[Extemporaneous examination of the sentinel lymph node in breast cancer: is the glass half full or half empty?]

Intra-operative examination of sentinel LN is controversial. Concordance with definitive exam of SLN in this series was 81%, though only 54% of positive cases were diagnosed. Micrometastases and ITC were usually lost intraoperatively, accounting for 14% of cases. Frozen section and touch prep of the SLN were approximately equivalent. The latter has the advantage of preserving tissue for step-analysis of SLN. The ultimate method of intraoperative analysis of SLN which can combine cost-effectiveness and accuracy needs to be determined.

Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature

BACKGROUND

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, there are some pitfalls due to the limits of current technology and the use of inappropriate ligature material, with a relevant risk of injuries and postoperative, mainly biliary, complications. Ultrasonically activated scissors may divide both vessels and cystic duct, with no need of further ligature, and possibly reduce the risk of thermal injuries.

METHODS

A prospective nonrandomized clinical trial was started in 1999 to test harmonic shears (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH, USA) in 461 consecutive patients undergoing LC in order to evaluate the theoretical benefits of ultrasonic dissection and the possible reduction in intraoperative bile duct injuries (BDIs) and postoperative complications. Patients were divided in two groups: in group 1 (HS; 331 patients) the operation was performed by Ultracision (including coagulation-division of cystic duct and artery); in group 2 (LOOP; 130 patients) the cystic duct, after coagulation-division by harmonic scissors, was further secured with an endo-loop. Both groups were further divided into two subgroups: expert and surgeon-in-training. The following categories of data were collected and analyzed: individual patient data, indication for laparoscopic cholecystectomy, surgical procedure data (associated procedures, intraoperative cholangiography, intraoperative complications, length of surgery, and conversion to open), and postoperative course data (postoperative morbidity, postoperative mortality, reinterventions, and postoperative hospital stay). Furthermore, biliary complications were analyzed as a single parameter comparing the incidence within groups and subgroups. Cumulative complications (intraoperative and postoperative) were also analyzed as a single parameter comparing their incidence in the series of each surgeon within the surgeon-in-training subgroup to the average results of the expert subgroup. Finally, length of surgery, postoperative complication rate, and length of postoperative hospital stay within subgroups were analyzed to evaluate the learning curve.

RESULTS

Overall conversion rate was 0.87%. The mean operating time was 76.8 min (median, 70 min) in group 1 and 97.5 min (median 90 min) in group 2. BDI occurred in 1 case (0.32%) in the surgeon-in-training subgroup. Overall BDI rate was 0.22% (1/461). The overall incidence of postoperative bile leak was 2.7% (9 patients of subgroup 1 and 1 patient of subgroup 2). Clinical observation with spontaneous resolution occurred in 4 patients, and in 1 case the management consisted in an endoscopic biliary drainage; surgery was requested in the remaining cases. A laparoscopic approach was successfully attempted in all cases. Overall morbidity rate was 8.76% in group 1 and 13.84% in group 2. Rates of major complications, overall biliary complication, and postoperative bile leaks within the expert and surgeon-in-training subgroup differ significantly (p = 0.026, p = 0.03, and p = 0.049, respectively). There was 1 death (0.22%) due to sepsis that resulted from a small bowel injury by trocar insertion. Mean postoperative stay was 4.28 days for group 1 and 5.05 days for group 2.

CONCLUSION

No significant difference was found in both patient groups regarding postoperative mortality and complications, biliary complications, and especially cystic duct leaks. A retrospective comparison of literature data showed that use of ultrasonic dissection during LC seems to reduce the risk of BDI. Nevertheless, a learning curve in the use of ultrasonic-activated devices is required: a significant differences in postoperative major complications and biliary complications between the expert and the surgeon-in-training subgroups was shown. Furthermore, ultrasonic scissors misuse may cause bowel injuries in patients with severe adhesions, and this could represent a possible limitation for surgical safety.

Urinary iodine excretion in pregnant women residing in areas with adequate iodine intake

OBJECTIVE

Pregnancy is accompanied by profound alterations in thyroid economy and relative iodine deficiency. The aim of this study was to evaluate urinary iodine excretion of pregnant women in cities with adequate and more than adequate iodine intake.

METHODS

A cross-sectional study was performed on schoolchildren and pregnant women in four cities in the Islamic Republic of Iran. Urinary iodine excretion was measured for 438 schoolchildren and 403 pregnant women. In addition, in Isfahan City, thyroid volume was measured by sonography for 30 pregnant women in each trimester of pregnancy and for 90 non-pregnant women who also had urinary iodine measurement.

RESULTS

Median urinary iodine of schoolchildren was 31.2, 25.0, 20.2 and 19.3 microg/dl in Rasht, Isfahan, Ilam and Tehran, respectively. Corresponding values for pregnant women were 33.8, 21.2, 19.0 and 18.6 microg/dl. The percentage of pregnant women with urinary iodine below 20 microg/dl was 16, 45, 55 and 54, and below 10 microg/dl was 1, 7, 7 and 13, in Rasht, Isfahan, Ilam and Tehran, respectively. In Isfahan, urinary iodine was significantly decreased in the third trimester of pregnancy, compared with controls. Mean thyroid volume was 7.8 +/- 3.1 ml and 7.8 +/- 2.8 ml in pregnant and non-pregnant women, respectively.

CONCLUSION

Recommended values for dietary iodine through universal salt iodisation may not be adequate for pregnant women, and the specific problem of iodine and pregnancy should be considered further in the light of the latest recommendations.

Synthesis and calcium channel antagonist activity of nifedipine analogues containing 4(5)-chloro-2-methyl-5(4)-imidazolyl substituent

Dihydropyridine having substituted imidazole at 4-position in conjunction with various C3, C5 diesters have calcium channel antagonist activity. In this paper a group of dialkyl, dicycloalkyl and diaryl ester analogues of nifedipine, in which the ortho-nitro phenyl group at position 4 replaced by 2-methyl-4(5)-chloro-5(4)-imidazolyl substituent, were synthesized and evaluated as calcium channel antagonists using the high K+ contraction of guinea-pig ileal longitudinal smooth muscle (GPILSM). The results for the symmetrical ester series showed that increasing the length chain in C3 and C5 ester substituents increased activity. When increasing of the length or lipophilicity accompany with increasing the hindrance, the activity decreased. In asymmetrical diester series, the results showed when R1 is methyl or ethyl, increasing of the lipophilic property in R substituent increases the activity if this high lipophilicity don't accompany with steric hindrance. Our results demonstrate that in symmetrical and asymmetrical series aromatic compounds were more active than aliphatic compounds. In symmetrical diesters compounds, the most active compound was diphenylethyl ester derivative, that it was more active than the reference drug nifedipine. These structure activity data indicate that the 2-methyl-4(5)chloro-5(4)-imidazolyl moiety is bioisoester of 2-nitrophenyl and 2-chlorophenyl moieties.

[Sentinel lymph node for breast cancer: remove less to know more]

BACKGROUND

Our aim was to study the value of sentinel lymph node (SLN) biopsy in patients with breast cancer seen at a community hospital.

METHODS

Consecutive cases receiving primary treatment for unicentric breast cancer less than 3 cm in diameter were prospectively studied from January 1999 to July 2000. All patients signed a detailed informed consent. The majority of patients (89%) underwent a combined technique of intradermal injection of 0.3-1.2 mCi of (99)Tc and 1-3 cc of Patent Blue at the biopsy site. Intraoperative localization was performed with a hand-held gamma probe. The first 15 patients underwent routine back-up lymphadenectomy. Thereafter, only patients with positive SLN, suspicious findings, or personal preference underwent formal axillary dissection.

RESULTS

One hundred eight cases were included in the study with a median age of 61 years and a median diameter of the breast tumor of 1.5 cm. Success rate for identification of SLN was 94% (101/108 cases). A total of 917 additional lymph nodes were removed after SLN biopsy (median 6.5 lymph nodes/patient). Correlation between SLN and the final axillary status was 98%. In 20/36 patients (61%) with positive axillary status the sentinel lymph node was the only positive one. Ten patients had only microscopic foci of cancer found in the SLN. Sixty-seven patients (62%) could have avoided axillary dissection becouse the SLN was found, it was negative, and there were no other intraoperative suspicious findings.

CONCLUSIONS

SLN biopsy is accurate and easily reproduced. Our data confirms that the majority of breast cancer patients may no longer need routine axillary lymphadenectomy.

Various durations of a standard regimen (amoxycillin, metronidazole, colloidal bismuth sub-citrate for 2 weeks or with additional ranitidine for 1 or 2 weeks) on eradication of Helicobacter pylori in Iranian peptic ulcer patients. A randomized controlled trial

INTRODUCTION

One of the most economical and effective therapeutic regimens for eradication of Helicobacter pylori is the classic triple therapy with amoxycillin or tetracycline, metronidazole and a bismuth derivative. Addition of H2-receptor antagonists to these drugs may heighten the rate of eradication and shorten the duration. We therefore performed a randomized controlled trial comparing twice daily metronidazole, bismuth derivative and amoxycillin for 2 weeks with additional ranitidine for 1 or 2 weeks.

PATIENTS AND METHODS

In total, 240 adult patients with duodenal ulcer and H. pylori infection were randomly assigned to one of the following regimens: (1) amoxycillin 1 g bid, metronidazole 500 mg bid, bismuth sub-citrate 240 mg bid and ranitidine 300 mg bid for 1 week; (2) triple therapy without ranitidine for 2 weeks; or (3) triple therapy plus ranitidine 300 mg bid for 2 weeks. Side-effects of the drugs were evaluated two weeks after starting the treatment. The rapid urease test and histology from antrum and corpus, and/or 14C- urea breath test were used to determine H. pylori eradication six weeks after starting the treatment.

RESULTS

In total, 195 patients were followed up for 6 weeks. The most frequent drug side-effects were unpleasant taste (46%), dry mouth (41%) and fatigue (26%), which had an equal distribution in all treatment groups. Endoscopy and 14C- urea breath test were performed for 178 and 123 patients, respectively. Eradication of H. pylori was documented in 19/64 (29.7%), 29/63 (46%) and 50/68 (73.5%) of patients in groups 1, 2 and 3, respectively (P < 0.000001 for group 1 versus group 3; P < 0.0014 for group 2 versus group 3; difference not significant for group 1 versus group 2). An intention-to-treat analysis showed eradication rates of 19/80 (23.75%), 29/80 (36.25%) and 50/80 (62.5%) for groups 1, 2 and 3, respectively. At four weeks post-treatment, the most sensitive test for evaluation of eradication of H. pylori was histology.

CONCLUSION

Although combined use of an H2-receptor antagonist and twice daily triple therapy in a two-week regimen is more effective than two-week triple or one-week quadruple therapy in Iranian patients, none of these regimens is ideal in countries with a probable high rate of resistant and strongly toxic strains of H. pylori.

Effects of iodized salt consumption on goiter prevalence in Isfahan: the possible role of goitrogens

OBJECTIVE

To evaluate the success of the Iranian Iodine Deficiency Disorders Committee in achieving World Health Organization (WHO) goals for reducing the prevalence of goiter in children by adding iodine to table salt beginning in 1989.

METHODS

In 1997, 8,000 male and female 6- to 18-year-old students were selected by cluster sampling in schools of Isfahan. Their thyroids were examined by four endocrinologists, and goiter was staged on the basis of the WHO classification. As an index of iodine consumption, urinary iodine concentrations were measured in 3,000 students.

RESULTS

Goiter was observed in 62% of the students. Of the overall study group, 94% had sufficient iodine consumption (urinary iodine concentration of 10.0 microg/dL or more). Of those students who had sufficient iodine intake, 63.2% had goiter. Of the 6% of students with iodine deficiency, 5% had mild, 0.9% had moderate, and only 0.1% had severe iodine deficiency. Goiter was absent in half of the students with severe iodine deficiency. The prevalence of goiter in 6- to 10-year-old children was 65%.

CONCLUSION

Despite sufficient iodine intake, the prevalence of goiter is still high in Isfahan City. Apparently, either this high prevalence has no relationship to iodine deficiency and possibly other unknown goitrogens are involved in the pathogenesis of goiter in Isfahan or the period of iodine intake has been too brief to affect thyroid sizes. Inasmuch as goiter prevalence is also high in the 6- to 10-year-old children, who have had iodized salt available for most of their lives, the second option is less probable. Another possibility is an increased rate of autoimmune thyroid diseases (because of iodine repletion) that resemble goiter during their early stages.

An ion-pair high-performance liquid chromatography method for stability studies of epinephrine acid tartrate in injectable solution

An isocratic technique was developed for the analysis of epinephrine acid tartrate using ion-pair high-performance liquid chromatography (HPLC) with UV detection and a phenyl reversed phase column. The chromatographic separation was accomplished by a mixture mobile phase consisting of methanol: water (50:50, v/v) containing 7.28 mM sodium dodecyl sulfate adjusted to pH 3.5. The stability of the drug in injectable solution was studied. Using the kinetic information generated from the high temperature studies at 70, 80 and 90 degrees C, an Arrhenius plot for epinephrine acid tartrate degradation was constructed and the shelf life of the drug was estimated. We concluded that the shelf life of epinephrine acid tartrate at room temperature (25 degrees C) was 346.1 days.

Sensitive high-performance liquid chromatographic method for determination of captopril in plasma

A rapid, simple and sensitive high-performance liquid chromatographic method for the determination of captopril in plasma has been developed. Captopril is derivatized with a new reagent, 2-bromo-2'-acetonaphthone to form a product that showed ultraviolet-absorbing properties. For plasma samples, the protein was removed with 6% perchloric acid and the derivatized captopril was extracted with diethyl ether. The chromatographic separation was performed on an analytical mu bondapak NH2 column (300 x 3.9 mm, i.d.) with an isocratic mobile phase consisting of n-hexane-2-propanol-methanol-acetic acid (68:15:15:2). Using ultraviolet detection at 246 nm, the quantification limit for captopril in plasma was 10 ng/ml. The calibration curve was linear over the concentration range 12.5-500 ng/ml. The average recovery was 95% for plasma. The inter-day and intra-day assay coefficients of variation were found to be less than 12%.

(+)-Bulbocapnine-beta-N-oxide from glaucium fimbrilligerum

A new aporphine alkaloid, (+)-bulbocapnine-beta-N-oxide (1), was isolated from Glaucium fimbrilligerum. Its structure and the stereochemistry at the N-oxide center were determined by spectroscopic methods and confirmed by synthesis.

Prevalence and risk factors of diabetes mellitus in the Isfahan city population (aged 40 or over) in 1993

The objective of this study was to estimate the prevalence of diabetes among people aged 40 or more and to compare selected factors such as systolic and diastolic blood pressure, body mass index and lipid profile in diabetic and non-diabetic subjects. This is a cross-sectional study of subjects aged over 40 in Isfahan. Selection of diabetic subjects were based on multi-stage random sampling. Diabetes status was defined by the World Health Organization criteria and was based on fasting plasma glucose and oral glucose tolerance test results. Data on age, body mass index, blood pressure and lipid profile were obtained. Results show that a total of 3910 eligible subjects were examined and classified into different diabetes status. The overall age-standardized prevalence of diabetes was 7.54% (95% CI: 6.24-8.84%) in males and 7.97% (95% CI: 6.75-9.19%) in females with no difference. Similarly, the overall age standardized prevalence was 7.76% (95% CI: 6.87-8.65%). The prevalence of diabetes was shown to increased in the older age groups. Multiple logistic regression analysis showed that age, systolic blood pressure, hypertriglyceridemia, being overweight and also obesity were independently associated with diabetes. A large number of newly-diagnosed diabetic subjects were identified, which necessitates powerful screening programs. High levels of blood pressure, body mass index and lipid profile should draw attention to probable presence of diabetes.

Systemic lupus erythematosus with membranous glomerulonephritis and uterine vasculitis

We report a case of lupus vasculitis with uterine localization and concurrent membranous nephropathy. Immunofluorescence study suggested the occurrence of an immune complex nephropathy and a pauci-immune pathogenesis of vasculitis. Our case points out the event of tissue damage in two organs mediated by different pathogenetic mechanisms. In addition, uterine vasculitis without pregnancy may be observed in patients with systemic lupus erythematosus nephritis.

Interobserver variability on the histopathologic diagnosis of cutaneous melanoma and other pigmented skin lesions

PURPOSE

To assess the interobserver agreement on the diagnosis and classification of cutaneous melanoma.

MATERIALS AND METHODS

A set of 140 slides of cutaneous melanoma, including a small subset of benign pigmented skin lesions, were circulated to four experienced histopathologists. The kappa statistic for multiple ratings per subject was calculated using the method described by Fleiss.

RESULTS

The kappa value on the diagnosis of cutaneous melanoma versus benign lesions was 0.61. There was some discordance on the diagnosis in 37 of 140 cases (26%). For the histopathologic classification of cutaneous melanoma, the highest kappa values were attained for Breslow thickness (kappa = 0.76) and presence of ulceration (kappa = 0.87). The agreement was generally poor for other histologic features, such as level of dermal invasion (kappa = 0.38), presence of regression (kappa = 0.27), and lymphocytic infiltration (kappa = 0.27).

CONCLUSION

Our study suggests considerable disagreement among pathologists on the diagnosis of melanoma versus other pigmented lesions. Tumor thickness and presence of ulceration are the most reproducible histologic features of cutaneous melanoma.

Surgical resection of pulmonary metastases from colorectal carcinoma. Five-year survival and main prognostic factors

Between 1986 and 1994, 19 patients underwent pulmonary resection for metastatic colorectal carcinoma. The mean interval between colon resection and appearance of pulmonary metastasis was 41 +/- 21 months. All the patients had no more than two metastases. Wedge resection alone or associated with lobectomy was performed in four patients, lobectomy in ten, and pneumonectomy in five. One patient died within the month after surgery. Mean follow-up was 35 +/- 26 months. The 5-year survival rate was 38.7%. Repeat thoracotomy for recurrent metastases was performed in one patient. The disease-free interval, the size of metastases, the type of pulmonary resection, and the location and the stage of primary cancer had no apparent influence on survival, but the survival rate at 4 years was 25% for patients with high carcinoembryonic antigen (CEA) level versus 80% for those with low CEA level. We conclude that, at least when the number of metastases is less than two, resection of colorectal lung metastasis is safe and effective.