Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction

Breast conservation has been associated with poor cosmetic outcome when used to treat breast cancer in patients who have undergone prior augmentation mammaplasty. Radiation therapy of the augmented breast can increase breast fibrosis and capsular contraction. Skin-sparing mastectomy and immediate reconstruction are examined as an alternative treatment.Six patients with prior breast augmentation were treated for breast cancer by skin-sparing mastectomy and immediate reconstruction. One patient underwent a contralateral prophylactic skin-sparing mastectomy. Silicone gel implants had been placed in the submuscular location in five patients and in the subglandular position in one patient a mean of 10.2 years (range, 6 to 20 years) before breast cancer diagnosis. The mean patient age was 41.3 years (range, 33 to 56 years). Four independent judges reviewed postoperative photographs to grade the aesthetic results in comparison with the opposite native or reconstructed breast. The American Joint Committee on Cancer staging was stage 0 in one patient, stage I for four patients, and stage II for one patient. Five of the six patients presented with a palpable breast mass. Latissimus dorsi flap reconstruction was performed in four patients (bilaterally in one) and a transverse rectus abdominis muscle (TRAM) flap was used in two patients. Three patients were treated by skin-sparing mastectomy with preservation of the breast implant (two patients with latissimus flaps, and one patient with a TRAM flap). The tumor location necessitated the removal of implants in two patients (one patient with a latissimus flap and one with a TRAM. A saline implant was placed under the latissimus flap after gel implant removal. The patient who underwent bilateral skin-sparing mastectomies desired explantation and placement of saline implants. No remedial surgery was performed on the opposite breast to achieve symmetry. Complications occurred in two patients at the latissimus dorsi donor site (seroma in one patient, and seroma and infection in one). Five patients underwent complete nipple reconstructions. The mean duration of follow-up was 33.6 months (range, 15.5 to 70.3 months), and there were no recurrences of breast cancer. The aesthetic results were judged to be good to excellent in all cases.Skin-sparing mastectomy and immediate reconstruction can be used in patients with prior breast augmentation, with good to excellent cosmetic results. Depending on the tumor and implant location, the implant may be preserved without compromising local control.

Using nucleotide analogs to probe protein-RNA interactions

Synthetic nucleotide analogs provide the opportunity to evaluate the importance of individual functional groups on the RNA in protein-RNA complexes. The general approach is to incorporate analogs at a defined position(s) in the RNA target and to evaluate the effect of this substitution on the thermodynamic stability of the protein-RNA complex. The underlying assumption is that if the presence of the analog reduces the stability of the complex, then the functional groups that are altered in the analog interact with the protein. Here we describe the protocols for incorporation of nucleotide analogs either by in vitro transcription using T7 RNA polymerase or by synthetic chemistry. We also describe how we have used this approach to study the interaction of the TRAP protein from Bacillus subtilis with its cognate RNAs consisting of 11 repeats of GAG and/or UAG triplets. By comparing the results of these analog studies with the crystal structure of TRAP bound to an RNA containing 11 GAG repeats, we are able to see that all the functional groups identified by analogs forge direct interactions with the protein. Analog studies also correctly identified residues that do not contact the protein. Moreover, analogs can have indirect effects on the complex stability by altering the structural properties of the RNA.

Results of immediate breast reconstruction after skin-sparing mastectomy

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.

Cushing's disease: a new approach to therapy in equine and canine patients

Forty-one cases of Cushing's Disease affecting both equine and canine patients were treated with an identical mixture of two homeopathically prepared remedies (ACTH 30c and Quercus robur 30c), and the clinical improvements seen in the cases assessed. Homeopathy has been described as a medicine that can only be prescribed on the basis of individual symptoms shown, fitting the remedy to the patient, not the disease. The aim of this study was to define whether a standardised approach, using homeopathically prepared remedies, was a valid system of therapy for this disease, and if so, whether results were repeatable between species. The overall success rate for the therapy was 80% and results were broadly similar between the two species, indicating that homeopathy lends itself to the treatment of Cushing's Disease, and also to both cohort studies and group medicine.

Virus-like gene transfer into cells mediated by polyoma virus pseudocapsids

Mouse polyoma virus-like particles (or pseudocapsids) are composed solely of recombinant viral coat protein. They can interact with DNA and transport it to cells, resulting in gene expression both in tissue culture and in mice. We demonstrate that DNA transfer in vitro depends on partial packaging of DNA within the virus-like capsid. Cell surface sialic acid residues and an intact microtubule network, required for viral infectivity, are also necessary for pseudocapsid-mediated gene expression from heterologous DNA. Thus, gene delivery in this system requires pathways utilised by polyoma virions, rather than proceeding via the 'nonspecific' endosomal route typical of nonviral systems such as liposomes or calcium phosphate precipitates. Despite the fact that all cells appear to internalise pseudocapsid/DNA complexes, only a proportion show productive gene delivery. Bulk internalisation of complexes is dependent on actin fibres, but not cell surface sialic acid or microtubules, indicating that a second transport pathway exists for pseudocapsids which is nonproductive for gene transfer. The model suggested by these data demonstrates the virus-like properties of the pseudocapsid system, and provides a basis for further development to produce a highly effective gene delivery vehicle. Gene Therapy (2000) 7, 2122-2131.

Do consumer reports of health plan quality affect health plan selection?

OBJECTIVE

To learn whether consumer reports of health plan quality can affect health plan selection.

DATA SOURCES

A sample of 311 privately insured adults from Los Angeles County.

STUDY DESIGN

The design was a fractional factorial experiment. Consumers reviewed materials on four hypothetical health plans and selected one. The health plans varied as to cost, coverage, type of plan, ability to keep one's doctor, and quality, as measured by the Consumer Assessment of Health Plans Study (CAHPS) survey.

DATA ANALYSIS

We used multinomial logistic regression to model each consumer's choice among health plans.

PRINCIPAL FINDINGS

In the absence of CAHPS information, 86 percent of consumers preferred plans that covered more services, even though they cost more. When CAHPS information was provided, consumers shifted to less expensive plans covering fewer services if CAHPS ratings identified those plans as higher quality (59 percent of consumers preferred plans covering more services). Consumer choices were unaffected when CAHPS ratings identified the more expensive plans covering more services as higher quality (89 percent of consumers preferred plans covering more services).

CONCLUSIONS

This study establishes that, under certain realistic conditions, CAHPS ratings could affect consumer selection of health plans and ultimately contain costs. Other studies are needed to learn how to enhance exposure and use of CAHPS information in the real world as well as to identify other conditions in which CAHPS ratings could make a difference.

The stress process in neighborhood context

The positive relation between socio-economic status (SES) and health, both mental and physical, is examined within a stress-process framework. Telephone survey data of adults age 45-74 are analyzed to test the roles of stressors and resources as mediators of the SES-health relation. Next, the stress process is tested in neighborhood context by splitting the sample in half according to residence in lower- or higher-SES neighborhoods. The relative impact of stressors on mental and physical health, and effectiveness of resources in protecting mental and physical health, are tested separately for both types of neighborhoods. The results indicate that social support is only protective of mental and physical health among residents of higher-SES neighborhoods. The implications of the results for future research are discussed.

Quality of life in children following mitral valve replacement

OBJECTIVE

To measure the health related quality of life (QoL) following mitral valve replacement in childhood.

DESIGN

Cross sectional study.

SETTING

Tertiary referral centre.

METHODS

19 patients, median age (range) 14.4 (9.7-25.4) years, were studied at a median of 7.6 (0.5-11.2) years after their most recent mitral valve replacement. General health status was measured using age specific validated questionnaires. Ten children aged between 9-15 years completed the child health related quality of life questionnaire, and for nine older patients the UK version of the short form 36 was used. Specific questions were added to the existing questionnaires to study the effect of long term anticoagulation treatment.

RESULTS

All patients in the younger age group reported impaired QoL. Five rated their QoL within the range of children with chronic physical disabilities, and in the remaining five it was worse. In the older age group, all but two patients perceived their QoL as normal or near normal compared with a reference population matched for sex and age. Having regular blood tests had a negative effect on QoL in three young children, and one older patient reported impaired QoL related to taking daily warfarin tablets.

CONCLUSIONS

In this small group, the effect of mitral valve replacement on QoL appears to be age specific, with more impairment in younger children. Long term anticoagulation treatment is well tolerated in most patients.

Mitral valve replacement in children: mortality, morbidity, and haemodynamic status up to medium term follow up

OBJECTIVE

To investigate the outcome of mechanical mitral valve replacement in children after up to 11 years of follow up.

DESIGN

Retrospective analysis of case records. Operative survivors underwent echocardiographic studies to define current haemodynamic status and prosthetic valve function.

SETTING

Tertiary referral centre.

PATIENTS

All 54 children who underwent mitral valve replacement between January 1987 and December 1997.

RESULTS

30 day mortality was 20.3% and was associated with small valve size and supra-annular position. The actuarial freedom from the following events at five years (70% confidence interval (CI)) was: death, including 30 day mortality and transplantation, 68% (70% CI 62% to 75%); bleeding, 89% (70% CI 84% to 94%); non-structural valve dysfunction and reoperation, 92% (70% CI 87% to 97%). The incidence of endocarditis and thromboembolism was low and there was no structural valve failure. Event-free survival was 52% (70% CI 45% to 60%). Low weight, young age, and small valve size increased the chance of death or reoperation. On echocardiography, left ventricular dilatation and wall motion abnormalities were often observed. A high mean gradient over the prosthesis was associated with small valve size but not with length of follow up.

CONCLUSIONS

With the use of mechanical prostheses for mitral valve replacement in children, the problem of structural valve failure is no longer an issue. However, the procedure is still associated with a high complication rate, both at surgery and during follow up, and should therefore be reserved for patients in whom valve repair is not technically feasible.

Impact of zanamivir on antibiotic use for respiratory events following acute influenza in adolescents and adults

BACKGROUND

Influenza infections commonly lead to respiratory tract complications that result in antibiotic treatment.

OBJECTIVES

To determine frequency of respiratory events leading to antibiotic use following influenza illness in adolescents and adults, and to assess whether treatment with topical zanamivir prevents these complications.

METHODS

Meta-analysis of 7 randomized, double-blind, placebo-controlled trials; 3815 mainly healthy adolescents and adults (mean age, 34 years) with an influenzalike illness of less than 2 days' duration were randomly assigned to receive combined inhaled and intranasal zanamivir, inhaled zanamivir, or corresponding placebos. Twelve percent of enrolled subjects were high-risk patients. The main outcome was the incidence of respiratory events leading to antibiotic prescriptions in patients with proven influenza.

RESULTS

Influenza infections were laboratory confirmed in 2499 (66%) of 3815 patients (influenza A in 88% and B in 12%). Placebo recipients developed a respiratory event leading to antibiotic use in 17% of cases, mainly for acute bronchitis or acute sinusitis. Among zanamivir-treated patients (n = 1494) the incidence of respiratory events leading to the use of antimicrobials was 11% (relative risk [RR] compared with placebo, 0.69; 95% confidence interval [CI], 0.57-0.84). Intranasal and inhaled zanamivir seemed to reduce the number of upper (RR, 0.59; 95% CI, 0.36-0.97) and lower respiratory tract events (RR, 0.64; 95% CI, 0.38-1.08). Inhaled zanamivir reduced the number of lower respiratory tract events (RR, 0.60; 95% CI, 0.42-0.85), but the reduction in the number of upper respiratory tract events was not statistically significant (RR, 0.90; 95% CI, 0.63-1.27).

CONCLUSIONS

Respiratory complications or worsening of symptoms leading to antibiotic use occurred in about 17% of adolescents or adults with influenza infection. Early treatment of influenza illness with zanamivir reduced the number of these antibiotic prescriptions. Arch Intern Med. 2000;160:3234-3240.

Clinical signs and symptoms predicting influenza infection

BACKGROUND

New antiviral drugs are available for the treatment of influenza type A and type B infections. In clinical practice, antiviral use has rarely been guided by antecedent laboratory diagnosis. Defined clinical predictors of an influenza infection can help guide timely therapy and avoid unnecessary antibiotic use.

OBJECTIVE

To examine which clinical signs and symptoms are most predictive of influenza infection in patients with influenza-like illness using a large data set derived from clinical trials of zanamivir.

METHODS

This analysis is a retrospective, pooled analysis of baseline signs and symptoms from phase 2 and 3 clinical trial participants. It was conducted in mainly unvaccinated (mean age, 35 years) adults and adolescents who had influenza-like illness, defined as having fever or feverishness plus at least 2 of the following influenza-like symptoms: headache, myalgia, cough, or sore throat who underwent laboratory testing for influenza. Clinical signs and symptoms were evaluated in statistical models to identify those best predicting laboratory confirmation of influenza.

RESULTS

Of 3744 subjects enrolled with baseline influenza-like symptoms, and included in this analysis, 2470 (66%) were confirmed to have influenza. Individuals with influenza were more likely to have cough (93% vs 80%), fever (68% vs 40%), cough and fever together (64% vs 33%), and/or nasal congestion (91% vs 81%) than those without influenza. The best multivariate predictors of influenza infections were cough and fever with a positive predictive value of 79% (P<. 001). The positive predictive value rose with the increase in the temperature at the time of recruitment.

CONCLUSION

When influenza is circulating within the community, patients with an influenza-like illness who have both cough and fever within 48 hours of symptom onset are likely to have influenza and the administration of influenza antiviral therapy may be appropriate to consider. Arch Intern Med. 2000;160:3243-3247.

Structured implicit review: a new method for monitoring nursing care quality

BACKGROUND

Nurses' independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has been central to Medicare quality management and is considered the gold standard for reviewing physician care, but peer implicit review of nursing processes of care has not received similar attention.

OBJECTIVE

The objective of this study was to develop and evaluate nurse structured implicit review (SIR) methods.

RESEARCH DESIGN

We developed SIR instruments for rating the quality of inpatient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally representative sample of randomly selected medical records for each disease from 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospective Payment System study).

SUBJECTS

The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283).

MEASURES

We developed and tested scales reflecting domains of nursing process, evaluated interrater and interitem reliability, and assessed the extent to which items and scales predicted overall ratings of the quality of nursing care.

RESULTS

Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scales (CVA) was > or = 0.40. Interitem reliability was > 0.80 for all but 1 scale (both diseases). Functional Assessment, Physical Assessment, and Medication Tracking ratings were the strongest predictors of overall nursing quality ratings (P < 0.001 for each).

CONCLUSIONS

Nurse peer review with SIR has adequate interrater and excellent scale reliabilities and can be a valuable tool for assessing nurse performance.

Lip-reading ability and patterns of cortical activation studied using fMRI

Lip-reading is a complex cognitive skill with large individual differences in performance. The basis of these individual differences remains poorly understood. Functional magnetic resonance imaging (fMRI) techniques allows brain activation accompanying complex cognitive activities to be studied noninvasively. In the present paper, fMRI was used to study the patterns of cortical activation that occur during the silent lip-reading of connected speech and to investigate whether there are detectable differences in activation between subjects with widely differing lip-reading abilities. From a cohort of 26 volunteers, nine subjects who fell into three distinct lip-reading ability groups were selected. Brain activation was measured in two conditions: an experimental condition where subjects attempted to lip-read sentences; and a baseline condition where subjects passively viewed a static image of a talker's face. Relative to the baseline condition, lip-reading induced activation in several cortical areas, including the auditory cortices, despite the lack of an auditory component to the task. In comparison to the better two groups of lip-readers, subjects in the poorest group displayed significantly less activation in superior and middle temporal gyrus, but not inferior temporal gyrus. These preliminary results justify more extensive investigations of the cortical basis of individual differences in lip-reading.

Testosterone improves rehabilitation outcomes in ill older men

OBJECTIVES

To determine whether testosterone supplementation improves rehabilitation outcomes in ill older men.

DESIGN

A randomized, placebo-controlled, double-blind study.

SETTING

A Geriatric Evaluation and Management (GEM) unit based at a university- affiliated Veterans Affairs Medical Center.

PARTICIPANTS

Fifteen men aged 65 to 90 years admitted to the GEM for rehabilitation.

INTERVENTION

Subjects were randomized to receive weekly intramuscular injections with testosterone enanthate 100 mg or placebo.

MEASUREMENTS

Task-specific performance using the Functional Independence Measure (FIM) and grip strength was measured at the onset of the study and at the time of discharge from the GEM.

RESULTS

At baseline, FIM scores were similar between the placebo and the testosterone group (73.7 vs 70.7, P = .637), as was grip strength (49.7 vs 55.3 pounds, P = .555). At discharge from the GEM, testosterone-treated patients had improved FIM scores compared with baseline (93.6 vs 70.7; P = .012) and grip strength (68.7 vs 55.3 pounds; P = .033). In the placebo group there was no significant improvement of FIM scores compared with baseline (78.0 versus 73.7; P = .686) or of grip strength (48.9 vs 49.7 pounds; P = .686).

CONCLUSIONS

Testosterone supplementation may improve rehabilitation outcomes in ill older men.

Zanamivir: a review of clinical safety

Preclinical and clinical studies have clearly demonstrated that zanamivir, a potent and highly selective inhibitor of the influenza A and B virus neuraminidase, has an impressive safety profile. This report describes the safety and tolerability findings from the clinical studies completed up to the 17 July 1998 involving over 6000 adult and adolescent patients from North America, Europe and the Southern Hemisphere. Serious adverse events from an ongoing Japanese clinical programme are also reported. Zanamivir was administered in various dose forms and frequencies and was found to have a comparable safety profile with placebo when given for both the treatment and prophylaxis of influenza-like illness. These findings were independent of age and underlying medical condition. 4152 patients received zanamivir and the most commonly reported adverse events were consistent with the signs and symptoms of influenza-like illness. Most of the adverse events were mild and did not result in patient withdrawal from the studies. Less than 1% of zanamivir and placebo recipients reported a serious adverse event. In addition, 490 healthy volunteers received zanamivir in clinical pharmacology studies. It was well tolerated and the incidence of adverse events was similar in zanamivir and placebo recipients. In addition, no clinically significant laboratory abnormalities were detected. Results from in vitro and in vivo animal studies suggest that zanamivir has low acute toxicity and no significant systemic toxicity or respiratory tract irritancy at plasma exposures more than 100-fold higher than those anticipated following clinical use. Neither genotoxic nor reproductive types of toxicity have been observed in toxicology studies at doses equal to 17 to 197 times the current therapeutic dose (20 mg/day). The characteristics of the molecule and the low systemic exposure indicate a very low potential for drug interactions with the inhaled route. Furthermore, repeated 600mg intravenous doses were well tolerated in healthy volunteers. The observed safety profile of zanamivir compares favourably with currently available agents with anti-influenza virus activity, such as rimantadine and amantadine, as well as GS4104, a neuraminidase inhibitor currently in phase III development. This may be attributed to the low systemic bioavailability of zanamivir, which is given by oral inhalation, direct to the primary site of viral replication. The potential advantages of this include a reduced risk of drug-drug interactions, other nontarget organ toxicities (e.g. brain) and drug clearance issues from both kidney and liver. Therefore, the safety profile of zanamivir supports its use in the management of influenza.

In vivo ATP synthesis rates in single human muscles during high intensity exercise

1. In vivo ATP synthesis rates were measured in the human medial gastrocnemius muscle during high intensity exercise using localized 31P-magnetic resonance spectroscopy (31P-MRS). Six-second localized spectra were acquired during and following a 30 s maximal voluntary rate exercise using a magnetic resonance image-guided spectral localization technique. 2. During 30 s maximal voluntary rate exercise, ATPase fluxes were predominantly met by anaerobic ATP sources. Maximal in vivo glycogenolytic rates of 207 +/- 48 mM ATP min-1 were obtained within 15 s, decreasing to 72 +/- 34 mM ATP min-1 by the end of 30 s. In contrast, aerobic ATP synthesis rates achieved 85 +/- 2 % of their maximal capacity within 9 s and did not change throughout the exercise. The ratio of peak glycolytic ATP synthesis rate to maximal oxidative ATP synthesis was 2.9 +/- 0.9. 3. The non-Pi, non-CO2 buffer capacity was calculated to be 27.0 +/- 6. 2 slykes (millimoles acid added per unit change in pH). At the cessation of exercise, Pi, phosphomonoesters and CO2 were predicted to account for 17.2 +/- 1.5, 5.57 +/- 0.97 and 2.24 +/- 0.34 slykes of the total buffer capacity. 4. Over the approximately linear range of intracellular pH recovery following the post-exercise acidification, pHi recovered at a rate of 0.19 +/- 0.03 pH units min-1. Proton transport capacity was determined to be 16.4 +/- 4.1 mM (pH unit)-1 min-1 and corresponded to a maximal proton efflux rate of 15.3 +/- 2.7 mM min-1. 5. These data support the observation that glycogenolytic and glycolytic rates are elevated in vivo in the presence of elevated Pi levels. The data do not support the hypothesis that glycogenolysis follows Michealis-Menten kinetics with an apparent Km for [Pi] in vivo. 6. In vivo -measured ATP utilization rates and the initial dependence on PCr and glycolysis were similar to those previously reported in in situ studies involving short duration, high intensity exercise. This experimental approach presents a non-invasive, quantitative measure of peak glycolytic rates in human skeletal muscle.