Quality of Life Issues Following Breast Cancer Treatment.

Breast surgeons are trained in diagnostic modalities, treatment effectiveness, patient safety, and operative techniques, with emphasis on "the right treatment at the right time for the right patient." But delivering quality breast cancer care means more than achieving good outcomes. Physicians have routinely measured disease-free survival and overall survival to determine success in treating breast cancer. Patients are demanding attention to "quality of life" outcomes as well. As clinicians caring for patients with breast cancer, our focus must shift from early detection to survivorship to re-evaluate our own definition of cure and address the important issues affecting the quality of life of all of our patients.

Management of Cystic Conditions.

Cystic conditions are the most common disorder of the breast. Simple cysts are not malignant and do not require intervention. Patients with symptomatic simple cysts can undergo elective aspiration, and typical cyst fluid can be discarded. Bloody fluid should be sent for cytology. Cysts with thick walls, thick septations, or solid components have a risk of malignancy and should undergo biopsy.

Vaccination with the immunoglobulin M-degrading enzyme of Streptococcus suis, Ide Ssuis, leads to protection against a highly virulent serotype 9 strain.

Vaccination of weaning piglets with the recombinant IgM degrading enzyme of Streptococcus suis (S. suis), rIde Ssuis, elicits protection against disease caused by serotype (cps) 2 infection. In Europe, S. suis cps9 is at least as important as cps2 in causing severe herd problems associated with meningitis, septicemia and arthritis. The objective of this study was to determine humoral and cellular immunogenicities of rIde Ssuis suckling piglet vaccination and to investigate protection against a virulent cps9 strain. Vaccination in the 2nd and 4th week of life with rIde Ssuis and an oil-in-water adjuvant induced seroconversion against Ide Ssuis in 13 of 20 vaccinated piglets. In the 5th week, survival of the S. suis cps9 strain was significantly reduced in the blood of prime-booster vaccinated piglets. After a 2nd booster vaccination Ide Ssuis -reactive T helper (Th) cells partially producing TNF-α, IL-17A or IFN-É£ were detectable in rIde Ssuis -vaccinated but not in placebo-treated piglets and frequencies of Ide Ssuis -reactive Th cells correlated with α-Ide Ssuis-IgG levels. An intravenous challenge, conducted with a cps9 strain of sequence type (ST) 94, led to 89% mortality in placebo-treated piglets due to septicemia and meningitis. In contrast, all rIde Ssuis prime-booster-booster vaccinated littermates survived the challenge despite signs of disease such as fever and lameness. In conclusion, the described rIde Ssuis vaccination induces humoral and detectable Ide Ssuis -reactive Th cell responses and leads to protection against a highly virulent cps9 strain.

Streptococcus suis cps7: an emerging virulent sequence type (ST29) shows a distinct, IgM-determined pattern of bacterial survival in blood of piglets during the early adaptive immune response after weaning.

Streptococcus (S.) suis is an important porcine pathogen causing meningitis, arthritis and septicemia. As cps7 emerged recently in Germany in association with severe herd problems, the objective of this study was to characterize the geno- and phenotype of invasive cps7 strains. Twenty cps7 strains were isolated from diseased pigs from different farms with S. suis herd problems due to meningitis and other pathologies. Eighteen of the cps7 isolates belonged to sequence type (ST) 29. Most of these cps7 strains secreted a short MRP variant in agreement with a premature stop codon. Expression of Ide Ssuis , an IgM specific protease, was variable in four further investigated cps7 ST29 isolates. Bactericidal assays revealed very high survival factors of these four cps7 ST29 strains in the blood of weaning piglets. In growing piglets, the increase of specific IgM led to efficient killing of cps7 ST29 as shown by addition of the IgM protease Ide Ssuis . Finally, virulence of a cps7 ST29 strain was confirmed in experimental infection of weaning piglets leading to meningitis and arthritis. In conclusion, this study characterizes cps7 ST29 as a distinct S. suis pathotype showing high survival factors in porcine blood after weaning, but IgM-mediated killing in the blood of older growing piglets. This underlines the relevance of IgM as an important host defense mechanism against S. suis.

Inflammatory bone loss associated with MFG-E8 deficiency is rescued by teriparatide.

A prolonged increase in proinflammatory cytokines is associated with osteoporotic and autoimmune bone loss and, conversely, anti-inflammatory pathways are associated with protection against bone loss. Milk fat globule-epidermal growth factor (MFG-E)-8 is a glycoprotein that is proresolving, regulates apoptotic cell clearance, and has been linked to autoimmune disease and skeletal homeostasis. The role of MFG-E8 in the young vs. adult skeleton was determined in mice deficient in MFG-E8 (KO). In vivo, trabecular bone was similar in MFG-E8KO and wild-type (WT) mice at 6 and 16 wk, whereas 22 wk adult MFG-E8KO mice displayed significantly reduced trabecular BV/TV. The number of osteoclasts per bone surface was increased in 22-wk MFG-E8 KO vs. WT mice, and recombinant murine MFG-E8 decreased the number and size of osteoclasts in vitro. Adult MFG-E8KO spleen weight:body weight was increased compared with WT, and flow cytometric analysis showed significantly increased myeloid-derived suppressor cells (CD11bhiGR-1+) and neutrophils (CD11bhiLy6G+) in MFG-E8KO bone marrow, suggesting an inflammatory phenotype. PTH-treated MFG-E8KO mice showed a greater anabolic response (+124% BV/TV) than observed in PTH-treated WT mice (+64% BV/TV). These data give insight into the role of MFG-E8 in the adult skeleton and suggest that anabolic PTH may be a valuable therapeutic approach for autoimmune-associated skeletal disease.-Michalski, M. N., Seydel, A. L., Siismets, E. M., Zweifler, L. E., Koh, A. J., Sinder, B. P., Aguirre, J. I., Atabai, K., Roca, H., McCauley, L. K. Inflammatory bone loss associated with MFG-E8 deficiency is rescued by teriparatide.

Streptococcus suis serotype 9 endocarditis and subsequent severe meningitis in a growing pig despite specific bactericidal humoral immunity.

INTRODUCTION: . Meningitis and endocarditis are common pathologies of Streptococcussuis infections in pigs and humans. S. suis serotype 9 strains contribute substantially to health problems in European pig production, and immune prophylaxis against this serotype is very difficult. CASE PRESENTATION: . We report the clinical course and histopathological picture of a 10-week-old growing pig following experimental intravenous infection with S. suis serotype 9. The piglet showed rapid onset of severe clinical signs of meningitis 11 days post-intravenous challenge following prime-booster vaccination. Histopathological findings revealed a diffuse fibrinosuppurative leptomeningitis. Additionally, a polyphasic endocarditis valvularis thromboticans with numerous bacterial colonies was diagnosed. Bacteriological culture of the brain and the mitral valve confirmed association with the challenge strain. However, virulent serotype 2 and 9 strains were killed in the blood of this piglet ex vivo prior experimental infection. CONCLUSION: . Endocarditis induced by S. suis infection might develop and persist despite the presence of high specific bactericidal activity in the blood. Severe leptomeningitis is a putative sequela of such an endocarditis.

Surgical Site Infections in Breast Surgery: The Use of Preoperative Antibiotics for Elective, Nonreconstructive Procedures.

Background. Antibiotic prophylaxis for surgical site infections (SSIs) for breast surgery is widespread, but the benefit in clean surgical cases is not well defined. Methods. A retrospective analysis of 855 patients undergoing elective, nonreconstructive breast operations was performed, with 401 patients receiving no antibiotics and 454 patients receiving a single dose of preoperative antibiotic. Results. Administration of a preoperative antibiotic did not decrease the SSI rate. In this community-based study, antibiotic use practices varied considerably by surgeon. In univariate analyses, SSI rates appeared to increase with prophylactic antibiotic use (12% SSI with antibiotics versus 4% without, p < 0.0001), likely because the use of underdosed antibiotics was associated with higher rates of SSI (13.2% SSI with cefazolin 1 gram, p < 0.0001, and 15.4% SSI with clindamycin 300 mg or less, p = 0.0269). Methicillin-resistant Staphylococcus aureus was the most common isolate from SSI cultures, 31.8% (7 of 22). In multivariable analyses, increased risk of SSI was associated with BMI > 25 kg/m2 (OR: 1.08, 95% CI: 1.04-1.11, p < 0.0001). Conclusion. The administration of a single dose of preoperative antibiotic did not decrease the rate of SSI in this large series of patients undergoing clean breast operations. BMI >25 kg/m2 and the use of an inadequate dose of antibiotics for prophylaxis may increase risk of SSI.