Raynaud Phenomenon of the Nipple: An Under-Recognized Condition.

BACKGROUND: Obstetricians often feel ill-equipped to address the symptom of breast pain in pregnant and postpartum patients. CASES: In the first case, a 40-year-old woman in the second trimester of pregnancy reported nipple discoloration and severe pain. She was treated with nifedipine, and her symptoms decreased quickly and markedly. In the second case, a 32-year-old woman presented for a routine postpartum visit. She described breast pain and sporadic purple discoloration of the nipples, a finding confirmed on examination. Conservative measures of maintaining warmth were recommended. CONCLUSION: Raynaud phenomenon of the nipple is an underdiagnosed condition affecting women in both the prenatal and postpartum periods. A careful history and physical must be obtained in women presenting with breast pain, because diagnosis and treatment allows breastfeeding continuation and mitigation of symptoms.

Implementation of an education package on breast engorgement aimed at lactation consultants and midwives to prevent conflicting information for postnatal mothers.

AIM: The aim of this evidence-based practice project was to improve local practice in the treatment of breast engorgement in postnatal mothers and to ensure the treatment of engorgement in postnatal mothers is performed according to the best available evidence. METHODS: This evidence-based practice project took place in a 28-bed postnatal ward in a large metropolitan tertiary hospital. Twenty midwives and 20 in-patients were recruited for the project. The project utilized an audit and feedback design. Midwives were asked a series of questions to test their knowledge on engorgement, and mothers were asked questions relating to the breastfeeding and engorgement care they received. The project was conducted in three phases: preparation for quality audit, implementation of best practice and postimplementation audit. RESULTS: Comparison of Audit 1 (preimplementation) and Audit 2 (postimplementation) results shows significant improvements in all eight audit criteria. An increase of 80% was achieved for the criteria 'midwives received formal education on engorgement' on completion of the project. A 20% increase in 'consistency of education regarding latch' was reported by the mothers, and there was a 30% increase in 'information given to mothers on prevention and signs of engorgement'. Sixty-five percent of midwives were able to correctly identify and manage engorgement, a significant improvement from 5% at baseline. CONCLUSION: This evidence-based practice project successfully identified and utilized best practice in the management of breast engorgement care in mothers in our clinical setting. With effective breast engorgement interventions in place, mothers could continue to successfully breastfeed their babies. The major challenges identified during the conduct of the project included: time constraints on the midwives to attend education sessions and to educate mothers on prevention. At the completion of this project, a closer relationship was forged between the lactation consultant team and the midwives in the project setting. This increased the satisfaction and productivity of the midwives, and motivated them to deliver high-quality care, which contributed to an improvement in mother's confidence and reduction in conflicting information.

[Experience of professor GUO Chengjie for mammary gland hyperplasia by disease-symptom diagnosis and treatment].

To introduce the experience of professor GUO Chengjie for mammary gland hyperplasia by disease-symptom diagnosis and treatment. Under disease-symptom combination and the reference of both Chinese medicine and western medicine,he took priority in diagnosis and then treated diseases by acupuncture and medicine,etc. Meanwhile,he considered the superficiality and origin of diseases and served patients based on individuals,seasons and regions. Also,regulation for mood was applied. As a result, the good effect was achieved.

Primary actinomycosis of the breast caused by Actinomyces turicensis with associated Peptoniphilus harei.

Actinomycosis of the breast is a rare disease which may mimic malignancy in presentation. Clinical presentation may make it difficult to distinguish primary actinomycosis from mastitis and inflammatory carcinoma. A 22-year-old lady presented with a 3-week history of right breast pain and greenish discharge through her nipple piercing. Physical examination revealed a palpable fluctuant lump in the upper inner quadrant of the right breast and a nipple jewelry in-situ in the upper inner quadrant of the right breast with an abscess at the edge of the areola. Needle aspiration was performed and microbiological examination of the aspirate isolated Actinomyces turicensis and Peptoniphilus harei. Actinomycosis of the breast is rare and the specie, Actinomyces turicensis, is even rarer especially in association with Peptoniphilus harei. Actinomyces is a difficult organism to treat due to its relative indolent course with potential scarring and disruption of local tissue. However, surgical intervention could be avoided with an intensive course of high-dose intravenous antibiotics and prolonged oral antibiotics afterwards.

[Radio-induced breast morphoea: an unrecognized complication]. / Morphée du sein radio-induite : une complication méconnue.

Morphoea is a localized scleroderma. Since the 1990s, it is described as a complication after irradiation for breast cancer. This complication is unrecognized and underdiagnosed. Irradiation seems to be a factor inducing an autoimmune process. Clinicians should be aware in case of an erythema in a treated area, appearing on average one year after the end of the irradiation. Histology alone can prove the diagnosis and rule out differential diagnoses: principally mastitis (carcinomatous, infectious), chronic radiodermatitis or radiation recall. Treatment of this rare complication is not consensual; it is most often topical steroids. The evolution is marked by a gradual decrease from the initial inflammation. Sclerosis persists, more or less substantially.

Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions.

The implementation of a breast clinic based on the use of an advanced registered nurse practitioner at Virginia Mason Medical Center in Seattle, Washington, substantially improved care timeliness and efficiency for women with symptomatic benign breast conditions. Women received their final benign diagnosis in an average of four rather than sixteen days, with fewer imaging studies and physician visits, when compared to a control group. Savings to the employer were estimated at $316 per woman, primarily from increased work productivity. Direct care costs decreased an estimated 19 percent, to $213 per woman. By decreasing both direct medical costs and indirect costs such as work absenteeism and presenteeism, the Virginia Mason Breast Clinic has created substantial savings for providers and employers while delivering care that patients rate highly. This model demonstrates the feasibility of achieving higher quality at lower cost through integrated care.

Pathologic analysis on hyperplasia of mammary gland with different syndromes based on infrared radiation temperature of acupoints.

OBJECTIVE: To explore the pathologic characteristics of hyperplasia of the mammary gland (HMG) by observing differences in infrared radiation temperature of points of HMG in patients with different syndromes compared with healthy controls. METHODS: A FLIR Systems Therma CAM P30 infrared thermal camera was used to detect the infrared temperature of Shanzhong (CV 17), Qimen (LR 14), Zhongwan (CV 12), Qihai (CV 6), Guanyuan (CV 4), Taixi (KI 3), and Taichong (LR 3) in 113 patients with HMG. Of these patients, 71 were placed in the Liver Qi stagnation group, 34 were placed in the Dysfunction of conception and thoroughfare vessels group, and 8 were placed in the Phlegm and blood stasis in combination group. The infrared radiation temperature of each point in the patients was compared with that of healthy controls, and the differences in the infrared radiation temperatures of the points in the patients were analyzed. RESULTS: Overall, the bilateral corresponding point in both the controls and patients exhibited no significant difference in infrared radiation temperature. In all cases, the infrared radiation temperature of the points from proximal to distal tended to decrease. In a comparison of the patients and controls, the infrared radiation temperature of the trunk points Shanzhong (CV 17), Qimen (LR 14), Zhongwan (CV 12), Qihai (CV 6), and Guanyuan (CV 4) of the patients was higher than that of the controls, while the infrared radiation temperature of the lower extremity points Taixi (KI 3) and Taichong (LR 3) was lower than that of the controls. Of these points, Shanzhong (CV 17) (P=0.0368), Zhongwan (CV 12) (P=0.0028), Qihai (CV 6) (P=0.0085), and Guanyuan (CV 4) (P=0.0018) showed significant differences. In a comparison of the corresponding point on the same side in the Liver Qi stagnation group and controls, the infrared radiation temperature of Shanzhong (CV 17) (P=0.0089), right-side Qi-men (LR 14) (P=0.0382), Zhongwan (CV 12) (P= 0.0000), Qihai (CV 6) (P=0.0011), and Guanyuan (CV 4) (P=0.0000) of the patients was significantly higher than that of the controls, while the differences in the infrared radiation temperature of the other points were not statistically significant (P= 0.0833-0.8397). In a comparison of the corresponding point on the same side in the Dysfunction of conception and thoroughfare vessels group and controls, the infrared radiation temperature of left-side Taichong (LR 3) (P=0.0048), right-side Taichong (LR 3) (P=0.0329), left-side Taixi (KI 3) (P= 0.0171), and right-side Taixi (KI 3) (t=0.544, P= 0.0165) of the patients was significantly lower than that of the controls, while the differences in the infrared radiation temperature of the other points were not statistically significant (P=0.3793-0.9197). In a comparison of the corresponding point on the same side in the Phlegm and blood stasis in combination group and controls, the infrared radiation temperature of Shanzhong (CV 17), Qimen (LR 14), Qihai (CV 6), Guanyuan (CV 4), Taixi (KI 3), Taichong (LR 3), and Zhongwan (CV 12) tended to increase, but without statistical significance (P=0.175-.759). CONCLUSION: The corresponding points of HMG patients with different syndromes are in different deficiency/excess states. Changes in the infrared radiation temperature of the trunk points Shanzhong (CV 17), Qimen (LR 14), Zhongwan (CV 12), Qihai (CV 6), and Guanyuan (CV 4) are closely related to the pathological characteristics of the Liver Qi stagnation syndrome of HMG patients, while changes in the infrared radiation temperature of the lower extremity points Taixi (KI 3) and Taichong (LR 3) are closely related to the pathological characteristics of the Dysfunction of conception and thoroughfare vessels syndrome of HMG patients. On the whole, HMG patients with Liver Qi stagnation syndrome are characterized by "upper excess," and those with Dysfunction of conception and thoroughfare vessels syndrome are characterized by "lower deficiency."

Red breast as a presenting complaint at a breast center: an institutional review.

BACKGROUND: The differential diagnosis of a red breast is extensive and includes both benign and malignant diseases. The literature documents patients who present with a red breast with delays in diagnosis of inflammatory cancer. We recorded our institutional experience prospectively in the evaluation, diagnosis, and treatment of a red breast. METHODS: Data were collected prospectively on patients who presented with a red breast during a 14-month period. A retrospective review of final diagnosis and outcome was then conducted. A PubMed and Ovid Medline literature search were performed. RESULTS: Twenty-two patients presented with a red breast. This number accounted for only 0.6% (22/3,762) of patients evaluated in our breast center during this time period. Final diagnoses were as follows: mastitis in 31.8%, breast abscess in 13.6%, erythematous changes secondary to radiation therapy in 13.6%, cellulitis in 9.1%, and venous hypertension in 9.1%. Other diagnoses included postradiation morphea, benign dermatologic inflammation, Paget disease of the breast, inflammatory breast cancer, and psoriasis (1 patient each). After treatment, 67% (17/22) patients had resolution of their symptoms and 18% (4/22) were improved. Only 1 (4.5%) of 22 patients had a change in diagnosis in a median follow-up of 8.8 months. CONCLUSION: A red breast is an uncommon presenting complaint in patients evaluated at a breast center; however, the differential diagnosis is extensive. With appropriate diagnosis and treatment, most patients will have improvement or resolution of their symptoms. The diagnostic algorithm used by our breast center identified the cause of the red breast correctly in >95% of patients at presentation, and it can serve as a guide to evaluate patients with a red breast. This algorithm is in agreement with National Comprehensive Cancer Network guidelines.

Nine years' experience of needle localized breast biopsy in a university hospital: results and evaluation of the role of the surgeon in decision making.

BACKGROUND: Needle localized breast biopsy is an effective means of detecting breast cancer in its early stages. We analysed the indications for needle localized biopsies, evaluated the results, and determined the surgeon's role in the decision-making process. METHODS: The needle localized open biopsy results of 350 patients were assessed. RESULTS: Malignancy was encountered in 7 of 56 patients in whom the radiologist suggested follow-up due to mammographical images, although a surgeon performed a biopsy with the assessment of the patient's historical and clinical findings (12.5%). Biopsy failure rates were higher for office-based ambulatory patients (9.1%) than for those patients who underwent biopsies in an operating theatre (1.9%; P < .05). Patients undergoing operating theatre biopsies under local anaesthesia showed statistically significant failure rates compared with those under general anaesthesia (p = .04). The rate of malignancy of micro-calcification was highest in patients younger than 40 years of age (64.3%), while spicular lesions were commonly malignant in patients over 50 years of age. CONCLUSIONS: From our experience, we suggest that needle localized biopsies should be performed in the operating theatre with the patient under general anaesthesia. Although both micro-calcifications and spicular lesions have a high rate of malignancy in all decades, micro-calcifications are more prevalent in younger patients while spicular lesions prevail in older patients. The final decision, to follow-up or biopsy, should be based on a patient's clinical and historical perspective and not only on the guidance of the mammography report.

Evaluation of pain experienced during breast ductal endoscopy.

PURPOSE: Ductal endoscopy is valuable for the differential diagnosis of bloody nipple discharge; however, the pain associated with this procedure has not been evaluated. This study aims to assess the pain experienced by patients during ductal endoscopy. METHODS: We studied a consecutive series of women who underwent ductal endoscopy, to investigate the cause of bloody nipple discharge. The procedure was performed using standard local anesthesia (lidocaine 1% 10 ml without epinephrine, involving nipple block and periaureolar administration). Patients were asked to score the level of pain with a visual analog scale, 1, 4, 7, 12, 17, 22, 27, and 32 min after the procedure, and describe their overall and maximum pain. RESULTS: This series comprised 20 women aged from 27 to 68 years old. The overall pain (mean +/- SE) score was equal to 5.8 +/-0.3, and the maximum pain score was 8.3 +/- 0.2. The peak of pain corresponded with when the dilator was inserted through the sphincter. The group in which the dilator was inserted after 4 min experienced more intense maximum and overall pain after 7, 12, 17 and 22 min. CONCLUSIONS: Pain is an important factor in ductal endoscopy, and peaks relatively early. A standard, baseline local lidocaine dose of greater than 10 ml may be necessary at the beginning of the procedure. Late insertion of the dilator seems to be an indicator of the force of the procedure.

Advanced transmission Raman spectroscopy: a promising tool for breast disease diagnosis.

A novel approach to noninvasively probe the composition of endogenous materials concealed deeply within mammalian tissue is presented. The method relies upon transmission Raman spectroscopy and permits the detailed characterization of the chemical composition of the probed volume. The technique has been enhanced by the deployment of chemometric methods and the use of a dielectric optical element at the surface to force escaping photons back into the tissue and, thus, enhance the relatively weak signals from the deeper tissue and its components. This permitted reaching both the clinically relevant depth and sufficient sensitivity in phantoms for the noninvasive identification of the calcification types associated with benign or malignant breast disease. Both calcium hydroxyapatite and calcium oxalate monohydrate have been chemically identified from depths of up to 2.7 cm within a breast phantom made up of porcine tissues. The technique has shown significant potential for probing human breasts to provide complementary data in the early diagnosis of breast cancer.

Evaluation of aromatherapy in treating postoperative pain: pilot study.

This study compared the analgesic efficacy of postoperative lavender oil aromatherapy in 50 patients undergoing breast biopsy surgery. Twenty-five patients received supplemental oxygen through a face mask with two drops of 2% lavender oil postoperatively. The remainder of the patients received supplemental oxygen through a face mask with no lavender oil. Outcome variables included pain scores (a numeric rating scale from 0 to 10) at 5, 30, and 60 minutes postoperatively, narcotic requirements in the postanesthesia care unit (PACU), patient satisfaction with pain control, as well as time to discharge from the PACU. There were no significant differences in narcotic requirements and recovery room discharge times between the two groups. Postoperative lavender oil aromatherapy did not significantly affect pain scores. However, patients in the lavender group reported a higher satisfaction rate with pain control than patients in the control group (P = 0.0001).

The accuracy of midwives' clinical breast examination in detection of breast lumps.

BACKGROUND: Screen-detected breast cancers are usually diagnosed at earlier stages. Therefore, countries with limited resources are recommended to implement clinical breast examination (CBE) as a screening method in conjunction with mammography. Since there are so many limitations to performance of CBE by surgeons in the health system and CBE by midwives is more feasible, this study was conducted to test the agreement of CBE by midwives and surgeons. METHODS: One thousand and twenty seven patients with no personal history of breast cancer received breast physical examination by both a midwife and a surgeon and designed forms including patients' general information, cause of referral and abnormal physical findings were completed for each patient. RESULTS: The inter-observer agreement (kappa) for mass detection was 36 % (95% CI= 31% to 41%), indicating a "fair" agreement exists between the midwife's and the surgeon's physical examination. Sensitivity, specificity, positive and negative predictive values of "midwife's physical examination" to detect abnormal breast masses in comparison to "surgeon's physical examination" as the gold standard were 75, 67, 48, and 87 percent respectively. CONCLUSIONS: The results of this study do not justify the replacement of general surgeons by midwives in the health care system as the first examiner for clinical breast screening. Decisions about this issue need more comprehensive studies considering cost-effectiveness and training procedures.

Medical and psychosocial predictors of delay in seeking medical consultation for breast symptoms in women in a public sector setting.

We examined demographic, medical and psychosocial factors related to delay in seeking medical consultation for breast symptoms. In this cross-sectional survey, 124 women with breast symptoms attending an outpatient breast surgery clinic in a county general hospital completed questionnaires measuring demographic, medical and psychosocial variables. Our outcome variable was delay in seeking medical consultation. Younger age (p

Management of benign breast conditions. Part 1--Painful breasts.

This is the first article in a series on breast disorders with an emphasis on diagnosis and management in the general practice setting. This article provides an overview of the investigation of patients with a breast symptom and discusses the assessment and management of mastalgia.

European randomized, multicenter study of goserelin (Zoladex) in the management of mastalgia.

BACKGROUND: Breast pain is a common symptom in patients attending breast clinics. The purpose of this study was to evaluate the efficacy of goserelin (Zoladex) as compared with sham injection in patients with mastalgia. STUDY DESIGN: One hundred forty-seven premenopausal women were randomized to treatment with either goserelin injection (3.6 mg/month) or sham injection for a total of 6 injections. Patients' daily self-assessment of breast pain using Cardiff breast pain chart was recorded during the 6-month treatment period and for 6 months in the posttreatment period. RESULTS: A significant treatment difference between the 2 groups in favor of goserelin was noted during the treatment period. Mean breast pain score improved by 67% in the goserelin group and 35% in the sham group during the treatment period. The mean pain scores increased in both groups in the posttreatment period. No significant posttreatment difference was found between the two groups. Side effects were more common with goserelin than sham injection. Patients receiving goserelin experienced vaginal dryness, hot flushes, decreased libido, oily skin or hair, and a decrease in breast size more frequently than sham patients. CONCLUSION: Goserelin is an effective short-term treatment for mastalgia. However, side effects are common, and thus, goserelin should be kept in reserve for patients who are refractory to other forms of treatment. Potentially, goserelin could be used to induce a rapid relief of symptoms that could be maintained with alternative therapies.