Accuracy of a multidisciplinary team-led discussion in predicting postmastectomy radiotherapy

INTRODUCTION

Immediate breast reconstruction (IBR) is performed increasingly following mastectomy for breast cancer. The literature suggests higher reconstructive failure and poorer cosmesis in the subgroup of patients receiving postmastectomy radiotherapy (PMRT) following IBR. We set out to determine the accuracy of a multidisciplinary team (MDT) discussion in predicting PMRT.

METHODS

Preoperative MDT discussions were recorded prospectively over a 12-month period (from February 2011) in a symptomatic breast unit. The estimated need for PMRT was stratified into 'PMRT not required', 'PMRT possibly required', 'PMRT probably required' and 'PMRT required' groups.

RESULTS

Of 156 referrals included in the study, 76 patients (49%) underwent mastectomy: 61 simple mastectomy, 10 skin sparing mastectomy (SSM) and delayed-immediate breast reconstruction, 3 SSM and implant-based IBR, and 2 mastectomy IBR with an autologous flap. The IBR rate was therefore 19.7%. The proportion of patients who received PMRT was 14% (3/21) in the 'PMRT not required', 30% (7/23) in the 'PMRT possibly required', 65% (9/14) in the 'PMRT probably required' and 94% (17/18) in the 'PMRT required' groups. Assigning a linear numerical score (1-4) to these groups (higher score representing greater likelihood of receiving PMRT), the predicted need for PMRT correlated with the proportion of patients who ultimately received PMRT (linear regression r(2)=0.98, p=0.01).

CONCLUSIONS

This study has examined the factors influencing MDT discussions regarding IBR, demonstrating that the MDT is reasonably accurate at predicting need for PMRT. Whether such accuracy is clinically adequate and/or reproducible across units is debatable.

Effect of the neuropeptides vasoactive intestinal peptide, peptide histidine methionine and substance P on human major salivary gland secretion

OBJECTIVE

The parasympathetic transmitters vasoactive intestinal peptide (VIP) and substance P (SP) are secretagogues in salivary glands of animals. Currently, we hypothesise that in human salivary glands, these neuropeptides and the VIP-related peptide histidine methionine (PHM) also exert secretory actions, reflected morphologically by exocytosis of acinar protein/glycoprotein-storing granules.

MATERIALS AND METHODS

Submandibular and parotid gland tissues, exposed in vitro to VIP and PHM, and SP, respectively, were examined by light and transmission electron microscopy. For comparison, the response to in vitro stimulation of isoproterenol, phenylephrine and carbachol was examined. Moreover, the peptidergic innervation of the glands was examined by immunohistochemistry.

RESULTS

Vasoactive intestinal peptide- and PHM-immunoreactive nerves were in close proximity to acini and ducts in the two glands, while these elements lacked a SP-positive innervation. While no morphological changes occurred in response to SP (parotid glands), VIP and PHM administration (submandibular glands) caused conspicuous acinar degranulation accompanied by luminal space broadening. In the two glands, both α1 - and β-adrenergic receptor stimulation and muscarinic receptor stimulation caused similar changes as to VIP/PHM, although to varying extent.

CONCLUSIONS

Vasoactive intestinal peptide and PHM, but not SP, are likely transmitters in the parasympathetic control of salivary (protein) secretion in humans.

The Hall-Findlay mammaplasty pattern for skin-sparing mastectomy: case report

We present an application of the Hall-Findlay mammaplasty skin pattern for skin-sparing mastectomy (SSM). This is a simplified vertical reduction mammaplasty. Vertical reduction mammaplasty is the procedure advised for patients with moderator or large ptotic breasts, who wish to have a simultaneous contra-lateral breast reduction/mastopexy at the time of SSM for cancer or prophylactic mastectomy. It is particularly suitable for breast reconstruction with autologous tissue in the form of free transverse rectus abdominis myocutaneous (TRAM), deep inferior epigastric artery perforator (DIEP) and extended latissimus dorsi (ELD) flaps.

Adaptation of the Hall-Findlay technique for simultaneous contralateral reduction in delayed breast reconstruction with extended latissimus dorsi flap

In the past we have validated Hall-Findlay technique of breast reduction with our independent results. The technique combines the safety of the superomedial pedicle with advantages of a vertical scar in a quick but safe manner ensuring adequate resection and sound healing with less scars and faster recovery for the patient. We now report our experience of using an adaptation of the same in simultaneous contralateral reduction in delayed breast reconstruction with extended latissimus dorsi flap.

METHOD

Thirty consecutive patients underwent simultaneous contralateral balancing reduction. The modifications consisted of wider upper pole reduction with smaller, thinner pedicle reducing the projection.

RESULTS

All patients had an uneventful recovery with no haematoma, infection or seroma. Two patients (6.66%) wished further reduction and one (3.33%) required dog-ear revision.

CONCLUSION

The modifications allow the reduction of the contralateral breast with a lower projection to match the extended latissimus dorsi (ELD) flap reconstruction. We have found the modified technique to be reliable and versatile with a shorter operative and recovery time adding minimal morbidity of simultaneous contralateral reduction and effectively reducing the need of a delayed balancing reduction.

Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap

A combined microvascular flap composed of serratus anterior myo-osseous and a latissimus dorsi myocutaneous flap has been performed for resurfacing massive scalp and skull defects, accompanied by chronic infection and heavy radiation damage. The authors present a case report where the combined procedure allowed a single-stage reconstruction of this complex defect.

Somatostatin- and Substance P-ergic neurons and Glial cell line-derived neurotrophic factor in the human archicortex

By means of immunohistochemistry, the localization of Somatostatin (SOM)- and Substance P (SP)-ergic neuronal populations was compared to the occurrence of Glial cell line-derived neurotrophic factor (GDNF) in the human hippocampus from prenatal to adult life stages. The results obtained i) confirm previous reports on the distribution of SOM and SP; ii) show that GDNF-like immunoreactivity occurs in an ample population of hippocampal neurons, with a main location in the pyramidal cells; iii) identify regions of codistribution of either neuropeptide with GDNF-positive elements. Although coexistence of GDNF with SOM or SP was not detected, the possibility that the trophic factor may act on the neuropeptide-containing neurons can be envisaged and is worth further analysis.

An anatomical study of the relationship between excursion of the flexor tendons and digital mobility: proposition of an intraoperative test for flexor tendon tenolysis

The excursion of the flexor tendons of the thumb and fingers was studied in ten fresh cadaveric upper limbs. For each centimetre of tendon movement, obtained by traction of the flexor tendons at the wrist, the angular changes of the digital articulations were measured; movement started at extension and proceeded to maximum flexion. A further five upper limbs were used to evaluate the effect of pressure over the musculotendinous area of the flexor tendons of the fingers and thumb. Pressure on the muscle bellies in the forearm causes movement of the tendons, different for each finger, with the accompanying digital flexion depends on the magnitude of the movement. On the basis of this anatomical study a test is described which may be beneficial in the diagnosis of pathology and trauma of the flexor tendons and, particularly, in the intraoperative evaluation of the quality of motion obtained during tenolysis.

Glial cell line-derived neurotrophic factor-like immunoreactivity in human trigeminal ganglion and nucleus

Glial cell line-derived neurotrophic factor (GDNF) is shown by immunohistochemistry in human trigeminal sensory system from 22 weeks of gestation to adulthood. In the trigeminal ganglion, a distinct subpopulation of GDNF-positive neurones is observed, which amounts to about 15% at early pre-term and adult ages and peaks to around 30% at perinatal ages. Labelled neurones are mostly small- and medium-sized. Occasionally, Schwann and satellite cells are stained. GDNF/substance P (SP) and GDNF/calcitonin gene-related peptide (CGRP) double stained neurones occur at all ages examined, whereas GDNF/trkA coexistence can be observed in pre- and full-term newborns only. Centrally, GDNF-immunostained fibers and terminal-like structures are mainly restricted to the spinal trigeminal nucleus, where they are codistributed with SP and CGRP. In the subnucleus caudalis, positive neurones can also be observed both in the superficial laminae and in the magnocellular part, with higher frequency in adults. These results suggest that GDNF may play a functional role in human trigeminal primary sensory neurones throughout life and provide indication for its possible involvement in the regulation of pain-related neuronal circuits in human trigeminal sensory system.

[Factors influencing coverage, response and participation in breast cancer screening program]

BACKGROUND

The objective was to analyze sociodemographic, organizational and health care-related factors associated to level of enrollment in a breast cancer screening program developed in one area of Barcelona (Spain).

MATERIAL AND METHODS

Three types of indicators were used: coverage, response and participation. The influence of age, educational level, previous clinical contacts, the person who received the citation and the reason for not attending after the first citation were studied. The odds ratio (OR) was used to estimate the magnitude of the association between variables. The OR were adjusted by age and education through unconditional logistic regression.

RESULTS

The rates were: coverage 79.2%, response 74.6%, and participation 61%. The response after the first citation was influenced by the recipient of the letter (p < 0.001); when it was the target-woman, the response was 75%. The response after the successive citations was 50.5% if the reason for not attending previously was circumstantial, and 11.5% when it was lack of interest. Having had previous clinical contacts in the primary care centre or in the reference hospital multiplied by 4 to 7 times the response. Coverage decreased with age, and it presented a curvilinear pattern with respect to educational level. Multivariate analyses emphasized the importance of previous clinical contacts (ORs between 3.5 and 8.1; p < 0.001).

CONCLUSIONS

Previous contacts with the health system, the method of citation and the reason for not attending after the initial phase were factors clearly associated with participation in a breast cancer screening program. Research on factors influencing participation would contribute to improve the results of screening programs currently underway in Spain.

[The initial symptom attributable to cancer in digestive tube tumors. A study of agreement between the patient and the physician]

BACKGROUND

Clinical practice shows that certain patients may underestimate and others overestimate some initial symptoms of their disease. In studies on the interval between first symptoms and treatment onset, estimating the date in which symptoms first appeared is crucial. The study analyzed patient-physician agreement in assessing first symptom attributable to cancer.

METHODS

During two years, two physicians personally interviewed, through a structured questionnaire, all symptomatic patients with a neoplasm of the digestive tract admitted to Hospital del Mar (Barcelona, Spain). Patients had a mid-low sociocultural profile and most had been admitted through the Emergency Department.

RESULTS

Absolute agreement (symptom and date) occurred in 85% of the 183 subjects. In most discordant cases, patients had overlooked some component of the "toxic syndrome", and the date of symptom onset was, based on physician's assessment, chronologically prior to the date elicited from the patient. Disagreement was directly related to the patient's health status (p < 0.05) and to the number of reported symptoms until hospital admittance (p = 0.002), but not to tumour stage. Agreement increased with the importance attributed by the patient to the first symptom (p < 0.05).

CONCLUSIONS

In spite of difficulties inherent to measuring symptomatic onset of diseases, structured patient interviews appear to be a reasonably valid method and deserve further development in this and other areas of research.

[Domiciliary care of the terminal cancer patient: evaluation and proposals by physicians and nurses]

OBJECTIVE

To detect problems that terminal cancer patients pose to primary health care (PHC) professionals.

DESIGN

Cross-sectional study.

SETTING

PHC professionals of the Manresa (province of Barcelona) health Sector of the National Health System.

PARTICIPANTS

151 professionals (87 physicians and 64 nurses).

MEASUREMENTS AND RESULTS

Self-responded anonymous questionnaire. Dates: 10-20 December, 1990; response rate: 89%. Most participants said in the previous year they were responsible for 3 or more home terminal cancer patients. 35.6% said emergencies were handled in a hospital; professionals working in non-urban areas and in the non-reformed Primary Care system less often used hospitals. Access to consultants was deemed difficult by most interviewees, but most said consultants' reports were good or excellent; physicians valued reports higher than nurses (odds ratio [OR] = 5.43, P < 0.001). Most participants reported continuous education to be scarce or nonexistent. Also, most said care given to terminal cancer patients was inadequate; younger professionals (p = 0.001) y and those working in the reformed Primary Care system (P = 0.003) were more critical.

CONCLUSIONS

Interest of primary care professionals in terminal cancer patients was higher in less populated areas, among those having a permanent contract and in the reformed system.

[The optimization of the data base of a voluntary health care cooperative for the study of postoperative morbidity in benign prostatic hypertrophy]

BACKGROUND

Investigation in health care services by data bases (DB) is undergoing an important increase in numerous countries. Several of the most relevant epidemiologic studies on the postsurgical morbidity and mortality of benign hypertrophy of the prostate (BHP) have used DB. The aim of this study was to prepare and optimize the DB of a health cooperative (Asistencia Sanitaria Colegial).

METHODS

Since 1981 the DB contains sociodemographic variables, data concerning visits to general practitioners and specialists, complementary examinations and hospitalizations. The coding system was specifically developed by the cooperative. The study base was made up of all the policies of the members between January 1981 and December 1988 (101,400 males). To identify the policies 14 codes potentially related with BHP were initially chosen and all the policies containing any of these codes were selected, with the manual analysis of 204 policies being thereby performed.

RESULTS

The total number of policies initially selected for the study was 3,157. Manual revision discarded the use of 9 of the 14 codes used in the first selection. In agreement with the 5 codes able to define diseases of prostatic gland and to the file in which they appeared the policies were classified as probable diseases of prostatic gland (n = 1,007, 31.9%), possible (n = 805, 25.5%) and improbable (n = 1,345, 42.5%). Likewise, the strategy to follow for the selection of a cohort of BHP cases was defined.

CONCLUSIONS

The manual analysis of policies evidenced a remarkable coherence and exhaustiveness of the information registered. The principal difficulties found with the data base used were the lack of a sole diagnosis and the coding system used in addition to the impossibility of automatically controlling the assistance received by the patients outside the cooperative system. The availability of a data base such as that herein described with a well defined large population and with accessible sociodemographic and health care information justifies collaborative efforts among health care administrators, clinicians, computer scientists and epidemiologists.

[The prevalence of serological markers for the human immunodeficiency virus and the hepatitis B virus in a psychiatric hospital]

OBJECTIVES

To estimate the prevalence of antibodies to human immunodeficiency virus (HIV), antibodies to hepatitis B core antigen (anti-HBc), hepatitis B surface antigen (HBsAg), and antibodies to delta virus (anti-DV).

DESIGN

Cross-sectional (prevalence) study. A non-proportional (stratified by length of stay) random sample of 20% of admitted patients was selected.

CLINICAL SETTING

The Hospital Psiquiátrico Nuestra Señora de Montserrat (Sant Boi de Llobregat, Barcelona, Spain) admits about 670 patients in its short-term, rehabilitation (mid-term) and long-term wards.

SUBJECTS

139 patients were selected: 91% were males, mean age was 55 years, and 10% belonged to an HIV risk group; mean length of hospitalization since last discharge was 13 years.

MEASUREMENTS

Blood samples were drawn in October, 1988. Anti-HBc, HBsAg and anti-DV were determined by competitive enzyme immunoassay (EIA). Anti-HIV-1 were determined by sandwich EIA; negativity of results with high absorbency but below the cut-off point was confirmed by Western blot.

RESULTS

None of the sampled patients had circulating anti-HIV-1 antibodies. Four cases showing high absorbency (below the "cut-off" point) were ruled out by Western-blot. Overall, the prevalence of anti-HBc was 52.8% (54.4% in long-term wards, 35.0% in mid-term wards, and 13.8% in short-term wards). The prevalence of HBsAg was 2.3%, of anti-DV 1.5%, and of HDAg 0%.

CONCLUSIONS

Prevalence of anti-HIV is null in the studied institution. Current efforts to prevent HIV infection must continue; a hepatitis B vaccination program is highly warranted among patients and professionals of the studied hospital.

[Prevalence of buprenorphine use by heroin addicts undergoing treatment]

After buprenorphine was introduced as an analgesic, several clinical observations have stimulated the investigation of its potential abuse by heroin addicts. To evaluate the prevalence of buprenorphine use by a group of heroin abusers being treated on an outpatient basis, a cross-sectional study was carried out where the information given by the 188 subjects was verified by urine drug analyses. The patients had three different therapeutic modalities: methadone maintenance program (MMP), antagonist maintenance program (AMP), and drug-free program (DFP). The urine samples were analyzed with an enzyme immunoassay technique for the detection of heroin, methadone, dextropropoxyphene, cannabis and benzodiazepines. Buprenorphine was investigated with a radioimmunoassay technique. Overall 66% of the patients admitted having used buprenorphine throughout their toxicologic history (period prevalence) and 6.7% had positive urine controls for this drug (5% in the MMP group, 0% in the AMP group and 12% in the DFP group) (point prevalence). In 72% of the cases the drug was administered intravenously. In addition, a clinically statistically significant association was found between positivity for heroin and buprenorphine. The possible tolerance to the latter is suggested by the fact that the mean current dose was higher than the mean initial dose. In the study population, the use of cannabis and benzodiazepines was also very high. The results suggest that most patients had a previous history of buprenorphine use. This drug could have a higher potential for abuse than that found in previous experimental studies.

[The symptom-diagnosis interval: a possible approximation to the natural history of neoplasms]

In order to assess the influence that age, sex, site of the primary tumor (SPT), the extension and histology may have on the interval first symptom-diagnosis (ISD), 1.149 cases of lung, breast, stomach, colon and rectum cancer registered in the Tumor Registry of the Hospital del Mar (Barcelona) were analyzed. Overall, mean ISD was 5.7 months. 12.7% of women and 5.5% of men (p less than 0.0001) had an ISD greater than one year. Age does not appear to influence ISD in this population (r = 0.014). Among women, the ISD for each SPT was as follows: breast cancer, 9.1 months; rectal cancer, 6.5; stomach, 4.9; colon, 4.7; lung, 2.7. Men's ISD were: rectum, 6.2; stomach, 5.9; colon, 5.7; lung 3.2. Age, sex, SPT, the extension and histology jointly explain only 18% of the ISD variability (multiple r = 0.42 p less than 0.0001). SPT and histology appear to be the strongest predictors, both remaining statistically significant when adjusting for the other four factors. While only breast cancer clearly showed a positive association between ISD and tumor extension, an unexpected inverse relationship was observed in rectal cancer. In some tumors, the ISD may just be an indicator for the rate of tumor growth. ISD data registered in a Tumor Registry can contribute to the study of a part of the natural history of neoplasms. Such analyses are also relevant for studies of secondary prevention and screening programs, access to and quality of care, and psychosocial predictors of the care seeking process.