Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy

BACKGROUND

Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling.

METHODS

In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed.

RESULTS

A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P<0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m2; 95% CI, -7.99 to -4.74; P<0.001), end-diastolic volume (-3.87 mL/m2; 95% CI, -6.77 to -0.98; P=0.009), and end-systolic volume (-3.25 mL/m2; 95% CI, 4.87 to -1.63; P<0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P<0.001) and 2.8% (95% CI, 1.4-4.1; P<0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P=0.024) and a reduction in left atrial volumes of -4.33 mL/m2 (95% CI, -5.52 to -3.21; P<0.001) between baseline and follow-up when adjusted for baseline differences in measures.

CONCLUSIONS

Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.

Kinetics of the reaction of ferrous ions with hydroxyl radicals in the temperature range 25-300 °C

The kinetics and mechanism of the reaction between OH radicals and ferrous ions in the temperature range 25-300 °C were studied using pulse radiolysis. At temperatures <150 °C the rate of reaction is essentially independent of temperature, while at temperatures >150 °C the activation energy is 45.8 ± 3.0 kJ mol-1. The change in activation energy is attributed to a change in the dominant mechanism from hydrogen atom transfer (HAT) to dissociative ligand interchange. The kinetic isotope effect (KIE) was measured by repeating experiments in heavy water. A value of 2.9 was measured at room temperature where HAT is the dominant mechanism. The KIE decreases to zero at temperatures > 150 °C as ligand interchange becomes dominant and the O-H bond is no longer involved in the reaction.

Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review

AIMS

Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum.

METHODS AND RESULTS

Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum.

CONCLUSION

The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.

High-Temperature Reaction Kinetics of the eaq- and HO2• Radicals with Iron(II) Ions in Aqueous Solutions

Pulsed electron radiolysis was used to determine the chemical reaction kinetics and Arrhenius parameters for iron(II) reactions in aqueous solutions under irradiation. The second-order Fe²⁺ reactions with the hydrated electron (e_aq^-) and the perhydroxyl radical (HO₂^•), arising from water radiolysis, were measured to high temperatures using custom-built flow-through cells with a multichannel optical detection system. The reaction with the HO₂^• radical was found to proceed via the formation of a metal-ion adduct species, Fe²⁺-HO₂^•. The adduct's molar extinction coefficient and its first-order decay rate coefficients are also reported.

Acute fetal response to high-intensity interval training in the second and third trimesters of pregnancy

The majority of women do not meet the recommended levels of exercise during their pregnancies, frequently due to a lack of time. High-intensity interval training offers a potential solution, providing an effective, time-efficient exercise modality. This exercise modality has not been studied in pregnancy therefore, the objective of this study was to evaluate fetal response to a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy. Fourteen active, healthy women with uncomplicated, singleton pregnancies participated in a high-intensity interval training resistance circuit between 28 + 0/7 and 32 + 0/7 weeks. A Borg rating of perceived exertion of 15-17/20 and an estimated heart rate of 80%-90% of maternal heart-rate maximum was targeted. Fetal well-being was evaluated continuously with fetal heart-rate tracings and umbilical artery Doppler velocimetry conducted pre-and post-exercise. Fetal heart rate tracings were normal throughout the exercise circuit. Post-exercise, umbilical artery end-diastolic flow was normal and significant decreases were observed in the mean systolic/diastolic ratios, pulsatility indexes and resistance indexes. Therefore, in a small cohort of active pregnant women, a high-intensity interval training resistance circuit in the late second and early third trimesters of pregnancy appears to be a safe exercise modality with no acute, adverse fetal effects but further study is required. Novelty: High-intensity interval training, at an intensity in excess of current recommendations, does not appear to be associated with any adverse fetal effects in previously active pregnant women. High-intensity interval training is an enjoyable and effective exercise modality in previously active pregnant women.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave

BACKGROUND

There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period.

METHODS

We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission.

RESULTS

There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery.

CONCLUSIONS

There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Consideration on modeling of Nb sorption onto clay minerals

Sorption distribution coefficient (Kd) of niobium-94 on minerals are an important parameter in safety assessment of intermediate-depth disposal of waste from core internals etc. The Kd of Nb on clay minerals in Ca(ClO4)2 solutions were, however, not successfully modeled in a previous study. The high distribution coefficients of Nb on illite in Ca(ClO4)2 solutions were successfully reproduced by taking Ca–Nb–OH surface species into account. Solubility of Nb was studied in Ca(ClO4)2 solutions and the results were reproduced by taking an aqueous Ca–Nb–OH complex species, CaNb(OH)6 +, into account in addition to previously reported Nb(OH)6 − and Nb(OH)7 2−. Based on this aqueous speciation model, the Ca–Nb–OH surface species responsible for the sorption of Nb on illite in Ca(ClO4)2 solutions was presumed to be X_OCaNb(OH)6. Although uncertainties exist in the speciation of aqueous Ca–Nb–OH species, the result of this study proposed a possible mechanism for high distribution coefficient of Nb on illite in Ca(ClO4)2 solutions. The mechanism includes Ca–Nb–OH complex formation in aqueous, solid and surface phases.

Hypoglycemia in unmonitored full-term newborns-a surveillance study

Background and objectives

Hypoglycemia monitoring is not recommended for most full-term newborns. We wished to determine the incidence, presentation and case characteristics of hypoglycemia in low-risk newborns.

Methods

With the assistance of the Canadian Paediatric Surveillance Program, we conducted a national study of severe hypoglycemia in apparently low-risk full-term newborns. Paediatricians who reported a case were sent a detailed questionnaire and the data were analyzed.

Results

All 93 confirmed cases were singletons, 56% were first-borns and 65% were male. An 8% rate of First Nations cases was twofold the population rate. Maternal hypertension rate was 23%, fourfold the general pregnancy rate. Maternal obesity was double the general pregnancy rate at 23%. Concerning signs or feeding issues were noted in 98% at the time of diagnosis. Median time to diagnosis was 4.1 hours. Mean blood glucose at intravenous (IV) start was 1.4 ± 0.5 hours (SD). Seventy-eight per cent had at least one of four potential stress indicators and were more likely to have early diagnosis (P=0.03). Major signs were present in 20%. Those cases presented later and had lower glucose levels (median=0.8 mmol/L versus 1.6 mmol/L, [P<0.001). Twenty-five per cent of cases had birth weight less than the 10th centile. Neurodevelopmental concern was reported in 20%. Of the 13 cases which had brain magnetic resonance imaging, 11 were abnormal.

Conclusion

Hypoglycemia in unmonitored newborns is uncommon but is associated with significant morbidity. We provide a range of clues to help identify these newborns soon after birth. Widespread adoption of norm-based standards to identify small-for-gestational age infants is supported.

Measurement of concentrations of four chemical ultraviolet filters in human breast tissue at serial locations across the breast

The human population is widely exposed to benzophenone-3 (BP-3), octylmethoxycinnamate (OMC), 4-methylbenzilidenecamphor (4-MBC) and homosalate from their use in consumer goods to absorb ultraviolet (UV) light. Their oestrogenic activity and presence in human milk suggest a potential to influence breast cancer development. In this study, high-performance liquid chromatography-tandem mass spectrometry was used to measure concentrations of these UV filters in human breast tissue from three serial locations across the breast from 40 women undergoing mastectomy for primary breast cancer. One or more of these UV filters were quantifiable in 101 of 120 (84%) of the tissue samples and at least one breast region for 38 of 40 women. BP-3 was measured in 83 of 120 (69%) tissue samples and at least one breast region for 33 of 40 women (range 0-26.0 ng g^-1 tissue). OMC was measured in 89 of 120 (74%) tissue samples and at least one breast region for 33 of 40 women (range 0-58.7 ng g^-1 tissue). 4-MBC was measured in 15 of 120 (13%) tissue samples and at least one breast region for seven of 40 women (range 0-25.6 ng g^-1 tissue). Homosalate was not detected in any sample. Spearman's analyses showed significant positive correlations between concentrations of BP-3 and OMC in each of the three breast regions. For ethical reasons cancerous tissue was not available, but as the location of the cancer was known, Mann-Whitney U-tests investigated any link between chemical concentration and whether a tumour was present in that region or not. For the lateral region, more BP-3 was measured when a tumour was present (P = .007) and for OMC the P value was .061. For seven (of 40) women with measurable 4-MBC, six of seven had measurable 4-MBC at the site of the tumour.

Attitudes to contralateral risk reducing mastectomy among breast and plastic surgeons in England

INTRODUCTION

Rates of contralateral risk reducing mastectomy (CRRM) are rising despite a paucity of data to support this practice. Surgeons work as part of the multidisciplinary team (MDT). They may counsel women on these requests without the benefit of established guidelines or agreed protocol. This study assessed the practices and perceptions of breast and plastic surgeons in England on CRRM.

METHODS

A postal questionnaire was sent to 455 breast and 364 plastic surgeons practising in England. Basic demographics, trends in CRRM, risk assessment, role of the MDT and knowledge base were assessed.

RESULTS

The response rate among breast surgeons was 48.3% (220/455) and 12.6% (46/364) among plastic surgeons. Nearly half (44%) of the respondents felt there had been an increase in rates of CRRM over the last three years. Seventy-one per cent of those surveyed performed 1-5 CRRMs annually while sixteen per cent did not perform this procedure at all. A third (32%) of respondents correctly quoted their patients an annual risk of 0.5-0.7%. Funding was refused in 4% of cases and 43% of the surgeons felt that in the future they would have to apply to relevant clinical commissioning groups. Over half (58%) of all respondents reported that decisions for CRRM are always discussed in the MDT meeting but 6% stated that these cases are never discussed by the MDT. BRCA mutation was perceived as the main risk factor for contralateral breast cancer by 81% of respondents. Surgeons felt that women requested CRRM mainly to alleviate anxiety. The next most common reasons were carriage of BRCA mutation and a desire to have reconstructions match.

CONCLUSIONS

A wide variation of surgical practices and perceptions exist in assessing women for CRRM. Guidelines to standardise practices are required.

The Manchester guidelines for contralateral risk-reducing mastectomy

Background

Rates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM.

Methods

We reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines.

Results

A simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups.

Conclusion

These guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.

Measurement of paraben concentrations in human breast tissue at serial locations across the breast from axilla to sternum

The concentrations of five esters of p-hydroxybenzoic acid (parabens) were measured using HPLC-MS/MS at four serial locations across the human breast from axilla to sternum using human breast tissue collected from 40 mastectomies for primary breast cancer in England between 2005 and 2008. One or more paraben esters were quantifiable in 158/160 (99%) of the tissue samples and in 96/160 (60%) all five esters were measured. Variation was notable with respect to individual paraben esters, location within one breast and similar locations in different breasts. Overall median values in nanograms per gram tissue for the 160 tissue samples were highest for n-propylparaben [16.8 (range 0-2052.7)] and methylparaben [16.6 (range 0-5102.9)]; levels were lower for n-butylparaben [5.8 (range 0-95.4)], ethylparaben [3.4 (range 0-499.7)] and isobutylparaben 2.1 (range 0-802.9). The overall median value for total paraben was 85.5 ng g(-1) tissue (range 0-5134.5). The source of the paraben cannot be identified, but paraben was measured in the 7/40 patients who reported never having used underarm cosmetics in their lifetime. No correlations were found between paraben concentrations and age of patient (37-91 years), length of breast feeding (0-23 months), tumour location or tumour oestrogen receptor content. In view of the disproportionate incidence of breast cancer in the upper outer quadrant, paraben concentrations were compared across the four regions of the breast: n-propylparaben was found at significantly higher levels in the axilla than mid (P = 0.004 Wilcoxon matched pairs) or medial (P = 0.021 Wilcoxon matched pairs) regions (P = 0.010 Friedman ANOVA).

Should Physicians be Co-Managing Elective Joint Replacements with Orthopaedic Surgeons?

Orthopaedic surgeons have worked closely with geriatricians in the management of elderly patients with trauma, predominantly with fractures of the neck of femur, for over 50 years. This collaborative orthogeriatric model of care, pioneered by Devas and Irvine in Hastings in the 1960s, is now practised to some degree in most trauma units in the UK with success.

Level III Lymph Node Involvement Cannot Be Predicted Following Positive Sentinel Node Biopsy

Background: Radiotherapy is a treatment alternative to axillary node clearance following a positive sentinel node biopsy. However level III lymph nodes are not usually treated with current axillary radiotherapy protocols, raising the concern of inadequate treatment.Methods: A retrospective review of 636 patients undergoing sentinel node biopsy for breast cancer, following normal axillary ultrasound, to identify factors predicting for level III involvement.Results:In total 115 (18% of 636 women undergoing sentinel node biopsy had node involvement. Subsequent axillary node clearance in these patients identified 50% with further axillary node involvement. Further lymph node involvement was not predicted by standard pathological factors (oestrogen/progesterone/Her 2 neu receptor status/tumour size/grade). The Memorial Sloane Kettering Cancer Center (MSKCC) breast nomogram for additional node metastases had limited clinical utility. The mean (range) score to predict node involvement in node positive patients was 22% (4-95%) and node negative patients was 13% (5-33%) (p=0.01). 11% of patients had metastatic disease in level III nodes at surgery. Level III involvement was not predicted by routine clinicopathological factors, and although the MSKCC breast nomogram gave higher scores for the prediction of patients with subsequent level III involvement (level III positive: 32% (6-95%); negative: 14% (4-69%)), it was not discriminatory.Conclusion: Neither the MSKCC breast nomogram or standard clinicopathological factors predict for level III node involvement following positive sentinel node biopsy. Level III axillary node clearance must therefore be recommended as the gold standard for positive axillary disease to avoid the risk of undertreating 11% of patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1015.

The dying art of plastering: a survey of orthopaedic trainees' plastering experience

It is possible that some persons are more naturally equipped for acquiring manipulation skills than others, but it is unlikely that there is any special gift which cannot be conscientiously acquired by everyone.

Screening younger women with a family history of breast cancer – does early detection improve outcome?

Women with a family history are often offered mammographic surveillance at an earlier age and with greater frequency than those in the National Breast Screening Programme. In this study, we compared the survival of 62 breast cancer patients diagnosed in the context of a family history clinic offering 12-18 monthly mammographic screening with that of 1108 patients of the same age range but having no exposure to screening. We subtracted the expected additional observation time due to lead time from the survival of the screen-detected cases. Survival was significantly better in the family history group with relative hazards of 0.19 (95% CI 0.07-0.52, P<0.001) for breast cancer death and 0.19 (95% CI 0.08-0.43, P<0.001) for disease-free survival. After correcting for lead-time, the relative hazards were 0.24 (95% CI 0.09-0.66, P=0.005) for breast cancer death and 0.25 (95% CI 0.11-0.57, P<0.001) for disease-free survival. These results strongly suggest that screening younger women with a family history of breast cancer leads to improved survival. More precise estimates of the benefit will accrue from further follow-up and other such studies.

Surgical decisions made by 158 women with hereditary breast cancer aged <50 years

AIM

To establish the uptake of contralateral risk reducing mastectomy in women informed of their risks and options at time of diagnosis of their primary unilateral breast cancer.

METHODS

We have assessed the surgical choices of 70 women diagnosed with breast cancer <50 years as part of a family history surveillance program and fully informed about their contralateral risks and surgical options. We have compared this to women from other surgical clinics who were subsequently found to harbour a pathogenic BRCA1/2 mutation.

RESULTS

Sixty-five percent (13/20) of BRCA1/2 mutation carriers and 59% (n=20/34) of those at the highest level of risk pre-diagnosis (33+% lifetime risk) opted for contra-lateral mastectomy in the study sample. In contrast only 10% (n=9/88) women identified as mutation carriers from other clinics opted for such surgery.

CONCLUSIONS

We would suggest that women with a significant family history and therefore a high contra-lateral breast cancer risk, should have these risks and management options discussed at the time of diagnosis of breast cancer.

High-grade carcinomas of the breast showing patterns of mixed ductal and myoepithelial differentiation (including myoepithelial cell-rich carcinoma of the breast)

AIMS

To assess the clinical, morphological and immunophenotypic characteristics of breast carcinomas showing patterns of mixed epithelial and myoepithelial differentiation.

METHODS AND RESULTS

Included in the study were four carcinomas containing a mixed population of epithelial and myoepithelial cells identified using morphological features at the light microscopic level which were found amongst a review of 500 archival cases and two recently accessioned cases. The carcinomas varied in size from 20 to 38 mm and all were grade 3 ductal carcinomas. Most showed nodular and sheet-like cellular aggregates, although one case showed small solid cell aggregates with duct formation. The cells were large, round, polygonal or spindle-shaped and had areas of clear or eosinophilic cytoplasm in variable proportions. Foci of metaplasic carcinoma were present in three cases. All cases showed strong, patchy positivity for cytokeratin (CK)14, calponin, smooth actin and muscle specific actin. Epithelial membrane antigen and CK8 were positive in a similar proportion of cells. One patient died 23 months following diagnosis with metastatic carcinoma, another patient died of unrelated disease and four patients are alive with follow-up ranging from 18 months to 25 years.

CONCLUSIONS

High-grade carcinomas of the breast showing patterns of mixed ductal and myoepithelial differentiation may show additional morphological features such as foci of metaplasia and appear to have a good prognosis similar to myoepithelial cell-rich carcinomas. However, young age and lymph node metastasis may portend a worse prognosis.

Management of accessory breast tissue in the axilla

Background

Accessory breasts occur in 0·4–6 per cent of women. They may be asymptomatic or cause pain, restriction of arm movement, cosmetic problems or anxiety. It is currently recommended that all accessory breasts be removed surgically but complications following this procedure have been poorly documented.

Methods

All patients who presented with axillary accessory breasts between July 1999 and October 2000 were identified from a computer database. A retrospective review of patients listed for excision of accessory breast tissue was undertaken to determine any postoperative complications.

Results

Women with axillary accessory breasts represented 0·5 per cent of all new referrals. A total of 28 women (80 per cent of those diagnosed) had surgery. Eleven patients experienced postoperative complications; the majority followed operations performed by a trainee.

Conclusion

Excision of accessory axillary breast tissue was associated with significant morbidity.

Long term results of a randomised prospective study of preservation of the intercostobrachial nerve

AIM

We have previously reported in a randomised controlled trial comparing intercostobrachial nerve (ICBN) preservation with division that no difference in symptoms was seen between the groups at 3 months follow-up although a reduced area of sensory loss was measured on the arm. To determine if longer follow-up provides evidence for ICBN preservation, follow-up of patients in the trial at 3 years (range 32-38 months) postoperatively was performed.

METHODS

Sensory symptoms and deficits, pain, shoulder movements, arm circumference and the presence of neuromas were documented in 73 patients from the original group of 120.

RESULTS

No difference in survival or axillary recurrence was observed. The only symptom which differed between the two groups was a subjective assessment of 'different sensation' (P=0.006). No significant difference was observed in other sensory symptoms, pain, shoulder movement, arm circumference or presence of neuromas. A larger area of sensory deficit was measured in women with sacrificed nerves compared to preserved (P=0.009).

CONCLUSION

Preservation of the intercostobrachial nerve does not affect patient survival. It improves patient sensory deficit significantly and modestly improves long-term symptoms.

There may never be a final cure for breast cancer

This paper challenges the perception that the success of the human genome project has brought us to the threshold of a cure for many common cancers. Paradoxically, the message emerging from the genetics of breast cancer may be that the genetic damage associated with malignant transformation, and the mutations predisposing to the disease in our gene pool, may prove impossible to eliminate.

Enoxaparin and abciximab adjunctive pharmacotherapy during percutaneous coronary intervention

Randomized controlled trials of patients with non-ST segment elevation acute coronary syndromes have established the superiority of enoxaparin (versus unfractionated heparin) for reducing adverse ischemic outcomes. Furthermore, adjunctive abciximab therapy during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes. Since algorithms for integrating these pharmacotherapies have not been determined, patients undergoing elective PCI were enrolled into 2 distinct and separate studies conducted by the National Investigators Collaborating on Enoxaparin (NICE) study groups (NICE 1 and NICE 4 studies). Patients in NICE 1 were administered enoxaparin 1.0 mg/kg intravenously (without abciximab) and those enrolled in NICE 4 were administered a reduced dose (0.75 mg/kg) of enoxaparin in combination with standard-dose abciximab intravenously during PCI. Bleeding events and ischemic outcomes assessed in-hospital and at 30-days post-PCI were infrequent with either pharmacologic regimen. In the dose regimens studied, enoxaparin with or without abciximab appears to provide safe and effective anticoagulation during PCI. The combination of reduced-dose enoxaparin and abciximab was associated with a low incidence of adverse outcomes (bleeding or ischemic events). Additional studies may be required to establish the relative safety and efficacy of this new adjunctive pharmacologic strategy when compared with the combination of low-dose, weight-adjusted unfractionated heparin and abciximab.

Asymptomatic large main pulmonary artery thromboembolism with a low-probability ventilation-perfusion lung scan

The incidence of the interpretation of low-probability lung scans in asymptomatic patients with large central pulmonary embolisms and the prognostic implication of the ventilation-perfusion scan appearance in this clinical setting is not documented.

Mixed apocrine/endocrine ductal carcinoma in situ of the breast coexistent with lobular carcinoma in situ

An unusual mixed form of ductal carcinoma in situ (DCIS) of the breast is described, which exhibits a biphenotypic morphology encompassing a range of differential diagnostic DCIS subtypes. In addition, immunophenotypic and ultrastructural studies demonstrate neuroendocrine and apocrine differentiation, raising questions regarding appropriate classification and biological behaviour. In two cases, coexistence of this mixed form of DCIS with lobular carcinoma in situ (LCIS) in the same duct lobular units is an additional unusual feature that might, at least in some cases, indicate a closer relation between them.

Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ

BACKGROUND

Breast conserving surgery (BCS) is common practice for unifocal ductal carcinoma in situ (DCIS) less than 4 cm in size, but the extent of tumor free margin width around DCIS necessary to minimize recurrence is unclear.

METHODS

Clinical and pathologic details were recorded from all patients with pure DCIS < 4 cm in size, treated with BCS between 1978 and 1997. Histologic margins were measured by using an ocular micrometer. Patients with clear margins (> 1 mm) were divided up into 3 groups for analysis based on margin of normal tissue excised: 1.1-5 mm, 5.1-10 mm, and 10.1-40 mm.

RESULTS

There were 66 patients with close margins (< or = 1 mm), of which 25 cases (37.9%) recurred. The recurrence rates for the 3 clear margin groups ranged from 4.5-7.1%. Median followup was 47 months (range 12-197 mos). Risk of recurrence in the group with close margins was greater than the subgroups with clear margins (P < 0.001); no differences in recurrence was seen between the individual subgroups with clear margins. Nuclear Grade 3 was predictive of recurrence (P = 0.03). Following excision alone, the recurrence rate was 18.6%, compared with 11.1% when radiotherapy was given as adjuvant therapy. Women with clear margins following excision had a recurrence rate of only 8.1%.

CONCLUSION

After BCS for DCIS, close margins were associated with a high risk of local recurrence. Radiotherapy did not compensate for inadequate surgical clearance.

Force relaxes before the fall of cytosolic calcium in the photomechanical response of rat sphincter pupillae

In the rat sphincter pupillae, as in other smooth muscles, the primary signal transduction cascade for agonist activation is receptor --> G protein --> phospholipase C --> inositol trisphosphate --> intracellular Ca(2+) concentration ([Ca(2+)](i)) --> calmodulin --> myosin light chain kinase --> phosphorylated myosin --> force development. Light stimulation of isolated sphincters pupillae can be very precisely controlled, and precise reproducible photomechanical responses (PMRs) result. This precision makes the PMR ideal for testing models of regulation of smooth muscle myosin phosphorylation. We measured force and [Ca(2+)](i) concurrently in sphincter pupillae following stimulation by light flashes of varying duration and intensity. We sampled at unusually short (0.01-0.02 s) intervals to adequately test a PMR model based on the myosin phosphorylation cascade. We found, surprisingly, contrary to the behavior of intestinal muscle and predictions of the phosphorylation model, that during PMRs force begins to decay while [Ca(2+)](i) is still rising. We conclude that control of contraction in the sphincter pupillae probably involves an inhibitory process as well as activation by [Ca(2+)](i).

Ready or not: assessing youths' preparedness for independent living

This article discusses the utility of the Ansell-Casey Life Skills Assessment (ACLSA) in assessing life skills necessary for living successfully in the community upon emancipation from out-of-home care. ACLSA, completed by youths and their caregivers, identifies skills that have been mastered and those yet to be learned. Assessment information can be used for goal setting, strength identification, and relationship building, as well as to direct program planning and training in self-sufficiency services.

Combination enoxaparin and abciximab therapy during percutaneous coronary intervention: "NICE guys finish first"

Data from randomized clinical trials support the administration of both enoxaparin and platelet glycoprotein IIb/IIIa blockade to patients who present with non-ST segment evaluation acute coronary syndromes. Enoxaparin does not activate platelets, has a more predictable dose response that facilitates weight-adjusted dosing and may have enhanced antithrombotic (increased anti-Xa activity) and safety (reduced anti-IIa activity) properties when compared with unfractionated heparin. Abciximab administration during percutaneous coronary intervention reduces the incidence of ischemic adverse outcomes and may improve survival in long-term follow-up. The preliminary experience with combining abciximab and intravenous enoxaparin during percutaneous coronary intervention in the NICE-4 Trial demonstrates a low incidence of minor/major bleeding (TIMI definition) and transfusion and infrequent major cardiac events to 30 days follow-up. Future algorithms to facilitate the transition of patients from the clinical service who have received subcutaneous administration of enoxaparin to the cardiac catheterization laboratory prior to percutaneous coronary intervention are forthcoming and will provide seamless integration of "optimal" adjunctive pharmacology through the course of hospitalization for patients with non-ST elevation acute coronary syndromes.

Effect of glycoprotein IIb/IIIa inhibition without thrombolytic therapy on reperfusion in acute myocardial infarction: results of ReoMI pilot study

The efficacy of abciximab and moderate dose heparin in attaining reperfusion in acute MI was tested in a multicenter pilot study. Patients with acute MI of less than 6-hr onset triaged to primary PTCA received intravenous abciximab bolus and infusion and heparin (70 u/kg) in the emergency room. Mean time to angiography from administration of abciximab was 34 +/- 23 min. TIMI flow rates were: grade 0-62%, grade I-20%, grade II-9%, and grade III-9%. Primary PTCA was performed with 100% success rate. Access site bleeding occurred in 10% of patients with no incidence of intracranial bleeding. TIMI II/III flow rates were 50% in a patient subset where angiography was delayed by 45 min. While not an alternative to thrombolytics in AMI, abciximab administration in the emergency room in patients triaged to PTCA may be beneficial in situation where door to needle time is delayed as TIMI II/III flows may be attained in some patients. Cathet. Cardiovasc. Intervent. 48:430-434, 1999.

Further evidence for the selective disruption of intercellular communication by heptanol

The lack of selective gap junctional uncoupling agents has hampered evaluation of the contribution of intercellular communication to pharmacomechanical coupling and vascular contractility. Thus we further explored the utility and selectivity of heptanol as a gap junctional uncoupling agent in isolated rat aortic rings. Fifty-two aortic rings were obtained from 15 rats and were precontracted to approximately 75% of maximum with phenylephrine (PE). When contraction achieved steady state (approximately 5 min), a single concentration of heptanol (200 microM) was added to each aortic ring at 1- to 3-min intervals for up to 42 min post-PE addition. At early time points (5-10 min after PE), heptanol elicited an approximately 50% loss of tension (i.e., relaxation). At subsequent time points post-PE, a gradual and time-dependent decrease in the magnitude of the heptanol-induced relaxation was observed until, after approximately 40 min, addition of heptanol was associated with little, if any, detectable relaxation. Linear regression analysis of the magnitude of the heptanol-induced relaxation vs. the square root of the elapsed time interval (from addition of PE) revealed a highly significant negative correlation (P < 0.001, R = 0.81). Studies conducted on KCl-precontracted aortic rings revealed no detectable heptanol-induced relaxation after development of the steady-state KCl-induced contraction. These data extend our previous observations to further document the potential utility of heptanol as a "relatively selective" uncoupling agent.

New ultraviolet signal actuated switching valve for the measurement of low level impurities by liquid chromatography/mass spectrometry

A new ultraviolet (UV) signal actuated switching valve for diverting the main matrix compound to waste, preventing it entering the ion source of the mass spectrometer is described. Sensitivity for trace impurities eluting after the drug substance cimetidine or related compounds could be enhanced by a factor of 4-5. The increase in sensitivity was dependent on the type of ion source which interfaced the mass spectrometer. The benefit of the switching valve was greater with a line of sight type source than with an orthogonal one. The detection limit for a trace compound in a matrix compound was improved by up to a factor of 10 with the line of sight type source but only by a factor of 5 with the orthogonal source.

Randomised controlled trial of effects of early discharge after surgery for breast cancer

OBJECTIVE

To determine the effect of early discharge from hospital after surgery for breast cancer on physical and psychological illness.

DESIGN

Randomised controlled trial comparing discharge two days after surgery (before removal of drain) with standard management (discharge after removal of drain).

SETTING

Regional breast unit.

SUBJECTS

100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80).

MAIN OUTCOME MEASURES

Physical illness (infection, seroma formation, shoulder movement) and psychological illness (checklist of concerns, Rotterdam symptom questionnaire, hospital anxiety and depression scale) preoperatively and at one month and three months postoperatively.

RESULTS

Women discharged early had greater shoulder movement (odds ratio 0.28 (95% confidence interval 0.08 to 0.95); P = 0.042) and less wound pain (odds ratio 0.28 (0.10 to 0.79); P = 0.016) three months after surgery compared with women given standard management. One month after surgery scores were significantly lower on the Rotterdam symptom questionnaire in patients who were discharged early (ratio of geometric mean scores 0.73 (0.55 to 0.98) P = 0.035), but rates of psychological illness generally did not differ between groups.

CONCLUSIONS

Increased rates of physical or psychological illness did not result from early discharge after surgery for breast cancer. This policy can be recommended for patients with support at home.