Evolving indications and long-term oncological outcomes of risk-reducing bilateral nipple-sparing mastectomy.

Background: Bilateral nipple-sparing mastectomy (NSM) is a technically feasible operation and is associated with excellent cosmetic outcomes. The aim of this study was to evaluate trends in patient characteristics, indications for surgery and long-term outcomes of bilateral NSM for breast cancer risk reduction over time. Methods: A review of a single-centre experience with bilateral NSM performed between 2001 and 2017 for breast cancer risk reduction in patients without breast cancer was performed. Trends in patient characteristics and indications for surgery were evaluated over four time intervals: 2001-2005, 2006-2009, 2010-2013 and 2014-2017. Statistical analysis was performed using χ2 tests. Results: Over the study period, 272 NSMs were performed in 136 patients; their median age was 41 years. The number of bilateral NSMs performed increased over time. The most common indication was a mutation in breast cancer-associated genes (104 patients, 76·5 per cent), which included BRCA1 (62 patients), BRCA2 (35), PTEN (2), TP53 (3) and ATM (2). Other indications were family history of breast cancer (19 patients, 14·0 per cent), lobular carcinoma in situ (10, 7·4 per cent) and a history of mantle irradiation (3, 2·2 per cent). The proportion of patients having a bilateral NSM for mutation in a breast cancer-associated gene increased over time (2001-2005: 2 of 12; 2006-2009: 9 of 17; 2010-2013: 34 of 41; 2014-2017: 61 of 66; P < 0·001). Mean follow-up was 53 months; no breast cancers were found during follow-up. Conclusion: The use of bilateral NSM for breast cancer risk reduction is increasing and the indications have evolved over the past 16 years. These excellent long-term oncological results suggest that bilateral NSM is a good option for surgical breast cancer risk reduction.

Autologous inferior dermal sling (autoderm) with concomitant skin-envelope reduction mastectomy: an excellent surgical choice for women with macromastia and clinically significant ptosis.

BACKGROUND: Skin-sparing mastectomy and prosthetic reconstruction can be complicated by poor surgical outcomes in large-breasted, obese women. This article describes a single surgeon's experience comparing conventional skin-sparing mastectomy (SSM) and skin-reduction mastectomy using an autologous vascularized inferior dermal/cutaneous sling (autoderm). METHODS: From July 2007 to May 2012, patients undergoing skin-sparing mastectomy were evaluated for surgical outcomes. After July 2009, the surgeon performed skin-reduction mastectomies with autoderm (SRM-AD) on all patients with macromastia or grade 3-4 ptosis. Remaining patients in this time period (SSM-cont) underwent conventional skin-sparing mastectomies while all previous patients (historical) also underwent skin-sparing mastectomies (SSM-hist). A predictive model was used to compare the large historical patients (who would have had reduction mastectomy if available) with the smaller historical patients to evaluate the effect of the procedure. RESULTS: Body mass index (BMI) and specimen weight were higher in both the SRM group and large historical group. The hazard ratio for having skin-reduction mastectomy was 0.53 (P = 0.51) compared with the historical group. There was a total of 16 complications for the whole study. Smoking was the only significant risk factor. CONCLUSIONS: This study shows that mastectomy with prosthetic reconstruction using a skin-reduction technique with autoderm can be done safely with a low complication rate and improved cosmetic outcomes in the traditionally "at-risk" group of women with high BMI and large ptotic breasts.

Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers.

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.

Early-onset neonatal group B streptococcal infection: implications for practice.

Group B streptococcus (GBS) is the leading bacterial infection associated with morbidity and mortality of newborns in the United States. Most neonatal infections can be prevented through the use of intrapartum antimicrobial prophylaxis in women who are at increased risk for transmitting infection to their newborns. However, prevention strategies have not been implemented widely or consistently, and the incidence of neonatal GBS disease has not declined. An understanding of GBS epidemiology, clinical presentation, and prevention strategies enhances the PNP's decision-making skills in the nursery and strengthens the PNP's ability to evaluate and compare new approaches to GBS prevention.

Relationship of obesity and specimen weight to complications in reduction mammaplasty.

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction.

PURPOSE: To analyze the acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous (TRAM) flap reconstruction following modified radical mastectomy for breast cancer. METHODS AND MATERIALS: Twenty-five consecutive patients were treated with postoperative radiation therapy after TRAM flap reconstruction between 1985 and 1999. The radiation records for these patients were retrospectively reviewed. Information regarding treatment techniques, timing, and dose was obtained and correlated with the extent of erythema, desquamation, and the need for treatment break. RESULTS: The median age was 48 years. The median dose of chest wall radiation was 5040 cGy. Additional boost doses were delivered in 13 patients. Twelve patients (48%) developed mild erythema in the treatment field during the course of treatment and 13 patients (52%) developed moderate (40%) or brisk (12%) erythema. Only 10 patients (40%) developed any kind of desquamation; 5 patients (20%) developed dry desquamation and another 5 patients (20%) developed moist desquamation. No patients required a break in the course of treatment because of acute side effects. None of the parameters evaluated (the use of chemotherapy prior to radiation, the interval between surgery and radiation, smoking, prior incidence of fat necrosis, the use of bolus during radiation, and the use of a boost) were predictive of an increased incidence of either the extent of erythema or the development of desquamation in the treatment field. CONCLUSION: Postmastectomy radiation for TRAM flap reconstruction is well tolerated and is not associated with an increased incidence of acute side effects. Radiation technique and the use of preradiation chemotherapy do not appear to be correlated with an increased incidence of acute side effects.

Patient care guidelines in pediatrics.

The increase in availability of patient care guidelines is consistent with the expansion of managed care health care systems and enhanced efforts of health care providers to deliver evidence-based patient care. When used effectively, guidelines support: 1) the reduction of unexplained variation in health care practice; 2) education of practitioners and health care delivery systems; and 3) the continuous improvement in processes that improve patient outcomes. It is with these goals in mind that Milliman and Robertson released its latest publication of Health Care Management Guidelines entitled Pediatric Health Status Improvement and Management (HSIM). This publication contains comprehensive information on many aspects of pediatric care, from the prenatal period through adolescence, from preventive medicine through chronic care. Like other Milliman and Robertson Health Care Management Guidelines publications, Pediatric HSIM offers both treatment guides and benchmarks that enable health care professionals to provide optimal levels of care and to measure their performance against peers. The primary focus of Pediatric HSIM is on wellness across a child's lifetime, an objective that fits well with our goal as providers of care to children of keeping patients healthy through preventive medicine.

Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents.

The purpose of this study was to determine whether the occurrence of accidental blood-borne pathogen exposure incidents in medical students and residents in training varies during the 24 h. A retrospective review of reported exposures was conducted in a large urban teaching institution--the University of Texas Health Science Center in Houston--between November 1993 and July 1998. Professional level (year of student or level of resident), time of exposure, means/route of exposure (needle stick, laceration, or splash), and type of medical service were recorded. Analysis of the clock time of the 745 reported blood-borne pathogen exposures showed they occurred more frequently during the day than night. Over the nearly 5-year span, 531 incidents took place between 06:00 and 17:59 in comparison to only 214 between 18:00 and 05:59. To account for the day-night difference in medical student and resident hospital staffing, the data were reexpressed as exposure rates, that is, in terms of the number of events per hour per 1000 medical students and residents. Based on the total number of reported exposures over the almost 5-year span of data collection, the average rate was 40 accidents per hour per 1000 doctors in training during the 12 h daytime span (6:00-17:59). It was 50% greater at night (18:00-05:59), with 60 incidents per hour per 1000 doctors in training. The day-night difference in rate of exposures was statistically significant (p < .04). The relative risk ratio for residents and students when working during the day shift compared to working the night shift was 0.67. This means that doctors in training are at a 1.50 higher risk of sustaining a blood-borne pathogen exposure when working nights than when working days.

Comparison of arbitrary definitions of circadian time periods with those determined by wrist actigraphy in analysis of ABPM data.

Determining blood pressure (BP) values at different daily time periods is a well recognised measure to assess the risk of end-organ damage. However, the use of various definitions of these periods, eg, day vs night, sleep vs wake or arbitrary definitions, makes clinical decisions based on available data difficult. In the present study, we compared BP loads in actual sleep-wake periods to default day-night definition provided by the ambulatory BP monitoring (ABPM) software (day 06.00 to 22.00; night 22.00 to 06.00) as well as to an arbitrary definition of sleep-wake periods in children published in Soergel et al (J Pediatr 1997; 130: 178-184)1 (awake 08.00 to 20.00 and sleep 00.00 to 06.00. We used an actigraphy, an accelerometer, to define the actual sleep-wake periods in 46 patients with essential hypertension who are on various treatment regimens. BP data was obtained by using Spacelabs 90207 monitors for a full 24 h. There were significant differences between actual sleep-wake and default definition for BP load. No similar finding was noted when arbitrary definition was used. The proportion of hypertensives was not significantly different when default and arbitrary definitions were used. Classification of dippers and non-dippers is greatly affected by the definition of sleep interval using the default method. Although some of the misclassifications were not statistically significant, their clinical importance must be considered. Determination of sleep and wake periods for analysis of ABPM data should be based on careful determination of actual periods. Using other definitions may not provide complete information or accommodate for individual variation.

T-cell adoptive immunotherapy of metastatic renal cell carcinoma.

OBJECTIVES: To determine the feasibility and toxicity of the adoptive transfer of ex vivo-activated T lymphocytes that have been sensitized to autologous tumor vaccine in vivo. METHODS: Twenty patients with extensive metastatic renal cell carcinoma received systemic adoptive immunotherapy with autologous T cells in the absence of conjunctional interleukin-2 (IL-2) administration. Patients were vaccinated intradermally with irradiated autologous tumor cells and granulocyte-macrophage colony-stimulating factor as an adjuvant to stimulate an immune response. Inguinal lymph nodes draining the vaccine site were surgically removed, and the cells were stimulated with staphylococcal enterotoxin A followed by expansion in 60 IU/mL IL-2, and in some cases additionally stimulated with anti-CD3 monoclonal antibody and IL-2, to obtain a large number of cells. RESULTS: The staphylococcal enterotoxin A/IL-2 activation induced vigorous proliferation of T cells (median expansion 26-fold) that were a mixture of CD4 and CD8 T lymphocytes. Activated cells were infused intravenously at doses ranging from 2x10(9) to 9.5x10(10). There was minimal toxicity consisting of grade 1 or 2 fever and nausea, and the entire treatment was delivered as outpatient therapy. One patient had a partial response, one had a mixed response, and 8 had stable disease lasting at least 5 months. CONCLUSIONS: Adoptive transfer of ex vivo-activated, tumor vaccine-primed lymph node cells is feasible and is associated with minimal toxicity when used alone. These results warrant further study in a Phase II trial.

Technical aspects of blood pressure measurement in pediatric patients.

BACKGROUND: Prolonged hypertension in adults has been associated with end-organ damage, in addition to increased morbidity and mortality. Accurate measurement of blood pressure in pediatric and adult patients is imperative for the appropriate diagnosis of hypertension, so that measures may be instituted to prevent these adverse sequelae. Although intermittent office measurement of blood pressure is practiced in most parts of the world, the technique is fraught with problems. Errors during the actual measurement and difficulties in interpretation of the data are well-studied challenges associated with intermittent blood pressure measurements that have been well studied. Ambulatory blood pressure monitoring offers several advantages over intermittent measurement: blood pressure measurements are available over a prolonged period of time (including the sleep period), measurements are not as dependent on observer biases as are intermittent measurements, and in adults the data appear to correlate well to measures of end-organ damage. In children, the ambulatory blood pressure monitor is well tolerated and accurate. This new technology may offer pediatric specialists the opportunity to identify more accurately the child with increased blood pressure, so that preventive measures can be instituted to reduce the well-known morbidity and mortality associated with hypertension. OBJECTIVE: To review the technical aspects of blood pressure measurement in children, with special attention to the emerging field of ambulatory blood pressure monitoring and its potential use in children.

Comparison of arbitrary definitions of circadian time periods with those determined by wrist actigraphy in analysis of ABPM data.

Determining blood pressure (BP) values at different daily time periods is a well recognised measure to assess the risk of end-organ damage. However, the use of various definitions of these periods, eg, day vs night, sleep vs wake or arbitrary definitions, makes clinical decisions based on available data difficult. In the present study, we compared BP loads in actual sleep-wake periods to default day-night definition provided by the ambulatory BP monitoring (ABPM) software (day 06.00-22.00; night 22.00-06.00) as well as to an arbitrary definition of sleep-wake periods in children published in Journal of Pediatrics (Soergel et al, 1997) (awake 08.00-20:00 and sleep 00.00-06.00). We used an actigraph, an accelerometer, to define the actual sleep-wake periods in 46 patients with essential hypertension who are on various treatment regimens. BP data were obtained by using Spacelabs 90207 monitors for a full 24 hours. There were significant differences between actual sleep-wake and default definition for BP load. No similar findings were noted when arbitrary definition was used. The proportion of hypertensives was not significantly different when default and arbitrary definitions were used. Classification of dippers and non-dippers is greatly affected by the definition of sleep interval using the default method. Although some of the misclassifications were not statistically significant, their clinical importance must be considered. Determination of sleep and wake periods for analysis of ABPM data should be based on careful determination of actual periods. Using other definitions may not provide complete information or accommodate for individual variation.

Rebound bilirubin levels in infants receiving phototherapy.

A retrospective medical record review was completed for 264 consecutive newborns receiving phototherapy for hyperbilirubinemia to determine whether a "rebound" increase in total serum bilirubin (TSB) level occurs after termination of phototherapy. The difference between mean TSB levels at discontinuation of phototherapy and at rebound was calculated by paired t test. TSB levels at rebound were significantly lower than at discontinuation of phototherapy for infants weighing > 1800 g (positive and negative Coombs' test results). There were no statistically significant differences among infants in the smaller weight categories, regardless of Coombs' test results. Infants completing phototherapy for hyperbilirubinemia who are otherwise healthy do not require follow-up solely to identify a rebound bilirubin level.

Primary lymphedema of the genitalia in children and adolescents.

PURPOSE: Congenital lymphedema is a rare disorder that may result in disfiguring edema of the male genitalia. We reviewed our experience with 5 cases to advance our understanding of this challenging problem. MATERIALS AND METHODS: Four boys with significant lymphedema underwent excision of the involved subcutaneous genital tissue and coverage with local skin flaps. Two boys in whom this approach failed later underwent complete excision of the involved subcutaneous tissue and skin, and coverage with split thickness skin grafts. The boy with minimal edema was observed. RESULTS: Two of the 4 boys who underwent subcutaneous genital tissue resection and coverage with local skin flaps are markedly improved, although 1 requires further revision. In the other 2 boys treatment failed, necessitating repeat genital tissue excision and grafting. While there have been no recurrences in the grafted areas, each patient has required additional operations to manage recurrent edema in adjacent tissues of the perineum and inguinal region, and in 1 significant contraction of the grafted skin developed. Mild genital lymphedema in the remaining patient has remained stable during 10 years of followup. CONCLUSIONS: Congenital lymphedema of the genitalia is a challenging problem. Recurrences requiring multiple operations are common. We recommend expectant management of mild cases. In more severe cases excision without grafting should be attempted. While skin grafting may be the most definitive solution, it does not prevent recurrence in adjacent regions, and it carries the risk of skin contraction. Skin grafts should only be used when other techniques have failed.