Oncoplastic Breast Surgery: A Global Perspective on Practice,Availability, and Training

Oncoplastic surgery is the seamless joining of the extirpative and reconstructive aspects of breast surgery that is performed by a single surgeon. A symposium was held at ISW 2007 in Montreal with a prearranged aim to publish an article on the current and historical record of the developing specialty of oncoplastic breast surgery. The presenters and authors are well-known breast surgeons from Australia, Croatia, India, Sweden, and South Africa. Based on a BSI symposium, ISW 2007, Montreal, Canada.     

Dexamethasone alters sleep and fatigue in pediatric patients with acute lymphoblastic leukemia

BACKGROUND: Dexamethasone improves the cure rate of childhood acute lymphoblastic leukemia (ALL) but causes physical and behavioral adverse events. The objective of the current study was to determine the effect of dexamethasone exposure on sleep and fatigue in pediatric patients with ALL. METHODS: One hundred pediatric patients with low-risk or standard-risk ALL were enrolled on 1 of 3 protocols (St. Jude Total XV, Children's Oncology Group [COG] 9904, or COG 9905) at 3 institutions. The mean age of the cohort was 9.24 +/- 3.23 years (range, 5.03-18.14 years). The majority of patients were white (79%) males (62%) with standard-risk ALL (63%). The cohort was divided into 4 subgroups: St. Jude low-risk, St. Jude standard-risk, COG low-risk, and COG standard-risk. Patients wore a wrist actigraph to monitor sleep activity during 2 consecutive 5-day periods: During the first period, they did not receive dexamethasone; and, during the second period, they did. Patients and their parents completed fatigue instruments on Days 2 and 5 of each period, and parents completed sleep diaries. RESULTS: Actual sleep minutes, sleep duration, total daily nap minutes, and fatigue increased significantly during the dexamethasone treatment for 3 to 4 of the subgroups. Total daily nap minutes increased significantly for both standard-risk groups during the dexamethasone treatment. Parents reported significant increases in their child's nighttime awakenings, restless sleep, and nap time during dexamethasone treatment. CONCLUSIONS: Dexamethasone treatment during continuation therapy for childhood ALL significantly and adversely altered sleep and fatigue, confirming that sleep and fatigue are behavioral responses to dexamethasone.     

Excavation of the chest due to railway mishap

Injuries sustained due to railway mishaps are well documented. In these mishaps, ascertaining the cause of death is usually not difficult, but frequently circumstances do raise questions as to the manner of death. It is a real challenge for an autopsy surgeon to correlate the alleged history with injuries present on the body, thereby helping the investigating officer to come to a conclusion on the manner of death. Here, we present a case of an unusual excavation injury to the chest due to train impact, and discuss the mechanism of causation of this injury and the manner of death.     

In contrast to AAV-mediated Cntf expression, AAV-mediated Gdnf expression enhances gene replacement therapy in rodent models of retinal degeneration.

While AAV- and lentivirus-mediated gene replacement therapy can produce structural and functional improvements in various animal models of inherited retinal degeneration, this approach often has very limited effects on the rate of photoreceptor cell loss. Neurotrophic factors such as ciliary neurotrophic factor (CNTF) and glial cell line-derived neurotrophic factor (GDNF) have been shown to prolong photoreceptor survival in rodent models of retinal degeneration, but AAV-mediated Cntf expression also results in suppression of electrophysiological responses from the retina. In this study using mice, we show that while the deleterious effects mediated by CNTF are dose-dependent, administering a dose of CNTF that does not adversely affect retinal function precludes its ability to delay photoreceptor cell death. In evaluating GDNF as a neuroprotective agent, we show that AAV-mediated Gdnf expression does not produce adverse effects similar to those of CNTF. In addition, we demonstrate the ability of AAV-mediated delivery of Gdnf to slow cell death in two rodent models of retinitis pigmentosa and to enhance retinal function in combination with the relevant gene replacement therapy. These data show for the first time that a combination of these approaches can provide enhanced rescue over gene replacement or growth factor therapy alone.     

MAGNIFICATION ENDOSCOPY IN THE UPPER GI TRACT

Magnification endoscopy in conjunction with chromoendoscopy provides additional valuable and detailed information with respect to mucosal morphology. The most promising indications include the depiction and staging of squamous cell cancer of the esophagus, the potential to identify neoplasia within Barrett's esophagus, and the demarcation of early gastric cancer. However, the exact role of magnification endoscopy for routine clinical practice is not yet determined and is currently under investigation     

Effect of Pre-treatment of α-Ketoglutarate on Cyanide-induced Toxicity and Alterations in Various Physiological Variables in Rodents

Objective To investigate the effects of pre-treatment of α-ketoglutarate (α-KG) on cyanide-induced lethality and changes in various physiological parameters in rodents. Methods The LD50 of potassium cyanide (KCN) given orally (po), intraperitoneally (ip), subcutaneously (sc) or intravenously (iv) was determined in male mice, in the presence or absence α-KG given po, ip or iv. α-KG was administered 10, 20 or 40 min prior to KCN at 0.50, 1.0 or 2.0 g/kg by po or ip route, and at 0.10, 0.20 or 0.40 g/kg by iv route. Protection index (PI) was calculated as the ratio of LD50 of KCN in the presence of α-KG (protected animals) and LD50 of KCN in the absence of α-KG (unprotected animals). In a separate experiment, several physiological variables viz. mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), neuromuscular transmission (NMT) and rectal temperature (RT) were measured in anesthetized female rats pre-treated (-10 min) with po (2.0 g/kg) or iv (0.125 g/kg) α-KG and then administered sub-lethal (0.75 LD50) or lethal (2.0, 4.0 or 8.0 LD50) doses of KCN (po). Results PI of 4.52, 6.40 and 7.60 at -10 min, 3.20, 5.40 and 6.40 at -20 min, and 1.40, 3.20 and 5.40 at -40 min of po administration with α-KG was observed for 0.50, 1.0 and 2.0 g/kg doses, respectively, against KCN given by po route. When KCN was given ip, a PI of 3.38, 4.79 and 5.70 was observed for 0.50, 1.0 and 2.0 g/kg α-KG given ip (-10 min), respectively. A lower PI of 3.37, 2.83 and 2.38 was observed when KCN given sc was challenged by 2.0 g/kg α-KG given ip at -10, -20 or -40 min, respectively. Similarly, a PI of 3.37, 2.83 and 2.0 was noted when KCN given sc was antagonized by 2.0 g/kg α-KG given po at -10, -20 or -40 min, respectively. No appreciable protection was observed when lower doses of α-KG (ip or po) challenged KCN given by sc route. Pre-treatment of iv or po administration of α-KG did not afford any protection against KCN given po or iv route. Oral treatment of 0.75 LD50 KCN caused significant decrease in MAP and HR after 15 min, RR after 30 min and NMT after 60 min. There was no effect on RT. No reduction in MAP, HR, RR and RT was observed when rats received 2.0 or 4.0 LD50 KCN after pre-treatment of α-KG (po; 2.0 g/kg). However, no protection was observed on NMT. Protective efficacy of α-KG was not observed on MAP, HR, RR, and NMT decreased by 8.0 LD50 KCN. Decrease in MAP and NMT caused by 2.0 LD50 KCN (po) was resolved by iv administration of α-KG. Conclusions Cyanide antagonism by α-KG is best exhibited when both α-KG and KCN are given by po route. The protective effect of α-KG on cyanide-induced changes in several physiological parameters also indicates a promising role of α-KG as an alternative cyanide antidote.     

Cirumstances and motivations for seeking abortions: a community based study in Chandrapur District, Maharashtra

The present population based group comparison study was undertaken to study the circumstances, motivations and influencing factors for seeking abortion in women in Chandrapur District of Maharashtra. Participants of the study included 500 cases of induced abortion and the equal number of normal delivered women during the same period and in the same area as comparison group. Having two children, domestic problems and unwanted pregnancy were conditions acceptable to study subjects to terminate the pregnancy. Family and domestic problems, poor socio-economic status, short inter-pregnancy interval and completed family size were some of the important reasons quoted by study subjects for not desiring to continue the current pregnancy. Majority of the subjects felt that the decision to terminate or keep pregnancy is usually taken jointly by both the husband and wife. Family and domestic problems, poor socioeconomic status and short inter pregnancy interval were the important reasons quoted by abortion cases for seeking abortion in the current pregnancy. Only 1.80% of the cases reported failure of contraceptive method as a cause of seeking abortion services. In 78.4% of abortion cases as compared to 5.4% subjects from the comparison group, pregnancy was un-planned.     

Masked Hypertension and Elevated Nighttime Blood Pressure in CKD: Prevalence and Association with Target Organ Damage

Background and objectives

Masked hypertension and elevated nighttime BP are associated with increased risk of hypertensive target organ damage and adverse cardiovascular and renal outcomes in patients with normal kidney function. The significance of masked hypertension for these risks in patients with CKD is less well defined. The objective of this study was to evaluate the association between masked hypertension and kidney function and markers of cardiovascular target organ damage, and to determine whether this relationship was consistent among those with and without elevated nighttime BP.

Design, setting, participants, & measurements

This was a cross-sectional study. We performed 24-hour ambulatory BP in 1492 men and women with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. We categorized participants into controlled BP, white-coat, masked, and sustained hypertension on the basis of clinic and 24-hour ambulatory BP. We obtained echocardiograms and measured pulse wave velocity in 1278 and 1394 participants, respectively.

Results

The percentages of participants with controlled BP, white-coat, masked, and sustained hypertension were 49.3%, 4.1%, 27.8%, and 18.8%, respectively. Compared with controlled BP, masked hypertension independently associated with low eGFR (−3.2 ml/min per 1.73 m²; 95% confidence interval, −5.5 to −0.9), higher proteinuria (+0.9 unit higher in log₂ urine protein; 95% confidence interval, 0.7 to 1.1), and higher left ventricular mass index (+2.52 g/m^2.7; 95% confidence interval, 0.9 to 4.1), and pulse wave velocity (+0.92 m/s; 95% confidence interval, 0.5 to 1.3). Participants with masked hypertension had lower eGFR only in the presence of elevated nighttime BP (−3.6 ml/min per 1.73 m²; 95% confidence interval, −6.1 to −1.1; versus −1.4 ml/min per 1.73 m²; 95% confidence interval, −6.9 to 4.0, among those with nighttime BP <120/70 mmHg; P value for interaction with nighttime systolic BP 0.002).

Conclusions

Masked hypertension is common in patients with CKD and associated with lower eGFR, proteinuria, and cardiovascular target organ damage. In patients with CKD, ambulatory BP characterizes the relationship between BP and target organ damage better than BP measured in the clinic alone.     

Multivessel total arterial revascularization via left thoracotomy

Off-pump coronary artery bypass grafting is now becoming the preferred method of coronary revascularization. The trend is towards complete revascularization, preferably arterial. We are describing here a method of multivessel, total arterial, complete revascularization via an anterolateral thoracotomy approach in 27 patients. There was an average of 3.2 grafts/patient. Angiograms were performed in 9 patients (33.33 %). There were no operative mortalities. None of the patients required conversion to cardiopulmonary bypass or midsternotomy.