally in order to capture or kill the leader of Al Qaeda.
Such a fight would have set off an even larger breach with the Pakistanis than has taken place since officials in Islamabad learned that helicopters filled with members of a Navy Seals team had flown undetected into one of their cities, and burst into a compound where Bin Laden was hiding.
One senior Obama administration official, pressed on the rules of engagement for one of the riskiest clandestine operations attempted by the C.I.A. and the military’s Joint Special Operations Command in many years, said: “Their instructions were to avoid any confrontation if at all possible. But if they had to return fire to get out, they were authorized to do it.”
The planning also illustrates how little the administration trusted the Pakistanis as they set up their operation. They also rejected a proposal to bring the Pakistanis in on the mission.

Under the original plan, two assault helicopters were going to stay on the Afghanistan side of the border waiting for a call if they were needed. But the aircraft would have been about 90 minutes away from the Bin Laden compound.
About 10 days before the raid, Mr. Obama reviewed the plans and pressed his commanders as to whether they were taking along enough forces to fight their way out if the Pakistanis arrived on the scene and tried to interfere with the operation.
That resulted in the decision to send two more helicopters carrying additional troops. These followed the two lead Black Hawk helicopters that carried the actual assault team. While there was no confrontation with the Pakistanis, one of those backup helicopters was ultimately brought in to the scene of the raid when a Black Hawk was damaged while making a hard landing.
“Some people may have assumed we could talk our way out of a jam, but given our difficult relationship with Pakistan right now, the president did not want to leave anything to chance,” said one senior administration official, who like others would not be quoted by name describing details of the secret mission. “He wanted extra forces if they were necessary.”
With tensions between the United States and Pakistan escalating since the raid, American officials on Monday sought to tamp down the divisions and pointed to some encouraging developments.
A United States official said that American investigators would soon be allowed to interview Bin Laden’s three widows, now being held by Pakistani authorities, a demand that Mr. Obama’s national security adviser, Thomas E. Donilon, made on television talk shows on Sunday.
American officials say the widows, as well as a review of the trove of documents and other data the Seals team collected from the raid, could reveal important details, not only about Bin Laden’s life and activities since he fled into Pakistan from Afghanistan in 2001, but also information about Qaeda plots, personnel and planning.
“We believe that it is very important to maintain the cooperative relationship with Pakistan precisely because it’s in our national security interest to do so,” said the White House spokesman, Jay Carney.
In an effort to help mend the latest rupture in relations, the C.I.A. director, Leon E. Panetta, will talk soon with his counterpart, Lt. Gen. Ahmad Shuja Pasha, head of the Inter-Services Intelligence Directorate, or ISI, “to discuss the way forward in the common fight against Al Qaeda,” an American official said.
On Sunday, Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff, called the Pakistani Army chief, Gen. Ashfaq Parvez Kayani. “Mullen just wanted to check in with him,” said an American military official. “The conversation was civil, but sober, given the pressure that the general is under right now.”
In describing the mission, the officials said that American surveillance and reconnaissance aircraft were watching and listening to how Pakistan’s police forces and military responded to the raid. That determined how long the commandos could safely remain on the ground going through the compound collecting computer hard drives, thumb drives and documents.
American forces were under strict orders to avoid engaging with any Pakistani forces that responded to the commotion at the Bin Laden compound, senior administration officials said.
If a confrontation appeared imminent, there were contingency plans for senior American officials, including Admiral Mullen, to call their Pakistani counterparts to avert an armed clash.
But when he reviewed the plans, Mr. Obama voiced concern that this was not enough to protect the troops on the mission, administration officials said.
In planning for the possible capture of Bin Laden, officials decided they would take him aboard a Navy ship to preclude battles over jurisdiction.
The plan, officials said, was to do an initial interrogation for any information that might prevent a pending attack or identify the location of other Qaeda leaders.
“There was a heck of a lot of planning that went into this for almost any and all contingencies, including capture,” one senior administration official said.
In the end, the team organized to handle his death was called into duty. They did a quick forensics study of the body, washed it, and buried it at sea.
But the officials acknowledged that the mission always was weighted toward killing, given the possibility that Bin Laden would be armed or wearing an explosive vest.

By ERIC SCHMITT, THOM SHANKER and DAVID E. SANGER

@ NYTimes

Migraine : Update on New Therapies

Drugs with a better efficacy or side–effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.

•The oral calcitonine gene–related peptide antagonist Telcagepant is efficacious in acute treatment.
•Triptans, as other drugs, are more efficient if taken early but nonsteroidal anti–inflammatory drugs and analgesics remain useful for acute treatment, according to several meta–analyses.
•Single–pulse transcranial magnetic stimulation during the aura rendered more patients pain–free (39%) than sham stimulation (22%) in one study.
•Topiramate could be effective for migrainous vertigo, but it did not prevent transformation to chronic migraine in patients with high attack frequency.
•Onabotulinumtoxin A was effective for chronic migraine and well tolerated, but the therapeutic gain over placebo was modest; the clinical profile of responders remains to be determined before widespread use.
•Occipital nerve stimulation was effective in intractable chronic migraine with 39% of responders compared to 6% after sham stimulation. This and other neuromodulation techniques, such as sphenopalatine ganglion stimulation, are promising treatments for medically refractory patients but large controlled trials are necessary.
•One study suggests that outcome of patent foramen ovale closure in migraine might depend on anatomic and functional characteristics.

study by : Magis D et al

@Current Opinion in Neurology

Beyond Revenge

it's an interesting article ,psychological analysis of ecstatic joy after Bin Laden's death/Pedram

Some Americans celebrated the killing of Osama bin Laden loudly, with chanting and frat-party revelry in the streets. Others were appalled — not by the killing, but by the celebrations.
“It was appropriate to go after Bin Laden, just to try to cut the head off that serpent, but I don’t think it’s decent to celebrate a killing like that,” said George Horwitz, a retired meat cutter and Army veteran in Bynum, N.C.
Others were much more critical. “The worst kind of jingoistic hubris,” a University of Virginia student wrote in the college newspaper, The Cavalier Daily. In blogs and online forums, some people asked: Doesn’t taking revenge and glorying in it make us look just like the terrorists?
The answer is no, social scientists say: it makes us look like human beings. In an array of research, both inside laboratories and out in the world, psychologists have shown that the appetite for revenge is a sensitive measure of how a society perceives both the seriousness of a crime and any larger threat that its perpetrator may pose.
Revenge is most satisfying when there are strong reasons for exacting it, both practical and emotional.
“Revenge evolved as a deterrent, to impose a cost on people who threaten a community and to reach into the heads of others who may be contemplating similar behavior,” said Michael McCullough, a psychologist at the University of Miami and author of “Beyond Revenge: The Evolution of the Forgiveness Instinct” (Jossey-Bass, 2008). “In that sense it is a very natural response.”
Many of the sources of the joyous outburst were obvious: A clear victory after so many drawn-out conflicts. A demonstration of American competence, and of consequences delivered. The public relations value of delivering a public blow to a worldwide terror network. And, it needs to be said, the timing: The news hit just as many bars were starting to clear out for the night.
But this was much more than a simple excuse to party.
“Pure existential release,” said Tom Pyszczynski, a social psychologist at the University of Colorado at Colorado Springs, who has studied reactions to 9/11. “Whether or not the killing makes any difference in the effectiveness of Al Qaeda hardly matters; defeating an enemy who threatens your worldview, the very values you believe are most protective, is the quickest way to calm existential anxiety.”
After almost 10 years, the end was nothing if not final. “The emotions were so strong, I think, because the event was compacted: Bin Laden was found and killed, and it was done — done and over, just like that,” said Kevin Carlsmith, a social psychologist at Colgate University and the Center for Advanced Study in the Behavioral Sciences at Stanford. “We’re so used to people being brought in, held at Guantánamo, the trials, the appeals; it feels like justice is never done.”
As a rule, people are far more forgiving than they might guess, studies find. After most betrayals, like being dumped by a love interest or insulted, the urge for revenge erodes around the same rate that certain memories do: sharply in the first few weeks, and much more slowly afterward. The same kind of pattern can follow even physical assaults, depending on the circumstances and the personality of the victim.
“The intensity of the emotion falls off precipitously, simply because the body can’t carry such a giant load of outrage and function very well,” Dr. McCullough said.
But the urge for payback — especially for a crime like the Sept. 11, 2001, attacks, which killed almost 3,000 civilians — never goes to zero. “There is a stubborn part of the memory that hangs on to the urge, to a little piece of it,” and the pain is refreshed every time the memory is recalled, Dr. McCullough said.
It is easy to forget how much fear was in the air after the 9/11 attacks: the anthrax    mailings, the airport lines, the color-coded terror alerts. Many of those celebrating late on Sunday and early Monday were teenagers during those years, young people who have lived much of their lives under the threat of terrorism — and this terrorist in particular — and who had the time and energy to hit the streets and share the moment.
“For them this was a chance to be a part of history,” Dr. Pyszczynski said.
In a long series of studies, psychologists have shown that when people are reminded that they will one day die, they fixate on attributes they consider central to their self worth. Those who are religious become more so; those who value strength or physical attractiveness intensify their focus on these qualities; and people generally become more patriotic, more supportive of aggressive military action.
“Even subtle reminders of 9/11 have the same effect,” Dr. Pyszczynski said.
The sight of Bin Laden’s face on television or a smartphone news feed might have been enough to move people from the sidelines into the streets, to cheer for the home team.
Finally, people everywhere have a strong belief in “just desserts” punishment. In a 2002 study, psychologists at Princeton University had more than 1,000 participants evaluate specific crimes and give sentencing recommendations for each. The subjects carefully tailored each recommended sentence to the details of the infraction, its brutality and the record of the perpetrator.
The drive to enforce those sentences varies widely from person to person. But in a crowd of like-minded people, the most intense drives for justice become the norm: People who may have felt a mix of emotions in response to the news can be swept up in the general revelry.
Thus the natural urge for revenge — satisfied so suddenly, releasing a decade of background anxiety, stoked by peers — feeds on itself. Delight turns to chanting turns to climbing on lamp posts.

by : Benedict Carey

Leukotriene Antagonists as Effective as Other Asthma Therapies?

Leukotriene-receptor antagonists may be as effective as inhaled corticosteroids for first-line treatment of asthma and as effective as long-acting beta agonists for add-on therapy, according to two "real-world" trials reported in the New England Journal of Medicine.

The two trials included individuals aged 12 years and older with asthma. In one, some 300 patients beginning asthma therapy were randomized to open-label treatment with either a leukotriene antagonist or an inhaled glucocorticoid. In the other, roughly 350 patients already taking an inhaled glucocorticoid were randomized to add-on therapy with a leukotriene antagonist or a long-acting beta agonist.

The primary endpoint — asthma-related quality of life at 2 months — was similar between treatment groups. However, the researchers report that at 2 years, outcomes did not quite meet equivalence criteria.

Editorialists note that leukotriene antagonists likely work well in real-world settings because of their ease of use (i.e., pill vs. inhaler).

She's Everything To Me

She never stopped believing, Even though I gave her reason. She weathered out the lonliness and cold. The years have not been easy, All those winter nights, those breezy Drafty, rainy times that make a man feel old. She smiles when a smile can still my heart. Her kisses lift me as a man apart From the man I am, And I'm free again. And she's everything... She's everything to me. She's never stopped her trying, Though I'd hear her softly crying, Asking God, in her own way, For strength to last another day. She's taken everything I am And has made me a much Better man. And in all my wonder, I confess, This love my Lady does possess, Makes me smile, And every once in a while All I see Is her being free. Yet she's still here loving me.  Poem : Richard D. Remler Image :  Ferdinand Victor Eugène Delacroix   ("Head of a Woman"1822 :This haunting oil study of an old woman in despair, prepared for the Massacre at Chios, was taken from a Parisian model.)

Ready For Chelsea

United's defeat at Arsenal last weekend has opened the door for the defending champions who appeared to be out of the title race just a few weeks ago. The Reds still hold their destiny in their own hands and know victory on Sunday will all but guarantee a record 19th championship crown.

"Everyone's aware of the magnitude of Sunday's game and it's one we're looking forward to," Sir Alex told reporters at his pre-match press conference.

"Last Sunday's result has certainly brought an awareness to us of how important this game is and I think it's one of the reasons I had to pick the team I did on Wednesday. It's given us a fresh team for Sunday. It should be a fantastic match and if we win, we should win the league."

The Reds possess one of the best home records in Europe having dropped just two points all season in the league. And the boss is hoping his team can produce can another match-winning display against Ancelotti's men.

"Our home form is a big advantage. That's the reason we're there [on top]," said Sir Alex. "It's probably the best in Europe. Some of our performances at home have been absolutely terrific. Hopefully we get the result we want."

@Manutd.com

Sir Alex : We Were Vindicated

After his side demolished Schalke 6-1 on aggregate in the Champions League semi-final, the jubilant boss said: "It's fantastic for the club (to be in a third final in four years). I've said it many times, we should have done better in Europe over the years.

"I think we're getting closer to that. I think this team can win the cup. I think it's a team full of great desire and determination. These qualities, allied to their ability, will help them at Wembley."

Sir Alex acknowledges that Barcelona - conquerors of United in the respective clubs' last final, in 2009 - are a different prospect to Schalke, indeed to any other team in the world currently.

"I think they (Barcelona) are definitely, without doubt, the team of the moment. There's no question about that. They play fantastic football. It's a pleasure to watch them play. Their semi-final (against Real Madrid) was unfortunate in that we expected a lot better from both sides."

Turning back to his own team, the manager admitted he'd lost some sleep on the eve of Wednesday's win over Schalke, as he pondered his line-up. He made eight changes from the side that started at Arsenal and given the stage of the competition, this was seen in some quarters as a gamble.

"I woke up about four times last night and picked different teams. But they did me proud. When I analysed each individual who was playing, I said to myself, 'This is a Manchester United player. Why can't I play him?' The fact it's a semi-final and such an important game does create a certain bit of doubt in your mind as to whether you're doing the right thing but I'm glad we were vindicated.

"We're in the final now and we'll prepare properly. We've got a big game on Sunday, so let's look forward to that."

Sir Alex recognises, of course, that a European Cup final at Wembley has special meaning for United, given that the Reds first won the biggest prize in club football there back in 1968. Could that be an omen?

"Let's hope so. This club has created destiny many times and its fate follows things like that."

@Manutd.com