It's Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain.

Introduction: Health care providers treating lactating women for nipple and breast pain often attribute symptoms to Candida albicans infection. However, multiple other conditions may present with pain, erythema, and pruritis. We explored the experience of a breastfeeding medicine practice that received referrals for patients failing antifungal therapy and who desired further evaluation for alternative diagnoses. Materials and Methods: We conducted a retrospective chart review of breastfeeding women referred for evaluation of "yeast" to a breast surgery/breastfeeding medicine practice from July 2016 to August 2019. Results: Twenty-five women met inclusion criteria. Median age was 33 (range 24-43) and median months postpartum was 4 (range 0.5-18). All 25 women reported minimal to no improvement on oral and/or topical antifungal therapy. In addition to history and examination, milk culture was obtained in four women, punch biopsy in one, and core needle biopsy in one. No woman was confirmed to have a diagnosis of Candida. Diagnoses were changed to the following: subacute mastitis/mammary dysbiosis (n = 8), nipple bleb (n = 6), dermatitis (n = 6), vasospasm (n = 2), milk crust (n = 1), hyperlactation (n = 1), and postpartum depression (n = 1). Treatment included discontinuation of antifungal medication, as well as the following per individual diagnoses: antibiotics and probiotics; 0.1% triamcinolone cream; heat therapy; discontinuation of exclusive pumping; and antidepressant medication and counseling referral. All women experienced resolution of symptoms following revision of diagnosis and change in management (range 2-42 days). Conclusion: While persistent nipple and breast pain in breastfeeding is often attributed to Candida, this cohort demonstrates that providers should consider multiple other conditions in their differential diagnosis. Accurate, timely diagnosis is crucial, as pain is a risk factor for premature cessation of breastfeeding. Symptomatic resolution occurs on appropriate therapy.

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.

[Chinese patent medicines with function of resolving hard lump for cyclomastopathy: network Meta-analysis].

This systematic review aims to systematically evaluate the efficacy and safety of Chinese patent medicines with resolving hard lump function for the treatment of cyclomastopathy. We searched CNKI, WanFang, SinoMed, PubMed, EMbase, and The Cochrane Library from the inception to January 3 2018, to collect the randomized controlled trials（RCTs）on Chinese patent medicines with resolving hard lump function in treating cyclomastopathy. Two reviewers independently screened literature, extracted data and assessed the methodological quality of included studies. Then, statistical analysis was performed by using Stata 12.0 and WinBUGS 1.4.3 software. A total of 52 RCTs involving 9 605 patients were finally included. The inventions included 11 commercial Chinese patent medicines with functions of resolving hard lump, such as Rupi Sanjie Capsules, Xiaoru Sanjie Capsules, Ruhe Sanjie Pills, and Hongjin Xiaojie Capsules. The result of direct Meta-analysis showed that: as compared with the simple western medicine group, the Chinese patent medicines such as Hongjin Xiaojie Capsules, Ruhe Sanjie Pills, Rupi Sanjie Capsules, Xiaoru Sanjie Capsules and Xiakucao Oral Liquid could significantly improve the clinical efficacy. In addition, the incidence of adverse reactions of Chinese patent medicines with resolving hard lump function was lower than that in Western medicine group in gastrointestinal reactions, menstrual disorders, leucorrhea abnormalities, liver dysfunction and estrogen-like effect. The network Meta-analysis showed that: Xiaoru Sanjie Capsules, Ruhe Sanjie Pills, Yanlu Rukang Capsules, Quyu Sanjie Capsules, and Hongjin Xiaojie Capsules were the top five in terms of treatment effect. Chinese patent medicines with resolving hard lump function had better clinical efficacy. Due to the low quality of included studies， more high quality RCTs are needed to verify the above conclusion.

Screening for the anti-inflammation quality markers of Xiaojin Pills based on HPLC-MS/MS method, COX-2 inhibition test and protein interaction network.

Nowadays, breast disorders seriously affect women's health in an increasing number. In China, Xiaojin Pills are commonly used in the treatment of breast diseases. Doctors have concluded that the combined use of Xiaojin Pills with conventional therapy can significantly improve the efficacy with fewer side effects. However, the prescription of Xiaojin Pills is complicated and their quality control methods cannot completely ensure the quality of Xiaojin Pills. On the basis of its mechanism, our study combined chemical evaluation and biological evaluation to identify the anti-inflammatory markers of Xiaojin Pills. In this manuscript, 13 compounds in Xiaojin Pills were quantified. At the same time, the cyclooxygenase-2 inhibition rates of different Xiaojin Pills were measured and the possible markers were screened by spectrum-effect relationship. Further, anti-inflammatory activities of markers were verified and protein interaction network was analyzed, identifying the components of Protocatechuate, Beta-Boswellic acid and Levistilide A as the anti-inflammatory quality markers of Xiaojin Pills. We hope our studies can provide a scientific theoretical basis for accurately quality control of Xiaojin Pills and reasonable suggestions for pharmaceutical companies and new ideas for the quality control of other medicines.

In vitro antibiotic susceptibility and biofilm production of Staphylococcus aureus isolates recovered from bovine intramammary infections that persisted or not following extended therapies with cephapirin, pirlimycin or ceftiofur.

Staphylococcus aureus intramammary infections (IMIs) have low cure rates using standard antibiotic treatment and increasing the duration of treatment usually improves therapeutic success. Chronic IMIs are thought to be caused by bacteria presenting a specific virulence phenotype that includes the capacity to produce greater amounts of biofilm. In this study, antibiotic susceptibility and biofilm production by S. aureus isolates recovered from IMIs that were cured or not following an extended therapy with cephapirin, pirlimycin or ceftiofur for 5, 8 and 8 days, respectively, were compared. An isolate was confirmed as from a persistent case (not cured) if the same S. aureus strain was isolated before and after treatment as revealed by the same VNTR profile (variable number of tandem repeats detected by multiplex PCR). The antibiotic minimal inhibitory concentrations (MICs) were determined for these isolates as well as the capacity of the isolates to produce biofilm. Isolates from persistent cases after extended therapy with cephapirin or ceftiofur had higher MICs for these drugs compared to isolates from non-persistent cases (p < 0.05) even though the antibiotic susceptibility breakpoints were not exceeded. Isolates of the ceftiofur study significantly increased their biofilm production in presence of a sub-MIC of ceftiofur (p < 0.05), whereas isolates from the pirlimycin group produced significantly less biofilm in presence of a sub-MIC of pirlimycin (p < 0.001). Relative antibiotic susceptibility of the isolates as well as biofilm production may play a role in the failure of extended therapies. On the other hand, some antibiotics may counteract biofilm formation and improve cure rates.

[Clinical observation of breast hyperplasia treated with auricular point sticking therapy and Xiaopijian].

OBJECTIVE: To observe the efficacy difference in the treatment of breast hyperplasia between the combined therapy of auricular point sticking and Xiaopijian and the simple application of Xiaopijian. METHODS: Ninety-one patients were randomized into an observation group (46 cases) and a control group (45 cases). In the observation group, the sticking therapy on the auricular points was applied in combination with the oral medication of Chinese herbal medicine, Xiaopijian. Auricular points included Ruxian, Neifenmi (CO18), Luanchan, Shenmen (TF4), Gan (CO2), Pi (CO13). The auricular point sticking therapy was applied once a week on the auricular points of one side alternatively. Xiaopijian was the self-prepared decoction. The main ingredients are radix bupleuri Bupleurum chinense, spica prunellae prunella vulgaris and radix peoniae alba Paeonia lactiflora, 30 mL each time, three times a day. In the control group, Xiaopijian was simply prescribed for oral administration, 30 mL each time, 3 times a day. The treatment was discontinued during menstruation in the two groups. The menstrual cycle of one month made one session of treatment. The treatments for 3 sessions were observed. The scores of symptoms and physical signs, including the degree of breast pain, hardness and size of breast masses as well as the scores of general and supplementary symptoms were compared before and after treatment in the patients of the two groups. The clinical efficacy was compared between the two groups. RESULTS: After treatment, the scores of symptoms and physical signs were reduced apparently as compared with those before treatment in the patients of the two groups (both P<0. 05). The score reduction in the observation group was much more than that in the control group (11.02±1. 78 vs 9.82±1. 53, P<0. 05). The total effective rate was 95.7% (44/46) in the observation group, higher apparently than 80. 0% (36/45, P<0. 05). CONCLUSION: The combined therapy of auricular point sticking and Xiaopijian achieves the superior efficacy on breast hyperplasia as compared with the simple application of Xiaopijian.

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.

[Granulomatous lobular mastitis associated with mammary duct ectasia: a clinicopathologic study of 32 cases with review of literature].

OBJECTIVE: To study the clinicopathologic features of granulomatous lobular mastitis and mammary duct ectasia. METHODS: The clinicopathologic data from August 2005 to May 2013 of 32 cases of granulomatous lobular mastitis and mammary duct ectasia were retrospectively reviewed. RESULTS: The age of patients ranged from 26 to 45 years. Two patients had no history of delivery. Fourteen patients had no history of lactation or lactational disorder in the lesional side. Most of the remaining patients had history of breast feeding. Gross examination showed that the lesions were poorly circumscribed and varied from 3 to 12 cm in greatest dimension. Tiny abscess cavities, ranging from 0.1 to 0.5 cm in diameter and containing light yellowish to greyish secretion, were demonstrated. Histologic examination showed granuloma formation and ductal dilatation. Eleven patients had received antibiotic treatment. Twelve cases were complicated by sinus formation related to skin incision and drainage. The duration of follow-up ranged from 5 to 90 months. Three cases showed ipsilateral recurrence and 3 cases had similar pathology in the contralateral breast. Four patients defaulted follow-up. CONCLUSIONS: Granulomatous lobular mastitis is associated with mammary duct ectasia. Accurate pathologic diagnosis is prudent for clinical management and control of local recurrence.

Failure of oral antibiotic therapy, including azithromycin, in the treatment of a recurrent breast abscess caused by Salmonella enterica serotype Paratyphi A.

We report a case of recurrent, multifocal Salmonella enterica serotype Paratyphi A breast abscesses, resistant to ciprofloxacin, which relapsed despite surgery, aspiration and multiple courses of antibiotics, including co-trimoxazole and azithromycin. The patient was cured after a prolonged course of intravenous ceftriaxone.

Modulation of expression of p16 and her2 in rat breast tissues of mammary hyperplasia model by external use of rupifang extract.

OBJECTIVE: To observe the effect of Rupifang Extract in external use on expression of proto-oncogenes her2 and tumor suppression genes p16 in rat breast tissues of mammary hyperplasia model. To explore the mechanisms of Rupifang Extract in external use for preventing and treating mammary hyperplasia. METHODS: Thirty virginal female Wistar rats were randomized into 5 groups, 6 in each, A: blank control group; B: model group; C: the low dose group of Rupifang; D: the middle dose group of Rupifang; and E: The high dose group of Rupifang. The mammary hyperplasia rat models were produced by injecting estradiol benzoate and progesterone and irritating by tail nipping. Drug intervention was also launched during the model formation. After 30 days, the expression of her2 and p16 in breast tissues of rats in each group were detected by the SP immunohistochemical method. RESULTS: Compared with Blank control group, the expression of her2 in breast tissues in Model group was higher, and the expression of p16 was lower (P < 0.05 or P < 0.01). After intervention with Rupifang Extract, compared with Model group, the expression of her2 in breast tissues in Rupifang groups was lower, and the expression of p16 higher (P < 0.05 or P < 0.01). CONCLUSION: The mechanisms of Rupifang Extract in external application for preventing and treating mammary hyperplasia may be reducing the expression of proto-oncogenes her2 and increasing the expression of tumor suppression genes p16.

Scapulothoracic bursitis as a significant cause of breast and chest wall pain: underrecognized and undertreated.

OBJECTIVES: Pain is one of the most commonly reported breast complaints. Referred pain from inflammation of the shoulder bursa is often overlooked as a cause of breast pain. The objective of this study is to evaluate the role of shoulder bursitis as a cause of breast/chest pain. METHOD: An IRB-approved retrospective review from July 2005 to September 2009 identified 461 patients presenting with breast/chest pain. Cases identified with a trigger point in the medial aspect of the ipsilateral scapula were treated with a bursitis injection at the point of maximum tenderness. The bursitis injection contains a mixture of local anesthetic and corticosteroid. Presenting complaint, clinical response and associated factors were recorded and treated with descriptive statistics. RESULTS: Average age of the study group was 53.4 ± 12.7 years, and average BMI was 30.4 ± 7.4. One hundred and three patients were diagnosed with shoulder bursitis as the cause of breast pain and received the bursitis injection. Most cases (81/103 or 78.6%) presented with the breast/chest as the site of most significant discomfort, where 8.7% (9/103) had the most severe pain at the shoulder, 3.9% (4/103) at the axilla and 3.9% (4/103) at the medial scapular border. Of the treated patients, 83.5% (86/103) had complete relief of the pain, 12.6% (13/103) had improvement of symptoms with some degree of residual pain, and only 3.9%(4/103) did not respond at all to the treatment. The most commonly associated factor to the diagnosis of bursitis was the history of a previous mastectomy, present in 27.2% (28/103) of the cases. CONCLUSIONS: Shoulder bursitis represents a significant cause of breast/chest pain (22.3% or 103/461) and can be successfully treated with a local injection at site of maximum tenderness in the medial scapular border.

Vitamin E and evening primrose oil for management of cyclical mastalgia: a randomized pilot study.

OBJECTIVE: To evaluate the effectiveness of vitamin E, evening primrose oil (EPO), and the combination of vitamin E and EPO for pain control in women with cyclical mastalgia. PROCEDURE: A double-blind, randomized, placebo-controlled trial was conducted at two U.S. academic medical centers. Eighty-five women with premenstrual cyclical breast discomfort were enrolled. Participants were randomly assigned to one of four six-month oral treatments: vitamin E (1,200 IU per day), EPO (3,000 mg per day), vitamin E (1,200 IU per day) plus EPO (3,000 mg per day), or double placebo. The primary outcome measure was change in breast pain, measured by the modified McGill Pain Questionnaire at enrollment and at six months. RESULTS: Forty-one patients completed the study. Intent-to-treat analysis (pretesting and post testing) showed a difference in worst-pain improvement with the treatments EPO (p=0.005), vitamin E (p=0.04), and EPO plus vitamin E (p=0.05), but no difference with placebo (p=0.93). Results from two-sample t-test showed a nonsignificant decrease in cyclical mastalgia individually for the three treatment groups compared with the placebo group (EPO, p=0.18; vitamin E, p=0.10; and EPO plus vitamin E, p=0.16). The data were also analyzed with the separation test by Aickin, which showed a trend toward a reduction of cyclical mastalgia with vitamin E and EPO individually and in combination. CONCLUSION: Daily doses of 1,200 IU vitamin E, 3,000 mg EPO, or vitamin E and EPO in combination at these same dosages taken for six months may decrease the severity of cyclical mastalgia.

MRSA as a cause of postpartum breast abscess in infant and mother.

This report describes the unusual occurrence of mastitis and breast abscess in both mother and infant, both caused by methicillin-resistant Staphylococcus aureus (MRSA). Mother and child were both immunocompetent, and their only risk factor was routine confinement. The case highlights the importance of considering MRSA as a cause for mastitis in mothers and infants. MRSA is increasingly common, and failure to consider it as a cause for mastitis will lead to delays in treatment (as it did in this case). The case also demonstrates the role of Hospital in the Home in the treatment of postnatal infections, where hospitalization can be extremely disruptive.

A review of the clinical efficacy of evening primrose.

The oil obtained from the evening primrose (Oenothera biennis) plant is usually taken orally in a gel cap form. This herbal supplement is most commonly used for the treatment of mastalgia and atopic dermatitis. While recommending this supplement to patients for many years for the treatment of mastalgia, this author was interested in researching the plant and the evidence supporting its use for this complaint and its other potential uses. The oil is rich in omega-6 fatty acids, which are essential for many bodily functions; however, a lack of strong scientific evidence exists to support its use for the relief of mastalgia or atopic dermatitis.