Surgery for giant tumours of the breast: a 15 year review.

BACKGROUND: Giant tumours of the breast tend to occur in the adolescent age group. Racial predilection has been noted in the literature. The mass often occupies most of the breast, leading to its distortion. Many authors have advocated a mastectomy for benign tumours that severely distort the breast. Giant benign tumours when treated by simple excision risk persistence of asymmetry. To avoid this asymmetry, some authors have resorted to excision and immediate reduction mammaplasty. The aim of this retrospective study was a report on giant tumours of the breast presenting to a plastic surgery unit and to analyse demographic factors, clinical presentations, tumour pathology, management, complications, as well as patient and breast outcomes. METHODS: Medical records of patients with giant tumours were retrospectively analysed for assessing demographic factors, clinical presentation, tumour pathology, the technique of surgery performed and patient and breast outcomes in a single hospital setting. Breast outcomes were rated by panel of 4 experienced plastic surgeons using the 4 Point Likert scale. Their ratings were statistically analysed for inter-rater agreement. RESULTS: Twenty-three subjects were identified to have giant tumours of the breast. Of these South African patients, 19 were black, 3 were Indian and 1 was of mixed ethnicity. The age range was 12-49 years (y) with an average of 19y. All masses were palpable. The final pathological diagnosis was fibrocystic disease in 3, giant fibroadenoma in 14, phyllodes tumour in 4, and hamartoma in 2. The size range was 10-45 cm with a median size of 18 cm. All but one patient had simple excision followed by immediate reduction mammaplasty. Twenty patients were assessed after operation. A minimum of 1 to a maximum of 4 patients per reviewer showed unsatisfactory outcomes and a minimum of 18 to a maximum of 21 patients per reviewer showed satisfactory to excellent outcomes. The overall agreement between assessors for this was 84%. CONCLUSION: Benign giant tumours (> 10 cm) of the breast are suitably managed by excision of the mass and a reduction mammoplasty technique of reconstruction.

Knowledge, attitude and psychological impact of cyberbullying among adolescents. A cross-sectional study.

Purpose: To identify the awareness, behaviour and psychological impact of cyberbullying among adolescent. Method: A Cross-sectional questionnaire-based study conducted on secondary school students from grades 9-12th. The study got approval from the Institutional Research Board. The Inclusion criterion was school students of all nationalities who were willing to participate. Signed informed consent signed was taken. We used a P value of < 0.05 and a 95% confidence interval (CI). Result: Out of 513 enrolled, 450 completed the survey (response rate 87.7%). Age ranged between 13 to 20 years of them 303 (67.3%) were female. Awareness of cyberbullying was 96.2%. The prevalence of cyberbullying among adolescence was 22.2% (95% CI: 18.89-26.93). 42% of Victims reported cyberbully event leading to stoppage in 78.6% of cases. Most of the victims reported to their parents followed by friends then cyber helpline or Police. Characteristics of perpetrators were males, below-average academic performance and social relations, from same batch, and had emotionally unstable personalities. Association of being a victim does not relate to their Age, gender, grade, or parent's education but relate to their nationality (P < 0.001) and being younger siblings (P < 0.027). Association between event reporting and gender was not significant (P < 0.859). Association between worsening social relationships (teachers and parents) (P < 0.001), feeling neglected (P < 0.001), personality type (agreeableness and emotional instability) (P < 0.016) and being a Cyberbully victim was statistically significant. Association of depression and anxiety with being a cyberbully victim was statistically significant (P < 0.001) and directly proportional to the severity. Conclusion: High rate of awareness and Low prevalence of cyberbullying was found among adolescence. High risk of psychological problems was reported and a good social relationship (teachers and parents) was an important protective factor from it.

Two step reconstruction of traumatic ear skin avulsion using Integra graft.

Treatment of traumatic ear injuries have always been a challenge. Preservation of the auricular cartilage is key for reconstruction. Many techniques have been reported for the management of exposed ear perichondrium. We present patient who sustained right ear soft tissue avulsion. Initial examination the patient revealed skin avulsion with exposed cartilage from the concha, scapha and antihelix on the right ear. The treatment sequence included debridement and application of Integra graft. This was followed by dressing changes every three days and three weeks. Once adequate vascularization was noted a split thickness skin graft was used for final reconstruction. Integra has been widely used for the management of burns as well as exposed bone and cartilage. However, its use in traumatic ear injuries has not been reported. This technique allowed for the reconstruction of a large skin avulsion from the right ear with minimal donor site morbidity and avoidance of local rotational flaps that could hinder later reconstructions if needed.

Survival and variability over time from out of hospital cardiac arrest across large geographically diverse communities participating in the Resuscitation Outcomes Consortium.

BACKGROUND: The Resuscitation Outcomes Consortium (ROC)epidemiological registry (Epistry) provides opportunities to assess trends in out-of-hospital cardiac arrest treatment and outcomes. METHODS: Patient, event, system, treatment, and outcome data from adult (≥18 years) out-of-hospital cardiac arrest (OHCA) from 10 geographically diverse North American ROC sites over four 12-month epochs, from July 1, 2011 to June 30, 2015, were assessed. Descriptive statistics were used to characterize the sample and logistic regression assessed the association of study epoch and key covariates on survival. RESULTS: Overall, 85,553 patients were assessed by Emergency Medical Services (EMS) and 45,516 (53.2%, site range 30.4%-69.9%) had resuscitation attempted by EMS. Patient and event characteristics were consistent except for increases in bystander CPR (41.3%-44.9%) and bystander AED application (3.9%-5.2%). EMS CPR depth and compression fraction increased while pre-shock pause interval decreased. Targeted temperature management was performed in 51.1% of admitted patients and early coronary angiography in 30.2%. Survival to hospital discharge improved (from 10.9% to 11.3% across epochs) with epoch significantly associated with survival (p < 0.001) showing an increasing trend in survival over time. (p = 0.02). Marked site variation in survival persisted within and across epochs (overall site range: 4.2%-19.8%). Patients with an initially shockable rhythm (VT/VF) had an overall survival of 32.2% (site range: 11.9%-47.1%) while survival in bystander witnessed VT/VF was 35.8% (site range: 12.9%-53.1%). CONCLUSIONS: Survival from adult OHCA in multiple large geographically-separate sites improved over the study period. Marked site differences in survival persist and addressing this variation is essential to improve outcomes from OHCA across North America.

An evaluation of the contribution of membrane lipids to protection against ultraviolet radiation.

Using dioleoylphosphatidylcholine liposomes incorporating various fatty acids and neutral lipids, we have examined the ability of such lipids to provide protection of Escherichia coli and vesicular stomatitis virus (VSV) against the lethal effect of ultraviolet (254 nm) radiation. While the presence of varying amounts of saturated (palmitic) or polyunsaturated (arachidonic) fatty acids or the lipid antioxidant, alpha-tocopherol, had little effect on killing by ultraviolet radiation, considerable radioprotection was observed with beta-carotene, retinal and vitamin K-1 at final concentrations of 1 mg/ml. In another approach, vesicular stomatitis virus grown under conditions in which its envelope fatty acid composition was substantially modified, showed little change in its sensitivity to inactivation by ultraviolet radiation. The results provide strong evidence for a radioprotective role of certain, relatively rare natural lipid components with conjugated polyene systems, but not of the more ubiquitous and abundant membrane fatty acids.

Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study.

BACKGROUND: Empirical evidence suggests that people value emergency medical services (EMS) but that they may not use the service when experiencing chest pain. This study evaluates this phenomenon and the factors associated with the failure to use EMS during a potential cardiac event. METHODS AND RESULTS: Baseline data were gathered from a randomized, controlled community trial (REACT) that was conducted in 20 US communities. A random-digit-dial survey documented bystander intentions to use EMS for cardiac symptoms in each community. An emergency department surveillance system documented the mode of transport among chest pain patients in each community and collected ancillary data, including situational factors surrounding the chest pain event. Logistic regression identified factors associated with failure to use EMS. A total of 962 community members responded to the phone survey, and data were collected on 875 chest pain emergency department arrivals. The mean proportion of community members intending to use EMS during a witnessed cardiac event was 89%; the mean proportion of patients observed using the service was 23%, with significant geographic differences (range, 10% to 48% use). After controlling for covariates, non-EMS users were more likely to try antacids/aspirin and call a doctor and were less likely to subscribe to (or participate in) an EMS prepayment plan. CONCLUSIONS: The results of this study indicate that indecision, self-treatment, physician contact, and financial concerns may undermine a chest pain patient's intention to use EMS.

Effect of mechanical deformation on structure and function of polymorphonuclear leukocytes.

The present studies were designed to test the hypothesis that mechanical deformation of polymorphonuclear leukocytes (PMN) leads to functional changes that might influence their transit in the pulmonary capillaries. Human leukocytes were passed through 5- or 3-micron-pore polycarbonate filters under controlled conditions. Morphometric analysis showed that the majority of PMN were deformed and that this deformation persisted longer after filtration through 3-micron filters than through 5-micron filters (P < 0.05) but did not result in the cytoskeletal polarization characteristic of migrating cells. Flow cytometric studies of the filtered PMN showed that there was a transient increase in the cytosolic free Ca2+ concentration after both 3- and 5-micron filtration (P < 0.01) with an increase in F-actin content after 3-micron filtration (P < 0.05). Although L-selectin expression on PMN was not changed by either 5- or 3-micron filtration, CD18 and CD11b were increased by 3-micron filtration (P < 0.05). Priming of the PMN with N-formyl-methionyl-leucyl-phenylalanine (0.5 nM) before filtration resulted in an increase of CD11b by both 5 (P < 0.05)- and 3-micron (P < 0.01) filtration. Neither 5- nor 3-micron filtration induced hydrogen peroxide production. We conclude that mechanical deformation of PMN, similar to what occurs in the pulmonary microvessels, induces both structural and functional changes in the cells, which might influence their passage through the pulmonary capillary bed.

REACT theory-based intervention to reduce treatment-seeking delay for acute myocardial infarction. Rapid Early Action for Coronary Treatment.

Coronary heart disease (CHD) remains the leading cause of mortality in the U.S. Innovations in reperfusion therapies can potentially reduce CHD morbidity and mortality associated with acute myocardial infarction (AMI) when treatment is initiated within the first few hours of symptom onset. However, delay in seeking treatment for AMI is unacceptably lengthy, resulting in most patients being ineligible for reperfusion therapies. The Rapid Early Action for Coronary Treatment (REACT) Trial is a four-year, 20-community, randomized trial to design and test the effectiveness of a multi-component intervention to reduce patient delay for hospital care-seeking for AMI symptoms. This manuscript describes the development and content of the theoretically-based REACT intervention and summarizes: (1) the research literature used to inform the intervention; (2) the behavioral theories used to guide the development, implementation, and evaluation of the intervention; (3) the formative research undertaken to understand better decision-making processes as well as barriers and facilitators to seeking medical care as perceived by AMI patients, their families, and medical professionals; (4) the intervention design issues that were addressed; (5) the synthesis of data sources in developing the core message content; (6) the conceptualization for determining the intervention target audiences and associated intervention components and strategies, their integration with guiding theoretical approaches and implementation theories for the study, and a description of major intervention materials developed to implement the intervention; and (7) the focus of the outcome, impact, and process measurement based on the intervention components and theories on which they were developed.

Liver transplantation for severe Amanita phalloides mushroom poisoning.

Amanita phalloides mushroom poisoning is an increasingly common and potentially lethal problem for which liver transplantation offers definitive therapy in selected patients. When significant liver dysfunction appears, early transfer to a liver transplant center is important to identify appropriate candidates and to begin the search for a donor organ. The clinical course of five severely poisoned patients, four of whom underwent liver transplantation, is reviewed. Indications for transplantation included primarily a markedly prolonged prothrombin time that was only partially correctable and a constellation of findings including metabolic acidosis, hypoglycemia, hypofibrinogenemia, and increased serum ammonia, following a marked elevation in serum aminotransferase levels. Unlike viral fulminant hepatic failure, grade III or IV hepatic encephalopathy, marked elevation of the serum bilirubin level, and azotemia were not indications for transplantation. Resected livers demonstrated hepatocyte viability of 0% to 30%. Manifestations of Amanita poisoning complicating preoperative and/or postoperative care included severe diarrhea, gastrointestinal hemorrhage, hypophosphatemia, bowel edema, and marrow suppression with lymphopenia, thrombocytopenia, and neutropenia. All five patients are well 1 year later. This largest experience with liver transplantation for Amanita poisoning further defines the early clinical and laboratory indications for, and the unique complicating features of, transplantation in this setting.

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction.

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.

The role of protease-dependent cell membrane fusion in persistent and lytic infections of murine hepatitis virus.

We have defined three categories of cultured cell lines on the basis of their permissiveness (susceptibility to initial infection) to mouse hepatitis virus (MHV). Fully permissive L-2 cells gave rise to 100-1000-fold higher numbers of infectious centers than did semi-permissive LM, LM-K or C-1300 cells, whereas non-permissive Vero or C-6 cells were refractory to MHV infection. On an infected cell basis, there was no deficiency on the part of semi-permissive cell lines to replicate total viral RNA, viral polypeptides or progeny virions. Two of the semi-permissive cell lines (LM and LM-K) supported persistent MHV infection, while a third (C-1300) succumbed to lytic infection. LM and LM-K cells, but not C-1300 cells showed resistance to MHV-induced membrane fusion, even when placed in contact with fusion-active MHV-infected L-2 cells. The ability of a given cell to undergo fusion did not correlate with membrane lipid characteristics (unsaturated fatty acid and sterol content) which contribute to membrane "fluidity". In order to more closely study the parameters of MHV-induced cell fusion, membranes were prepared from MHV-infected L-2 cells and monitored for their fusogenic potential with permissive L-2 cells, semi-permissive LM cells and non-permissive vero cells. Fusion was only observed with the permissive L-2 cells, and only when exogenous protease (trypsin or chymotrypsin) was added. When the membranes were prepared from 35S-methionine-labeled MHV-infected L-2 cells and subjected to protease treatment, the radiolabeled 180,000 dalton form of the E2-glycoprotein underwent proteolytic cleavage to yield a major product of approximately 90,000 daltons. Both trypsin and chymotrypsin were effective in this proteolytic cleavage and in activating membrane fusion. In a normally permissive, fusogenic infection of MHV in L-2 cells, the protease inhibitors TPCK and ZPCK, but not TLCK, were found to inhibit cell fusion. In MHV-infected L-2 cells, E2 was found almost exclusively as the 180,000 dalton form but turned over rapidly as shown by pulse-chase studies. TPCK and ZPCK but not TLCK inhibited turnover. The results suggest that L-2 cells contain a protease which cleaves at aromatic amino acids such as phenylalanine, and that this protease cleaves the 180,000 dalton form of the E2 to peptide fragments, one or more of which may activate cell fusion.

Mouse fibroblast mutants selected for survival against mouse hepatitis virus infection show increased resistance to infection and virus-induced cell fusion.

We describe here a genetic approach to the analysis of host cell functions involved in determining permissiveness to mouse hepatitis virus (MHV). Using the chemical mutagen, ethyl methane sulfonate (EMS), mouse fibroblast cell mutants were generated which were selected for resistance to cell-killing by MHV. These mutants were then screened for their susceptibility to MHV infection, ability to replicate MHV and relative sensitivity to MHV-induced cell fusion. In contrast to wild type L-2 cells which were acutely and terminally infected by MHV, all five mutants examined replicated MHV in a persistent manner. These mutants showed a reduced susceptibility to MHV infection and an increased resistance to MHV-induced cell fusion. Fusion resistance was specific to that mediated by the MHV E2 protein; mutant as well as wild type L-2 cells were equally sensitive to fusion by polyethylene glycol. The combined effect of reduced infectability and increased fusion resistance was to limit MHV infection to only a small percentage of the total cells in culture, thereby permitting survival of both virus and cells. The observed high rate of generation of the cell mutants suggests that the conversion of a fully MHV-susceptible cell to a semi-resistant one (capable of supporting a persistent infection) is a fairly common event, possibly involving a single mutation.

Occupational infectious disease exposures in EMS personnel.

Reports of occupationally transmitted hepatitis B virus (HBV) and human immunodeficiency virus (HIV) prompted the Portland Bureau of Fire Rescue and Emergency Services (PFB) to institute a comprehensive program for handling and tracking on-the-job infectious disease exposures. Data were collected for a 2-year period beginning January 1, 1988, and ending December 31, 1989, utilizing verbal and written exposure reports, prehospital care reports, and PFB statistical information. Two hundred and fifty-six (256) exposures were categorized. The overall incidence of reported exposure was 4.4/1,000 emergency medical service (EMS) calls. Of these exposures, 14 (5.5%) were needle sticks, 15 (5.9%) were eye splashes, 8 (3.1%) were mucous membrane exposures, 38 (14.8%) were exposure to nonintact skin, 120 (46.9%) were exposures to intact skin, and 61 (23.8%) involved respiratory exposure only. The incidence of exposure of nonintact skin or mucous membranes to blood or body fluids and needle sticks was 1.3/1,000 EMS calls. Forty-eight individuals (64% of those incurring needle sticks, or exposure of non-intact skin or mucous membranes to blood or body fluids) were treated and followed for signs of infection. Of this group, 11 individuals (26%) previously vaccinated against hepatitis B demonstrated inadequate HBsAb titers at the time of exposure. Requests for HIV and HBV information on source patients were made for needle sticks or exposure of nonintact skin or mucous membranes to blood or high-risk body fluids. Information on the source patient's HIV status was obtained for 57% of these requests.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors that influence personal perceptions of the risk of an acute myocardial infarction.

Personal risk perceptions of acute myocardial infarction (AMI) affect people's preventive health behaviors as well as their beliefs during a heart attack episode. The authors investigated factors that are associated with personal risk perceptions of having an AMI. A random-digit-dial survey was conducted among 1294 respondents, aged 18 years or older, in 20 communities across the nation as part of the Rapid Early Action for Coronary Treatment (REACT) trial. Results of two mixed-model linear regression analyses suggested that worse perceived general health, more risk factors, and greater knowledge were associated with greater perception of AMI risk. The results also showed that women who answered, incorrectly, that heart disease is not the most common cause of death for women in the United States reported significantly lower risk perceptions than women who answered this question correctly. The findings in this study suggest that interventions need to target specific misconceptions regarding AMI risk.

ExacTech blood glucose meter clinical trial.

INTRODUCTION: Current prehospital protocols for the management of patients with altered mental status include the empiric administration of hypertonic glucose, naloxone, and thiamine. The injudicious use of 50% dextrose (D50W) may result in hyperosmolarity, a worsening of hypokalemia, and unwarranted additional health-care costs for the patient. The administration of D50W also may worsen the neurological outcome of patients with local or generalized ischemia. OBJECTIVE: To evaluate the ExacTech blood glucose meter's ability to estimate blood glucose levels accurately and rapidly. METHODS: Emergency medical technicians (EMTs) from selected advanced life support (ALS) units in the Portland, Ore., metropolitan area participated in a prospective clinical trial of the ExacTech blood glucose meter. A convenience sample was drawn from emergency medical services (EMS) patients with suspected diabetic emergencies, altered mental status, and other neurological deficits. Venous blood samples were drawn from these populations at the same time as the ExacTech readings were obtained. The venous blood was submitted to the receiving hospitals for laboratory analysis of blood glucose levels, and a comparison was made between the results of the two methods. RESULTS: A total of 80 matched sets of data were obtained from 1 April 1990 through 6 May 1991. The hospital blood glucose values ranged from 8 to 1233 mg/dl. Sixteen (20%) of the patients were hypoglycemic (&.lt.60 mg/dl) and 23 (28.8%) were hyperglycemic ( greater than 180 mg/dl). The ExacTech device sensitivity and specificity for hypoglycemia using venous samples were 94.6% and 89.2%, respectively. For hyperglycemia, these same parameters were 87.5% and 97.1%. Pearson's r over the range of the instrument (40-450 mg/dl) was 0.8656 (p less than .001). If the prehospital "definition" of hypoglycemia (for threshold-to-treat) is raised to 65 mg/dl, the device has 100% sensitivity in the sample population. CONCLUSION: The device functioned accurately and consistently in the prehospital environment over a wide range of temperatures, and in the hands of many different individuals.

Reduction mammoplasty in cases of giant fibroadenoma among adolescent females. Case reports and literature review.

Giant tumours of the breast cause massive enlargement of the breast resulting in asymmetry. Simple excision of the tumour fails to restore symmetry, and in some cases leaves the patient with a secondary deformity. We present two cases of giant fibroadenoma in adolescent females. Both patients underwent a one-stage excision of the giant fibroadenoma and reduction mammoplasty. Relevant operative details and results are presented together with a review of the literature.

Outpatient clinic's staffing: a case study.

Suggests that the traditional approach for establishing staffing levels in hospital systems is not feasible. Presents steps taken to study the staffing levels in an outpatient clinic of a central hospital. Puts forward recommendations for a periodic evaluation of staffing levels.