Axillary Dissection Versus No Axillary Dissection in Elderly Patients with Breast Cancer and No Palpable Axillary Nodes: Results After 15 Years of Follow-Up

Objective

To assess the long-term safety of no axillary clearance in elderly patients with breast cancer and nonpalpable axillary nodes.

Background

Lymph node evaluation in elderly patients with early breast cancer and clinically negative axillary nodes is controversial. Our randomized trial with 5-year follow-up showed no breast cancer mortality advantage for axillary clearance compared with observation in older patients with T1N0 disease.

Methods

We further investigated axillary treatment in a retrospective analysis of 671 consecutive patients, aged ≥70 years, with operable breast cancer and a clinically clear axilla, treated between 1987 and 1992; 172 received and 499 did not receive axillary dissection; 20 mg/day tamoxifen was prescribed for at least 2 years. We used multivariable analysis to take account of the lack of randomization.

Results

After median follow-up of 15 years (interquartile range 14–17 years) there was no significant difference in breast cancer mortality between the axillary and no axillary clearance groups. Crude cumulative 15-year incidence of axillary disease in the no axillary dissection group was low: 5.8% overall and 3.7% for pT1 patients.

Conclusions

Elderly patients with early breast cancer and clinically negative nodes did not benefit in terms of breast cancer mortality from immediate axillary dissection in this nonrandomized study. Sentinel node biopsy could also be foregone due to the very low cumulative incidence of axillary disease in this age group. Axillary dissection should be restricted to the small number of patients who later develop overt axillary disease.     

Mechanisms of Laser Hair Removal: Could Persistent Photoepilation Induce Vitiligo or Defects in Wound Repair?

BACKGROUND: Current laser hair removal modalities achieve a long-term but not persistent (irreversible) hair loss. OBJECTIVE: This review highlights the mechanisms of the current laser hair removal technology and explores possible side effects. METHODS: The literature is reviewed. RESULTS: The hair shaft plays a key role in the mechanisms underlying current photoepilation procedures by acting as a vector for heat transfer. Together with inherent properties of the hair growth cycle and the anatomic specifics of the follicular stem cells located in the bulge, the crucial role of the hair shaft and its lack of complete destruction with present technology are also likely culprits for the nonpersistent nature of present laser hair removal. Future persistent photoepilation may be associated with vitiligo or vitiligolike changes. Disturbances in wound repair of previously lasered sites are less likely. CONCLUSIONS: The currently available laser hair removal protocols are safe, not the least because they achieve long-term but not persistent epilation. The adverse effects of persistent laser hair removal technology possibly available in the future are potentially problematic.     

Effects of Laparoscopic Pneumoperitoneum and Changes in Position on Arterial Pulse Pressure Wave-Form: Comparison Between Morbidly Obese and Normal-Weight Patients

Background: Laparoscopic adjustable gastric banding (LAGB) is commonly indicated in morbidly obese patients. There is controversy regarding the hemodynamic effects of pneumoperitoneum (PNP) in obese patients. PNP and changes in body posture have complex effects on venous return that may be detected by respiratory changes in the arterial pressure waveform. The aim of this study was to compare pneumoperitoneum-induced and reverse Trendelenburg (RT) changes in arterial pulse pressure in obese and normal-weight patients. Methods: 15 morbidly obese patients undergoing LAGB were compared to 15 normal-weight patients undergoing laparoscopic surgery. Arterial pressure was non-invasively recorded using an arterial tonometer. Respiratory changes in pulse pressure (ΔPp) were recorded in the supine position without and with PNP, and in RT position with pneumoperitoneum. Results: PNP increased ΔPp values in normal weight (P<0.001), but not in obese patients. RT position increased ΔPp values in obese patients, but did not cause additional changes in normal-weight patients. Conclusions: Unlike normal-weight patients, PNP in the supine position has minimal effect on the arterial pulse-pressure wave-form in obese patients. This observation may reflect physiological differences in total blood volume and loading conditions of the heart between morbidly obese and normal-weight patients, which affect venous return during PNP. Differences in abdominal vascular zone conditions between obese and normal weight-patients may explain these results.     

Mychophenolate Mofetil Increased Chagas Disease Reactivation in Heart Transplanted Patients: Comparison Between Two Different Protocols

Heart transplantation (HT) remains the treatment of choice for advanced chagasic cardiomyopathy. New immunosuppression protocols have provided better control of rejection (RJ) and cardiac allograft vasculopathy. However, their influence on infection and Chagas disease reactivation (CDR) is not well established. The aim of this study was to compare the CDR rate in patients under two different immunosuppression protocols. We studied 39 chagasic patients who had undergone orthotopic HT between April, 1987 and June, 2004. They were divided into two groups, one taking azathioprine (group 1=24 patients) and the other taking mycophenolate mofetil (group 2=15 patients), in the standard doses (2 mg/kg/day and 2 g/day, respectively), beside prednisone and cyclosporine, in equivalent doses. The number of CDR and RJ episodes were analyzed in the first and second years after HT. CDR rates were 8%+/-5% at 1 year and 12%+/-6% at 2 years of follow-up in group 1. Otherwise, patients in group 2 presented CDR rates of 75%+/-10% and 81%+/-9% at the same periods, respectively (p<0.0001, hazard ratio=6.06). When comparing RJ rates in the first year after HT, both groups had similar behavior under both immunosuppression protocols (p=0.88). These data show that current prescribed doses of mycophenolate mofetil increase the early risk of CDR without changing RJ incidence in this period.     

不同年龄直肠癌患者行腹腔镜与行开腹根治术的比较

目的 探讨腹腔镜直肠癌根治术在不同年龄患者中受益程度的差别.方法 从2008年1月至2009年3月期间我院对76例患者行直肠癌根治术,大于70岁的老年组34例,其中行腹腔镜根治术16例,开腹根治术18例;小于70岁的中青年组42例,其中行腹腔镜根治术23例,开腹根治术19例.对这2组患者围手术期的各项数据进行回顾性分析,并分别比较2组行腹腔镜与开腹根治术的差异.结果 2组均无手术死亡病例;在术后通气、进食及住院时间方面,2组中的腹腔镜根治术患者均明显短于开腹根治术患者(P＜0.05,P＜0.01);术中出血量及术后镇痛比例也更少(P＜0.01);在平均手术时间及淋巴结清扫数目方面两种手术之间差异均无统计学意义(P>0.05).在中青年组,除切口感染率LR明显低于OR(P＜0.05)外,在并发症发生率和术后生活自理比例方面,腹腔镜根治术与开腹根治术患者比较差异均无统计学意义(P>0.05);而在老年组,腹腔镜根治术患者的各项并发症发生率均明显低于开腹根治术患者(P＜0.05),而术后生活自理比例则显著增高(P＜0.01).结论 腹腔镜下直肠癌根治术可以安全地用于老年及中青年患者.相比较而言,在术后并发症发生率及术后生活质量方面,老年直肠癌患者接受腹腔镜根治术的获益则显得更加明显,腹腔镜根治术对于老年直肠癌患者可能有更好的应用前景.     

Association Between Pulse Pressure and Cardiovascular Disease in Renal Transplant Patients

Elevated pulse pressure in general population has been shown to be associated with cardiovascular disease, which is the main cause of death in renal transplant patients. We investigated the effect that a wider pulse pressure range may have on cardiovascular disease after renal transplantation in 532 transplant patients with functioning graft for more than 1 year. Patients were classified into two groups depending on 1-year pulse pressure (< or >/=65 mmHg) and we analyzed patient and graft survival, post-transplant cardiovascular disease and main causes of death. Higher pulse pressure was associated with older recipient age (40.8 +/- 10.8 vs. 50 +/- 11.3), higher systolic blood pressure (132.7 +/- 16.1 vs. 164.5 +/- 16), lower blood diastolic pressure (84.5 +/- 11.6 vs. 84.4 +/- 11.2), higher prevalence of diabetes (12% vs. 23%) and total cardiovascular disease (20.9% vs. 33.6%). Five- and 10-year patient survivals were lower in the group with higher pulse pressure, being vascular disease the main cause of death in both groups. In a Cox regression model increased pulse pressure was associated with higher cardiovascular disease (RR = 1.73, 95% CI: 1.13-2.32 p < 0.01). In conclusion, pulse pressure was an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant patients.     

Comparison of Kidney Transplantation Results From the Same Deceased Donor Between Patients With the First Transplantation and Retransplanted Patients

Background

It has been determined that there are about 25% patients with renal allograft failure on the waiting lists.

The Combination of Glycolic Acid Peels With a Topical Regimen in the Treatment of Melasma in Dark-Skinned Patients: A Comparative Study

BACKGROUND: Melasma continues to be a difficult condition to treat, especially in dark-skinned patients, although various topical modalities including hydroquinone, tretinoin, and/or topical steroids have been used singly or in combination with variable results. OBJECTIVE: To determine if serial glycolic acid peels provide additional improvement when combined with a time-tested topical regimen, a modification of Kligman's formula (hydroquinone 5%, tretinoin 0.05%, hydrocortisone acetate 1% in a cream base). All cases had epidermal melasma as detected by Wood's light examination. METHODS: Forty Indian melasma patients were divided into two groups of 20 each. One group received serial glycolic acid peel combined with a topical regimen, modified Kligman's formula. The other, a control group, received only modified Kligman's formula. The results were evaluated by a clinical investigator both subjectively and with photographs taken at baseline, 12 (before the fourth peel), and 21 (3 weeks after the sixth peel) weeks. For clinical evaluation, the Melasma Area and Severity Index (MASI) was used. RESULTS: A significant decrease in the MASI score from baseline to 21 weeks was observed in both groups (P <.001). The group receiving the glycolic acid peels showed a trend toward more rapid and greater improvement, with statistically significant results (P <.001). Only a few side effects were observed in the peel group. CONCLUSION: This study demonstrates that serial glycolic acid peels provide an additional effect to a topical regimen which is a modification of the time-tested Kligman's regimen for treating melasma in dark-complexioned individuals if used judiciously and under supervision. It demonstrates that superficial chemical peels are beneficial in the treatment of melasma.     

Cold Induced Vasospasm in Replanted Digits: A Comparison Between Different Methods of Arterial Reconstruction

Nineteen patients each of whom had had a single digit replanted were examined after replantation. The arterial reconstruction had been done with long grafts (n = 10) or short grafts or no graft (n = 9). The effect of local or whole body cooling on the replanted and uninjured opposite digits was monitored (9–46 months after the replantation), and the patients were given a questionnaire (9–95 months after replantation) designed to explore the development of their coid related symptoms in relation to time. All patients were troubled by cold intolerance, and improvement occurred in only 60% of the cases. Pathological (vasospastic) arterial reactions to cold measured as finger systolic pressure, were less common after replantation with long grafts. Perceived cold intolerance was significantly more pronounced in the group of patients (60%) who had evidence of cold induced arterial spasm in the replanted finger.     

A Comparison Between the HeRO Graft and Conventional Arteriovenous Grafts in Hemodialysis Patients

Venous stenosis and occlusion are a major cause of vascular access dysfunction and failure. The HeRO Graft bypasses occlusion and traverses stenosis with outflow directly into the central venous circulation. A randomized, multicenter study was conducted to evaluate the efficacy and safety of the HeRO Graft relative to conventional AV grafts. The design was to enroll 143 patients in a 2:1 randomization ratio between HeRO and conventional AV control groups. Data on 72 subjects (52 HeRO Graft and 20 AV graft controls) were obtained. The HeRO Graft and control cohorts were comparable in baseline characteristics. Adequacy of dialysis, bacteremia rates, and adverse events were consistent between groups. Twelve month Kaplan–Meier estimates for primary and secondary patency rates were 34.8% and 67.6% in the HeRO Graft cohort, and 30.6% and 58.4% in the control cohort. There was no statistical difference in terms of patency between groups. The rates of intervention were 2.2/year for HeRO Graft and 1.6/year for the control (p = 0.100). Median days to loss of secondary patency was 238 for HeRO Graft versus 102 for the control (p = 0.032). The HeRO Graft appears to provide similar patency, adequacy of dialysis, and bacteremia rates to those of conventional AV grafts.     

Induced Cell Trauma During in Vitro Perfusion: A Comparison Between Two Different Perfusion Systems

The purpose of this study was to compare blood cell activation during in vitro long-term perfusion using 2 parallel in vitro extracorporeal membrane oxygenation (ECMO) systems. We compared two substantially different perfusion systems, an assistance respiratoire extra corporelle (AREC) system on one hand, containing an AREC pump, silicon tubing, and a hollow-fiber oxygenator, and a centrifugal pump system, on the other hand, containing a Biomedicus centrifugal pump, PVC tubing, and a membrane oxygenator. We measured the platelet count using an automated blood cell counter. Platelet activation was evaluated using a flow cytometric technique for the platelet membrane expression of glycoproteins and ELISA for the plasma concentration of β-thromboglobulin (β-TG), a platelet specific protein released into the blood upon platelet activation. The neutrophil count was assayed using an automated blood cell counter and the plasma concentration of cytokines using an ELISA kit. A significant difference between the two systems was observed in terms of the platelet membrane expression of glycoprotein (GP)Ib (p = 0. 0001) and GPIIb/IIIa (p = 0.0037), indicating a lower degree of platelet activation in the AREC system. The concentration of neutrophils was significantly lower in the centrifugal system (p = 0.002) compared to the AREC system. The neutrophil membrane expression of CD11b was significantly lower (p = 0.0067) in the AREC system, indicating a lower degree of neutrophil activation compared to the centrifugal pump system. A significantly lower degree of hemolysis, as expressed by plasma hemoglobin, was observed in the AREC pump system (p = 0.0491). In conclusion, lower degrees of the platelet membrane expression of GPIb and GPIIb/IIIa and of the neutrophil membrane expression of CD11b were observed in the AREC system, indicating a lower degree of platelet and neutrophil activation in this system. No significant difference between the two systems as to the plasma concentration of interleukin (IL)-1β, IL-6, or IL-8 could be recorded. Further studies are warranted to specify the role of each individual component of the two systems.     

Comparison of Three Different Surgical Methods in Aortic Root Aneurysms: Long-Term Results

Abstract Background: Degenerative ascending aortic aneurysms frequently present with aortic valve pathology. If only the noncoronary sinus of Valsalva is dilated, replacement of the noncoronary sinus by tailoring the supracoronary graft with or without aortic valve replacement (AVR) can be a simple operation strategy. We sought to describe our experiences in this kind of operation, and compare them with a relatively homogeneous group of patients who underwent the classical Bentall operation. Methods: Between January 1997 and June 2007, 99 patients who had dilated ascending aortas with root dilatation and aortic valve pathology underwent operation. Patients were divided into three groups according to the surgical procedure. Classical Bentall operation was applied in 54 patients with dilated sinuses (Group 1). The other patients with dilated noncoronary sinus underwent either ascending aortic replacement with noncoronary sinus replacement (NSR, n = 27) (Group 2), or separate AVR and ascending aortic replacement with NSR (AVR + NSR, n = 18) (Group 3). Results: There were significant reduction of aortic root in Group 2 (Z =?4.560, p < 0.001), and Group 3 (Z =?3.758, p < 0.001). Degree of aortic regurgitation was decreased from 1.56 ± 0.5 to 0.67 ± 0.5 postoperatively in Group 2 (Z =?3.874, p < 0.001). Hospital mortality was six (6.1%) (three in Group 1; three in Group 2). Late mortality rate was 6.1% (three in Group 1, three in Group 2). The type of operation was not found to be an independent predictor of overall mortality. No patients in the NSR and AVR‐NSR groups had aortic root aneurysm, and there were no reoperations or verified deaths caused by aortic root aneurysm in these patients. Conclusions: Noncoronary cusp replacement for aortic root remodeling in patients with ascending aortic aneurysm is a technically simple and durable operation. Short‐ and mid‐term results of this method were favorable compared to the Bentall procedure.     

胫骨骨折外固定器固定与内固定疗效比较

目的：探讨单侧简易外固定器与内固定治疗胫骨骨折疗效。方法：６５例胫骨骨折随机２组,１组３７例行外固定器固定,另１组２８例行内固定,从平均住院日、骨折愈合时间、并发症３个方面进行比较分析,结果：外固定器组平均骨折愈合时间４．２月,平均住院日短,并发症少。结论：单侧简单易外固定器固定治疗胫骨骨折疗效优于内固定组。     

Living or Deceased Donor Kidney Transplantation: A Comparison of Results and Survival Rates Among Iranian Patients

Objective

Kidney transplantation is the selective treatment of end-stage renal disease. Although most previous studies have concluded that living kidney donation achieves better graft survival, some factors may limit this type of donation. This study investigated the survival rates of living and deceased donor kidney transplantations among Iranian patients.

Materials and Methods

The records of kidney transplantations up to year 2005 were used to compare 50 deceased (group I) with 50 living donor transplants (group II). The recipients were matched by transplantation time. We used SPSS version 15 software to analyze the data.

Results

Group I patients included 28 males and 22 females of mean age of 38 ± 13 years, while 26 males and 24 females in group II had a mean age of 34.6 ± 14 years. The rejection and graft nephrectomy rates were significantly higher among group I than group II (P = .01, P = .02). The first-year graft survival was higher in group II (P = .001). The graft survival was significantly lower in recipients who needed a biopsy or dialysis (P = .006 and P = .02, respectively) and higher among those who had a urine volume >4200 mL within the first 24 hours after transplantation (P = .003). Patient survivals were not significantly different between the groups.

Conclusion

Living donor kidney transplantations showed higher graft survival and lower acute rejection rates compared with those from deceased donors.