Hospital Bqyhallh

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

OBJECTIVE: Scientific evidence suggests that cyclic fluctuations in a variety of nutrients, especially calcium, may help to explain some features of premenstrual syndrome (PMS). We determined the efficacy of calcium supplementation in women suffering from PMS. MATERIALS AND METHODS: A double-blind clinical trial was designed to evaluate the effect of calcium supplement therapy on PMS symptoms. The study groups were selected from young female college students, based on PMS criteria. The subjects were divided in two groups; one group received placebo and the other received 500 mg of calcium carbonate twice daily for 3 months. The severity and intensity of symptoms, including early fatigability, changes in appetite, and depression, were evaluated using a standard questionnaire. Symptoms were compared before and after treatment. RESULTS: The mean age was 21.4 +/- 3.6 years. Early tiredness, appetite changes, and depressive symptoms were significantly improved in the group receiving calcium treatment compared with the placebo group. CONCLUSION: Our results showed that calcium supplements reduced early fatigability, changes in appetite, and depression in women with PMS.

BACKGROUND: One of the most common cancers is skin cancer worldwide. Since incidence and cost of treatment of the cancer are increasing, it is necessary to further investigate to prevent and control this disease. This study aimed to determine skin cancer trend and epidemiology in Iran. METHODS: This study was done based on existing data. Data used in this study were obtained from a national registry of cancer cases and the Disease Management Center of Ministry of Health in Iran. All cases registered in the country were included during 2004-2008. Incidence rates were reported based on the direct method and standard population of World Health Organization. RESULTS: Based on the results of this study, the incidence of skin cancer is rising in Iran and the sex ratio was more in men than women in all provinces. The age-standardized incidence rate (ASR) of skin cancer was highest in males in Semnan, Isfahan, and Hamedan provinces (34.9, 30.80, and 28.84, respectively). The highest ASRs were seen in females in Semnan, Yazd, and Isfahan provinces (26.7, 24.14, and 18.97, respectively). The lowest ASR in male was observed in Sistan and Baluchestan, and in female in Hormozgan provinces. CONCLUSIONS: The incidence of skin cancer is increasing in the country. Therefore, the plan for the control and prevention of this cancer must be a high priority for health policy makers.

The aim of this study was to assess the significance of QRS morphology in determining the prevalence of mechanical dyssynchrony in heart failure (HF) patients considered eligible for cardiac resynchronization. A total of 200 consecutive HF patients (158 males, mean age 56 ± 13.5 years) with standard indications for cardiac resynchronization therapy (CRT) were evaluated prospectively. The prevalence of an interventricular mechanical delay ≥40 ms was lower in patients with pure right bundle branch block (RBBB) than that in those with RBBB plus left fascicular hemiblock (RBBB-LFH) and those with left bundle branch block (LBBB) (33 vs. 50 vs. 54%, P = 0.05). A maximal difference in peak myocardial systolic velocity among all 12 segments (Ts)>100 ms was found in 63% of the patients with LBBB, whereas it was present in 31% of the patients with pure RBBB and in 42% of those with RBBB-LFH ( P < 0.001). A standard deviation of Ts (Ts-SD)>34 ms was present in 58% of the LBBB subjects, but in only 29% and 42% of the patients with pure RBBB and RBBB-LFH, respectively ( P < 0.001). Intraventricular dyssynchrony, however, was not different in patients with pure RBBB and in those with RBBB-LFH in terms of maximal difference in Ts ( P = 0.25) and Ts-SD ( P = 0.17). Although LBBB was more often associated with intraventricular dyssynchrony, ECG sign of additional left ventricular (LV) conduction delay is not a helpful tool for the identification of intra-LV mechanical dyssynchrony in HF patients with RBBB who would benefit from CRT.

OBJECTIVES: There is still contradictory evidence on disclosure preferences regarding cancer diagnosis. The aim of this study was to evaluate the preference of cancer patients for knowing the truth about their disease, as well as the factors that might have an impact on these preferences. METHOD: This study was conducted in 11 cancer centers in Iran. A questionnaire was used to collect data, and all patients above 15 years of age who were willing to participate were included in the study. The patients were asked if they were aware of the malignant nature of their disease, and if they came to know about their disease at the time of initial diagnosis, or later. The patients were then asked about the way they looked upon their disease. In the final part of the questionnaire, the participants were asked the level of involvement they prefer to have in making treatment decisions. RESULTS: In total, 1226 patients were enrolled in this study, only 565 (46.7%) of whom were aware of their disease at the time of diagnosis, and 878 (72.7%) at the time of interview, while 980 (85.2%) were willing to receive information about their disease. Patients' awareness was significantly associated with age under 50 years, female gender, having breast, skin or head and neck cancer, and having medical care in Shiraz or Hamadan while it was not associated with the stage or accompanying illness. CONCLUSION: While the majority of Iranian cancer patients prefer to be aware of the nature of their disease and have an active role in treatment decision making, they do not receive this information.

Tuberculosis (TB) persists as a public health problem in Iran. Characterization of Mycobacterium tuberculosis isolates circulating in this area will contribute to understand and control the spread of the strains. The aims of this study were to understand the genetic diversity and drug susceptibility of M. tuberculosis isolates circulating in Iran and to analyze the relationship between genotype and drug resistance. A total of 291 M. tuberculosis isolates collected from TB patients were genotyped by spoligotyping. Drug susceptibility testing was performed using proportion method. Spoligotyping resulted in 75 distinct patterns. 86.2% of isolates were grouped in 35 clusters while the remaining isolates were unique. Ural was found to be the most predominant lineage (34.3%) followed by Central Asian strain (CAS) (24%), T (18.2%), Manu2 (7.5%) and Latin American-Mediterranean (LAM) (6.1%). The five largest clusters were Ural/Spoligotype International Type (SIT)127 (15.8%), CAS1/SIT26 (9.2%), T1/SIT53 (6.1%), T1/SIT284 (5.4%), and CAS1/SIT25 (4.4%). About 5% of isolates had multidrug resistance (MDR) and 10% had other resistance. MDR was significantly associated with Beijing strains, but not with Ural family. This study highlights dominance of Ural, CAS, and T families in Iran. Biogeographic specificity of CAS and T families to border provinces of Iran including Sistan-Baluchestan and Kermanshah, respectively, suggested that this family strains might be transmitted from these regions to other provinces of the country.

INTRODUCTION: Chronic skin lesions are common late complications of sulphur mustard exposure in veterans injured in chemical warfare. Pruritus is the most common complaint in the chronic phase, with significant effects on the patient's quality of life. The current study evaluated the efficacy of a combination of one percent phenol and one percent menthol in the control of pruritus in these affected patients. METHODS: This randomised, double-blinded clinical trial was performed in chemical warfare-injured veterans with mustard gas-induced pruritus. 80 subjects were selected randomly and divided into two equal groups. One group was treated with a combination of one percent phenol and one percent menthol twice a day, while the other group received a placebo. The therapeutic effects and side effects were evaluated during a six-week treatment course. Pruritus score with a range of 1-48 points was used to calculate the severity of pruritus before and after treatment in both groups. RESULTS: The final pruritus score in the drug group was significantly different, compared with the placebo group (p-value equals 0.03). There was also a statistically-significant difference between the pre-treatment (19 points) and post-treatment (15.5 points) pruritus scores in the drug group (p-value equals 0.001), but there was no significant difference in the response in the placebo group (p-value equals 0.66). Only a few patients had complaints about the drug, and these were generally minor. The most common complaints were of the greasy nature of the drug and its intolerable odour. CONCLUSION: A phenol one percent and menthol one percent combination has significant therapeutic effects for mustard gas-induced pruritus in chemical warfare-injured veterans, in comparison with the placebo.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the 'Save PDF' action button.

BACKGROUND: Currently, the main goal of cancer research is to increase longevity of patients suffering malignant cancers. The promising results of BCc1 in vitro and vivo experiments made us look into the effect of BCc1 nanomedicine on patients with cancer in a clinical trial. METHODS: The present investigation was a randomized, double-blind, placebo-controlled, parallel, and multicenter study in which 123 patients (30-to-85-year-old men and women) with metastatic and non-metastatic gastric cancer, in two separate groups of BCc1 nanomedicine or placebo, were selected using a permuted block randomization method. For metastatic and non-metastatic patients, a daily dose of 3000 and 1500 mg was prescribed, respectively. Overall survival (OS) as the primary endpoint and quality of life (measured using QLQ-STO22) and adverse effects as the secondary endpoints were studied. RESULTS: In metastatic patients, the median OS was significantly higher in BCc1 nanomedicine (174 days [95% confidence interval (CI) 82.37-265.62]) than in placebo (62 days [95% CI 0-153.42]); hazard ratio (HR): 0.5 [95% CI 0.25-0.98; p = 0.046]. In non-metastatic patients, the median OS was significantly higher in BCc1 nanomedicine (529 days [95% CI 393.245-664.75]) than in placebo (345 days [95% CI 134.85-555.14]); HR: 0.324 [95% CI 0.97-1.07; p = 0.066]. The QLQ-STO22 assessment showed a mean difference improvement of 3.25 and 2.29 (p value > 0.05) in BCc1 nanomedicine and a mean difference deterioration of - 4.42 and - 3 (p-value < 0.05) in placebo with metastatic and non-metastatic patients, respectively. No adverse effects were observed. CONCLUSION: The findings of this trial has provided evidence for the potential capacity of BCc1 nanomedicine for treatment of cancer. Trial registration IRCTID, IRCT2017101935423N1. Registered on 19 October 2017, http://www.irct.ir/ IRCT2017101935423N1.

BACKGROUND: Helicobacter pylori is an important pathogen of human gastric mucosa. Antibiotic resistance, especially resistance to clarithromycin is a major factor for treatment failure of H. pylori infections. The main mechanism of clarithromycin resistance in these bacteria is related to point mutations in three different locations of 23S rRNA gene. OBJECTIVES: The aims of this study were to evaluate the resistance rate to clarithromycin among local H. pylori isolates by the E-test method and to determine the profile of point mutation in 23S rRNA by real-time polymerase chain reaction (PCR) method. PATIENTS AND METHODS: Eighty biopsy samples were collected from dyspeptic patients by endoscopy during 2011 - 2012. All samples were homogenized immediately and cultured on supplemented brucella blood agar and incubated under microaerophilic conditions. Further biochemical tests and ureC gene PCR was done for H. pylori confirmation. The H. pylori OC1096 strain was used as the control strain, simultaneously. Frequency of clarithromycin resistance was determined by the E-test method based on the clinical and laboratory standard institute (CLSI) standards. Point mutation profile was determined by real-time PCR and further analysis of melting curve, amplicon sequencing was done continuously. RESULTS: From 80 biopsy samples, 20 positive H. pylori isolates were detected and confirmed by biochemical tests and PCR method. Overall, 21.7% of the H. pylori isolates, showed clarithromycin resistance phenotype by use of the E-test. Also, the minimal inhibitory concentration of clarithromycin was determined as ≥ 0.5 mg/L by the E-test method. Only point mutation in the location of A2143G with melting temperature of 54.7°C was observed in all resistant isolates. CONCLUSIONS: This study showed that the frequency of H. pylori clarithromycin resistance in Iran is relatively high. Since clarithromycin is not commonly used in Iran for H. pylori eradication, the high rate of resistance could be related to cross-reactivity between other macrolides. Therefore, macrolide antibiotics must be prescribed with precaution in any case of treatment other than H. pylori infections. All resistant isolates showed A2143G mutation in 23S rRNA as the dominant pattern of point mutation at least in Tehran H. pylori isolates.

BACKGROUND: The hand and wrist bones are infrequent sites for osteoid osteoma, and its diagnosis can be difficult. This paper reports 25 cases of osteoid osteoma in the hand and wrist. METHODS: Records of the 25 patients who had pathological conditions of osteoid osteoma of the hand and wrist were reviewed and analyzed. RESULTS: Twenty-five cases of osteoid osteoma of the hand and wrist were treated in 20 years period. The average age was 25.2±7.6 years (range, 16 to 46 years) with men to women and right to left side ratio of 5.25 and 4 respectively. The most common site was in the proximal phalanx (ten cases). The diagnosis was made using x-rays, three- phase Technetium bone scans, CT, and MRI and all the diagnoses were confirmed by histological examination. The average time from the onset of symptom to successful treatment was 16.3±11.1 months, and at a mean follow-up of 36.6±46.9 mouths. Five recurrences of disease took place in which three of them were operated elsewhere. All five patients subsequently were treated and cured by reoperation. CONCLUSION: Osteoid osteoma is relatively rare lesions in the hand and wrist that can be a persistent source of hand and wrist pain. Patients under age of 40 who have otherwise unexplained pain should be evaluated.

The present study reports a new method for analyzing class 1 residual solvents (RSs), 1,1-dichloroethene (1,1-DCE), 1,2-dichloroethane (1,2-DCE), 1,1,1-trichloroethane (1,1,1-TCE), carbon tetrachloride (CT), and benzene (Bz), in pharmaceutical products using dispersive liquid-liquid microextraction (DLLME) combined with gas chromatography-flame ionization detection (GC-FID). Unlike common DLLME methods, solvents of high boiling point were selected as dispersive and extraction solvents in order to prevent their chromatographic peaks from overlapping with those of analytes that have short retention times. Therefore N,N-dimethyl formamide (DMF) and 1,2-dibromoethane (1,2-DBE) were chosen as dispersive and extraction solvents, respectively. Analytical parameters of the proposed method were determined and good linearities and broad linear ranges (LRs) were obtained. Taking 500 mg samples, limit of detections for the tested pharmaceuticals were obtained as 0.11, 0.03, 0.05, 0.05, and 0.006 μg g(-1) for CT, 1,1-DCE, 1,2-DCE, 1,1,1-TCE, and Bz, respectively, which are considerably much lower than their permissible limits in pharmaceuticals.

BACKGROUND: Although phlebotomy is a common procedure, there is limited information concerning to documented complications of venipuncture. CASE PRESENTATION: A 45 year old left- handed woman was refered for elecrodiagnostic study with dysesthesia and pain in left medial forearm. She noted these symptoms three weeks after phelebotomy. Electrodiagnostic study showed severe involvement of left side Medial Antebrachial Cutaneous nerve (MAC nerve). CONCLUSION: Phelebotomy is a cause of MAC nerve injury. Electrodiagnostic testing can be helpful in evaluating cases of sensory disturbance after phlebotomy.

OBJECTIVE: To determine the value of known prognostic factors for metastasis in breast cancer by accounting for patient-specific effect of patients who received surgical treatment followed by adjuvant treatment using the frailty model. METHODS: One hundred seventeen women with breast cancer who underwent surgery followed by adjuvant therapy at 3 hospitals in Tehran, Iran between 1995 and 2003 were enrolled in this study. Women with defined breast cancer with no distant metastases at time of diagnosis that have undergone modified radical mastectomy or breast-conserving surgery were enrolled. Tumors were classified according to the Tumor, Node, Metastasis (TNM) system of the American Joint Committee on cancer. Grading was performed according to Scarff-Bloom-Richardson method. Estrogen receptor (ER) was measured by immunohistochemistry method. The patients have been followed regularly by routine clinical laboratory profile, serologic markers (CEA, CA15-3) and para-clinical examinations; furthermore, we have followed missing materials by other access ways such as calling. RESULTS: Median follow up time for patients was 26 months after surgery. During the follow up time 44 (38%) patients developed metastasis and 20 (45%) of these 44 patients experienced the second metastasis. The median disease-free survival for patients in the study was 49.6 month. The median time to experience second metastasis after the first one was 22.5 months. Risk of occurrence of a metastasis in the first year after surgery was 12%. Risk of experience a metastasis up to the second year was 32% and up to fifth years was 69%. Result of fitting a frailty model to data showed that size of tumor, number of positive lymph nodes and histologic grade had a significant effect on the risk of metastasis (p<0.05). Patients with tumor size larger than 5 cm were in higher risk of metastasis compared with others. Increase in the number of positive lymph nodes to more than 10, increased risk of metastasis. Patients with moderate or undifferentiated histologic grade were in higher risk of metastasis to well differentiated patients. Age, family history, lymph node stage, and ER had no significant effect. It was found that there was heterogeneity between patients after adjusting for other covariates because variance of frailty was 0.315. It means that based on the variance of the distribution of frailty, the relative risk of high-risk patients to low-risk patients was 7.2, wherein high-risk group is defined as a cluster at the 95th percentile and low-risk to a cluster of 5th percentile of the frailty distribution. CONCLUSION: Known risk factors describe the risk of metastasis partly and other unknown or unmeasured factors, such as genetics or environmental factors are important to describe the risk of metastasis in breast cancer.

OBJECTIVES: Pre-hospital care plays a vital role in the management of trauma patients. The present study was designed to evaluate the efficacy of the pre-hospital care performed by the Tehran Emergency Medical Service (EMS) in trauma patients. METHODS: The prospective study was performed on trauma patients referred to the emergency department of a teaching hospital by the Tehran EMS from September 2004 until 2005. Considering the lack of scientific observation-based protocols on pre-hospital care, certain protocols were developed based on the available up-to-date protocols in the emergency medicine text books and were used as the gold standard for comparing the provided care by EMSs. RESULTS: The effectiveness of pre-hospital care performed by Tehran emergency technicians, compatible with the patients' condition, was evaluated in 994 patients. Wound bandaging and haemostasis were done correctly in 80% of the indicated cases. Splint was applied correctly in 50% of patients in need for such a device, whereas collar and spinal bed were not performed in 80% of the indicated cases. CONCLUSIONS: Tehran's EMS is not capable of providing trauma patients with effective and accurate pre-hospital care, indicating that major changes are needed to improve this.

Brain metastasis from esophageal carcinoma is rare. In our center, among 301 cases of esophageal cancer referred for radiotherapy during a 14-year period, brain metastasis from esophageal carcinoma was detected in one case. An unusual case of esophageal carcinoma that presented with brain metastasis is reported.

An integral part of intact canal wall mastoidectomy (ICWM) is an adequate canalplasty.1 Extensive soft tissue mobilization can result in stenosis of the membranous canal, so that no matter how effective a bony canal widening procedure has been, an easily inspected self-cleaning ear will not be obtained. When standard adequate meatoplasty techniques23 are employed in conjunction with ICWM, there is a significant risk of creating a mastoid-cutaneous fistula. Z-meatoplasty4 allows for adequate cartilage resection with the creation of a wide meatus as well as providing soft tissue and skin cover to the posterior canal wall, obviating the risk of fistula. The procedure is usually carried out under general anesthesia as part of the ICWM, but in an existing stenosis the surgery can be done under local anesthesia, as an outpatient procedure. Left ear: surgeon's view. An incision runs along the roof of the external auditory canal (EAC) beginning laterally at the inter-tragal notch (a-d). A second incision (b-c), parallel to the first, begins at the junction of the floor of the EAC and the conchal cartilage. A third incision (a-b) runs along or just behind the free edge of the conchal cartilage. Elevation of flaps d,a,b and c,b,d exposes a wide area of conchal cartilage (shaded area), which is then resected. The flaps are then transposed and sutured with 4 × 0 Dexon. An end-aural incision (A–D) is carried into the roof of the external auditory canal (EAC) (Fig. 1). A second parallel incision begins near the floor of the EAC at the conchal junction and extends upward and backward (B–C). The third incision runs along or just behind the conchal free margin to connect points A and B (Fig. 2). Elevation of flap A,B,C gives access to the area of the conchal cartilage to be resected. Soft tissue deep to the cartilage can be resected as required. Flap D,A,B is also elevated, then the flaps are transposed and fixed with 4 × 0 interrupted Vicril sutures (Fig. 3). The EAC is then packed in the usual fashion. View of Z-meatoplasty at conclusion of procedure. Closure of the skin in a broken line (the Z line) prevents retraction and reduces the stenosis of the meatus. Stenosis secondary to wound disruption has not occurred in our experience. Although many methods of meatoplasty have been published,5-7 the authors are not aware of any description of the Z-meatoplasty. The maneuver is simple and quick to perform and represents an effective treatment and prevention of lateral canal stenosis in intact canal wall surgery.

Several lines of evidence suggest the role of the immune system in the pathogenesis of sudden sensorineural hearing loss (SSNHL). Macrophage migration inhibitory factor (MIF) mediates its role in various immune and inflammatory conditions by the regulation of immune reactions. Several studies have confirmed an association between MIF gene polymorphisms and susceptibility to various inflammatory and autoimmune disorders. The aim of this study was to explore the association between the MIF (-173 G/C) polymorphism (rs755622) and SSNHL in an Iranian population. In this case-control association study, SSNHL cases (n = 77) were included. Normal healthy subjects (n = 100) were also recruited from the same region. Genotyping for MIF (-173 G/C) polymorphism was carried out using the polymerase chain reaction-restriction fragment length polymorphism technique. The frequency of the MIF -173 C allele carriers (GC + CC genotype) was significantly elevated in SSNHL patients who responded to glucocorticoid treatment compared with the patients with no response to treatment. These results suggest that the MIF gene polymorphism is associated with a response to glucocorticoid treatment in patients with SSNHL.

The majority of people have experienced pain in their low back or neck in their lives. In this paper a type-2 fuzzy rule based expert system is presented for diagnosing the spinal cord disorders. The interval type-2 fuzzy logic system permits us to handle the high uncertainty of diagnosing the type of disorder and its severity. The spinal cord disorders are studied in five categories using historical data and clinical symptoms of the patients. The main novelty of this paper lies in presentation of the interval type-2 fuzzy hybrid rule-based system, which is a combination of the forward and backward chaining approaches in its inference engine and avoids unnecessary medical questions. Using of parametric operations for fuzzy calculations increases the robustness of the system and the compatibility of the diagnosis with a wide range of physicians’ diagnosis. The outputs of the system are comprised of type of disorder, location and severity as well as the necessity of taking a M.R. Image. A comparison of the performance of the developed system with the expert shows an acceptable accuracy of the system in diagnosing the disorders and determining the necessity of the M.R. Image.

AIMS AND BACKGROUND: Identifying the risk factors of recurrence of breast cancer is important for both the physician and patient. Analysis of the first recurrence may lead to an inaccurate evaluation of the factor's effects because it does not completely reflect the history of the disease and may result in the loss of valuable information. The present study aimed to determine the factors that influence breast cancer recurrence and to estimate disease-free survival, adjusting for multiple metastases in breast cancer patients. METHODS AND STUDY DESIGN: Patients were selected from a longitudinal study carried out at Fayazabakhsh Hospital in Tehran, Iran. Women who were diagnosed with breast cancer and who underwent either modified radical mastectomy or breast-conserving surgery between January 2006 and April 2008 were recruited to take part in the study. Breast cancer recurrence was defined as the occurrence of a tumor in the contralateral breast, local-regional relapse, or distant metastasis to other organs. Using an extended Cox model, the effect of age, tumor size, estrogen receptors, HER2, progesterone receptors as well as lymph node ratio was analyzed. RESULTS: Over a 5833 person-month follow-up, 25 of 133 patients (18.8%) had died and 108 patients (81.2%) were still alive, 9 of them with metastasis. Thirty-four patients (25.6%) experienced their first disease recurrence. A total of 11 patients had a second metastasis. The mean time to first metastasis was 19.93 months, and mean gap time between two metastases was 7.15 months. Risk of experiencing a metastasis or death in the third and fifth year after surgery was approximately 22% and 28%, respectively. Fitting multiple recurrent regression shows that high lymph node ratio, high histologic grade, large tumor size and HER2-positive tumors are prognostic factors for shorter disease-free survival. CONCLUSIONS: Our novel approach might be helpful in clinical practice to predict breast cancer recurrence after surgery and might be adapted to be used in other malignancies as well.