Impact of specialist management on survival from radiation-associated angiosarcoma of the breast.

BACKGROUND: Radiation-associated angiosarcoma of the breast (RAAS) is a rare complication of adjuvant radiotherapy associated with poor survival. The British Sarcoma Group guidelines recommend that all angiosarcomas are referred to a sarcoma multidisciplinary team, although there is no recommendation that patients are managed within a sarcoma service. The aims of this study were to compare survival, complete excision rates and local recurrence rates of patients managed within a sarcoma service and those managed within local hospitals. METHODS: All patients with RAAS referred to a regional sarcoma service between 1998 and 2015 were identified from prospective databases. Patient records, and radiology, pathology and operation notes were reviewed retrospectively. RESULTS: Thirty-six patients were operated on with curative intent; 26 were managed by the sarcoma service (of whom 21 underwent radical excision of the irradiated field followed by chest wall reconstruction) and ten were managed locally. Median age was 69·5 (range 43-85) years. Disease-specific survival was significantly longer in patients managed by the sarcoma service than in those managed locally: median 91·1 (range 69·2-113·0) versus 48·8 (18·6-79·1) months respectively (P = 0·012). Overall survival rates were similar (P = 0·112). There was no difference in complete excision rate (18 of 26 in sarcoma service versus 5 of 10 in local services; P = 0·456), although the local recurrence rate was significantly lower among patients managed by the sarcoma service (9 of 26 versus 8 of 10; P = 0·015). CONCLUSION: Specialist management of RAAS leads to fewer local recurrences and improved disease-specific survival. Early referral and management within specialist units is recommended.

Changing patterns of disease on an inpatient medical service: 1961-1962 to 1981-1982.

To assess changes in disease on an internal medicine teaching service, the records of 292 patients admitted to University Hospital, Denver, Colorado, in the academic years 1961-1962 or 1981-1982 were reviewed. It was hypothesized that patients admitted more recently would be older, more chronically and catastrophically ill, and more likely to have multiple illnesses than patients of an earlier era. Over time, length of stay and mortality rates decreased and acuteness of illness increased, whereas age, chronicity, and co-morbidity remained constant. Changes in the prevalence of some common diseases reflected evolving medical and social influences on hospital use. Modern medical residents are exposed to more patients for a shorter time. They see more acute illness but less of the ongoing process of diagnosis and treatment. Awareness of such changes can help educators design residency programs that better prepare internists for practice.

Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?

BACKGROUND: The value of the history and physical examination in diagnosing chronic obstructive pulmonary disease (COPD) is uncertain. This study was undertaken to determine the best clinical predictors of COPD and to define the incremental changes in the ability to diagnose COPD that occur when the physical examination findings and then the peak flowmeter results are added to the pulmonary history. SUBJECTS AND METHODS: Ninety-two outpatients with a self-reported history of cigarette smoking or COPD completed a pulmonary history questionnaire and received peak flow and spirometric testing. The subjects were independently examined for 12 physical signs by 4 internists blinded to all other results. Multivariate analyses identified independent predictors of clinically significant, moderate COPD, defined as a forced expiratory volume in 1 second (FEV1) less than 60% of the predicted value or a FEV1/FVC (forced vital capacity) less than 60%. RESULTS: Fifteen subjects (16%) had moderate COPD. Two historical variables from the questionnaire--previous diagnosis of COPD and smoking (70 or more pack-years)--significantly entered a logistic regression model that diagnosed COPD with a sensitivity of 40% and a specificity of 100%. Only the physical sign of diminished breath sounds significantly added to the historical model to yield a mean sensitivity of 67% and a mean specificity of 98%. The peak flow result (best cutoff value was less than 200 L/min) significantly added to the models of only one of the four physicians for a mean final sensitivity of 77% and a specificity of 95%. Subjects with none of the three historical and physical variables had a 3% prevalence of COPD; this prevalence was unchanged by adding the peak flow results. CONCLUSIONS: Diminished breath sounds were the best predictor of moderate COPD. A sequential increase in sensitivity and a minimal decrease in specificity occurred when the quality of breath sounds was added first to the medical history, followed by the peak flow result. The chance of COPD was very unlikely with a normal history and physical examination.

Hepatitis B. Cytologic localization of virus antigens and the role of the immune response.

Antigens of the hepatitis B virus have been localized within liver tissue by various immunologic, histochemical, and electron microscopic methods. The abundance and distribution of these virus antigens are in part determined by the host immune response. This interaction of immune mechanisms with the hepatitis B virus may be related to the pathogenesis and natural history of human hepatitis B virus infection.

Pathologic findings associated with interleukin-2-based immunotherapy for cancer: a postmortem study of 19 patients.

The use of interleukin-2 (IL-2), either alone or in combination with lymphokine-activated killer cells, tumor infiltrating lymphocytes, or other immunotherapeutic agents has added a new list of alternatives to conventional antineoplastic regimens. Little information is available about the pathologic changes occurring in patients treated with these agents. In this study, we reviewed the necropsy materials from 19 patients, 12 men and 7 women, with a variety of malignancies including melanoma, renal cell carcinoma, gastrointestinal and pulmonary adenocarcinoma, and metastatic gastrinoma, who died after receiving IL-2-based immunotherapy. Death occurred at intervals ranging from less than 1 hour to 143 days following the last dose of therapy. All patients dying at or less than 43 days following cessation of therapy had lymphoid infiltrates of varying intensity in residual tumor. At necropsy, the major cause of death unrelated to the presence of metastatic tumor was bacterial sepsis. In addition, we found evidence of significant cardiac and pulmonary toxicity: two patients with acute myocardial infarction, one with and one without significant coronary artery disease, two cases of unexplained lymphocytic myocarditis, and one case of fatal pulmonary capillary plugging following an infusion of lymphokine-activated killer cells. Thus, not unlike other forms of therapy for cancer, IL-2-based immunotherapy does not appear to be without significant toxicity.

The clinical evaluation for diagnosing obstructive airways disease in high-risk patients.

OBJECTIVE: We measured the ability of the medical history, physical examination, and peak flowmeter in diagnosing any degree of obstructive airways disease (OAD). DESIGN: Prospective comparison of historical and physical findings with independently measured spirometry. SETTING: University outpatient clinic. PATIENTS: Ninety-two adult consecutive outpatient volunteers with a self-reported history of smoking, asthma, chronic bronchitis, or emphysema. MEASUREMENTS: All subjects completed a pulmonary history questionnaire and received peak flow (PF) and spirometric testing. The subjects were independently examined for 12 pulmonary physical signs by four internists blinded to all other results. Multivariable analysis was used to create a diagnostic model to predict OAD as diagnosed by spirometry (FEV1 < 80 percent of predicted not secondary to restrictive disease, or FEV1/FVC less than 0.7). RESULTS: The best model diagnosed OAD when any of three variables were present--a history of smoking more than 30 pack-years, diminished breath sounds, or peak flow less than 350 L/min. This model had a sensitivity of 98 percent and specificity of 46 percent. In addition, the model detected all subjects with probable restrictive lung disease. Thirty-one percent of subjects had none of these variables and were at very low (3 percent) risk of OAD. Fifty percent of subjects with one or more abnormal variables had OAD. CONCLUSIONS: The history, physical examination, and peak flowmeter can be used to screen high-risk patients for OAD. Using this diagnostic model, 31 percent of subjects could be classified at very low risk of OAD while half of those referred for spirometry would have abnormal results.

A well-deserved break: respite programs offered by California's statewide system of Caregiver Resource Centers.

This article describes the range of respite care options that are helping families of cognitively impaired adults under the auspices of California's statewide system of Caregiver Resource Centers. Types of respite provided include in-home care, adult day care and other group care programs, and overnight respite options outside the home, ranging from short-term care of the patient in a facility to weekend retreats designed for caregivers. The hallmarks of the program are flexibility, choice, and consumer control.

Are persons with cognitive impairment able to state consistent choices?

PURPOSE: This study examined the decision-making capacity of persons with cognitive impairment with respect to their everyday care preferences and choices. This is the first in a series of articles to report on findings from a larger study that examines choice, decision making, values, preferences, and practices in everyday care for community-dwelling persons with cognitive impairment and their family caregivers. DESIGN AND METHODS: Fifty-one respondent pairs, or dyads, were interviewed, that is, persons with cognitive impairment (n = 51) and their family caregivers (n = 51). All persons with cognitive impairment were interviewed twice within a week using a parallel interview to determine stability and accuracy of responses. The family caregiver was interviewed once. RESULTS: Persons with mild to moderate cognitive impairment (i.e., Mini-Mental State Exam scores 13-26) are able to respond consistently to questions about preferences, choices, and their own involvement in decisions about daily living, and to provide accurate and reliable responses to questions about demographics. IMPLICATIONS: Including the perspective of persons with cognitive impairment in both research and practice has the potential to enhance their autonomy and improve their quality of life.

Depression and health in family caregivers: adaptation over time.

This study examined the predictors of caregiver depression and "adaptation" over time in a sample of 202 family caregivers of cognitively impaired adults. By examining caregiver adaptation (i.e., a caregiver's ability to adjust psychologically to the demands of providing long-term in-home care), we were able to account for initial levels of depression, regression to the mean, and floor and ceiling effects. Results indicated that the strongest predictors of caregiver depression 1 year after baseline were initial levels of depression, worsening of caregiver subjective physical health status and burden, and short-term use of in-home respite assistance. These findings suggest that caregivers who experience deterioration in levels of physical health and burden and who use in-home respite on a short-term or sporadic basis may be especially vulnerable to the chronic stress of providing long-term in-home care.

Arthromitus (Bacillus cereus) symbionts in the cockroach Blaberus giganteus: dietary influences on bacterial development and population density.

The filamentous spore-forming bacterium Arthromitus, discovered in termites, millipedes, sow bugs and other soil-dwelling arthropods by Leidy (1850), is the intestinal stage of Bacillus cereus. We extend the range of Arthromitus habitats to include the hindgut of Blaberus giganteus, the large tropical American cockroach. The occurrence and morphology of the intestinal form of the bacillus were compared in individual cockroaches (n=24) placed on four different diet regimes: diurnally maintained insects fed (1) dog food, (2) soy protein only, (3)purified cellulose only, and (4) a dog food-fed group maintained in continuous darkness. Food quality exerted strong influence on population densities and developmental stages of the filamentous bacterium and on fecal pellet composition. The most dramatic rise in Arthromitus populations, defined as the spore-forming filament intestinal stage, occurred in adult cockroaches kept in the dark on a dog food diet. Limited intake of cellulose or protein alone reduced both the frequency of Arthromitus filaments and the rate of weight gain of the insects. Spores isolated from termites, sow bugs, cockroaches and moths, grown on various hard surfaces display a branching mobility and resistance to antibiotics characteristic to group I Bacilli whose members include B. cereus, B. circulans, B. alvei and B. macerans. DNA isolated from pure cultures of these bacilli taken from the guts of Blaberus giganteus (cockroach), Junonia coenia (moth), Porcellio scaber (sow bug) and Cryptotermes brevis (termite) and subjected to Southern hybridization with a 23S-5S B. subtilis ribosomal sequence probe verified that they are indistinguishable from laboratory strains of Bacillus cereus.

Perioperative care of patients with cardiac disease.

Patients with cardiovascular disease commonly present with problems requiring surgical treatment. They are more vulnerable than patients without cardiovascular disease to the cardiovascular stresses associated with general anesthesia and surgery--hypotension, hypoxemia, sepsis, and thromboembolism. Their risk of morbidity and mortality is higher. Certain clinical factors have a profound impact on the patient's likelihood of serious cardiac complications or death: Overt heart failure, recent myocardial infarction, and cardiac arrhythmias are the most worrisome. A careful clinical evaluation and formal assessment of the patient's risk dictate better perioperative monitoring and treatment. Early hospital admission provides time for control of other health problems. Prophylaxis with heparin and antimicrobial agents minimizes problems of thromboembolism and sepsis, respectively. Overaggressive treatment of hypertension is avoided, and withdrawal of propranolol or clonidine is carefully supervised. The use of digoxin is restricted to patients with atrial tachyarrhythmias or heart failure. Hemodynamic monitoring via a Swan-Ganz catheter or temporary transvenous pacing may be necessary for selected high-risk patients. Such careful evaluation, monitoring, and treatment are the clinician's methods for improving the chance for patients with heart disease to benefit from surgery.

Evaluation of postoperative changes in mental status.

When confronted with a patient with an alteration in mental status following surgery, the physician must consider both organic and psychosocial causes and their synergistic interactions. A careful medical assessment will rule out metabolic disorders, sepsis, cardiopulmonary complications, and adverse drug effects. A mental status examination and psychiatric history from the patient and family will identify psychosocial determinants. Simultaneous treatment of the organic and psychosocial components is essential if the physician hopes to provide the best patient care and maximize the likelihood of recovery.