Oral versus Intravenous Antibiotics for Bone and Joint Infection

BACKGROUND

The management of complex orthopedic infections usually includes a prolonged course of intravenous antibiotic agents. We investigated whether oral antibiotic therapy is noninferior to intravenous antibiotic therapy for this indication.

METHODS

We enrolled adults who were being treated for bone or joint infection at 26 U.K. centers. Within 7 days after surgery (or, if the infection was being managed without surgery, within 7 days after the start of antibiotic treatment), participants were randomly assigned to receive either intravenous or oral antibiotics to complete the first 6 weeks of therapy. Follow-on oral antibiotics were permitted in both groups. The primary end point was definitive treatment failure within 1 year after randomization. In the analysis of the risk of the primary end point, the noninferiority margin was 7.5 percentage points.

RESULTS

Among the 1054 participants (527 in each group), end-point data were available for 1015 (96.3%). Treatment failure occurred in 74 of 506 participants (14.6%) in the intravenous group and 67 of 509 participants (13.2%) in the oral group. Missing end-point data (39 participants, 3.7%) were imputed. The intention-to-treat analysis showed a difference in the risk of definitive treatment failure (oral group vs. intravenous group) of -1.4 percentage points (90% confidence interval [CI], -4.9 to 2.2; 95% CI, -5.6 to 2.9), indicating noninferiority. Complete-case, per-protocol, and sensitivity analyses supported this result. The between-group difference in the incidence of serious adverse events was not significant (146 of 527 participants [27.7%] in the intravenous group and 138 of 527 [26.2%] in the oral group; P=0.58). Catheter complications, analyzed as a secondary end point, were more common in the intravenous group (9.4% vs. 1.0%).

CONCLUSIONS

Oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the first 6 weeks for complex orthopedic infection, as assessed by treatment failure at 1 year. (Funded by the National Institute for Health Research; OVIVA Current Controlled Trials number, ISRCTN91566927 .).

Effect of intermittent rifampicin on the pharmacokinetics and safety of raltegravir

OBJECTIVES

Previous studies of raltegravir and rifampicin have not studied the interaction when rifampicin is dosed intermittently. This study aimed to assess the pharmacokinetics of twice daily raltegravir and intermittently dosed rifampicin.

METHODS

This was a prospective, open, single-arm, three-part, controlled study in healthy volunteers. Over a period of 38 days subjects received 5 days of standard-dose raltegravir (400 mg twice daily) followed by 28 days of standard-dose raltegravir plus rifampicin three times a week followed by 5 days of high-dose (800 mg twice daily) raltegravir plus rifampicin three times a week. Pharmacokinetic sampling was performed on days 5, 33 and 38. Raltegravir pharmacokinetic parameters were determined by non-compartmental analysis and reported as geometric means and 90% CIs. ClinicalTrials.gov: NCT01424826.

RESULTS

Sixteen subjects (12 females) completed the study. Raltegravir trough plasma concentration (C12) was significantly lower in the presence of rifampicin when dosed at 400 mg twice daily (40%), which was not observed with 800 mg twice daily dosing. Raltegravir Cmax and AUC0-12 were both significantly higher in the presence of rifampicin when dosed at 800 mg twice daily (76% and 84%, respectively), but this dose was well tolerated.

CONCLUSIONS

This study suggests that rifampicin induction of raltegravir is comparable between daily and intermittent rifampicin. In the absence of definitive clinical efficacy data to suggest otherwise, doses of 800 mg of raltegravir twice daily with rifampicin thrice weekly are well tolerated and yield higher AUCs and comparable C12 when compared with raltegravir alone.

Melatonin exerts direct inhibitory actions on ACTH responses in the human adrenal gland

In nonhuman primates and rodents, melatonin acting directly on the adrenal gland, inhibits glucocorticoid response to ACTH. In these species, an intrinsic adrenal circadian clock is involved in ACTH-stimulated glucocorticoid production. We investigated whether these findings apply to the human adrenal gland by determining i) expression of clock genes in vivo and ii) direct effects of melatonin in ACTH-stimulated adrenal explants over a) expression of the clock genes PER1 (Period 1) mRNA and BMAL1 [Brain-Muscle (ARNT)-like] protein, ACTH-induced steroidogenic acute regulatory protein (StAR), and 3β-hydroxysteroid dehydrogenase (3β-HSD) and b) over cortisol and progesterone production. Adrenal tissue was obtained from 6 renal cancer patients undergoing unilateral nephrectomy-adrenalectomy. Expression of the clock genes PER1, PER2, CRY2 (Cryptochrome 2), CLOCK (Circadian Locomotor Output Cycles Kaput) and BMAL1, was investigated by RT-PCR in a normal adrenal and in an adenoma. In independent experiments, explants from 4 normal adrenals were preincubated in culture medium (6 h) followed by 12 h in: medium alone; ACTH (100 nM); ACTH plus melatonin (100 nM); and melatonin alone. The explants' content of PER1 mRNA (real-time PCR) and StAR, 3β-HSD, BMAL1 (immuno slot-blot), and their cortisol and progesterone production (RIA) were measured. The human adrenal gland expresses the clock genes PER1, PER2, CRY2, CLOCK, and BMAL1. ACTH increased PER1 mRNA, BMAL1, StAR, and 3β-HSD protein levels, and cortisol and progesterone production. Melatonin inhibited these ACTH effects. Our study demonstrates, for the first time, direct inhibitory effects of melatonin upon several ACTH responses in the human adrenal gland.

The relationship between nevirapine plasma concentrations and abnormal liver function tests

Abnormal liver function tests are frequently observed in HIV-infected individuals receiving nevirapine (NVP). Here we investigate the relationship between total and unbound plasma concentrations of NVP and the liver enzymes alanine aminotransferase (ALT) and gamma-glutamyl transferase (gammaGT). HIV-infected individuals [n = 85, 22 female, 34 hepatitis C or B virus (HCV or HBV(+))] receiving NVP (200 mg bd; median duration 66 weeks, range 3-189) and two nucleoside reverse transcriptase inhibitors (NRTIs) were enrolled into this study. Blood samples were taken at C(trough) (12 hr postdose) for measurement of NVP and liver function tests (ALT and gammaGT). Plasma protein bound and unbound drug was separated using ultrafiltration and NVP concentrations quantified using HPLC-MS/MS. A linear relationship was observed between total and unbound NVP C(trough) (r(2) = 0.77, p < 0.0001). Patients with elevated ALT (>37 IU/liter; n = 31) had higher NVP unbound C(trough) than those with ALT within the normal range (median 2268 vs. 1694 ng/ml, p = 0.04) but there was no difference in total C(trough). Logistic regression revealed no association between higher NVP C(trough) and ALT elevations. Significantly higher NVP total and unbound C(trough) were observed in patients with increased gammaGT (>40 IU/liter; n = 63; total 6747 vs. 4530 ng/ml, p = 0.001; unbound 2113 vs. 1557 ng/ml, p = 0.03). Significantly higher unbound NVP C(trough) was observed in HCV/HBV(+) (median 2275 vs. 1726 ng/ml, p = 0.02) and on bivariate analysis, higher NVP C(trough) was associated with HCV/HBV coinfection (chi(2) = 4.228; p = 0.04). Overall we found no strong association between NVP concentrations and hepatotoxicity. Although in this study NVP was well tolerated in HCV/HBV coinfected patients, higher plasma concentrations were observed.

Pharmacokinetics of saquinavir co-administered with cimetidine

The present study evaluated the effect of cimetidine, a histamine H(2) receptor antagonist able to inhibit cytochrome P450 metabolism, on the steady-state pharmacokinetics of saquinavir soft gel. Twelve healthy volunteers (eight males and four females) participated in an open-label, double-phase pharmacokinetic study. Volunteers took saquinavir soft gel 1200 mg three times a day for 13 days and then saquinavir soft gel 1200 mg twice a day with cimetidine 400 mg twice a day from day 14 to 26. The pharmacokinetics of saquinavir on days 13 and 26 were compared. All 12 volunteers completed the study. The association of cimetidine with saquinavir soft gel 1200 mg twice a day resulted in a significant increase in saquinavir AUC(0-24) (120%; P = 0.023) and C(max) (179%; P = 0.019), whereas C(trough) did not differ significantly (32% increase; P = 0.272). Increased exposure to saquinavir was observed in healthy volunteers after co-administration with cimetidine. The most significant increase involved C(max). Further pharmacokinetic studies in HIV-infected subjects are warranted to confirm the boosting effect of cimetidine and to investigate any impact that the increase in saquinavir C(max) may have on intracellular accumulation of the drug.

Clinical use of lopinavir/ritonavir in a salvage therapy setting: pharmacokinetics and pharmacodynamics

Lopinavir/ritonavir was administered to 35 HIV-infected patients after therapeutic failure with other protease inhibitors. The pharmacokinetics (trough concentrations) and baseline viral genotype were determined, together with the immunovirological outcome. The 22 responders had significantly higher mean lopinavir concentrations and lower baseline numbers of mutations. On multivariate analysis, a lopinavir concentration of 5.7 microg/ml or greater was an independent predictor of viral suppression over a 9-month follow-up period.

Simultaneous determination of rifampicin and efavirenz in plasma

Complex drug interactions involving antiretroviral agents and drugs for the management of opportunistic infections demand the monitoring of plasma drug concentrations to prevent treatment failure. The high occurrence of tuberculosis in HIV-infected subjects makes the management of HIV treatment complex. Rifampicin, a potent inducer of the cytochrome P 450 metabolic pathway, is a very active antituberculosis drug that accelerates the metabolism of protease inhibitors. Regimens containing efavirenz, a non-nucleoside reverse transcription inhibitor, could be an alternative, but efavirenz plasma concentrations may be altered after the coadministration of rifampicin. Efavirenz is also a cytochrome P 450 inducer and may alter rifampicin plasma levels. Due to the increasing need to monitor plasma concentrations in HIV patients with tuberculosis, a high-performance liquid chromatographic (HPLC) method has been developed to measure rifampicin and efavirenz at the same time in a small amount of sample. This HPLC method is highly sensitive and precise, suitable for pharmacokinetic studies or routine clinical monitoring of rifampicin and efavirenz simultaneously in HIV patients with tuberculosis.

The unbound percentage of saquinavir and indinavir remains constant throughout the dosing interval in HIV positive subjects

AIMS

To measure the unbound plasma concentrations of saquinavir (SQV) and indinavir (IDV) and to relate them to the total plasma concentrations in order to establish the unbound percentage of protease inhibitors in vivo during a full dosage interval profile.

METHODS

HIV-infected subjects (n = 35; median CD4 cell count = 340 x 10(6) cells l-1, range: 120-825; viral load < 50 copies ml-1 in 22/35) treated with SQV or IDV containing regimens were studied. Plasma drug samples were collected at 0, 2, 4, 8 and 12 h postdose for the twice daily regimens and 0, 1, 2, 4 and 8 h for the three times daily regimens. Ultra-filtration was used to separate unbound IDV and SQV in plasma and their respective concentrations were measured by a fully validated method using high performance liquid chromatography-mass spectometry (h.p.l.c.-MS/MS).

RESULTS

Based on the ratio AUCunbound/AUCtotal, the median unbound percentage (95% CI for differences) of SQV and IDV from all the samples studied was 1.19% (0.99, 1.58%) and 36.3% (35.1, 44.2%), respectively. No significant difference was seen in the percentage binding of SQV between patients receiving SQV alone (median = 1.49%) or with ritonavir (median = 1.09%; P = 0.141; 95% CI for difference between medians = -0.145, 0.937) over the pharmacokinetic profile. Similarly, no significant difference was seen in the percentage binding of IDV in patients receiving IDV alone (median 35.2%) or with ritonavir (median = 41.3%; P = 0.069; 95% CI for difference between medians = -0.09, 15.4). The unbound concentrations of SQV (P < 0.0001; 95% CI for r(2) = 0.634, 0.815) and IDV (P < 0.0001; 95% CI for r(2) = 0.830, 0.925) remained constant as a proportion of total concentration over the full dosing profile.

CONCLUSIONS

These in vivo data confirm previously published in vitro measurements of SQV and IDV protein binding. The unbound percentage of both protease inhibitors remained constant over the dosing interval.

Pharmacokinetic interactions of nevirapine and methadone and guidelines for use of nevirapine to treat injection drug users

Administration of nevirapine to HIV-infected injection drug users who also receive methadone results in a significant reduction in methadone exposure after 7-10 days of therapy. Many patients require an increase in methadone dose to counteract this effect.

The pharmacokinetics of methadone in HIV-positive patients receiving the non-nucleoside reverse transcriptase inhibitor efavirenz

AIMS

Methadone is predominantly metabolized by cytochrome P450 3A4 and the non nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz is a recognized inducer of this enzyme. We evaluated the pharmacokinetics of methadone in the presence and absence of efavirenz when administered to HIV infected patients with a history of injection drug use (IDU).

METHODS

Eleven patients on stable methadone maintenance therapy, due to commence antiretroviral therapy (ART), participated in this study. Steady state methadone kinetic profiles were obtained on two occasions 0, 1, 2, 3, 4, 5, 6, 7, 8 and 24 h post dosing. Following centrifugation, separated plasma was heated at 58 degrees C for 30 min to inactivate HIV and stored at -80 degrees C until methadone analysis by high performance liquid chromatography.

RESULTS

When combined with efavirenz there was a marked decrease in the maximum plasma concentration (Cmax) of methadone from 689 (range 212-1568) to 358 (range 205-706) ng ml(-1), P = 0.007 : 95% confidence interval (CI) 112-549. The mean area under the methadone concentration curve 0-24 h (AUC(0,24 h)) was also significantly reduced from 12341 (range 3682-34147) to 5309 (range 2430-10349) ng ml(-1) h in the presence of efavirenz, P = 0.012 : 95% CI 1921-12143. Nine patients described symptoms of methadone withdrawal and received a dose increase. Although methadone AUC(0,24 h) was reduced by over 50% following efavirenz the mean increase in methadone dose required was 22% (range 15-30 mg).

CONCLUSION

The inclusion of the NNRTI efavirenz in once daily ART for HIV patients with a history of IDU receiving methadone maintenance results in a significant reduction in methadone plasma concentrations mediated by enzyme induction. It is important to distinguish efavirenz neurological effects which were observed between days 1-5 of therapy from symptoms of methadone withdrawal which occurred from day 8 onwards. The dose of methadone was adjusted by increments of 10 mg to counteract the efavirenz inducing effect.

Biopsy of sentinel lymph nodes guided by lymphoscintigraphic mapping in patients with breast cancer

OBJECTIVE

The purpose of this study was to determine the technical success rate of sentinel node biopsy with lymphoscintigraphy in women with breast cancer and the frequency with which sentinel node biopsy obviated axillary dissection. Factors affecting the success rate of sentinel node biopsy and lymphoscintigraphy were also evaluated.

MATERIALS AND METHODS

Retrospective review revealed 119 women with breast cancer who underwent lymphoscintigraphy and sentinel node biopsy at our institution during the study period. A planned axillary dissection was performed in 13 of the first 16 patients; otherwise, axillary dissection was only performed if tumor was present in sentinel nodes or if the sentinel node biopsy was unsuccessful.

RESULTS

Sentinel node biopsy was successful in 96% of patients, and sentinel node metastases were found in 20%. In 78% of patients, a negative sentinel node biopsy obviated axillary dissection. Prior excisional biopsy was not associated with a failed sentinel node biopsy (p = 0.750) but was associated with failed lymphoscintigraphy (p = 0.01). Successful lymphoscintigraphy was associated with successful sentinel node biopsy (p < 0.0001). No association was found between the histology or size of the tumor and a failed sentinel node biopsy (p = 0.46 and p = 0.1, respectively) or failed lymphoscintigraphy (p = 0.36 and p = 0.47, respectively).

CONCLUSION

Sentinel node biopsy guided by lymphoscintigraphy, intraoperative gamma probe, and isosulfan blue dye is an effective alternative to axillary dissection in patients with breast cancer. Lymphoscintigraphy improved the success rate of sentinel node biopsy. Large tumor size or prior excisional biopsy should not prevent patients from having sentinel node biopsy.

Breast cancer in vivo: contrast enhancement with thermoacoustic CT at 434 MHz-feasibility study

The authors performed thermoacoustic computed tomography (CT) with 434-MHz radio waves in five patients with documented breast cancer. Three of the patients underwent imaging before chemotherapy was initiated and two at the conclusion of their primary chemotherapy. In the former three patients, thermoacoustic CT demonstrated contrast enhancement in the region of the tumor. In the latter two patients, no contrast enhancement was seen, and pathologic examination after surgical resection of the area of original tumor confirmed complete remission of disease.

Benign versus malignant solid breast masses: US differentiation

PURPOSE

To investigate the general applicability and interobserver variability of ultrasonographic (US) features in differentiating benign from malignant solid breast masses.

MATERIALS AND METHODS

One hundred sixty-two consecutive solid masses with a tissue diagnosis were reviewed. Three radiologists reviewed the masses without knowledge of clinical history or histologic examination results.

RESULTS

US features that most reliably characterize masses as benign were a round or oval shape (67 of 71 [94%] were benign), circumscribed margins (95 of 104 [91%] were benign), and a width-to-anteroposterior (AP) dimension ratio greater than 1.4 (82 of 92 [89%] were benign). Features that characterize masses as malignant included irregular shape (19 of 31 [61%] were malignant), microlobulated (four of six [67%] were malignant) or spiculated (two of three [67%] were malignant) margins, and width-to-AP dimension ratio of 1.4 or less (28 of 70 [40%] were malignant). If the three most reliable criteria had been strictly applied by each radiologist, the overall cancer biopsy yield would have increased (from 23% to 39%) by 16%. When US images and mammograms were available, the increase in biopsy yield contributed by US was not statistically significant (2%, P = .73). However, in independent reviews, one to three reviewers interpreted four carcinomas as benign at US.

CONCLUSION

The data confirm that certain US features can help differentiate benign from malignant masses. However, practice and interpreter variability should be further explored before these criteria are generally applied to defer biopsy of solid masses.

Stereotactic biopsy of ductal carcinoma in situ of the breast using an 11-gauge vacuum-assisted device: persistent underestimation of disease

OBJECTIVE

The purpose of this study was to compare the diagnostic accuracy of 14-gauge automated gun and 11-gauge directional vacuum-assisted biopsy techniques in the diagnosis of ductal carcinoma in situ of the breast.

MATERIALS AND METHODS

We retrospectively reviewed 41 consecutive lesions that had been diagnosed as ductal carcinoma in situ using stereotactic needle biopsy. The first 21 lesions had been biopsied using a 14-gauge automated gun; the remaining 20 lesions, using an 11-gauge vacuum-assisted device. Surgical histopathologic results at lumpectomy were compared with the findings at needle biopsy and defined as either concordant, when only ductal carcinoma in situ (i.e., no evidence of invasive carcinoma) was evident at surgery, or discordant, when invasive carcinoma was found. One patient from the automated gun group was lost to follow-up and was not included in the analysis.

RESULTS

Invasive carcinoma was found at surgery in seven (35%) of the 20 cases diagnosed using the automated gun compared with three (15%) of the 20 cases diagnosed using the vacuum-assisted device (p = .13). In all three of these discordant vacuum-assisted cases, only microinvasive disease was found at surgery. However, in only two of the seven discordant automated gun cases was only microinvasive disease found at surgery.

CONCLUSION

The 11-gauge directional vacuum-assisted biopsy technique may improve the accuracy of ductal carcinoma in situ diagnosis. Underestimation of disease still occurs, however.

Advances in breast imaging

Many exciting developments are occurring in breast imaging. Digital mammography holds the promise of telemammography and computer-aided diagnosis. Mammoscintigraphy may be helpful in identifying drug-resistant tumors before therapy. There is renewed interest in evaluating ultrasound as a potential adjunctive screening tool in women with radiographically dense breasts. Finally, contrast-enhanced magnetic resonance imaging may be used more extensively in the monitoring of tumor response to primary chemotherapy and in the preoperative workup of patients being considered for breast conservation therapy.

Fine-needle aspiration cytology of cystic hypersecretory ductal carcinoma in situ of the breast: a case report

Cystic hypersecretory intraductal carcinoma is an unusual, cystic form of intraductal breast carcinoma affecting middle-aged women. Cytopathologists have rarely encountered this lesion, with only 2 other cases having been previously reported (Colandrea et al., Arch Pathol Lab Med 1988:112:560-563; Kim et al., Acta Cytol 1997;41:892-896). In our cases, the cytologic findings of both air-dried, Diff-Quick-stained and ethanol-fixed, Papanicolaou-stained smears are presented. The cytologic hallmarks of this entity include the presence of a few scattered epithelial cells with bland nuclear morphology in a background of extensive, amorphous, pink-staining material. Cytomorphologically, the differential diagnosis includes other entities containing pink-staining material such as colloid carcinoma, mucocele-like lesion of the breast, and benign fibrocystic change.

Marker clip placement following directional, vacuum-assisted breast biopsy

The purpose of this study was to evaluate the accuracy of marker clip placement after 11-gauge directional, vacuum-assisted breast biopsies. During a 9-month period, 150 stereotactic breast biopsies were performed using a directional, vacuum-assisted device and an 11-gauge probe. In 114 cases, a marker clip was deployed at the biopsy site using the through-probe method. In 94 cases, stereotactic coordinates of the clip were obtained and were available for retrospective review. Comparing the coordinates of the lesion with those of the clip, placement errors were calculated. Overall, clip placement was within 5 mm of the lesion in 81 per cent of cases, within 5-10 mm of the lesion in 17 per cent of cases, and >10 mm from the lesion in 2 per cent of cases. Mean total placement error was 4.5 mm. The mean z axis error was 3.2 mm, compared with 0.88 and 2.0 mm for the x and y axes, respectively. Marker clip placement after vacuum-assisted biopsy is an accurate method of localizing the biopsy site should subsequent surgery be required.

Fixed-facility workplace screening mammography

OBJECTIVE

Potential barriers to compliance with screening mammography guidelines include the cost and inconvenience involved with undergoing the procedure. Workplace screening with mobile mammography is one possible approach to the convenience barrier. However, fixed-facility workplace screening is a viable alternative for any company with a large workforce in one location. This paper describes our initial experience with one such fixed facility.

MATERIALS AND METHODS

The facility was a cooperative venture by a large pharmaceutical company and an academic radiology department to provide convenient, no-cost (to the patient) screening mammography to employees, dependents, and retirees more than 40 years old. The pharmaceutical company built the facility within its corporate headquarters and the academic radiology department provided the equipment and personnel. The company was billed a fixed cost per examination.

RESULTS

In the first 22 months of operation, 4210 (of 4559 scheduled) screening mammograms were obtained. The mean age of the population was 53 years old. Ninety percent of the screening mammograms were interpreted as negative or benign; 10% required additional workup. Of the screened population, 62 biopsies were recommended and 60 were performed. Of these, 42 were benign and 18 malignant. The cancer detection rate was 4.3 per 1000 (0.43%). At the time of diagnosis, six patients were stage 0, 10 patients were stage I, one patient was stage II, and one patient was stage III. Eleven of the 18 patients had minimal cancers. Of the patients who completed a satisfaction survey, 97% percent expressed a high degree of satisfaction with the screening process and stated they would use the facility in the future.

CONCLUSION

A fixed facility for workplace screening mammography is a viable way to provide nearly barrier-free access to high-quality mammography. Patient acceptance is high.

Sonography of the breast

Quality mammography remains the primary modality used to image the breast. Sonography currently is the most useful adjunctive technique to mammography, having roles in differentiating cystic from solid masses and in guiding interventional procedures. This article reviews these and other indications for breast ultrasound studies, including evaluation of palpable masses not visible in radiographically dense breasts, masses not completely evaluable with mammography, young patients especially susceptible to radiation damage, and abscesses. Ultrasound interpretation of cysts and solid masses are discussed, as are the relative disadvantages of ultrasound as a breast cancer screening tool.

Evaluation of the augmented breast

Silicone gel implants and their complications constitute a public health problem. Millions of American women have these implants and many are concerned about their possible health effects. The history of breast augmentation as well as current concepts in imaging augmented patients are discussed in this article. Special attention is paid to the diagnosis of implant rupture by mammography, sonography, and MR imaging.

Comparison of mammography, sonography, and magnetic resonance imaging in the detection of silicone-gel breast implant rupture

Silicone-gel breast implant rupture is difficult to diagnose preoperatively. A variety of radiological methods have been used for diagnosis. This study prospectively compares film-screen mammography, high-resolution sonography, and magnetic resonance imaging in the diagnosis of implant rupture using predetermined diagnostic criteria. Thirteen patients (24 implants) underwent film-screen mammography, sonography, and magnetic resonance imaging to evaluate the integrity of their implants. All patients subsequently underwent surgical removal of the implants. Preoperatively, the integrity of each implant was rated on a three-level classification system on the basis of one modality by a reviewer who was unaware of the results of the other two modalities. The three imaging modalities achieved the following sensitivities and specificities, respectively: mammography, 69% and 82%; sonography, 54% and 64%; MRI, 69% and 55%. Even though each modality addresses some of the limitations of the others, in this group of patients, there was no clearly superior imaging tool.

Cholesterol granuloma of the breast: a mimic of carcinoma

Cholesterol granuloma of the breast is a rare condition that may be related to the common disorder mammary duct ectasia. Its importance is in its tendency to mimic carcinoma clinically and radiologically. The authors report a case in a 65-year-old asymptomatic woman.

Preoperative needle localization in the breast: utility of local anesthesia

Eighty-nine consecutive patients undergoing needle localization at two facilities were alternately assigned to "local-anesthesia" (n = 46) and "no-local-anesthesia" (n = 43) groups. Those in the local-anesthesia group received 1-2 mL lidocaine hydrochloride 1% subcutaneously at the expected site of insertion of the localizing needle. All patients were asked to rate the level of pain they experienced from the procedure as a whole by using a 10-cm horizontal visual analog pain scale. Data about patient age, menopausal and menstrual status, average daily caffeine intake, and whether the patients considered mammography to be a painful procedure were collected. Patients who did not receive local anesthesia had a lower mean pain score (2.52) than those who did (3.27, P = .18). Premenopausal patients in the second half of their menstrual cycle at the time of the procedure had a significantly higher pain score than those in the first half (3.54 vs. 1.70, P = .05). Patients who considered mammography a painful procedure reported a higher level of pain than those who did not (3.79 vs 2.38, P = .012). There was no relationship between age, caffeine intake, or menopausal status and pain experienced.

A survey of interventional mammography practices

To evaluate the current state of interventional mammography in the United States, surveys were sent to 1,000 randomly selected active members of the American College of Radiology (group 1) and the entire 1991 membership (n = 73) of the Society of Breast Imaging (group 2). Three hundred seventy-one (37%) group 1 and 49 (67%) group 2 responses were received. Some respondents did not answer all questions. Of group 1 respondents, 331 (93%) performed preoperative needle localization and 272 (73%) used a hook wire; 92 (25%), a J wire; and 55 (15%), a needle-dye technique. For group 2 respondents and these techniques, the results were 45 (94%), 32 (65%), eight (16%), and seven (14%), respectively. One hundred ninety-nine (62%) group 1 and 24 (55%) group 2 physicians administered local anesthetic during needle localization. Fifty-six (16%) group 1 and 25 (56%) group 2 physicians performed fine-needle aspiration cytology, as opposed to 11 (3%) and nine (20%) for core-needle biopsy, respectively. Cyst aspiration was performed by 245 (70%) group 1 and 40 (82%) group 2 respondents, galactography by 126 (36%) of group 1 and 30 (61%) of group 2, and pneumocystography by 57 (16%) of group 1 and 23 (48%) of group 2. For most procedures, informed consent was obtained by a minority of radiologists in both groups.

Self-referred mammography patients: analysis of patients' characteristics

Among mammography patients, a small but growing group of highly motivated women refer themselves directly for screening without the suggestion of their physicians. We surveyed 485 patients during a 3-month period to study how self-referred mammography patients differ from physician-referred patients. Self-referred patients were more likely than physician-referred patients to have a family income of more than $30,000 per year, to be college graduates, and to consider their health as good or excellent. A large percentage of self-referred patients performed other health-promoting practices, but were not significantly more likely to do these than were physician-referred patients. Women who referred themselves were more likely to have a friend with breast cancer and to believe that cancer could be cured. They expressed much less worry about radiation exposure and were more likely to consider $50.00 an appropriate charge for a screening mammogram. By far, the greatest motivator for self-referred patients was health promotion and disease prevention. Self-referred mammography patients tend to be wealthier, more education, and less concerned about the cost and radiation dose of mammography when compared with physician-referred mammography patients.

Diagnostic importance of the radiographic density of noncalcified breast masses: analysis of 91 lesions

Radiographic density is considered an important feature in the evaluation of noncalcified breast masses, yet no studies assessing its value have been published. The radiographic densities of 91 biopsy-proved, nonfatty, noncalcified breast masses were evaluated by three mammographers. The density determinations made by each observer were compared with the histologic outcome for the 51 benign and 40 malignant lesions. With the kappa statistic, interobserver agreement was relatively poor (0.22 to 0.49), and intraobserver agreement for one expert mammographer was 0.50. When the majority opinion of the mammographers was used, sensitivity was 48%, specificity was 80%, and both positive and negative predictive values were 66%. As a solitary feature in lesion analysis, mammographic density is difficult to assess and is of limited value for the prediction of the benign or malignant nature of noncalcified breast masses.