Metaplastic sarcomatoid carcinoma of the breast appears more aggressive than other triple receptor-negative breast cancers.

Metaplastic sarcomatoid carcinoma (MSC) of the breast is usually triple receptor (ER, PR, and HER2) negative and is not currently recognized as being more aggressive than other triple receptor-negative breast cancers. We reviewed archival tissue sections from surgical resection specimens of 47 patients with MSC of the breast and evaluated the association between various clinicopathologic features and patient survival. We also evaluated the clinical outcome of MSC patients compared to a control group of patients with triple receptor-negative invasive breast carcinoma matched for patient age, clinical stage, tumor grade, treatment with chemotherapy, and treatment with radiation therapy. Factors independently associated with decreased disease-free survival among patients with stage I-III MSC of the breast were patient age > 50 years (P = 0.029) and the presence of nodal macrometastases (P = 0.003). In early-stage (stage I-II) MSC, decreased disease-free survival was observed for patients with a sarcomatoid component comprising ≥ 95% of the tumor (P = 0.032), but tumor size was the only independent adverse prognostic factor in early-stage patients (P = 0.043). Compared to a control group of triple receptor-negative patients, patients with stage I-III MSC had decreased disease-free survival (two-sided log rank, P = 0.018). Five-year disease-free survival was 44 ± 8% versus 74 ± 7% for patients with MSC versus triple receptor-negative breast cancer, respectively. We conclude that MSC of the breast appears more aggressive than other triple receptor-negative breast cancers.

Bicycle helmet use among schoolchildren. Impact of a community education program and a cycling fatality.

OBJECTIVE: To assess the effect of a community bicycle helmet education and subsidy program and the further effect of a bicycle rodeo on helmet ownership and use among elementary schoolchildren. The unanticipated effect of a child cyclist fatality was also measured. DESIGN: Helmet ownership and use were measured in two ways: a questionnaire was sent to all elementary schoolteachers asking about helmet ownership and use by their students; and volunteers counted the children riding their bicycles to school. SETTING: Elementary schools in the town of Goderich, population 7400, and the town of Kincardine, population 6227, both on Lake Huron in southwestern Ontario. PARTICIPANTS: More than 80% of the 1050 elementary school students in Goderich and, for comparison, more than 90% of the 1439 elementary school students in Kincardine. INTERVENTIONS: An extensive education campaign with programs, assemblies, teaching aids, speakers, and a colouring and poster contest, coupled with a discount helmet offer in October 1991. Incentives to helmet use, such as bicycle rodeos, took place in May 1992 and 1993. A child cyclist not wearing a helmet was fatally injured in September 1992. MAIN OUTCOME MEASURES: Teachers polled students on helmet use and student volunteers counted children riding bicycles and noted helmet use. RESULTS: A total of 250 helmets were purchased, and helmet use was observed to increase among 5- to 14-year-old children from 0.75% to 12.8% during 9 months. Program effect was significantly greater on younger children, and girls used helmets more often than boys did. The cycling fatality in Goderich was associated with a dramatic increase in helmet use (to more than 50%), a significantly higher rate than in Kincardine. A second subsidy and rodeo did not further increase helmet use. CONCLUSIONS: A small community with limited resources can mount a bicycle helmet education and incentive program with high exposure and participation rates by children. Despite an initial 17-fold increase in observed helmet use, more than 87% of cyclists still did not wear helmets. The cycling fatality was associated with a significant increase in helmet use.

Well baby visits: screening and health promotion.

Traditional child care consists of periodic health examinations and treatment for episodic illness. It is important to ensure that prevention, detection and early treatment of developmental problems are always done, especially in children with frequent illnesses. Educational and psychosocial factors, nutrition and physical assessment must also be stressed to promote child and family health. The authors have developed flow sheets for screening visits at age two weeks to two years, to check growth, nutrition, education, parenting, behavior, development, symptoms, examination procedures, and assessment. The sheets are a memory and charting aid in a busy office, allow other office staff to participate, and can be modified to suit the practice and the patient.

Rural family medicine training in Canada.

OBJECTIVE: To examine the status of postgraduate family medicine training that occurs in rural family practice settings in Canada and to identify problems and how they are addressed. DESIGN: A retrospective questionnaire sent to all 18 Canadian family medicine training programs followed by a focus group discussion of results. SETTING: Canadian university family medicine training programs. PARTICIPANTS: Chairs or program directors of all 18 Canadian family medicine training programs and people attending a workshop at the Section of Teachers of Family Medicine annual meeting. MAIN OUTCOME MEASURES: Extent of training offered, educational models used, common problems for residents and teachers. RESULTS: Nine of 18 programs offer some family medicine training in a rural practice setting to some or all of their first-year family medicine residents, and 99 of 684 first-year family medicine residents did some training in a rural practice. All programs offer some training in a rural practice to some or all of the second-year residents, and 567 of 702 second-year residents did some training in a rural setting. In 12 of 18 programs, a rural family medicine block is compulsory. Education models for training for rural family practice vary widely. Isolation, accommodation, and supervision are common problems for rural family medicine residents. Isolation and faculty development are common problems for rural physician-teachers. Programs use various approaches to address these problems. CONCLUSIONS: The variety of postgraduate training models for rural family practice used in the 18 training programs reflects different regional health care needs and resources. There is no common rural family medicine curriculum. Networking through a rural physician-teachers group or a faculty of rural medicine could further the development of education for rural family practice.

Penetrating chest wound: a case report.

An unusual penetrating chest injury was caused by a ball-point pen. Because of apparent penetration of the heart, preparations were made for an emergency open-heart procedure before emergency thoracotomy was undertaken, with the pen still in situ. The pen had bruised the epicardium but had not penetrated the pericardial sac. After removal of the pen, the wound was closed and a chest tube left in place. Recovery, apart from minor degrees of basal atelectasis, pleural effusion and wound infection, was uneventful. The outcome was consistent with that associated with current aggressive management of penetrating chest injuries. Management is based on three approaches. The primary one is intercostal thoracostomy tube drainage and fluid and blood replacement. In cases of massive hemorrhage or air leak, thoracotomy is necessary. The third approach is to prevent post-traumatic pulmonary insufficiency by using fine, high-efficiency filters during blood transfusion, avoiding excessive administration of intravenous fluids, performing tracheostomy after prolonged endotracheal intubation, and using a volume respirator with positive end-expiratory pressure. The average mortality for penetrating wounds of the heart is 25%.

Evidence-based well-baby care. Part 1: Overview of the next generation of the Rourke Baby Record.

PROBLEM BEING ADDRESSED: Well baby and child care in the primary care setting has not always been based on evidence that has been shown to be effective in preventing and detecting disease and injury. OBJECTIVE OF THE PROGRAM: To help physicians and nurses provide care that is more effective than a routine complete examination, the Rourke Baby Record has been revised to include evidence-based recommendations for preventive care for infants and young children. The revision incorporates the approach and recommendations of the Canadian Task Force on the Periodic Health Examination. The updated record is now called the Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance Guide (Rourke Baby Record: EB). MAIN COMPONENTS OF PROGRAM: Part 1 of this two-part article briefly describes the background for development and presents an overview of the revised record. Part 2 discusses in detail the evidence that exists for maneuvers included in the education and advice section of the revised record. CONCLUSION: Using the Rourke Baby Record: EB and incorporating it into their office record systems as a working guide will help increase the effectiveness of the primary preventive care physicians provide to infants and young children.

Evidence-based well-baby care. Part 2: Education and advice section of the next generation of the Rourke Baby Record.

PROBLEM BEING ADDRESSED: Well baby and child care in the primary care setting has not always been based on evidence that has been shown to be effective in preventing and detecting disease and injury. OBJECTIVE OF THE PROGRAM: To help physicians and nurses provide care that is more effective than a routine complete examination, the Rourke Baby Record has been revised to include evidence-based recommendations for preventive care for infants and young children. The revision incorporates the approach and recommendations of the Canadian Task Force on the Periodic Health Examination. The updated record is now called the Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance Guide (Rourke Baby Record: EB). MAIN COMPONENT OF PROGRAM: Part 2 of this two-part article discusses the maneuvers included in the education and advice section of the record. These maneuvers are discussed under the subheadings safety, behaviour, family coping, high-risk children, and other. CONCLUSION: Using the Rourke Baby Record: EB and incorporating it into their office record systems as a working guide will help increase the effectiveness of the primary preventive care physicians provide to infants and young children.