The effect of a pressure garment on post-surgical drainage and seroma formation in breast cancer patients

BACKGROUND

The treatment of choice for cancer of the breast are mastectomy and axillary clearance or wide excision with axillary clearance. The most common complication following such a procedure is seroma formation. Various methods have been used to prevent it. However, the use of a pressure garment in this context has not been fully evaluated in the current literature.

RESULTS

In a randomised trial comparing patients with a pressure garment with those without one, we have found no improvement in post-operative drainage with the use of a pressure garment. There were more complications in the group without the pressure garment (19%) compared with those with the garment (15.7%). The only seroma occurred in those patients not using the garment. The use of the pressure garment appeared to increase the duration of use of the drain (6.8 vs 6.1 days), these differences in the two groups was not significant. One of the patients in the pressure garment group was unable to tolerate the warmth and discontinued wearing the garment in the third post-operative day. This gave a rejection rate of 5%.

CONCLUSION

The use of a pressure garment does not reduce the post-operative drainage, however, the complication rate appears to be higher when the pressure garment is not being used.

Incorporation of tryptophan analogues into staphylococcal nuclease: stability toward thermal and guanidine-HCl induced unfolding

The tryptophan analogues, 5-hydroxytryptophan, 7-azatryptophan, 4-fluorotryptophan, 5-fluorotryptophan, and 6-fluorotryptophan, have been biosynthetically incorporated into Staphylococcal nuclease, its V66W mutant, and the Delta 137-149 fragment of the latter mutant. The guanidine-HCl induced unfolding and thermal unfolding of these proteins were studied to characterize the effect of incorporation of these tryptophan analogues on the thermodynamic stability of the proteins. The three proteins have tryptophan residues at positions 140 (in wild type) and 66 (in the Delta 137-149 fragment of V66W) and at both positions (in V66W). The unfolding data show that 5-hydroxytryptophan does not perturb the stability of wild-type nuclease, but it destabilizes the fragment and causes the V66W mutant to unfold in a more cooperative manner. 7-Azatryptophan is found to destabilize all three proteins. 4-Fluorotryptophan is slightly stabilizing of the three proteins, but the other two fluorotryptophans do not alter the stability of the proteins.

Phosphorescence and optically detected magnetic resonance characterization of the environments of tryptophan analogues in staphylococcal nuclease, its V66W mutant, and Delta 137-149 fragment

Phosphorescence and optically detected magnetic resonance (ODMR) measurements are reported on the triplet states of the tryptophan analogues, 7-azatryptophan (7AW), 5-hydroxytryptophan (5HW), and 4-, 5-, and 6-fluorotryptophan (4FW, 5FW, 6FW), when incorporated at position 140 of wild-type Staphylococcal nuclease (7AW-nuclease, etc. ), positions 66 and 140 of its V66W mutant (7AW-V66W, etc.), and the deletion fragment of the latter, Delta 137-149 (7AW-V66W', etc.). These measurements point to the retention of protein structure at position 140 in each of the wild-type nuclease analogues. Substitution of the analogue at both tryptophan sites of V66W leads to structured sites with differentiated triplet-state properties for all analogues except 7AW-V66W, whose structure is destabilized. 5HW-V66W' is the only fragment that apparently lacks structure at position 66. All other V66W' analogues exhibit a structured environment at position 66 (4FW-V66W' was not studied), but in each case this site can be differentiated readily from the corresponding site in intact V66W. 7AW-V66W' is resolved by ODMR into two discrete structures with slightly differing zero field splittings (ZFS). Interaction of the protein with 5HW at position 66 of 5HW-V66W induces a 2-fold increase in the ZFS E parameter, which is reduced to its normal value upon formation of the fragment, 5HW-V66W'. Analogous effects occur for 5FW, but on a smaller scale.

Incorporation of tryptophan analogues into staphylococcal nuclease, its V66W mutant, and Delta 137-149 fragment: spectroscopic studies

We have biosynthetically incorporated several tryptophan analogues into three forms of Staphylococcal nuclease to investigate the spectroscopic characteristics of these "intrinsic" probes and their effect on the structure of the proteins. The set of tryptophan analogues includes 5-hydroxytryptophan, 7-azatryptophan, 4-fluorotryptophan, 5-fluorotryptophan, and 6-fluorotryptophan. 5-Hydroxytryptophan and 7-azatryptophan have red-shifted absorbance spectra, and the latter has a red-shifted fluorescence, which is very sensitive to its environment (being heavily quenched in water). The fluorotryptophans can serve as 19F NMR probes, and 4-fluorotryptophan has a very low fluorescence quantum yield, thus making it a "knock-out" fluorescence analogue. The set of proteins studied includes wild-type nuclease, which has a single tryptophan site at position 140; its V66W mutant, which has a second tryptophan at position 66; and the Delta 137-149 fragment, V66W', which only has a tryptophan at position 66. The environments of positions 66 and 140 are significantly different; position 140 is near the end of the long C-terminal alpha-helix and is moderately solvent-exposed, whereas position 66 is in the beta-barrel core region of the protein and is surrounded by apolar side chains. Absorbance and 19F NMR spectra are used to estimate the extent of analogue incorporation for each protein. Steady-state and time-resolved fluorescence data are reported to characterize the emission of the analogues in these positions in the three proteins and to develop the use of the analogues as probes of protein structure and dynamics. Circular dichroism spectra are reported to show that, in all but a couple of cases, the secondary structure of the proteins containing the analogues is not significantly perturbed by the probes. Additionally, fluorescence anisotropy decay data show the variants of wild-type nuclease to have a rotational correlation time similar to that of tryptophan-containing nuclease.

Recurrence of accessory pathway conduction after successful radiofrequency ablation: histological findings

The histological findings from a patient with Wolff-Parkinson-White syndrome (right superior paraseptal accessory pathway) who underwent successful radiofrequency ablation and had recurrence of tachycardia one month later in the absence of overt pre-excitation are reported. Histology revealed three small, oval to circular shaped, whitish, smooth areas on the right endocardial surface, the one being situated at the atrial free wall, and the other two being at the ventricular aspect. A very small hole was present in the interventricular component of the membranus septum. The accessory pathway band passed to either side of the small hole albeit disrupted by fibrous tissue in places. These findings indicate that multiple applications may cause penetration of the myocardium, and to achieve success, complete disruption of the pathway at some point along its course is required. Recurrence of retrograde accessory pathway conduction can be explained with the impedance mismatch hypothesis.

Viable neurons with luxury perfusion in hydrocephalus

A woman with hydrocephalus due to aqueductal stenosis had functional imaging of cerebral perfusion and metabolism to demonstrate the effects of endoscopic third ventriculostomy--a new form of internal surgical shunting. Technetium-99m-ECD SPECT and 18F-FDG PET showed regional luxury perfusion at the left frontal region. Three months after a successful third ventriculostomy, a repeated imaging of cerebral perfusion and metabolism showed resolution of luxury perfusion and global improvement of both perfusion and metabolism. This concurred with postoperative clinical improvement. The paired imaging of cerebral perfusion and metabolism provides more information than just imaging perfusion or metabolism. Thus, the detection of perfusion and metabolism mismatch may open a new window of opportunity for surgical intervention.

Compatibility of vancomycin hydrochloride and famotidine 5% dextrose injection

The compatibility of vancomycin hydrochloride and famotidine in 5% dextrose injection stored at two temperatures was studied. Vancomycin hydrochloride and famotidine were reconstituted and diluted with 5% dextrose injection to form an admixture with a famotidine concentration of 0.2 mg/mL and a vancomycin concentration of 5 mg/mL. The admixture was stored in 100-mL vented intravenous containers in the dark at 4 and 25 deg C; three containers were stored at each temperature. A 2-mL sample was taken from each container after six and 12 hours and 1, 3, 5, 7, 10, 12, and 14 days of storage and visually inspected, tested for pH and assayed by a developed stability-indicating high performance liquid chromatographic method. Triplicate samples were prepared for each storage condition. No color change, precipitation or cloudiness was observed in any sample at any time during the study. Vancomycin 5 mg/mL and famotidine 0.2 mg/mL in admixtures in 5% dextrose injections are stable for 14 days at 4 and 25 deg C.

Cloning and characterization of two immunophilin-like genes, ilpA and fkpA, on a single 3.9-kilobase fragment of Aeromonas hydrophila genomic DNA

Antiserum to Aeromonas hydrophila A6 cell envelopes was shown in a previous study (C. Y. F. Wong, G. Mayrhofer, M. W. Heuzenroeder, H. M. Atkinson, D. M. Quinn, and R. L. P. Flower, FEMS Immunol. Med. Microbiol. 15:233-241, 1996) to protect mice against lethal infection by this organism. In this study, colony blot analysis of an A. hydrophila genomic library using antiserum to A. hydrophila A6 cell envelopes revealed a cosmid clone expressing a 30-kDa protein which has not been described previously in aeromonads. The nucleotide sequence of a 3.9-kb fragment derived from this cosmid which expressed the 30-kDa protein revealed two potential open reading frames (ORFs) with homology to known immunophilin proteins. ORF1 encoded a 212-amino-acid protein (molecular mass, 22.4 kDa) with 56% identity to the immunophilin SlyD protein of Escherichia coli. ORF1 was subsequently designated ilpA (immunophilin-like protein). ORF3 encoded a potential gene product of 268 amino acids with a typical signal sequence and a predicted molecular size of 28.7 kDa. The inferred amino acid sequence showed 46% identity with the sequence of the FkpA protein of E. coli and 40% identity with the sequence of the macrophage infectivity potentiator (Mip) protein of Legionella pneumophila. ORF3 was designated fkpA (FK506 binding protein) by analogy with the E. coli FkpA protein. Expression of the FkpA protein was confirmed by Western blot (immunoblot) analysis, which detected a 30-kDa protein, with antiserum to the Mip protein of Legionella longbeachae and a specific antiserum to anA. hydrophila 30-kDa membrane protein. PCR and Southern analysis showed that a DNA sequence encoding FkpA was found in all 178 aeromonads of diverse origins tested. A nonpolar insertion mutation in the fkpA gene did not attenuate virulence in a suckling mouse model nor did it affect the expression of hemolysins or DNase. This suggests that either the fkpA gene is not essential in the virulence of A. hydrophila under these conditions or there are other genes in A. hydrophila coding for proteins with similar functions.

Myocardial viability studies using fluorine-18-FDG SPECT: a comparison with fluorine-18-FDG PET

Multidetector SPECT systems equipped with a high-energy, or 511-keV collimator, have been proposed to offer a less expensive alternative to PET in myocardial viability studies with [18F]FDG. The objectives of this investigation included: (a) measuring the physical imaging characteristics of SPECT systems equipped with either a high-energy general-purpose collimator (HE), or the dedicated 511-keV collimator (UH), when imaging 511-keV photons, and comparing them with conventional FDG PET; and (b) directly and quantitatively comparing the diagnostic accuracy of SPECT, with either an UH or HE collimator, to that of PET in myocardial viability studies using 18F-FDG.

METHODS

Physical imaging characteristics of SPECT and PET were measured and compared. Both SPECT and PET studies were performed in two groups of 18 patients each, with Group I using HE SPECT and Group II using UH SPECT. Myocardial perfusion studies were also performed using 82Rb PET at rest and during dipyridamole stress to identify areas of persistent hypoperfusion. For each myocardial region with a persistent perfusion defect, a perfusion-metabolism match or mismatch pattern was established independently, based on the results of 18F-FDG SPECT as well as PET.

RESULTS

PET is superior to SPECT in all physical imaging characteristics, particularly in sensitivity and contrast resolution. PET had a sensitivity 40-80 times higher than that of SPECT, and its contrast resolution was 40-100% better than SPECT. Between FDG-SPECT using an HE collimator and that using a 511-keV collimator, the latter showed marked reduction in septal penetration (from 56% to 38%), improvement in spatial resolution (from 17 mm to 11 mm FWHM) as well as contrast resolution (from 34% to 45%), while suffering reduced system sensitivity (from 75 to 34 cpm/microCi). Patient studies demonstrated that although FDG-SPECT, using a HE or UH collimator, provided concordant viability information as FDG PET in a large majority of myocardial segments with persistent perfusion defects (88% and 90%, respectively), there is an excellent statistical agreement (kappa = 0.736) between SPECT with UH collimator and PET, while the agreement between SPECT using HE collimator and PET are moderate (kappa = 0.413).

CONCLUSION

Despite its markedly inferior physical imaging characteristics compared with PET, SPECT with the dedicated 511-keV collimator offers a low-cost, practical alternative to PET in studying myocardial viability using [18F]FDG. SPECT systems with a high-energy, general-purpose collimator, on the other hand, are inadequate in such studies.

Desmoid tumor (fibromatosis) of the breast. A clinician's dilemma--a case report and review

Desmoid tumor of the breast is a clinician's dilemma as it is difficult to differentiate it from carcinoma clinically, mammographically, and cytologically. Histologically, it must be distinguished from fibrosarcoma. Current management favors wide excision with clear margins. Recurrence is relatively common and usually occurs within 3 years of excision. Adjuvant hormonal therapy does not reduce local recurrence rates; evidence indicates that postoperative radiotherapy can improve the 10-year recurrence-free survival rate.

Biosynthetic incorporation of tryptophan analogues into staphylococcal nuclease: effect of 5-hydroxytryptophan and 7-azatryptophan on structure and stability

5-Hydroxytryptophan (5HW) and 7-azatryptophan (7AW) are analogue of tryptophan that potentially can be incorporated biosynthetically into proteins and used as spectroscopic probes for studying protein-DNA and protein-protein complexes. The utility of these probes will depend on the extent to which they can be incorporated and the demonstration that they cause minimal perturbation of a protein's structure and stability. To investigate these factors in a model protein, we have incorporated 5HW and 7AW biosynthetically into staphylococcal nuclease A, using a trp auxotroph Escherichia coli expression system containing the temperature-sensitive lambda cI repressor, Both tryptophan analogues are incorporated into the protein with good efficiency. From analysis of absorption spectra, we estimate approximately 95% incorporation of 5HW into position 140 of nuclease, and we estimate approximately 98% incorporation of 7AW, CD spectra of the nuclease variants are similar to that of the tryptophan-containing protein, indicating that the degree of secondary structure is not changed by the tryptophan analogues. Steady-state fluorescence data show emission maxima of 338 nm for 5HW-containing nuclease and 355 nm for 7AW-containing nuclease. Time-resolved fluorescence intensity and anisotropy measurements indicate that the incorporated 5HW residue, like tryptophan at position 140, has a dominant rotational correlation time that is approximately the value expected for global rotation of the protein. Guanidine-hydrochloride-induced unfolding studies show the unfolding transition to be two-state for 5HW-containing protein, with a free energy change for unfolding that is equal to that of the tryptophan-containing protein. In contrast, the guanidine-hydrochloride-induced unfolding of 7AW-containing nuclease appears to show a non-two-state transition, with the apparent stability of the protein being less than that of the tryptophan form.

Measurement of virulence of aeromonads using a suckling mouse model of infection

Virulent and avirulent strains of Aeromonas spp. were identified and virulence quantified using an animal model. Virulence was measured by determining a 50% lethal dose (LD50) 43 h after oral administration of live bacteria. The LD50 of virulent Aeromonas isolates ranged from log10 7.53 (mean) organisms to log10 8.88 (mean). Some isolates were avirulent in this model. Detection of cytotoxic activity in culture supernatants correlated with virulence (Fisher exact test, P = 0.0029). There was no correlation between LD50 and the source of the isolate, beta-haemolysis or lipopolysaccharide (LPS) banding profile on SDS-PAGE. In this animal model, virulence was multifactorial in that: (i) bacterial multiplication in the gut was associated with fatal infection; (ii) the increase in bacterial numbers in the gut of mice administered a lethal dose of bacteria was accompanied by accumulation of fluid; and (iii) there was evidence of extraintestinal spread of infection. Protection of suckling mice by rabbit antiserum to Aeromonas cell envelopes was observed.

Outcome of temporal lobe epilepsy surgery predicted by statistical parametric PET imaging

PET is useful in the presurgical evaluation of temporal lobe epilepsy. The purpose of this retrospective study is to assess the clinical use of statistical parametric imaging in predicting surgical outcome.

METHODS

Interictal 18FDG-PET scans in 17 patients with surgically-treated temporal lobe epilepsy (Group A-13 seizure-free, group B = 4 not seizure-free at 6 mo) were transformed into statistical parametric imaging, with each pixel representing a z-score value by using the mean and s.d. of count distribution in each individual patient, for both visual and quantitative analysis.

RESULTS

Mean z-scores were significantly more negative in anterolateral (AL) and mesial (M) regions on the operated side than the nonoperated side in group A (AL: p < 0.00005, M: p = 0.0097), but not in group B (AL: p = 0.46, M: p = 0.08). Statistical parametric imaging correctly lateralized 16 out of 17 patients. Only the AL region, however, was significant in predicting surgical outcome (F = 29.03, p < 0.00005). Using a cut-off z-score value of -1.5, statistical parametric imaging correctly classified 92% of temporal lobes from group A and 88% of those from Group B.

CONCLUSION

The preliminary results indicate that statistical parametric imaging provides both clinically useful information for lateralization in temporal lobe epilepsy and a reliable predictive indicator of clinical outcome following surgical treatment.

Thermodynamics of the unfolding and spectroscopic properties of the V66W mutant of Staphylococcal nuclease and its 1-136 fragment

Spectroscopic studies have been performed to characterize the solution structure of the V66W mutant of Staphylococcal nuclease and the corresponding 1-136 fragment, referred to as V66W'. Whereas wild-type nuclease has a single tryptophan residue at position 140, the V66W mutant has a second tryptophan residue at position 66, which is the only such residue in V66W'. Steady-state and time-resolved fluorescence studies show Trp-66 in V66W' to have a blue emission, a relatively large fluorescence quantum yield, a long lifetime, a significant degree of protection from solute quenchers, and to depolarize with a relatively long rotational correlation time. These results characterize Trp-66 in V66W' as being a buried residue, which indicates that this fragment retains some global structure. Circular dichroism (CD) data are consistent with the fragment having lost most of the alpha-helical content of the wild type, while retaining beta-sheet structure. The CD spectrum in the aromatic region also suggests that Trp-66 in the fragment experiences an asymmetric environment, which is not identical to that in the full length mutant, V66W. In addition, optical detection of triplet state magnetic resonance (ODMR) spectroscopy can clearly resolve the tryptophan residues and demonstrates differences between the local environment of Trp-66 in V66W and in V66W', as well as small differences in the Trp-140 environment in wild type and in V66W. Guanidine-HCl induced and thermally induced unfolding studies were performed by simultaneously acquiring CD and fluorescence data as a function of the perturbation and then performing a global analysis of such multiple data sets in terms of two-state and three-state unfolding models. Whereas data for wild-type nuclease and the V66W' fragment are well characterized by a two-state unfolding model, data for the V66W mutant are better characterized by a three-state process. That is, both the denaturant- and temperature-induced unfolding of V66W involves the significant population of an equilibrium unfolding intermediate. Our global analyses yield thermodynamic parameters for the unfolding transitions, and we show that the data for V66W can be described by a constrained three-state model in which the transition of the intermediate to the fully unfolded state is fixed to have the same thermodynamic parameters that describe the unfolding of the V66W' fragment.

Choledocholithiasis in anomalous biliary system

Although congenital biliary abnormalities are common, preduodenal portal vein is very rare, not to mention preduodenal common bile duct (CBD) which has not been described before in the literature. A case with both anomalies complicated by biliary tract stones is reported. A brief review of embryonic development is also presented to explain the unusual biliary anatomy of this patient.

Factor X Stockton: a mild bleeding diathesis associated with an active site mutation in factor X

A unique blood coagulation factor X variant has been identified in a family with a history of bleeding. Plasma from affected family members had prolonged prothrombin times and activated partial thromboplastin times, low to below normal factor X coagulant activity, and normal factor X antigen levels. Sequencing of DNA from the propositus revealed a single G to A substitution in one allele of factor X at base 964 resulting in an amino acid substitution of Asn for Asp at residue 282. This residue corresponds with the active site Asp102 of chymotrypsin. The substitution eliminates a TaqI restriction site and provided the basis for a screening assay to detect the mutation in polymerase chain reaction (PCR) amplified factor X exon VIII DNA. Fourteen additional family members were identified as having the mutation at base 964. Plasma factor X purified from the proposita using an anti-factor X monoclonal antibody immunoadsorbent exhibited an approximately 50% decrease in specific activity compared with factor X purified from a normal individual in a similar manner. Bleeding in family members with the mutation, termed factor X Stockton, appears to be due to disruption of normal hemostasis by the presence in plasma of circulating abnormal factor X. Factor X Stockton is the first naturally occurring substitution at the active site Asp of a serine protease and underscores the importance of this amino acid residue in factor Xa coagulant activity.

Sexuality of women after mastectomy

Changes in sexual functioning, attitudes and sexual behaviour in local women after mastectomy and conservative breast surgery for breast cancer were assessed in this study. Given the social bearing, only married women agreed to be entered into the study. The complexities of variables other than breast loss, contributing to sexual difficulties were recognized and assessed. Through questionnaires designed for local women, a significant proportion of mastectomy women were found to have disturbances in at least one area in their sexual functioning after surgery. A significant number experienced changes in their sexual habits as well.

Kimura's disease involving the median nerve: a case report

Kimura's disease is an uncommon chronic inflammatory process of obscure origin. It is more common among Orientals and affects particularly the young male. Sites of predilection include the head and neck region, primarily the subcutaneous tissue and dermis. Unusual sites of occurrence that have been reported include the kidney, the orbit, the ear and the spermatic cord. Kimura's disease involving a major nerve bundle has not been described, and we report here the findings of a case of histologically proven Kimura's disease of the median nerve occurring in a 21-year-old Chinese girl. Typical diagnostic histological features of Kimura's disease in contrast to angiolymphoid hyperplasia, and the treatment options for Kimura's disease are also described.