Abstract P5-16-17: Titanium-coated polypropylene mesh for immediate implant-based breast reconstruction – Our initial experience

Background: The use of titanium-coated polypropylene mesh (TCPM) is an alternative to a-cellular dermal matrix for the implant based breast reconstruction by providing extra implant coverage especially in the lower half. The aim of our study was to analyze short-term outcomes of TCPM based implant breast reconstruction and compare the patient- and procedure-related factors to implant loss and surgical complications.

Methods: Between 2013and 2016, implant breast reconstructions after conservative mastectomies using TCMP was performed in 50 patients (with 58 reconstructions). Complications were divided into major (need for additional surgery), minor (conservative treatment), and implant loss. Univariate analyses were performed to determine the influence of the patient- and procedure-related factors on postoperative complications and implant loss.

Results: Fifty patients had therapeutic mastectomies with 8 of them also had contra lateral risk reducing mastectomies. With median follow-up of 17.5 months, four of 50 patients had implant loss. Reasons for implant loss were skin necrosis in 2 cases, infection in 1 case and necrosis with infection in another case. One of these patients had a revised reconstruction one year later. One additional patient required implant replacement because of capsule contracture. No risk factors were observed for patient-associated complications. Univariate analysis revealed an increased risk for implant loss in patients with skin necrosis (p < 0.01).

Conclusions: This titanium-coated polypropylene mesh shows acceptable complication rates and its use in immediate implant breast reconstruction is safe and effective.

Citation Format: Munir A, Holt S, Huws A, Khan S, Shariaha Y, Khawaja S. Titanium-coated polypropylene mesh for immediate implant-based breast reconstruction – Our initial experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-16-17.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Effect of ractopamine hydrochloride (Optaflexx) dose and duration on growth performance and carcass characteristics of finishing steers

Three experiments evaluated the effects of ractopamine hydrochloride (RAC) dose and duration on growth performance and carcass characteristics of feedlot steers. In total, 1,509 crossbred steers (530 kg initial BW [SD 22]) were used in a randomized complete block design using a 3 × 3 factorial treatment structure. Treatments consisted of RAC dose (0, 100, or 200 mg/steer daily) and duration (28, 35, or 42 d) of RAC feeding prior to harvest. Initiation of RAC dose was staggered (7 d apart) based on RAC duration, which resulted in common days on feed among treatments. Data from the 3 experiments were combined for statistical analyses. There were no RAC dose × duration interactions ( ≥ 0.85) for growth performance. Live final BW was not different ( ≥ 0.24) as RAC dose increased. Dry matter intake linearly decreased ( < 0.01) as RAC dose increased. Live ADG and G:F linearly increased ( ≤ 0.01) as RAC dose increased. Carcass-adjusted ADG and G:F linearly increased ( ≤ 0.02) as RAC dose increased. Compared with steers fed 0 mg RAC/steer daily, G:F was improved by 5.0 and 13.0% when steers were fed 100 ( = 0.31) and 200 ( = 0.01) mg RAC/steer daily, respectively. Hot carcass weight tended ( = 0.10) to linearly increase as RAC dose increased, with carcasses from steers fed 100 ( = 0.38) and 200 ( = 0.10) mg RAC/steer daily being 2.2 and 4.1 kg heavier, respectively, than carcasses from steers fed 0 mg RAC/steer daily. Increasing RAC dose linearly ( < 0.01) increased LM area and linearly ( = 0.02) decreased marbling score. Live final BW was not different ( ≥ 0.60) among RAC durations. Carcass-adjusted final BW, ADG, and G:F were not different ( ≥ 0.41) as RAC duration increased. Carcass traits did not differ ( ≥ 0.18) among RAC duration. Feeding 200 mg RAC/steer daily improved ADG, feed efficiency, and HCW. Increasing the feeding duration of RAC had no effect of growth performance or carcass characteristics. These data indicate that feeding 200 mg RAC/steer daily for 28 d improves steer growth performance.

Abstract P2-01-22: The long term outcomes of Metasin RTqPCR intra-operative sentinel node analysis in early breast cancer

Background:

Axillary lymph node involvement is a prognostic factor in breast cancer and it is used to guide adjuvant therapy. Axillary clearance remains the standard of care in lymph node positive disease in most parts of the world. Usually this is performed as second procedure but immediate intra-operative node analysis allows clearance to be performed as part of the initial procedure where necessary.

The Metasin assay targets the breast epithelial cell markers CK19 and mammaglobin mRNA and detects the presence of breast tissue (metastatic disease) in the sentinel nodes. Evidence shows the Metasin assay to be fast (average assay time 41.2min) and accurate with a discordance rate below 4% compared with histology. The cost effectiveness of the assay has been reported in our previous studies.

Aim:

The aim of this study is to assess the risk of axillary recurrence following the use of the Metasin assay to guide axillary management.

Method:

This is a single centre retrospective study which included all patients presenting to a district general hospital with early clinically node negative breast cancer undergoing sentinel node biopsy between Oct 2011 and Dec 2014.

Alternate 2 mm slices of the node were examined intraoperatively using the Metasin assay and the remainder sent for histological examination. The results of the Metasin assay and histology were compared. The risk of axillary recurrence using the Metasin test to select patients for immediate axillary clearance was assessed.

Results:

1073 sentinel nodes from 545 patients were analysed during this three-year period. 2 patients were lost to follow up. 94 patients were node positive and underwent axillary clearance as part of their primary surgery. 449 patients had sentinel node biopsy with no further axillary procedure. There were 36 nodes (3.34%) with discordant results. Median follow up was 32 months (range 18 to 55 months).

Fourteen patients presented with recurrences (2.56%). The mean event free interval was 15 months. Of the 14 patients, 5 patients tested with Metasin had macrometastases and underwent immediate axillary clearance during the primary surgery. 7 patients were node negative and 2 patients were shown to have micrometastases. 11 patients recurred with distant metastases, 3 patients with local recurrence and 2 patients (0.36%) with axillary recurrences.

The two axillary recurrences occurred at 3 and 5 months after primary surgery. Both patients underwent Metasin intraoperative analyses of sentinel nodes which were negative. Subsequent histological examination confirmed no metastatic node involvement in one patient but micro-metastases in the other. Both of these patients had aggressive disease with local, axillary and distant metastasis and subsequently died of their disease.

Conclusions:

The Metasin assay is a reliable intraoperative test for sentinel node involvement and when used to guide surgical axillary management is associated with very low axillary recurrences (0.36% with a median follow up of 32 months).

Citation Format: Udayasankar S, Ashley E, Jenkins KS, Huws A, Sharaiha Y, Sai-Giridhar P, Thomas D, Munir A, Holt S, Khawaja S. The long term outcomes of Metasin RTqPCR intra-operative sentinel node analysis in early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-22.

Abstract P1-05-21: A comparison of oncotype DX recurrence scores in a screen detected vs a symptomatic cohort of patients with breast cancer: A UK experience

Background:

In the Western World, it has been stated that breast cancers detected on a screening program are indolent. There have been many recent publications stating that breast screening is overdiagnosing and therefore overtreating patients with breast cancer. With the advent of genomic testing, it can now be determined which patients have an aggressive tumor requiring systemic chemotherapy. We therefore conducted a retrospective study in the UK on patients having oncotype DX testing in both screen detected and symptomatic cancers.

Materials and Methods:

Patients in our institution undergoing oncotype DX testing for invasive breast cancer which was ER positive and node negative were part of this study. The detection of the breast cancer was documented as either a screening case or a symptomatic one. The recurrence scores of the oncotype DX testing was then compared in the screening versus the symptomatic cohort.

Results:

155 patients were included in this study. They underwent Oncotype DX testing between 2008 to 2016. The age of the patients ranged from between 31 years to 78 years. Eighty-nine patients were reported to have a low recurrence score; 45 had an intermediate score; and 21 had a high result. Fifty eight patients were screen detected, while 97 patients were symptomatic presentations. In the screening population, 32 patients had a low recurrence score; 22 had an intermediate result and 4 had a high recurrence score resulting in the latter groups being considered for chemotherapy. In the symptomatic cohort, 57 had a low recurrence score; 23 had an intermediate result; and 17 had a high score.

Conclusion:

The results of our study depict that even patients in a screeining cohort will have a high number of intermediate recurrence scores and some with a high recurrence score. This shows that the hypothesis that screening detects a majority of breast cancers which are indolent not requiring further systemic treatment should be looked at again in light of our results with genomic testing.

Citation Format: Khawaja S, Parab A, Thomas D, Huws A, Munir A, Udayasankar S, Sharaiha Y, Holt S. A comparison of oncotype DX recurrence scores in a screen detected vs a symptomatic cohort of patients with breast cancer: A UK experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-21.

Abstract P1-03-12: A simulation study depicting the inconsistency of adjuvant online compared to genomic testing when determining the benefit of chemotherapy

Background: Prognostic factors have been used for years to determine the benefit of adjuvant chemotherapy in breast cancer. However, reporting of the size and grade of the tumor are affected by interobserver variability in reporting. This can result in a change in the results of adjuvant online and an impact on decision making of chemotherapy. On the contrary, genomic testing such as oncotype Dx is reproducible. The purpose of our study was to assess the effect of pathological discordance on the adjuvant online results on a cohort of patients who also underwent oncotype Dx testing.

Materials and Methods: A total of 143 patients' histologies were included in this study. The results of the Phase III WSG-Plan B trial concerning central vs. local grade discrepancy rates were utilized to randomly change the grade of the tumors. 61 percent of grade 1 cancers were upgraded to grade 2 and 2% upgraded to grade 3. 4 percent of grade 2 cancers were downgraded to grade 1 and 26% were upgraded to grade 3. 1 percent of grade 3 cancers were downgraded to grade 1 and 25% were downgraded to grade 2. Likewise, change was made in the size of the tumor in 20 percent of patients. 8 to 10mm, 18-20, 28-30, and 48-50mm changed to 11, 21, 31 and 51mm respectively. 11-13mm, 21-23, 31-33, and 51-53mm was changed to 10, 20, 30, and 50mm. Ten percent of patients had the ER and Her 2 status changed.

Results: The simulation results showed that when the grade was only altered, the spearman correlation of the predicted 10 year mortality on adjuvant online with the original data was significantly changed from 1 to a result of 0.788. When the changed size was additionally added, the coefficient was 0.836. With the altered ER status, the result was 0.749 and with the Her 2 change, the spearman correlation was minimally changed to 0.742. The scattergrams showed a large number of outliers when the alteration in size was added to the altered grade.

Conclusion: Our simulation study confirms that with minimal changes in the clinical parameters because of the lack of perfect correlation between pathologist's results, there is a significant difference in the 10 year predicted mortality on adjuvant online. This is one step further in understanding the lack of correlation between adjuvant online and oncotype Dx, and the inconsistency of chemotherapy decision making with the sole use of adjuvant online.

Citation Format: Khawaja S, Thomas D, Udayasankar S, Munir A, Huws A, Sharaiha Y, Holt S. A simulation study depicting the inconsistency of adjuvant online compared to genomic testing when determining the benefit of chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-03-12.

[Pulmonary hypertension associated with left heart disease: recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more common forms of PH such as PH due to left heart disease. Despite the lack of data, targeted PAH treatments are increasingly being used for PH associated with left heart disease. This development is of concern because of limited ressources and the need to base treatments on scientific evidence. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease, representing an unmet need of targeted PH therapies. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, several working groups were initiated, one of which was specifically dedicated to PH associated with left heart disease. This article summarizes the results and recommendations of this working group.

Changing maternal perceptions of healthy feeding: a novel intervention

OBJECTIVE

This study sought to better understand factors influencing mothers' perceptions about healthy feeding. Additionally, a social consensus intervention was used to try to change mothers' likelihood to serve healthy foods.

METHODS

Mothers saw photographs of healthy and unhealthy snacks and meals and rated them on several factors that were hypothesized to predict the likelihood of serving the foods. Then, mothers were randomly assigned to the experimental or control condition. Those in the experimental condition received social consensus information about these foods, whereas the control condition did not. The change in perceptions in the control and experimental conditions was examined.

RESULTS

Mothers rated healthy meals and snacks less favourably than unhealthy meals and snacks on factors including cost, preparation time and difficulty, and child preference. Furthermore, mothers' perceptions of foods as liked by their child, easy to prepare and 'kid-friendly' predicted higher likelihood to serve those foods. Finally, mothers were more likely to describe the healthy snack as kid-friendly and indicated being more likely to serve it after receiving favourable social norm information about the food.

CONCLUSIONS

The use of social consensus interventions to change parents' perceptions of healthy snacks may be one means of increasing the quality of children's diets.

Is lymphatic endoglin expression a risk marker for breast cancer metastasis? Results of a pilot study

BACKGROUND

Studies have identified endoglin as a biological marker that is overexpressed on the microvessels of certain solid cancers (breast, colorectal cancer, and head and neck squamous cell cancers). There is, at present, no immunohistochemical marker that can discriminate between lymph node-negative and or lymph node-positive breast cancer tissue.

METHODS

The expression of endoglin was quantified by immunohistochemistry and assessment of microvessel density in 53 surgical specimens. These were comprised of breast tumor tissue that had not spread to the regional lymph nodes (lymph node-negative breast tumor tissue: 20 specimens), breast tumor tissue had spread to regional lymph nodes (lymph node-positive breast tumor tissue: 21 specimens), and normal breast tissue as a control (12 specimens).

RESULTS

Significant difference was observed between the expression of endoglin on microvessels of lymph node-negative and lymph node-positive breast cancer tissue (p<0.05). This significant difference was shown to be due to endoglin expression on lymphatic vessels (p<0.02), rather than on blood vessels (p>0.05).

CONCLUSIONS

These findings are the first to suggest that endoglin expression on breast tumor lymphatic vessels may have diagnostic potential as a discriminator between lymph node-negative and lymph node-positive breast cancer. Further studies would be required to confirm this.

Is lymphatic endoglin expression a risk marker for breast cancer metastasis?

The following abstracts won prizes at the 153rd East Midlands Surgical Society meeting held on 9 November 2012 at Leicester General Hospital. First prize was won by George et al. The paper by Ogunbiyi et al was placed second and the paper by Khanna et al was placed third.

A decision impact, decision conflict and economic assessment of routine Oncotype DX testing of 146 women with node-negative or pNImi, ER-positive breast cancer in the U.K

Background:

Tumour gene expression analysis is useful in predicting adjuvant chemotherapy benefit in early breast cancer patients. This study aims to examine the implications of routine Oncotype DX testing in the UK.

Methods:

Women with oestrogen receptor positive (ER+), pNO or pN1mi breast cancer were assessed for adjuvant chemotherapy and subsequently offered Oncotype DX testing, with changes in chemotherapy decisions recorded. A subset of patients completed questionnaires about their uncertainties regarding chemotherapy decisions pre- and post-testing. All patients were asked to complete a diary of medical interactions over the next 6 months, from which economic data were extracted to model the cost-effectiveness of testing.

Results:

Oncotype DX testing resulted in changes in chemotherapy decisions in 38 of 142 (26.8%) women, with 26 of 57 (45.6%) spared chemotherapy and 12 of 85 (14.1%) requiring chemotherapy when not initially recommended (9.9% reduction overall). Decision conflict analysis showed that Oncotype DX testing increased patients' confidence in treatment decision making. Economic analysis showed that routine Oncotype DX testing costs £6232 per quality-adjusted life year gained.

Conclusion:

Oncotype DX decreased chemotherapy use and increased confidence in treatment decision making in patients with ER+ early-stage breast cancer. Based on these findings, Oncotype DX is cost-effective in the UK setting.

Abstract P1-01-18: The results of 55 consecutive cases of intra-operative sentinel node analysis using real time polymerase chain reaction detection of cytokeratin 19 and mammoglobin expression (Metasin) to direct immediate axillary clearance

The standard management of early beast cancer is complete excision of the primary from the breast by either wide local excision or mastectomy and sentinel node biopsy to stage the axilla. The standard of care in the UK remains clearance of the axilla in node positive patients. Unless immediate multiple frozen section histology is available, positive patients require a second operation between 3 and 6 weeks later, with the associated increased cost, inconvenience and risk.

By using the real time polymerase chain reaction (PCR) to detect mammary derived cells in the sentinel lymph nodes (SLN), we aim to provide the surgeon with a reliable indicator of the presence or absence of nodal macro-metastases within a timeframe that will allow axillary clearance to be performed under the same anaesthetic as the initial surgery. We detect cytokeratin 19 (CK19) or mammoglobin within the lymph node using reagents developed by the UK National Health Service under the name Metasin.

Method: 55 consecutive patients undergoing SLN biopsy as part of their initial treatment for early breast cancer were tested using the Metasin. The nodes were divided into 2mm slices and alternate sections submitted to PCR and the remainder to conventional histology. The results were compared and an assessment of the costs made. The time taken report the Metasin result to the surgeon was recorded.

Results: Five patients had positive results by Metasin and proceeded to immediate axillary clearance. When compared to histology there were no false positive results (0%). Two patients were negative on Metasin testing with the threshold set at 2 mm but positive on histology (3.6%). The average time for the test was 43.2 minutes and the mean number of lymph nodes was 2.3. The average cost is £40 to test 2 nodes.

Discussion: The test is accurate. The two false negative cases were found to be due to the sampling, the metastases being only present by chance in the histologically examined specimens and not due to assay failure. The total cost to run the test for 55 patients was £2,520. The cost for completion axillary clearance as a separate procedure is estimated at £2,227. The total saving for 5 cases is about £11,000, making the test cost saving as well as safer, more acceptable to the patients and limiting delay in starting adjuvant therapies. The additional time of surgery caused by using Metasin was minimal.

Conclusion: Metasin has become our standard of care in patients requiring SLN biopsy and generally avoids second surgeries to clear the axilla in positive cases. We are considering analyzing the complete node using this technique and this would eliminate false negatives caused by sampling and offer further cost savings in the histology department.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-18.

p53 levels in human mammary epithelial cells expressing wild-type and mutant human papillomavirus type 16 (HPV-16) E6 proteins

Human fibroblast cells must overcome both the M1 and the M2 stages of cellular senescence to immortalize, at which point cells almost always express telomerase activity. The human papillomavirus (HPV) oncoproteins, HPV-16 E6 and E7, can block the progression to senescence in fibroblasts by associations with p53 and pRb, respectively. Human mammary epithelial (HME) cells require only HPV-16 E6 to bypass M1, suggesting that pRb may not have a direct role in HME cells senescence. In the present report, we show that only wild-type HPV-16 E6 allows complete degradation of p53, immortalization and reactivation of telomerase activity in HME cells. These results suggest that the ability of HPV-16 wild-type and mutant E6 proteins to degrade p53 in intact HME cells and keratinocytes does not completely correlate with their ability to degrade p53 in a cell-free system. This discrepancy between in vitro and in vivo p53 degradation may be biologically significant and may provide insight into the susceptibility of certain human cells and tissues for reactivation of telomerase and immortalization.

Genetics of colorectal cancer (Review)

There is an increasing awareness of the genetic basis of colon cancer and the application of gene therapy. The most commonly altered oncogenes are c-Ki-ras and c-myc, with less frequent involvement of c-src and c-erb. The loss of heterozygosity (LOH) on chromosome 5q has been frequently associated with adenomas, occurring on 17q, 18q, 1p35, 8p22 and 22q11-13 loci. This results in a loss of tumor suppressor gene for these chromosomes. The LOH on 5q was noted on the adenomatous polyposis coli (APC) and the gene on chrome-some 5 was mutated in over 55% cases of colorectal cancer, termed mutated in colon cancer (MCC). MCC is regarded as a tumor suppressor gene which is responsible for the initiation of colon cancer. The deleted in colon cancer gene (DCC) on 18q21 is a common cause of adenomas and the LOH on 17q in p53 gene are frequently seen in bowel cancer. Comparison of frequency with which tumor suppressor and oncogenes are altered in the adenomas and carcinomas suggests that there is a preferred order for their occurrence in the adenoma-carcinoma sequence. Our studies indicate that supplement with tumor suppressor oncoprotein may open a new avenue for gene therapy of colorectal cancer but steps in the identification of the gene(s) await further exploration.

Electrometric direct current I/V converter with wide bandwidth

A principle of operation and electrical characteristics of a high frequency current-to-voltage (I/V) converter are presented. The I/V converter measures the electric current with selectable gains of 10(5), 10(4), and 10(3) V/A in the frequency range from DC to 500 kHz, 1.2 MHz, and 2.4 MHz, respectively. These properties make this I/V converter suitable for wide range of applications such as tuning forks, torsion oscillators, ultrasound transducers measurements, detection of the piezoelectric transducers used in STM techniques, etc., in low temperature physics. The influence of the input impedance of a I/V converter on the precision of alternating current measurements is also discussed.

Why do hospital mastectomy rates vary? Differences in the decision-making experiences of women with breast cancer

BACKGROUND

Hospital mastectomy rates vary. This study explores the relationship between mastectomy rates and breast cancer patients' consultation and decision-making experiences with specialist clinicians.

METHODS

Qualitative semi-structured interviews were conducted with 65 patients from three purposively selected breast units from a single UK region. Patients provided with a choice of breast cancer surgery (breast conservation therapy (BCT) or mastectomy) were purposively recruited from high, medium and low case-mix-adjusted mastectomy rate units.

RESULTS

Low mastectomy rate unit patients' consultation and decision-making experiences were markedly different to those of the medium and high mastectomy rate breast units. Treatment variation was associated with patients' perception of the most reassuring and least disruptive treatment; the content and style of information provision (equipoise or directed); level of patient participation in decision making; the time and process of decision making and patient autonomy in decision making. The provision of more comprehensive less directive information and greater autonomy, time and support of independent decision making were associated with a lower uptake of BCT.

CONCLUSION

Variation in hospital mastectomy rates was associated with differences in the consultation and decision-making experiences of breast cancer patients. Higher mastectomy rates were associated with the facilitation of more informed autonomous patient decision making.

An exploratory analysis of factors associated with weight change in a 16-week trial of oral vs. orally disintegrating olanzapine: the PLATYPUS study

BACKGROUND

We conducted exploratory analyses of the data from a multinational, randomised study to identify factors associated with weight change after 16 weeks of treatment with standard olanzapine tablets (SOT) or sublingual orally disintegrating olanzapine (ODO).

METHODS

One hundred and forty nine outpatients who gained weight during prior SOT therapy were enrolled into the study and treated with ODO (N = 84) or SOT (N = 65). Exploratory analyses were conducted with the subset of compliant patients (ODO: n = 60; SOT: n = 47).

RESULTS

The decrease in the rate of weight gain at the end of study therapy (change from baseline) was greater in the ODO group than the SOT group (-0.59 kg/week vs. -0.38 kg/week, p = 0.0246). Age was negatively associated with weight change (p = 0.0203) in both treatment groups combined: patients gained 0.7 kg less for every 10 years of age. The least squares mean weight gain was lower with ODO than SOT in male patients (0.35 kg vs. 3.04 kg, p = 0.061), but not female patients and in American patients (0.55 kg vs. 6.21 kg, p < 0.0001), but not Canadian or Mexican patients.

CONCLUSIONS

Although not conclusive, these data suggest that ODO may be a reasonable treatment option for some patients who gain weight with SOT. Further research is required to confirm these findings.

[Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with commentary of the Cologne Consensus Conference 2010]

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update y appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to non-invasive diagnosis of PH. This commentary summarizes the results and recommendations of the working group on treatment of PAH.

Patient-prosthesis mismatch and left ventricular remodelling after implantation of Shelhigh SuperStentless aortic valve prostheses

AIM

Aortic valve replacement is a standard procedure for the treatment of severe aortic valve stenosis. Due to lower flow velocities stentless valves are associated with a more effective regression of left ventricular hypertrophy in comparison to stented valves. However, mismatch between body surface area and valve size supports unfavourable hemodynamic results. The aim of the study was to analyze hemodynamic parameters by echocardiography after implantation of the Shelhigh SuperStentless bioprosthesis and to analyze the occurrence of patient-prosthesis mismatch and left ventricular remodelling in this specific valve type.

METHODS

A total of 20 patients with severe aortic stenosis underwent implantation of a Shelhigh Super Stentless prosthesis. Clinical and echocardiographic assessment was done prior to, immediate after and six months after surgery.

RESULTS

All surgical procedures were successful, no surgery-related complication was documented perioperatively. One patient died after development of multiorgan failure. Echocardiography during the first eight days after surgery showed mean gradients of 16 mmHg, mean valve orifice areas of 1.8 cm(2) and indexed effective orifice areas at 0.95 cm(2)/m(2). Six-months follow-up data were obtained in 19/20 patients. There were no relevant changes in echocardiographic hemodynamic findings at the time of follow-up measurements. Significant regression of left ventricular hypertrophy was shown (P=0.0088). A patient-prosthesis mismatch occurred in one patient (0.54 cm(2)/m(2)). No recurrent symptoms were documented.

CONCLUSION

Patient-prosthesis mismatch after implantation of SuperStentless Shelhigh prosthesis is rare. A significant regression of left ventricular hypertrophy could be shown after six months. Hemodynamic valve function assessed by echocardiography may be predicted early after surgery.

The many faces of pheochromocytoma

OBJECTIVE

To recognize and manage pheochromocytomas in unusual settings.

METHODS

Three case reports are presented with clinical, biochemical, imaging, and operative findings. The pitfalls in diagnosis of pheochromocytomas and management are addressed.

RESULTS

We begin with a 27-yr-old gravida 2, para 1 Caucasian woman with unexplained tachycardia and hypertension during a routine pre-natal visit at 30 weeks estimated gestational age. Urinary studies revealed elevated catecholamines. Magnetic resonance imaging localized a 6.6-cm right adrenal mass with features consistent with a pheochromocytoma. She was medically managed with phenoxybenzamine and propranolol until 35 weeks, after which she underwent a combined Cesarean section, and open right adrenalectomy. Another patient, a 36-yr-old African-American woman presented to a hospital in cardiac arrest, with elevated serum troponins, and underwent cardiac catheterization, which revealed normal coronary arteries. A computed tomography (CT) scan revealed a left adrenal mass and CT-guided biopsy was consistent with a pheochromocytoma, although prior studies were negative. Finally, we present a 49-yr-old Caucasian woman who had a right adrenalectomy 10 yr prior and presented to the clinic with fluctuating blood pressures, headaches, and palpitations. Further testing revealed she had a recurrent metastatic pheochromocytoma. The challenges behind treating these patients are further explored.

CONCLUSION

Antenatal diagnosis of pheochromocytoma, though challenging, is associated with lower maternal and fetal morbidity and mortality. The differential diagnosis for cardiac arrest in the presence of normal coronary arteries should include a pheochromocytoma. Finally, treatment with iodinated metaiodobenzylguanidine may be a therapeutic option for those patients with metastatic pheochromocytomas.

Precision analog integrator with voltage hold

In some applications, like a magnetization and demagnetization of ordinary and superconducting magnets driven by the voltage controlled current sources, it is desirable to change the voltage smoothly and linearly toward an adjusted value and then hold this value in time. A circuit is presented that allows: (i) the slow, smooth, and linear change of the integrator output voltage without steps and (ii) the ability to hold the output voltage at a value given by a reference source. In a hold regime, the output voltage is stabilized by a negative feedback. A stability of one part of 10(5) at the output voltage of 2 V was achieved over a 12 h period.

Inhaled fluticasone propionate and adrenal effects in adult asthma: systematic review and meta-analysis

The dose-response relationship of inhaled fluticasone propionate (FP) for adrenal suppression in adults with asthma is not clear. The current authors carried out a systematic review and meta-analysis of placebo-controlled randomised dose-response studies of >or=4 weeks' duration, which assessed the adrenal effects of FP by cosyntropin stimulation tests in adult asthma. The main outcome measure was the proportion of subjects with adrenal function below the lower limit of the normal range. Five studies, with a total of 732 subjects with asthma, met the inclusion criteria. Data on daily doses >1,000 mug were limited to one study. The proportion of subjects with adrenal function below the lower limit of the normal range on placebo was 3.9%; for a 500-microg per day increase in FP dose the odds of an abnormality increased by 1.38 (95% confidence interval 1.01-1.59). The continuous secondary outcome measures showed an inverse linear relationship with the FP dose up to 2,000 microg.day(-1). In conclusion, for routine prescribing within the established therapeutic dose-response range (50-500 microg.day(-1)), fluticasone propionate has minimal effects on adrenal function. This conclusion is limited by the paucity of long-term studies of daily doses of fluticasone propionate >1,000 mug and by the considerable individual variability in the response.