Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: a meta-analysis

BACKGROUND

The main priorities in the surgical treatment of patients with breast cancer are to achieve cure, local control and prevent recurrence. It is increasingly important to address quality of life and self-image with women undergoing surgical intervention for breast cancer. There is a lack of consensus as to the oncologic safety of immediate breast reconstruction (IBR). The purpose of this paper is to systematically review the literature and compare the frequency of recurrence in patients with and without IBR following mastectomy for breast cancer.

METHODS

Two independent investigators searched PubMed, Embase, and the Cochrane database using predefined search terms. After application of inclusion and exclusion criteria, 10 articles remained. Each article was assessed for quality. Relevant data was collected including recurrence rates, cancer stage, type of mastectomy and reconstruction, adjuvant treatments, and duration of follow-up.

RESULTS

Inter-rater reliability was good at 74% (95% CI: 0, 93%). There was no evidence of study heterogeneity (p for Q-statistic=0.34 and I(2)=12%). The OR ratio for recurrence of breast cancer for mastectomy with IBR as compared to mastectomy alone was 0.98 (95% CI: 0.62, 1.54).

CONCLUSION

This meta-analysis demonstrated no evidence for increased frequency of local breast cancer recurrence with IBR compared with mastectomy alone.

Retrotransposition of a yeast group II intron occurs by reverse splicing directly into ectopic DNA sites

Group II introns, the presumed ancestors of nuclear pre-mRNA introns, are site-specific retroelements. In addition to "homing" to unoccupied sites in intronless alleles, group II introns transpose at low frequency to ectopic sites that resemble the normal homing site. Two general mechanisms have been proposed for group II intron transposition, one involving reverse splicing of the intron RNA directly into an ectopic DNA site, and the other involving reverse splicing into a site in RNA followed by reverse transcription and integration of the resulting cDNA by homologous recombination. Here, by using an "inverted-site" strategy, we show that the yeast mtDNA group II intron aI1 retrotransposes by reverse splicing directly into an ectopic DNA site. This same mechanism could account for other previously described ectopic transposition events in fungi and bacteria and may have contributed to the dispersal of group II introns into different genes.

Early detection of maedi-visna (ovine progressive pneumonia) virus seroconversion in field sheep samples

The aim of this work was to investigate whether an enzyme-linked immunosorbent assay (ELISA) was useful for early detection of maedi-visna virus (MVV) infection in sheep under field conditions. An ELISA based on p25 recombinant protein and a gp46 synthetic peptide was used. Sequentially obtained serum samples (n = 1,941) were studied for 4 years. ELISA results were compared with those of the agar gel immunodiffusion (AGID) test, and results of both tests were compared with a reference result established using consensus scores for at least 2 of 3 serologic techniques (AGID, ELISA, and western blotting, which was used to resolve result discrepancies between the other 2 techniques). A total of 247 discrepancies were observed between ELISA and AGID. Of these, 131 were due to an earlier detection of 120 sera by the ELISA and 11 sera by AGID. The remaining discrepancies (116) were due to the presence of false reactions in both tests. Fewer false-negative results were found by ELISA than with AGID (6 vs. 69 sera, respectively), whereas the number of false-positive results was virtually the same for ELISA and AGID (21 vs. 20, respectively). In relation to the reference result, ELISA sensitivity and specificity were 97.8% and 98.2%, respectively, whereas values for AGID were 76.3% and 98.3%, respectively. The agreement between ELISA and the reference result was higher than that between AGID and the reference result (K value: 0.96 and 0.77, respectively). A variation in the ELISA signal (based on optical density) was observed during the study period, suggesting different antibody levels throughout the animal's life. The ELISA was useful for detecting MVV-infected sheep in field conditions and has potential for use in control and eradication programs.

Multiple homing pathways used by yeast mitochondrial group II introns

The yeast mitochondrial DNA group II introns aI1 and aI2 are retroelements that insert site specifically into intronless alleles by a process called homing. Here, we used patterns of flanking marker coconversion in crosses with wild-type and mutant aI2 introns to distinguish three coexisting homing pathways: two that were reverse transcriptase (RT) dependent (retrohoming) and one that was RT independent. All three pathways are initiated by cleavage of the recipient DNA target site by the intron-encoded endonuclease, with the sense strand cleaved by partial or complete reverse splicing, and the antisense strand cleaved by the intron-encoded protein. The major retrohoming pathway in standard crosses leads to insertion of the intron with unidirectional coconversion of upstream exon sequences. This pattern of coconversion suggests that the major retrohoming pathway is initiated by target DNA-primed reverse transcription of the reverse-spliced intron RNA and completed by double-strand break repair (DSBR) recombination with the donor allele. The RT-independent pathway leads to insertion of the intron with bidirectional coconversion and presumably occurs by a conventional DSBR recombination mechanism initiated by cleavage of the recipient DNA target site by the intron-encoded endonuclease, as for group I intron homing. Finally, some mutant DNA target sites shift up to 43% of retrohoming to another pathway not previously detected for aI2 in which there is no coconversion of flanking exon sequences. This new pathway presumably involves synthesis of a full-length cDNA copy of the inserted intron RNA, with completion by a repair process independent of homologous recombination, as found for the Lactococcus lactis Ll.LtrB intron. Our results show that group II intron mobility can occur by multiple pathways, the ratios of which depend on the characteristics of both the intron and the DNA target site. This remarkable flexibility enables group II introns to use different recombination and repair enzymes in different host cells.

Noise level analysis of commercially available toys

There have been several isolated reports of hearing loss due to noise levels from toys. Guidelines for noise production by toys is regulated by the Voluntary Product Standards PS 72-76: Toy Safety Act of 1969. To determine the current risk of noise induced hearing loss from toys currently on the market, 25 toys were purchased at a national toy store chain and sound levels were measured at distances approximating ear level (2.5 cm) and a child's arm length (25 cm) from the surface of the toy. Testing revealed peak sound levels ranging from 81 to 126 dBA at 2.5 cm and 80 to 115 dBA at 25 cm from the surface of the toy.

Intermediate steps in cellular iron uptake from transferrin. II. A cytoplasmic pool of iron is released from cultured cells via temperature-dependent mechanical wounding

A previous study described a cytoplasmic, transferrin (Tf)-free, iron (Fe) pool that was detected only when cells were mechanically detached from the culture substratum at 4 degrees C, after initial incubation with 59Fe-125I-Tf at 37 degrees C (Richardson and Baker, 1992a). The release of this internalized 59Fe could be markedly reduced if the cells were treated with proteases or incubated at 37 degrees C prior to detachment. The present study was designed to characterize this Fe pool and understand the mechanism of its release. The results show that cellular 59Fe release increased linearly as a function of preincubation time with 59Fe-Tf subsequent to mechanical detachment at 4 degrees C using a spatula. These data suggest that the 59Fe release was largely composed of end product(s) and was not an "intermediate Fe pool." When the Fe(II) chelator, dipyridyl (DP), was incubated with 59Fe-Tf and the cells, it prevented the accumulation of 59Fe that was released following mechanical detachment at 4 degrees C. Other chelators had much less effect on the proportion of 59Fe released. Examination of the 59Fe released showed that after a 4-h preincubation with 59Fe-Tf, approximately 50% of the 59Fe was present in ferritin. These data indicate that mechanical detachment of cells at 4 degrees C resulted in membrane disruptions that allow the release of high M(r), molecules. Moreover, electron microscopy studies showed that detachment of cells from the substratum at 4 degrees C resulted in pronounced membrane damage. In contrast, when cells were detached at 37 degrees C, or at 4 degrees C after treatment with pronase, membrane damage was minimal or not apparent. These results may imply that temperature-dependent processes prevent the release of intracellular contents on membrane wounding, or alternatively, prevent wounding at 37 degrees C. The evidence also indicates that caution is required when interpreting data from experiments where cells have been mechanically detached at 4 degrees C.

Fc gamma receptor expression on sheep afferent lymph dendritic cells and rapid modulation of cell surface phenotype following Fc gamma receptor engagement in vitro and in vivo

Afferent lymph dendritic cells were analysed for the presence of Fc gamma receptors by Western blotting and for modulation of surface markers following Fc gamma receptor engagement in vitro and in vivo. The results showed that unstimulated dendritic cells expressed Fc gamma RII constitutively. When dendritic cells were incubated in vitro with antigen/antibody complexes in antibody excess, a marked reduction in surface staining was observed for MHC class II, CD1, CD44, and VLA-4 after 8 h in culture. These changes did not occur with antigen or antibody alone. DC expression of LFA-1 and LFA-3 were slightly reduced after 8 h in culture with Ova alone, but this was enhanced slightly when the cells were cultured with immune complexes. Even more marked reductions in surface staining for MHC class II, CD1, CD44 and VLA-4 were observed on dendritic cells 4-8 h following secondary antigen challenge in vivo. LFA-1 and LFA-3 expression was reduced only slightly. The level of expression of MHC class II, CD1, LFA-1 and LFA-3 was substantially increased over resting values 24 h after Fc gamma R occupancy. The intensity of staining at this time was also significantly elevated for CD44, LFA-1, LFA-3 and VLA-4. These results show that engagement of Fc gamma receptors cause a substantial modulation of the dendritic cell surface phenotype after immune complex uptake. The phenomenon may function to maximize subsequent presentation of the challenge antigen to T cells.

T and B cell responses to mycobacterial 65-kDa heat-shock protein in sheep infected with maedi visna virus

Sheep infected with maedi visna virus were tested for immune reactivity to recombinant HSP65 and tuberculin PPD from mycobacteria. The results showed that both naturally and experimentally infected animals had elevated IgM but not IgG or IgA antibodies to HSP65 from Mycobacterium leprae or M. bovis. In experimentally infected animals, the elevated IgM antibodies appeared in blood from about 3 to 4 weeks postinfection. Increased T cell proliferative responses to HSP65 and PPD were also found in both naturally and experimentally infected sheep. The T cell responses to HSP65 were substantially inhibited by antibodies to ovine major histocompatibility complex class II molecules, indicating that the responses were class II restricted. Increased expression of a putative HSP65 molecule was observed in synovial membranes from sheep infected with maedi visna virus and goats infected with the related, caprine arthritis encephalitis virus. The results thus show that lentivirus infection induces T and B cell anti-HSP65 immune responses and suggest that synovial inflammation may be due, at least in part, to T and B cell recognition of HSP65-like molecules expressed in joints.

The use of anti-D to improve post-transfusion platelet response: a randomized trial

Patients undergoing induction chemotherapy for acute leukaemia often become refractory to platelet transfusions. Increased clearance of transfused platelets due to alloimmune destruction has been identified as one of the primary mechanisms contributing to this refractory state. We performed a double-blind randomized trial to determine whether the administration of anti-D to Rh-positive individuals could prevent the refractory state and improve post-transfusion platelet response. Rh-positive patients with acute leukaemia undergoing induction chemotherapy and requiring platelet transfusions were allocated to weekly intravenous anti-D (20 micrograms/kg) or placebo. Platelets and red cell concentrates were administered according to standardized transfusion guidelines. Outcome measures included platelet transfusion utilization, red cell utilization, platelet recovery 18-24 h post-infusion, and the percentage of patients refractory to platelet transfusion. There were 43 patients studied: 21 received anti-D and 22 saline placebo. The mean number of platelet concentrates required per day of observation was 0.59 (SD 0.22) in the anti-D group and 0.61 (SD 0.22) in the placebo group, P = 0.86. No difference was detected between groups in terms of platelet recovery post-infusion, refractoriness to platelet transfusion or frequency of infection (P = 0.97). Red cell concentrate utilization was significantly increased in the anti-D group compared to the placebo group, 0.58 units per day versus 0.37 units per day respectively, P = 0.005. We conclude that the use of anti-D did not improve post-transfusion platelet response in Rh positive patients with acute leukaemia, but did result in an increased need for red cell transfusion.

What the SHO saw

As discussions about junior doctors' training and duty hours continue, we have looked at the actual 'on take' case load and case mix of a medical senior house officer (SHO) in a district general hospital (DGH) over a six-month period. In our DGH, on a one in four rota, exposure to a few common conditions is high and exceeds the minimum requirements for a post to be approved for general professional training. Limited but useful experience may also be gained in the management of many other conditions. The benefits in terms of structured training and lifestyle resulting from the implementation of the Calman report and the junior doctors' hours initiative need to be set against a possible reduction in patient exposure and in the associated opportunities to learn that may occur with a decrease in SHOs' 'front line' exposure.

The use of midazolam for hypnosedative interviews

The authors describe three cases in which midazolam was successfully used in diagnostic hypnosedative interviews. A discussion comparing and contrasting midazolam to other intravenous hypnosedatives is presented. The authors suggest that midazolam is an effective agent for diagnostic hypnosedative interviews and may be preferable to other agents when posthypnotic recollection of interview content is undesirable.

Distribution of viral abundance in the reef environment of Key Largo, Florida

The distribution of viral and microbial abundance in the Key Largo, Fla., reef environment was measured. Viral abundance was measured by transmission electron microscope direct counts and plaque titer on specific bacterial hosts in water and sediment samples from Florida Bay (Blackwater Sound) and along a transect from Key Largo to the outer edge of the reef tract in Key Largo Sanctuary. Water column viral direct counts were highest in Blackwater Sound of Florida Bay (1.2 x 10(7) viruses per ml), decreased to the shelf break (1.7 x 10(6) viruses per ml), and were inversely correlated with salinity (r = -0.97). Viral direct counts in sediment samples ranged from 1.35 x 10(8) to 5.3 x 10(8)/cm(3) of sediment and averaged nearly 2 orders of magnitude greater than counts in the water column. Viral direct counts (both sediment and water column measurements) exceeded plaque titers on marine bacterial hosts (Vibrio natriegens and others) by 7 to 8 orders of magnitude. Water column viral abundance did not correlate with bacterial direct counts or chlorophyll a measurements, and sediment viral parameters did not correlate with water column microbial, viral, or salinity data. Coliphage, which are indicators of fecal pollution, were detected in two water column samples and most sediment samples, yet their concentrations were relatively low (<2 to 15/liter for water column samples, and <2 to 108/cm(3) of sediment). Our findings indicate that viruses are abundant in the Key Largo environment, particularly on the Florida Bay side of Key Largo, and that processes governing their distribution in the water column (i.e., salinity and freshwater input) are independent of those governing their distribution in the sediment environment.

Autoimmune reactivity in sheep induced by the visna retrovirus

Sheep, either naturally or experimentally infected with visna virus, were examined for the production of autoantibodies. Elevated titres of IgM and IgG antiglobulins and rheumatoid factors as well as antibodies to ssDNA, cardiolipin or histones were found in serum of both groups of animals using ELISA techniques. IgA autoantibodies were usually absent or present in low titres. The specificity of the autoantibody reactivities was confirmed by inhibition assays, affinity chromatography, Western blotting and agglutination methods. Antiglobulin titres were slightly elevated in synovial fluids, although the levels of the other autoantibodies were not raised. No significant correlations were observed between autoantibody and immunoglobulin concentrations. In a separate group of sheep infected experimentally, small but significant rises in the levels of all IgM autoantibodies, except anti-histone antibodies, were observed during and subsequent to the primary immune response to the virus. The autoantibody profiles tended to parallel each other, suggesting a common stimulus for their induction and/or a high degree of polyreactivity. The results thus show that the visna retrovirus induces, either directly or indirectly, autoimmune reactivities that are commonly observed in human autoimmune diseases such as rheumatoid arthritis or systemic lupus erythematosis.

Inhibition of growth of subcutaneous xenografts and metastasis of human breast carcinoma by swainsonine: modulation of tumor cell HLA class I antigens and host immune effector mechanisms

Swainsonine, an indolizidine alkaloid, can decrease the organ colonization potential of metastatic murine tumor cells by augmentation of host immune effector mechanisms. In this report the above findings were extended by the demonstration that systemic administration of swainsonine strongly suppressed the growth of human breast carcinoma subcutaneous xenografts and experimentally induced lung metastases. This inhibition was not due to a direct effect of swainsonine on cell growth. However swainsonine treatment of tumor cells resulted in enhanced expression of HLA Class I antigens, and HLA class I mRNA. Swainsonine was a potent immunodulator as evidenced by the increased (a) cytotoxicity of splenocytes and macrophages, and, (b) proliferative potential of splenocytes and bone marrow cells. These data suggest that swainsonine-induced inhibition of tumor growth and metastases may be mediated via activation of host effector cells and/or alteration of tumor cell antigenicity.

Three antibodies to human intestinal brush border membrane are characterized as anti-Le(a)

In the course of raising monoclonal antibodies to human colonic and small intestinal epithelium, three were isolated which recognized epitopes on many colonic glycoproteins and many jejunal glycoproteins taken from some individuals, but not on the same glycoproteins from others. The specificities of these antibodies were examined by carrying out inhibitions of the binding of the antibodies to the jejunal glycoproteins by blood group substances and purified oligosaccharides. The glycoproteins were separated by electrophoresis and transferred to nitrocellulose strips which were then used for the inhibition experiments. The results indicated that the antibodies bind to Le(a)-active structures. The conditions were determined for achieving red cell agglutination by two of the antibodies.

Evaluation of a non-rebreathing circuit for small animal anaesthesia

Several new multi-purpose non-rebreathing anaesthetic systems have been developed for human anaesthesia. This study evaluated a New Zealand designed non-rebreathing circuit, the Palmerston Valve, in anaesthetised spontaneously breathing dogs and compared it to the widely used Lack coaxial circuit. Arterial blood gas measurements 60 minutes after induction demonstrated comparable slight increases in PaCO2 in nearly all dogs maintained on the Palmerston Valve and Lack coaxial circuit with halothane and oxygen mixtures, and a fresh gas flow rate of 70 ml/kg/min. Results suggest the Palmerston Valve is at least as efficient as the Lack coaxial circuit, while offering in the same unit the potential for economical controlled ventilation.

Organization of the human pro-alpha 2(I) collagen gene

Sixty kilobases of cloned DNA containing the entire human pro-alpha 2(I) collagen gene and 22 kilobases of flanking sequences have been isolated. Like the homologous avian gene, the 1366 amino acid residues of the human pre-pro-alpha 2(I) chain are encoded by 52 exons, whose relative locations and sizes have been determined. Analysis of the 5'- and 3'-untranslated regions have confirmed their exact lengths, as well as conclusively established the nature of five polymorphic mRNA transcripts.

Isolation and characterization of the human fibrillar collagen genes

In order to elucidate some of the mechanisms leading to the pathological expression of the human fibrillar collagens, as well as to understand the evolution of these loci, specific cDNA and genomic clones have been isolated. The primary structure of the COOH-terminal propeptide of the four collagen chains and either part or the entire exon/intron arrangement of the genes have been determined. Interspecies and pairwise comparison revealed that the four loci have evolved at slightly different rates, maintaining, however, remarkably similar exon/intron arrangement. The fibrillar genes, albeit sharing the same elaborate structure, exhibit different sizes that correlate with the average length of their intron sequences, possibly because of their different chromosomal origin.

Non-organic failure to thrive: a developmental perspective

Like other segments of the child's development, eating behavior follows a sequential pattern. To understand the infant's or child's feeding problems which can lead to failure to thrive or dwarfism we propose that a child's progression be studied through three stages of development: homeostasis, attachment and separation-individuation. Specific feeding problems can arise at each of these stages of development and consequently impede the child's weight gain. During the period of homeostasis the infant learns to regulate himself, to suck, to swallow and to time the onset and termination of feedings by giving signals of hunger and fullness. If he is unable to master these, he cannot be fed effectively. Failure to master these basic feeding skills interferes with the next developmental task of attachment and also impedes development of motor skills, language and affective engagement. During the period of attachment, the infant establishes distinct interactional patterns with his caretakers. Lack of engagement between mother and infant leads to lack of pleasure and lack of appetite or even to severe dysfunctional feeding patterns like vomiting and rumination. Feeding problems in the third developmental stage of separation and individuation can arise because of maladaption in the attachment phase or because of new difficulties which center around issues of autonomy vs. dependency. At this stage, the infant learns means-end differentiation and begins to understand that his actions elicit certain consequences. If the infant's struggle between autonomy and dependency gets caught in the feeding situation, the infant's emotional needs can dictate his eating behavior. The infant refuses to eat either to have his emotional hunger for mother's attention met or to assert his autonomy and to express his anger toward her. In order for the infant to learn to differentiate between his physiological feelings of hunger and his emotional need states, the caregiver needs to give contingent responses by offering food when the infant is hungry and comfort when the infant is distressed. Feeding problems which can create, co-exist with, or result from a growth problem must be considered within a developmental context. As the infant progresses through the developmental stages of homeostasis, attachment, and separation, he masters phase-appropriate feeding skills which help him to progress from reflex sucking to autonomous feeding. Early identification of maladaptive feeding behavior will assist the pediatrician in making timely interventions.

Observing the sun with a fully tunable Lyot-Ohman filter

We describe the properties of the Zeiss Universal Birefringent Filter and its optical and electronic interface with the Sacramento Peak Observatory'' vacuum telescope. The instrument permits observations of solar intensities, velocities, and/or magnetic fields in rapid succession in any Fraunhofer line in the 410-700-nm wavelength region with high spectral (0.004-0.013 nm) and high spatial (~1/3 sec of arc) resolution.

Determination of the von Willebrand's disease antigen (factor VIII-related antigen) in plasma by quantitative immunoelectrophoresis

Measurement of the von Willebrand's disease antigen (factor viii-related antigen) has become an increasingly useful tool in the differential diagnosis of those disorders of hemostasis characterized by an abnormality of factor viii procoagulant activity. Optimal conditions for assay of the von Willebrand's disease antigen in plasma by the quantitive immunoelectrophoretic technique are described. Potential sources ofsystematic error have been evaluated and a dilution effect has been identified.