A multidisciplined approach for the treatment of metastatic carcinoma of the breast.

We have reviewed our experience in a multidisciplined breast cancer clinic where we have utilized hormonal, ablative, and chemotherapetuci modalities. Our experience seesm to be similar to that of other groups in that oophorectomy treatment produces approximately a 61 per cent response (regression and arrest) rate, androgen therapy produces a 47 per cent response (regression and arrest) rate estrogen therapy produces a 40 per cent response (regression and arrest) rate, and ablative treatment produces approximately a 50 per cent response (regression and arrest) rate. Adrenalectomy and hypophysectomy showed similar response rates. Until it can be shown that hypophysectomy clearly offers enhanced benefits, this will not be utilized by our group except in those patients who cannot tolerate abdominal surgery (that is, patients with poor pulmonary reserve). Of interest is the high response rate (65 per cent) to ablative treatment in patients in whom disease exacerbates on additive hormonal treatment, with an increased duration of response and survival. Survival is increased in patients who are rebound responders after estrogen withdrawal. We expect to report data with future follow-up of this group of patients. New protocols will be instituted after review of the data in the hope of increasing clinical benefit and survival in this group of patients. Carcinoma of the breast accounts for almost 90,000 new cases of cancer a year, with metastases eventually developing in at least half of these patients. All physicians must be aware of the many complex problems associated with this disease and, hopefully, arrive at a logical approach for its control. We believe this can be achieved with a multidisciplined group approach as established at the Lahey Clinic Foundation.     

Ocular manifestations of Mycoplasma pneumoniae infection.

Ocular manifestations of Mycoplasma pneumoniae infection, other than conjunctivitis, are uncommon. Optic disk swelling, optic nerve atrophy, retinal exudates and hemorrhages, and cranial nerve palsies have been infrequently reported. We describe a 15-year-old patient who developed bilateral optic disk edema and iritis during an acute infection with M. pneumoniae and review the world literature on findings associated with ocular manifestations of infection with this pathogen. Although our patient experienced complete resolution of iritis and optic disk edema after 6 weeks, several patients described in the literature have experienced permanent sequelae as a result of optic neuropathy.     

Comparison of prehospital insertion success rates and time to insertion between standard endotracheal intubation and a supraglottic airway

Objective

To compare paramedic insertion success rates and time to insertion between standard ETI and a supraglottc airway device (King LTS-D™) in patients needing advanced airway management.

Methods

Between June 2008 and June 2009, consented paramedics from 4 EMS systems performed ETI or placed a King LTS-D according to a predetermined randomization calendar. Data collection occurred following each placement via telephone. Placement success (ability to ventilate to chest rise, absence of gastric sounds, presence of bilateral lung sounds, and when applicable, quantitative end-tidal CO₂ reading) was compared between treatment groups. Time to ventilation (time from airway device in hand ready to place to time of first successful ventilation) was also compared.

Results

A total of 213 patients in need of advanced airway management were treated during the study period, with 9 patients excluded from the analysis. The remaining 204 placements by 110 of the 272 consented paramedics were analyzed (median placements per paramedic = 1; range = 1-7). The overall placement success rate was virtually equal across the two groups (ETI = 80.2%, King LTS-D = 80.5%; p = 0.97). The median time to placement between ETI and the King LTS-D was also not significantly different (ETI = 19.5 s vs. King LTS-D = 20.0 s; z = −0.25; p = 0.80).

Conclusion

In this study, no differences in placement success rate or time to insertion were detected between the King LTS-D and ETI.     

Interaction of human platelets with heparinized agarose gel

Platelet interaction with surfaces to which heparin had been covalently bonded was investigated with a chromatographic technique employing agarose gel beads heparinized via a cyanogen bromide reaction. Heparinization significantly increased platelet retention by the gel. Platelet retention was unchanged after pretreatment of the heparinized gel with albumin but increased after pretreatment with fibrinogen. Pretreatment with plasma or purified AT III decreased platelet retention. Reduction in platelet retention was correlated with the amount of AT III removed from plasma. Plasma with decreased levels of AT III was less effective in surface passivation. Pretreatment of heparinized gel with PF4 or protamine sulfate did not decrease platelet retention, but subsequent exposure to plasma did. The results suggest that a surface with covalently bonded heparin is reactive toward platelets but can be passivated by formation of a heparin/AT III complex.     

Protective effect of a novel,potent inhibitor of poly(adenosine 5'-diphosphate-ribose) synthetase in a porcine model of severe bacterial sepsis

OBJECTIVE: To determine whether activation of the nuclear enzyme poly(adenosine 5'-diphosphate [ADP]-ribose) synthetase (PARS) contributes to mortality rate, myocardial dysfunction, and cardiovascular collapse in a porcine model of sepsis induced by implantation of an infected clot. DESIGN: Prospective, random animal study. SETTING: Research laboratory at Rush Presbyterian St. Luke's Medical Center. SUBJECTS: Twenty pigs were chronically instrumented with intracardiac transducers to measure left ventricular pressure, sonomicrometer crystals in the left ventricle to measure short axis diameter, an ultrasonic flow meter to measure cardiac output, and catheters in the pulmonary artery and aorta to measure blood pressures and collect samples. INTERVENTIONS: By using a randomized study design, we administered either the novel potent PARS inhibitor PJ34 (10 mg/kg for 1 hr, 2 mg x kg(-1) x hr(-1) for 96 hrs) or vehicle to pigs immediately before intraperitoneal implantation of Escherichia coli 0111.B4 (2.3 +/- 0.1 x 10(10) colony-forming units/kg)-laden fibrin clots to produce peritonitis and bacteremia. MEASUREMENTS AND MAIN RESULTS: In vehicle-treated pigs, 12% survival was recorded at 24 hrs, whereas 83% and 66% survival was recorded in the PJ34-treated animals at 24 and 96 hrs, respectively (p <.05). PJ34 treatment attenuated bacteremia-induced increases in systemic and pulmonary vascular resistances. In controls, peritonitis induced rapid increase in plasma tumor necrosis factor-alpha. PJ34 treatment significantly attenuated this cytokine response. The formation of peroxynitrite and the activation of PARS were confirmed in hearts and lungs of the septic pigs by the immunohistochemical detection of nitrotyrosine and poly(ADP-ribose), respectively. Inhibition of PARS with PJ34 abolished poly(ADP-ribose) formation in septic animals. CONCLUSIONS: Treatment with a potent PARS inhibitor improved survival and cardiovascular status and attenuated an important mediator component of the inflammatory response in a lethal porcine model of sepsis.