Robotic breast surgery: the pursue for excellence in treatment and satisfaction ­ a review

Introduction: Nipple sparing mastectomy (NSM) with immediate reconstruction is an option for the treatment of breast cancer or for risk-reducing surgery. This technique offers good aesthetic results without compromising oncological safety. Robotic nipple sparing mastectomy (RNSM) was first described in 2015 and has been executed in various centers ever since, but the costeffectiveness and oncological safety of this technique are still questioned. Objectives: The primary aim of this study was to critically review the literature and discuss the feasibility, advantages and limitations of robotic breast surgery. Methods: Search in PubMed database for publications related to "robotic breast surgery". Selection and review of relevant articles, and analysis of results from these studies. Results: Our search comprised the period between 2015 and 2019. The rates of complications were low and the learning curve is apparently rapid, though there is still a lack of data involving cost-effectiveness. Conclusions: RNSM with immediate reconstruction is a great advance in the surgical treatment for breast cancer. Cost-effectiveness and oncological safety must still be accessed through randomized clinical trials. KEYWORDS: breast neoplasms; robotic surgical procedures;

Bilateral axillary lymphadenopathy: differential diagnosis and management

Lymphonodopathy is an increase in volume and/or changes in the characteristics of lymph nodes, and it can be caused by benign or malignant diseases. Appropriate physical examination should define their clinical characteristics, and, if needed, complementary imaging or anatomopathological tests should be performed for diagnostic definition. In the present article, we report the case of a female patient, with sarcoidosis, who presented axillary lymph node disease, and the exams that followed until the diagnostic conclusion.

Evaluation of a bespoke training to increase uptake by midwifery teams of NICE Guidance for membrane sweeping to reduce induction of labour: a stepped wedge cluster randomised design.

BACKGROUND: National guidance recommends pregnant women are offered membrane sweeping at term to reduce induction of labour. Local audit suggested this was not being undertaken routinely across two maternity units in the West Midlands, UK between March and November 2012. METHODS: Bespoke training session for midwifery teams (nine community and one antenatal clinic) was developed to address identified barriers to encourage offer of membrane sweeping, together with an information leaflet for women and appointment of a champion within each team. The timing of training session on membrane sweeping to ten midwifery teams was randomly allocated using a stepped wedge cluster randomised design. All women who gave birth in the Trusts after 39 + 3/40 weeks gestation within the study time period were eligible. Relevant anonymised data were extracted from maternity notes for three months before and after training. Data were analysed using a generalised linear mixed model, allowing for clustering and adjusting for temporal effects. Primary outcomes were number of women offered and accepting membrane sweeping and average number of sweeps per woman. Sub-group comparisons were undertaken for adherence to Trust guidance and potential influence of pre-specified maternal characteristics. Data included whether sweeping was offered but declined and no record of membrane sweeping. RESULTS: Training was given to all teams as planned. Analyses included data from 2787 of the 2864 (97%) eligible low-risk women over 39 + 4 weeks pregnant. Characteristics of the women were similar before and after training. No evidence of difference in proportion of women being offered and accepting membrane sweeping (44.4% before training versus 46.8% after training (adjusted relative risk [aRR] = 0.90, 95% confidence interval [CI] = 0.71-1.13), nor in average number of sweeps per woman (0.603 versus 0.627, aRR = 0.83, 95% CI = 0.67-1.01). No differences in any secondary outcomes nor influence of maternal characteristics were demonstrated. The midwives evaluated training positively. CONCLUSIONS: This stepped wedge cluster trial enabled randomised evaluation within a natural roll-out and demonstrates the importance of robust evaluation in circumstances in which it is rarely undertaken. While the midwives evaluated the training positively, it did not appear to change practice. TRIALS REGISTRATION: ISRCTN14300475 . Registered on 23 August 2016.

Recollection in adolescents with Autism Spectrum Disorder.

INTRODUCTION: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder primarily affecting social interaction and communication. Recently, there has been interest in whether people with ASD also show memory deficits as a result of abnormal brain development. However, at least in adolescents with ASD, the recollection component of episodic memory has rarely been explored. This paper is an evaluation of recollection in three different experiments in adolescents with ASD, using both objective (source discrimination) and subjective methods (Remember-Know judgments). METHODS: Three experiments were designed to measure different aspects of contextual information: sensory/perceptual information (Experiment 1), temporal information (Experiment 2) and spatial information (Experiment 3). To measure objective and subjective recollection, for all three experiments, all participants were presented with information to learn in a specific context. At the recognition stage, they were asked whether they remembered the information or just knew the information was there (R/K response, subjective method). To assess the quality of these subjective judgments, participants justified their Remember responses using the contextual information. After the recognition task, to assess source memory (objective measure), all items presented at encoding were represented and participants have to recall the source for all these items. RESULTS: All three experiments showed that adolescents with ASD could correctly recall source information. However, in the first experiment adolescents with ASD gave significantly fewer Remember responses than controls. CONCLUSIONS: These findings point to a specific and subtle recollection impairment in adolescents with ASD, at least when subjective methods are used. We discuss how these might relate to differences in the self and to the brain abnormalities in ASD.

Efficacy of a reading and language intervention for children with Down syndrome: a randomized controlled trial.

BACKGROUND: This study evaluates the effects of a language and literacy intervention for children with Down syndrome. METHODS: Teaching assistants (TAs) were trained to deliver a reading and language intervention to children in individual daily 40-min sessions. We used a waiting list control design, in which half the sample received the intervention immediately, whereas the remaining children received the treatment after a 20-week delay. Fifty-seven children with Down syndrome in mainstream primary schools in two U.K. locations (Yorkshire and Hampshire) were randomly allocated to intervention (40 weeks of intervention) and waiting control (20 weeks of intervention) groups. Assessments were conducted at three time points: pre-intervention, after 20 weeks of intervention, and after 40 weeks of intervention. RESULTS: After 20 weeks of intervention, the intervention group showed significantly greater progress than the waiting control group on measures of single word reading, letter-sound knowledge, phoneme blending and taught expressive vocabulary. Effects did not transfer to other skills (nonword reading, spelling, standardised expressive and receptive vocabulary, expressive information and grammar). After 40 weeks of intervention, the intervention group remained numerically ahead of the control group on most key outcome measures; but these differences were not significant. Children who were younger, attended more intervention sessions, and had better initial receptive language skills made greater progress during the course of the intervention. CONCLUSIONS: A TA-delivered intervention produced improvements in the reading and language skills of children with Down syndrome. Gains were largest in skills directly taught with little evidence of generalization to skills not directly taught in the intervention.

The N400 effect in children: relationships with comprehension, vocabulary and decoding.

Using event-related potentials (ERPs), we investigated the N400 (an ERP component that occurs in response to meaningful stimuli) in children aged 8-10 years old and examined relationships between the N400 and individual differences in listening comprehension, word recognition and non-word decoding. Moreover, we tested the claim that the N400 effect provides a valuable indicator of behavioural vocabulary knowledge. Eighteen children were presented with picture-word pairs that were either 'congruent' (the picture depicted the spoken word) or 'incongruent' (they were unrelated). Three peaks were observed in the ERP waveform triggered to the onset of the picture-word stimuli: an N100 in fronto-central channels, an N200 in central-parietal channels and an N400 in frontal, central and parietal channels. In contrast to the N100 peak, the N200 and N400 peaks were sensitive to semantic incongruency with greater peak amplitudes for incongruent than congruent conditions. The incongruency effects for each peak correlated positively with listening comprehension but when the peak amplitudes were averaged across congruent/incongruent conditions they correlated positively with non-word decoding. These findings provide neurophysiological support for the position that sensitivity to semantic context (reflected in the N400 effect) is crucial for comprehension whereas phonological decoding skill relates to more general processing differences reflected in the ERP waveform. There were no correlations between ERP and behavioural measures of expressive or receptive vocabulary knowledge for the same items, suggesting that the N400 effect may not be a reliable estimate of vocabulary knowledge in children aged 8-10 years.

Practitioner Review: Reading disorders: what are the effective interventions and how should they be implemented and evaluated?

BACKGROUND: Two developmental reading disorders, dyslexia and reading comprehension impairment, are identified by different behavioural characteristics and traced back to different underlying cognitive impairments. Thus, reading interventions designed to address each of these reading disorders differ in content. METHOD: This review summarises the nature of dyslexia and reading comprehension impairment, and current understanding of best practice in associated reading interventions. CONCLUSION: There is strong evidence for the effectiveness of phonological-based reading interventions in supporting children with dyslexic difficulties, and a growing understanding of how to meet the needs of children with reading comprehension impairment, with vocabulary instruction offering a promising approach. Although the content of interventions must be tailored to an individual's reader profile, general principles regarding the implementation and evaluation of intervention programmes can be extracted.

Ameliorating children's reading-comprehension difficulties: a randomized controlled trial.

Children with specific reading-comprehension difficulties can read accurately, but they have poor comprehension. In a randomized controlled trial, we examined the efficacy of three interventions designed to improve such children's reading comprehension: text-comprehension (TC) training, oral-language (OL) training, and TC and OL training combined (COM). Children were assessed preintervention, midintervention, postintervention, and at an 11-month follow-up. All intervention groups made significant improvements in reading comprehension relative to an untreated control group. Although these gains were maintained at follow-up in the TC and COM groups, the OL group made greater gains than the other groups did between the end of the intervention and follow-up. The OL and COM groups also demonstrated significant improvements in expressive vocabulary compared with the control group, and this was a mediator of the improved reading comprehension of the OL and COM groups. We conclude that specific reading-comprehension difficulties reflect (at least partly) underlying oral-language weaknesses that can be effectively ameliorated by suitable teaching.

Emotion recognition in faces and the use of visual context in young people with high-functioning autism spectrum disorders.

We compared young people with high-functioning autism spectrum disorders (ASDs) with age, sex and IQ matched controls on emotion recognition of faces and pictorial context. Each participant completed two tests of emotion recognition. The first used Ekman series faces. The second used facial expressions in visual context. A control task involved identifying occupations using visual context. The ability to recognize emotions in faces (with or without context) and the ability to identify occupations from context was positively correlated with both increasing age and IQ score. Neither a diagnosis of ASD nor a measure of severity (Autism Quotient score) affected these abilities, except that the participants with ASD were significantly worse at recognizing angry and happy facial expressions. Unlike the control group, most participants with ASD mirrored the facial expression before interpreting it. Test conditions may lead to results different from everyday life. Alternatively, deficits in emotion recognition in high-functioning ASD may be less marked than previously thought.

Birthing alone: a concern for midwives?

The purpose of the two articles has been to provoke thoughts around the issues of supporting women who request a birth experience that challenges the norm. In the present climate of choice, midwives and obstetricians are falling short of providing the support that some women are requesting and who feel coerced into giving birth alone. We want to see a close in the gap between women, midwives, SOMs and obstetricians for all to work together to ensure that the risks and benefits of choice are provided and documented in a way that is legally adequate and desirable to women.

Patterns of reading ability in children with autism spectrum disorder.

This study investigated reading skills in 41 children with autism spectrum disorder. Four components of reading skill were assessed: word recognition, nonword decoding, text reading accuracy and text comprehension. Overall, levels of word and nonword reading and text reading accuracy fell within average range although reading comprehension was impaired. However, there was considerable variability across the sample with performance on most tests ranging from floor to ceiling levels. Some children read accurately but showed very poor comprehension, consistent with a hyperlexia reading profile; some children were poor at reading words and nonwords whereas others were unable to decode nonwords, despite a reasonable level of word reading skill. These findings demonstrate the heterogeneous nature of reading skills in children with ASD.

Production of the English past tense by children with language comprehension impairments.

Three experiments investigated the ability of eight-year old children with poor language comprehension to produce past tense forms of verbs. Twenty children selected as poor comprehenders were compared to 20 age-matched control children. Although the poor comprehenders performed less well than controls on a range of tasks considered to tap verbal-semantic abilities, the two groups showed equivalent phonological skills. Poor comprehenders performed as well as control children when asked to inflect novel verbs and regular verbs. In contrast, poor comprehenders were less skilled than controls at inflecting both high frequency and low frequency irregular verbs. Although the predominant error pattern for all children was to over-regularize, this was most marked in the poor comprehenders; control children were more likely to produce errors that contained knowledge of the irregular form than poor comprehenders. In addition, the ability to inflect irregular verbs was related to individual differences in verbal-semantic skills. These findings are discussed within a framework in which verb inflection is related to underlying language skills in both the phonological and semantic domains.

Leading the development of an ECV service.

This article has identified an area of practice that needed to be developed. Despite the service being a medical procedure, it fitted into the remit of my role. The findings provide a well-established with improving ECV clinical skills. The drive now will be to review the way women receive information about ECV (or ensure that they have the opportunity for a vaginal breech birth, if this is their choice). There is also the need to improve the chance of a vaginal birth following successful ECV. This initiative demonstrates a multidisciplinary team approach, working together to provide a service, which has been found to be safe and, above all, evaluated favourably by women.

Hidden language impairments in children: parallels between poor reading comprehension and specific language impairment?

This study investigates the oral language skills of 8-year-old children with impaired reading comprehension. Despite fluent and accurate reading and normal nonverbal ability, these children are poor at understanding what they have read. Tasks tapping 3 domains of oral language, namely phonology, semantics, and morphosyntax, were administered, along with measures that reflect an interaction of language domains that we refer to as broader language skills. Relative to control children matched for age and decoding ability, poor comprehenders were impaired across all measures except those tapping phonological skills. In addition to low oral language ability characterizing the group as a whole, some individuals had marked language impairments; it is argued that a substantial minority can be classified as having specific language impairment. However, none of the children had been previously recognized as having a language or reading impairment. These findings demonstrate that serious reading and language impairments are not always obvious in children who have good phonological ability and appear, superficially at least, to read well.

General cognitive ability in children with reading comprehension difficulties.

BACKGROUND: Children with specific reading comprehension difficulties read accurately and fluently but are poor at understanding what they read. AIMS: This study investigated cognitive ability in children with poor reading comprehension with a view to determining the relationship between general cognitive ability and specific reading comprehension difficulty. SAMPLE: Twenty-five poor comprehenders and 24 control children, matched for chronological age and word reading ability, participated in this study. METHODS: General conceptual ability (GCA) was assessed using the British Ability Scales (2(nd) edition; BAS-II); good and poor comprehenders' performance on different subscales was compared and related to underlying skills in reading accuracy, reading comprehension and number. RESULTS: There was a general tendency for poor comprehenders to achieve lower scores on verbal tasks than on non-verbal and spatial tasks. Although the poor comprehenders scored significantly below the control children across most subtests, most obtained GCA scores within the normal range. For these children, reading comprehension was significantly below GCA-expected levels. A subset of poor comprehenders with below average GCA showed a clear hyperlexic profile in which comprehension was not unexpectedly poor but rather, reading accuracy was surprisingly good. CONCLUSIONS: These findings highlight the heterogeneity of children presenting with poor reading comprehension. Although most poor comprehenders have weaknesses that appear to be restricted to the verbal domain, a minority have more general cognitive impairments.