Trends in breast reconstruction practices in a specialized breast tertiary referral centre.

BACKGROUND: Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population. METHODS: Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy. RESULTS: Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy. CONCLUSION: Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Interleukin-22 regulates antimicrobial peptide expression and keratinocyte differentiation to control Staphylococcus aureus colonization of the nasal mucosa.

The local immune response occurring during Staphylococcus aureus nasal colonization remains ill-defined. Studies have highlighted the importance of T-cell immunity in controlling S. aureus colonization of the nasal mucosa. We extend these observations, identifying a critical role for interleukin (IL)-22 in this process. IL-22 is basally expressed within the nasal mucosa and is induced upon S. aureus colonization. IL-22 is produced by CD4+ and CD8+ T lymphocytes at this site, with innate-like lymphocytes also contributing. IL-22-/- mice demonstrate significantly elevated levels of S. aureus nasal colonization as compared with wild-type (WT) mice. This was associated with reduced expression of antimicrobial peptides (AMPs) in the nose. Furthermore, expression of staphylococcal ligands loricrin and cytokeratin 10 was higher in the noses of IL-22-/- as compared with WT mice. IL-17 has been shown to regulate S. aureus nasal colonization by controlling local neutrophil responses; however, IL-17 expression and neutrophil responses were comparable in the noses of IL-22-/- and WT mice during S. aureus colonization. We conclude that IL-22 has an important role in controlling S. aureus nasal colonization through distinct mechanisms, with IL-22 mediating its effect exclusively by inducing AMP expression and controlling availability of staphylococcal ligands.

Longitudinal relationship of early life immunomodulatory T cell phenotype and function to development of allergic sensitization in an urban cohort.

BACKGROUND: Immunomodulatory T cells are thought to influence development of allergy and asthma, but early life longitudinal data on their phenotype and function are lacking. OBJECTIVES: As part of the Urban Environment and Childhood Asthma (URECA) study, we investigated the development of immunomodulatory T cell phenotype and function, and characterized their relation to allergic disease progression from birth through to 2 years of age. METHODS: Immunomodulatory T cell phenotype and function in cord blood mononuclear cells (CBMC) and peripheral blood mononuclear cells (PBMC) at 1 and 2 years of age were characterized by analysing CD25(bright) and FoxP3(+) expression, proliferative responses and cytokine production. The relation of immunomodulatory T cell characteristics to allergic sensitization and disease at 1- and 2-years of age was investigated. RESULTS: The proportion of CD4(+)CD25(bright) and CD4(+)CD25(+)FoxP3(+)T cells (n = 114, 83, 82 at birth, 1- and 2-years respectively) increased significantly, whereas there were no significant changes in the suppressive function of CD25(+)T cells (n = 78, 71, 81 at birth, 1- and 2-years respectively). Birth immunomodulatory T cell characteristics were not related to subsequent allergic sensitization or disease. However, increases in the numbers of CD4(+)CD25(bright) cells and their ability to suppress lymphoproliferative responses at 1 year of age were associated with reduced allergic sensitization at 1 (P = 0.03) and 2 (P = 0.02) years of age. Production of the anti-inflammatory cytokine IL-10 by CD25(+)T cells appeared to mediate this protective suppressive function. In contrast, by 2 years of age, we observed the emergence of a positive association of CD4(+)CD25(+) FoxP3(+) T cell numbers with allergic sensitization (P = 0.05) and eczema (P = 0.02). CONCLUSIONS AND CLINICAL RELEVANCE: These findings suggest that the relationship between immunomodulatory T cell subsets, allergic sensitization and eczema is developmentally regulated. In the first year of life, CD4(+)CD25(+) IL-10 producing T cells are associated with a reduced incidence of allergic sensitization. Once allergic sensitization or eczema is established, CD4(+)CD25(+)FoxP3(+)T-reg cells expand to potentially counteract the allergic inflammatory response. Understanding the relationship between development of immunoregulatory T cells and early onset atopy could lead to new preventive strategies for allergic diseases.

A comparative study of faecal occult blood kits in a colorectal cancer screening program in a cohort of healthy construction workers.

BACKGROUND: The incidence of colorectal cancer (CRC) has been increasing. We evaluated uptake rates and outcomes of faecal immunochemical test (FIT) and Guaiac test (gFOBT) kits as part of a two-step CRC screening. METHODS: A 3-year CRC screening program for a defined population of construction workers was conducted. Those satisfying the inclusion criteria were provided with gFOBT or FIT kits. Individuals testing positive were invited for a colonoscopy. RESULTS: A total of 909 faecal testing kits were distributed. Age range was 53-60 years. Compliance rate was higher for FIT (58.3%) as compared to gFOBT (46.7%) (p = 0.0006). FIT detected adenomatous polyps and CRC in 37.5 and 25%, respectively, whereas; gFOBT detected 23.5 and 18%. Colonoscopies were normal in 53 and 25% tested positive by gFOBT and FIT, respectively (p = 0.016). CONCLUSION: The FIT was more cost-effective when compared with gFOBT with higher return rate, sensitivity and specificity. A comparative study of faecal occult blood kits in a CRC screening program in a healthy cohort of construction workers.

Review article: the long-term use of proton-pump inhibitors.

More than 15 years after the launch of omeprazole in 1988, proton-pump inhibitors remain central to the management of acid-suppression disorders and are unchallenged with regard to their efficacy and popularity among doctors and patients. They are considered safe despite early concerns about the possibility of an association with cancer and gastric atrophy; current concerns about long-term proton-pump inhibitor therapy are centred mainly on a possible association with fundic gland polyps and between Helicobacter pylori and gastric atrophic changes. Long-term proton-pump inhibitor usage accounts for the majority of the total proton-pump inhibitor usage. Long-term usage is difficult to define and most patients take proton-pump inhibitors non-continuously. Data indicate that a substantial proportion of long-term users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment. Overall, on-demand therapy is more cost-effective than continuous therapy and should be considered wherever possible.

Haplotype variation at the IBD5/SLC22A4 locus (5q31) in coeliac disease in the Irish population.

In addition to the well-established association of coeliac disease (CD) with HLA-DQ (6p21) and possibly CTLA4 (2q33), there is considerable evidence for a susceptibility locus on chromosome 5q, which contains many potential candidates for inflammatory disease, including a cluster of cytokine genes in 5q31. CD cases and controls were genotyped for four single-nucleotide polymorphism (SNP) markers that together characterize >90% of the haplotype variation at the IBD5 locus encoding, among others, the SLC22A4 gene. IBD5 and SLC22A4 map to 5q31 and have recently been associated with Crohn's disease and rheumatoid arthritis. Haplotype frequencies do not differ significantly between CD cases and controls in the Irish population, and therefore the chromosome 5 CD susceptibility locus most likely lies elsewhere on 5q.

Differential regulation of chemokine production in human peritoneal mesothelial cells: IFN-gamma controls neutrophil migration across the mesothelium in vitro and in vivo.

Leukocyte recruitment into the infected peritoneal cavity consists of an early, predominant polymorphonuclear leukocyte (PMN) influx and subsequent, prolonged mononuclear cell migration phase. Although chemokine secretion by resident peritoneal cells plays a primary role in mediating this migration, the mechanisms involved in controlling the switch in phenotype of cell infiltrate remain unclear. The present study investigates a potential role for the Th1-type cytokine IFN-gamma in the process of leukocyte recruitment into the peritoneal cavity. Stimulation of cultured human peritoneal mesothelial cells with IFN-gamma (1-100 U/ml) alone or in combination with IL-1beta (100 pg/ml) or TNF-alpha (1000 pg/ml) resulted in significant up-regulation of monocyte chemoattractant protein-1 and RANTES protein secretion. In contrast, IFN-gamma inhibited basal and IL-1beta-, and TNF-alpha-induced production of IL-8. The modulating effects of IFN-gamma on chemokine production occurred at the level of gene expression, and the degree of regulation observed was dependent on the doses of IL-1beta and TNF-alpha used. Analysis of the functional effects of IFN-gamma on IL-1beta-induced transmesothelial PMN migration with an in vitro human transmigration system and an in vivo murine model of peritoneal inflammation demonstrated that IFN-gamma was able to down-regulate PMN migration induced by optimal doses of IL-1beta. These effects were mediated in vivo via down-regulation of CXC chemokine synthesis. These findings suggest that IFN-gamma may play a role in controlling the phenotype of infiltrating leukocyte during the course of an inflammatory response, in part via regulation of resident cell chemokine synthesis.

Il-6 and its soluble receptor orchestrate a temporal switch in the pattern of leukocyte recruitment seen during acute inflammation.

During acute inflammation, leukocyte recruitment is characterized by an initial infiltration of neutrophils, which are later replaced by a more sustained population of mononuclear cells. Based on both clinical and experimental evidence, we present a role for IL-6 and its soluble receptor (sIL-6R) in controlling this pattern of leukocyte recruitment during peritoneal inflammation. Liberation of sIL-6R from the initial neutrophil infiltrate acts as a regulator of CXC and CC chemokine expression, which contributes to a suppression of neutrophil recruitment and the concurrent attraction of mononuclear leukocytes. Soluble IL-6R-mediated signaling is therefore an important intermediary in the resolution of inflammation and supports transition between the early predominantly neutrophilic stage of an infection and the more sustained mononuclear cell influx.

Three-dimensional ultrasound and magnetic resonance imaging of pelvic anatomy: potential for complications from minimally invasive procedures.

OBJECTIVE: Several new minimally invasive therapies have recently been popularized for both malignant and benign prostate disorders, including interstitial implantation of radioactive seeds and high-radiofrequency wires, cryoablation, transurethral thermotherapy, and laser prostatectomy. Complications can be incurred during the various procedures, often as a result of injury to adjacent anatomic structures. Some of the complications are inadvertent, whereas others are inherent in the particular treatment process. We hope to increase awareness and understanding of some of the potential complications. METHODS AND MATERIALS: Magnetic resonance (MR) and three-dimensional transrectal ultrasonography (TRUS) imaging were utilized to illustrate the relevant pelvic anatomy in, respectively, a healthy volunteer and four patients undergoing evaluation for prostate symptoms. In addition, data from the Visible Human dataset (the Visible Human Project is part of the National Library of Medicine 1986 Long-Range Plan) were used. RESULTS: The potential complications relating to urinary sphincter and anal sphincter control, sexual function, pelvic musculature, and pelvic nerve physiology could be explained on the basis of the MR and TRUS findings using cryoablation for illustrative purposes. CONCLUSION: A clear understanding of the relevant anatomy and physiology is essential for the physician to provide patient counseling preoperatively regarding anticipated sequelae and to avoid preventable intraoperative complications related to minimally invasive therapeutic procedures for the prostate.

Sonography of intestinal abnormality in the right iliac fossa.

The findings on sonographic examination of intestinal disorders in the right iliac fossa are often nonspecific. We have found the classification system just described useful because it leads to a meaningful differential diagnosis, which may be narrowed on the basis of various distinguishing features. The use of other imaging techniques, imaging-guided aspiration or biopsy, or surgical intervention may be necessary to make the exact diagnosis.

An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy.

BACKGROUND: The mainstay of therapy for acute cholecystitis is cholecystectomy, which has a mortality of 5-30% in high-risk patients such as the elderly or critically ill. An alternative treatment option in patients suffering from acute cholecystitis with contraindications to emergency surgery is percutaneous cholecystostomy (PC) followed by interval laparoscopic cholecystectomy. Percutaneous cholecystostomy yields 10-12% mortality in high-risk patients and is therefore a safe temporizing measure, allowing delayed, elective cholecystectomy when the patient is in better condition for surgery. METHODS: Hospital charts and radiology films were reviewed for all 50 patients who underwent PC for acute cholecystitis between January 1990 and September 1993. Most patients were high risk for emergency cholecystectomy by virtue of their critical illness or underlying medical condition. Twenty-five patients went on to have interval cholecystectomies. We recorded whether they underwent laparoscopic or open cholecystectomy, as elective or emergency procedures, and we recorded direct complications, mortality, and postoperative length of hospital stay. RESULTS: Relief of symptoms occurred within 48 h of PC in 90% of patients, and two patients had complications of PC. Laparoscopic cholecystectomy was attempted in 13 patients and competed in nine. Four patients (31%) required conversion from laparoscopic to open cholecystectomies due to extensive adhesions (3) or bleeding (1). Three patients had direct complications of laparoscopic cholecystectomy. There was no mortality or major bile duct injury. CONCLUSION: Percutaneous cholecystostomy followed by interval laparoscopic cholecystectomy is a safe, minimally invasive approach which can be employed safely in the critically ill patient when contraindications to emergency surgery exist.

Outpatient percutaneous nephrostomy.

PURPOSE: To assess the feasibility of performing percutaneous nephrostomy (PCN) on an outpatient basis in a select group of patients. MATERIALS AND METHODS: In 6 years, 60 PCN procedures were performed in a subgroup of 48 patients (22 men, 26 women) carefully selected from a larger group of 881 nephrostomy procedures in 589 patients. Exclusion criteria included hypertension; untreated urinary tract infection, coagulopathy, and staghorn calculi. Indications were calculus (n = 17), benign stricture (n = 10), and malignant ureteric obstruction (n = 21). RESULTS: There was 100% technical success. Six of 48 patients (12%) were admitted within a week of PCN; there were no cost savings in these patients. Three of these patients (6%) were admitted as a direct consequence of PCN; one had sepsis, one had bleeding, and one was unable to manage the PCN tube. Outpatient treatment saved the cost of hospitalization in 42 patients (88%). CONCLUSION: Outpatient PCN is feasible and safe in carefully selected patients and yields major cost savings because it precludes hospital admission.

High resolution endoluminal ultrasonography in the staging of esophageal carcinoma.

Small catheters containing 20 MHz transducers have recently become available for high resolution endoluminal ultrasound. We report our early use of this technique to image and stage esophageal carcinoma. Fifteen patients undergoing high resolution endoluminal ultrasonography for suspected esophageal carcinoma were studied. Twelve of these patients also underwent computed tomography and pathologic correlation was available in seven. Satisfactory esophageal examination was possible in 14 of 15 patients. Of those with pathologic correlation, the depth of tumor invasion was correctly staged by high resolution endoluminal ultrasonography in six of seven patients and by computed tomography in only three of seven patients. Lymph node assessment correlated poorly with pathologic findings for both high resolution endoluminal ultrasound and computed tomography. With the increasing use of preoperative radiation therapy, we believe these early results predict a potential role for high resolution endoluminal ultrasonography in the staging of esophageal carcinoma.

CT of the liver after cryotherapy of hepatic metastases: imaging findings.

Cryotherapy is the in situ destruction of abnormal tissue using subzero temperatures (Fig. 1). Recent studies have demonstrated the technical feasibility, safety, and effectiveness of hepatic cryotherapy in the treatment of liver tumors [1, 2]. Such treatment can be precisely focused on the tumor, thereby preserving surrounding normal tissue. In addition, because major vessels with flowing blood are protected from cryoablation, tumors adjacent to these vessels can be treated without sacrificing vasculature. Hepatic cryoablation is therefore particularly suitable for patients who do not qualify for surgical resection because of multiple metastases involving both lobes of the liver, or because of lesions close to major blood vessels. After the procedure, CT during arterioportography is of little value in distinguishing cryolesion from malignant tumor (Fig. 2), and CT with IV contrast enhancement is recommended for follow-up. It is important to distinguish CT findings of successful and unsuccessful treatment, treatment complications such as abscess and cholestasis, and recurrent tumor. The purpose of this essay is to illustrate the findings on CT with IV contrast enhancement in various situations, emphasizing features that are useful in making accurate differential diagnosis.

MR imaging of adrenal masses: value of chemical-shift imaging for distinguishing adenomas from other tumors.

OBJECTIVE: CT and conventional MR imaging are helpful in characterizing adrenal tumors, but a specific diagnosis is not achieved for a substantial number of lesions. Chemical-shift imaging relies on the different resonance frequencies of protons in water and triglyceride molecules and therefore may permit a more specific diagnosis of adrenal adenomas, which are known to contain abundant lipid. The purpose of this study was to evaluate the usefulness of chemical-shift MR imaging in the differentiation of adrenal adenomas from other adrenal masses. SUBJECTS AND METHODS: Forty-one adrenal masses (17 nonhyperfunctioning adenomas, two aldosteronomas, six pheochromocytomas, one ganglioneuroma, five adrenal carcinomas, one lymphoma, seven metastases, one case of extramedullary hematopoiesis, and one leiomyosarcoma) suspected clinically or identified by sonography or CT in 38 patients were prospectively evaluated with MR imaging. Pathologic proof of diagnosis was obtained for 28 lesions, and stability on imaging follow-up (mean, 19 months) was accepted as proof of diagnosis of benign adenoma for 13 lesions. In-phase T1-weighted spin-echo sequences (500/20 [TR/TE]) and opposed-phase gradient-echo sequences (142/6.3, flip angle = 90 degrees) of the adrenal regions were applied. Quantitative analysis of signal intensity loss in the adrenal lesions relative to reference tissues (liver, muscle, and spleen) on in-phase and opposed-phase sequences was done to differentiate adenomas from nonadenomas. Region-of-interest signal intensity measurements were obtained in a standard fashion by selection of the largest possible representative sample. RESULTS: Using liver as the reference standard, we found that mean signal intensity ratios were 0.47 (range, 0.23-0.97) for adrenal adenomas and 0.88 (range, 0.65-1.32) for nonadenomas; signal intensity ratios for two adenomas overlapped those of the nonadenomas. Using muscle as the reference standard, we found that mean signal intensity ratios were 0.44 (range, 0.22-0.66) for adrenal adenomas and 0.85 (range, 0.59-1.39) for nonadenomas; signal intensity ratios for two adenomas overlapped those of the nonadenomas. Using spleen as the reference standard, we found that mean signal intensity ratios were 0.45 (range, 0.27-0.73) for adrenal adenomas and 0.97 (range, 0.8-1.18) for nonadenomas, with no overlap. The mean signal intensity ratios were significantly different between adenomas and nonadenomas for all three reference tissues (p < .001). CONCLUSION: Our results show that chemical-shift MR imaging is an important new technique that enables the differentiation of adrenal adenomas from other adrenal masses, reducing the need for biopsy and prolonged imaging follow-up in patients with adrenal tumors.

Imaging and intervention in abdominal emergencies.

While plain abdominal radiographs retain an essential place in acute abdominal emergencies, the dramatic advances in ultrasound, computed tomography and magnetic resonance imaging witnessed over the past two decades have revolutionized the practice of emergency medicine. Cross-sectional imaging techniques now play a key role in evaluating patients with abdominal emergencies, and allow confident diagnoses to be made in an ever increasing proportion of these patients. Unnecessary laparotomies are now uncommon, and a wide array of interventional radiological techniques can be used to treat abdominal emergencies without surgery.

Tumors of the adrenal gland: findings on CT and MR imaging.

Adrenal gland imaging has improved drastically since the advent of CT and MR imaging. The purpose of this essay is to illustrate findings on cross-sectional imaging of adrenal gland tumors. Emphasis is given to imaging features that help to characterize specific lesions.

Radiologically guided percutaneous cholecystostomy for acute cholecystitis: long-term outcome in 50 patients.

To assess the long-term outcome in patients with acute cholecystitis treated initially by percutaneous cholecystostomy, the authors reviewed the medical and radiology records of all such patients treated at their hospital from January 1990 to September 1993. Of the 50 patients, 29 had calculous and 21 had acalculous cholecystitis. In the group with calculous cholecystitis, 1 of the patients required no further treatment, 3 subsequently underwent percutaneous stone removal, 14 underwent elective cholecystectomy, 6 underwent emergency cholecystectomy and 5 died of the underlying condition shortly after cholecystostomy. In the group with acalculous cholecystitis, 12 of the patients needed no further treatment after a mean follow-up period of 12 months; 8 of these underwent follow-up ultrasound examination, which revealed gallbladder calculi in only 1 patient. Four patients underwent elective cholecystectomy, 1 underwent emergency cholecystectomy, and 4 died of the underlying condition shortly after cholecystostomy. Over the long term, 23 (79%) of the 29 patients with calculous cholecystitis underwent surgery or removal of calculi. In the other group surgery was required in only 5 (24%) of the 21 patients. The authors conclude that percutaneous cholecystostomy is a useful temporizing measure, which allows patients with calculous cholecystitis to undergo elective cholecystectomy. In most cases of acalculous cholecystitis the procedure is curative, obviating the need for cholecystectomy.

Malignant obstruction of the common bile duct: long-term results of Gianturco-Rosch metal stents used as initial treatment.

PURPOSE: To determine how long Gianturco-Rosch metal stents remain patent when used as the initial treatment for malignant obstruction of the common bile duct. MATERIALS AND METHODS: The patency of Gianturco-Rosch metal stents was prospectively studied in 26 patients with malignant obstructive jaundice. Biliary obstruction was caused by pancreatic carcinoma (n = 15), cholangiocarcinoma (n = 10), or metastatic lymphadenopathy (n = 1). Follow-up information was obtained every 3-4 months until death. RESULTS: Stent insertion was successful in all patients. Stent occlusion occurred in nine patients (35%). The overall mean patency period was 39.9 weeks. Adequate biliary drainage for a minimum of 80 weeks or until death was achieved in 19 patients (73%). Life-table analysis predicted stent patency rates of 86%, 75%, and 69% at 12, 24, and 48 weeks, respectively. CONCLUSION: These results are better than those previously reported in patients with plastic endoprostheses. The authors believe that insertion of the metal stent is the procedure of choice in patients with inoperable malignant biliary obstruction.