Bilateral Prophylactic Nipple-Sparing Mastectomy: Analysis of the Risk-Reducing Effect in BRCA1/2 Mutation Carriers.

BACKGROUND: Mutations in the BRCA1 or BRCA2 genes increase the lifetime risk of developing breast cancer to 68-72% by the age of 80. One of the modalities to manage the risk is a prophylactic mastectomy. Bilateral nipple-sparing mastectomy specifically offers the most favorable esthetic outcomes but the evidence for its oncological safety remains limited. Thus, we aimed to compare the occurrence of breast cancer between nipple-sparing mastectomy and surveillance groups of BRCA1 or BRCA 2 mutations carriers. MATERIALS AND METHODS: BRCA1 or BRCA2-positive patients undergoing bilateral prophylactic nipple-sparing mastectomy at our department were identified. Only those unaffected by breast cancer were eligible. Each patient was pair-matched with a BRCA1 or BRCA2-positive patient of equal age from the surveillance group. Breast cancer incidence in both groups was recorded and the results were compared. RESULTS: None of 105 patients who underwent NSM between 2009 and 2019 at a single institution with a mean follow-up time of 50 months developed breast cancer over this time period. One patient in this group died of an unrelated cause. Nine patients from 105 in the match-paired surveillance group were diagnosed with breast cancer during a mean follow-up time of 58.3 months, however, none of them died. CONCLUSION: To the best of our knowledge, this is the largest single-center study of risk-reducing bilateral NSM in healthy BRCA1 or BRCA2 mutation carriers. Based on our results and those of other series, we conclude that NSM in its current form appears to be at least equally as safe as other types of mastectomy for preventing breast cancer in BRCA1 or BRCA2 mutation carriers. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparison of continuous versus intermittent enteral nutrition in critically ill patients (COINN): study protocol for a randomized comparative effectiveness trial.

BACKGROUND: Enteral nutrition is part of the treatment of critically ill patients. Administration of enteral nutrition may be associated with signs of intolerance, such as high gastric residual volumes, diarrhea, and vomiting. Clinical trials regarding the effects of the mode of administration of enteral nutrition on the occurrence of these complications have yielded conflicting results. This trial aims to investigate whether the mode of administration of enteral nutrition affects the time to reach nutritional targets, intolerance, and complications. METHODS: COINN is a randomized, monocentric study for critically ill adult patients receiving enteral nutrition. Patients will be randomly assigned to two groups receiving (1) continuous or (2) intermittent administration of enteral nutrition. Enhancement of enteral nutrition will depend on signs of tolerance, mainly the gastric residual volume. The primary outcome will be the time to reach the energetic target. Secondary outcomes will be the time to reach the protein target, tolerance, complications, hospital and ICU lengths of stay, and 28-day mortality. DISCUSSION: This trial aims to evaluate whether the mode of application of enteral nutrition affects the time to reach nutritional targets, signs of intolerance, and complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT03573453. Registered on 29 June 2018.

Central venous catheter-related thrombosis in intensive care patients - incidence and risk factors: A prospective observational study.

BACKGROUND: One of the complications associated with central venous catheter (CVC) placement is catheter related deep vein thrombosis (CR-DVT). However a literature search revealed little evidence of this recognised complication. The primary aim of this study was to establish the incidence rate and risk factors for the development of CR-DVT in our critically ill adult patients. METHODS: All critically ill adult patients admitted to the medical-surgical ICU with CVC inserted were included in this observational prospective study. After catheter removal we performed duplex ultrasound examination to assess the patency of the vein and establish if CR-DVT was present. RESULTS: A total number of 308 catheters met the inclusion criteria of which 198 were included in the statistical analysis. The CVC was inserted into a subclavian vein (SCV) in 139 (70%) cases and in an internal jugular vein (IJV) in 59 (30%) cases. The 28-day mortality rate was 14.1%. We found CR-DVT during duplex ultrasound examination in 47 (26%) of all cases. 33 (70%) of the CR-DVT were diagnosed in the IJV and 14 (30%) in the SCV. The risk factors for the development of CR-DVT we identified included cannulation of the IJV and the use of treatment dose of LMWH. The effect of CR-DVT on 28-day mortality was not statistically significant. CONCLUSION: The risk factors for CR-DVT we identified were IJV as a site for CVC cannulation and the use of therapeutic anticoagulation prior to cannulation. Our recommendation would be preferential cannulation of a subclavian vein as opposed to an internal jugular vein in order to reduce the risk of CR-DVT.

Ischemic stroke in paediatrics - narrative review of the literature and two cases.

Stroke is a rare condition in childhood with an estimated incidence of between 1.3-13/100.000 patients. Clinical manifestation and risk factors for paediatric stroke are different from those of adults. The uncommon incidence, age-associated difference and plethora of clinical symptoms make the diagnosis of such strokes extremely difficult and often delayed. The history and clinical examination should point to diseases or predisposing factors. Neuroimaging (DWI MR) is the golden standard for diagnosis of paediatric stroke and other investigations can be considered according to the clinical condition. Despite advances in paediatric stroke research and clinical care, questions remain unanswered regarding acute treatment, secondary prevention and rehabilitation. The treatment recommendations are mainly extrapolated from studies on adult populations. In the review authors summarized the clinical characteristics and diagnostic steps for stroke in children/adolescents based on the most recent international guidelines and practical directions for recognising and managing the child/adolescent with stroke in paediatric emergency. In the two case reports, we describe the clinical course in both stroke patients.