Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

Aims

The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum.

Methods

Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses.

Results

Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS.

Conclusion

Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management.     

Laparoscopic Gastric Bypass for Failure of Adjustable Gastric Banding: A Review of 85 Cases

Laparoscopic adjustable gastric banding (LAGB) is the first bariatric procedure in Europe and is becoming more and more popular in North America. However, the failure rate at 5 years can reach 50%. Although there is still no consensus on revisional surgery, the trend seems to be in favor of conversion to gastric bypass (GBP) with encouraging results. The aim of this study was to assess the results, the risks of conversion into GBP after failure of gastric banding. From January 2003 to July 2010, 85 patients had a revisional GBP after failure of LAGB, performed by two experienced surgeons. Post-operative morbidity, functional results, and weight loss were analyzed. The conversion rate was 2.3%. The mean operative time was 166 min. The mean length of stay was 5.2 days. The early morbidity rate was 7% and the mortality rate was nil. The mean body mass index (BMI) at the time of LAGB was 47.2 kg/m² with the lowest BMI reached at 35. The mean BMI at conversion into GBP was 42.9 and the final BMI after a mean follow-up of 22 months was 34.8. Of the patients, 57.7% had a final BMI inferior to 35 and 15.3% had a final BMI superior to 40 and these were super obese and older patients. Super-obesity and advanced age appear to be factors of failure of LAGB and revisional GBP. However, conversion into GBP currently remains the choice procedure in case of gastric banding failure with satisfactory results and acceptable morbidity.     

How to manage gait and balance disorders among older adults aged 65 years and older with mild to moderate dementia in clinical practice?

Gait and balance disorders are frequent in demented older adults. Their management (i.e., diagnosis, assessment and treatment) is challenging in daily practice because of numerous evaluation tests available, difficulties to select the most adapted intervention, and the lack of knowledge of physicians and health professionals concerning adapted centers to refer their patients to those patients. Thus, a working group of experts was organized by the Gérontop?le of Pays de Loire, France, in December 2010 with the aim to provide clinical guidelines for the management of older adults aged 65 years and older with mild to moderate dementia with gait and balance disorders. These guidelines provide answers to the following questions: 1) Is there gait and/or balance disorders? 2) Which specific tests used? and 3) How to treat patients?     

Simultaneous assessment of liver volume and whole liver fat content: a step towards one-stop shop preoperative MRI protocol

Objective  

The purpose of this study was to evaluate the ability of a whole liver volume (WLV) segmentation algorithm to measure fat fraction (FF).     

Quorum sensing inhibitors increase the susceptibility of bacterial biofilms to antibiotics in vitro and in vivo

Although the exact role of quorum sensing (QS) in various stages of biofilm formation, maturation, and dispersal and in biofilm resistance is not entirely clear, the use of QS inhibitors (QSI) has been proposed as a potential antibiofilm strategy. We have investigated whether QSI enhance the susceptibility of bacterial biofilms to treatment with conventional antimicrobial agents. The QSI used in our study target the acyl-homoserine lactone-based QS system present in Pseudomonas aeruginosa and Burkholderia cepacia complex organisms (baicalin hydrate, cinnamaldehyde) or the peptide-based system present in Staphylococcus aureus (hamamelitannin). The effect of tobramycin (P. aeruginosa, B. cepacia complex) and clindamycin or vancomycin (S. aureus), alone or in combination with QSI, was evaluated in various in vitro and in vivo biofilm model systems, including two invertebrate models and one mouse pulmonary infection model. In vitro the combined use of an antibiotic and a QSI generally resulted in increased killing compared to killing by an antibiotic alone, although reductions were strain and model dependent. A significantly higher fraction of infected Galleria mellonella larvae and Caenorhabditis elegans survived infection following combined treatment, compared to treatment with an antibiotic alone. Finally, the combined use of tobramycin and baicalin hydrate reduced the microbial load in the lungs of BALB/c mice infected with Burkholderia cenocepacia more than tobramycin treatment alone. Our data suggest that QSI may increase the success of antibiotic treatment by increasing the susceptibility of bacterial biofilms and/or by increasing host survival following infection.     

No loss of chance of diabetic retinopathy screening by endocrinologists with a digital fundus camera

OBJECTIVE

To compare the efficacy of the diabetic retinopathy (DR) screening with digital camera by endocrinologists with that by specialist and resident ophthalmologists in terms of sensitivity, specificity, and level of “loss of chance.”

RESEARCH DESIGN AND METHODS

In a cross-sectional study, 500 adult diabetic patients (1,000 eyes) underwent three-field retinal photography with a digital fundus camera following pupillary dilatation. Five endocrinologists and two ophthalmology residents underwent 40 h of training on screening and grading of DR and detection of associated retinal findings. A κ test compared the accuracy of endocrinologist and ophthalmology resident screening with that performed by experienced ophthalmologists. Screening efficiency of endocrinologists was evaluated in terms of “loss of chance,” i.e., missed diagnoses that required ophthalmologist referrals.

RESULTS

The mean weighted κ of DR screening performed by endocronologists was similar to that of ophthalmology residents (0.65 vs. 0.73). Out of 456 DR eyes, both endocrinologists and ophthalmology residents misdiagnosed only stage 1 DR (36 and 14, respectively), which did not require ophthalmologist referral. There were no significant differences between endocrinologists and ophthalmology residents in terms of diabetic maculopathy and incidental findings except for papillary cupping and choroidal lesions, which were not the main purpose of the study or of the training.

CONCLUSIONS

The endocrinologist with specific training for DR detection using a three-field digital fundus camera with pupillary dilatation can perform a reliable DR screening without any loss of chance for the patients when compared with identical evaluation performed by experienced ophthalmologists.Diabetic retinopathy (DR) is one of the main causes of blindness in industrialized nations (1). The worldwide prevalence of diabetes in adults is estimated to rise to 7.7%, affecting 439 million adults by 2030 (2). In France, the increasing number of patients with diabetes, coupled with the lack of a national screening program, results in a steady rise in the visual handicaps related to the disease (3).Annual screening of DR is recommended as an effective approach to prevent visual loss related to diabetes (4,5). Currently, digital nonmydriatic fundus photography is increasingly used as a method of screening for ophthalmologists worldwide (5–7). According to consensus classifications (4,5), DR at a stage higher than 1 needs further ophthalmological management. Despite these recommendations, only 30% of the diabetic patients in France undergo DR screening each year. Partly, this is due to the lack of ophthalmologists and insufficient awareness about the visual consequences of the disease (3,8). The situation is slowly changing after implementation of telemedical screening networks using digital fundus photography (9–11). Further increase in screening coverage can be achieved with the involvement of allied medical professionals.Since the 1980s, the concept of “loss of chance” has emerged in medicine and law. The misdiagnosis during DR screening can lead to a loss of chance for patients requiring referral to an ophthalmologist for further examinations and management (12,13).Two studies have shown that screening performed by an endocrinologist using an ophthalmoscope (14) and a mydriatic camera (15), respectively, were reliable, although they didn’t evaluate the loss of chance. Furthermore, no endocrinologists’ team approach was evaluated so far.This clinical research trial has been designed to compare the efficacy of the DR screening with digital camera by a team of previously trained endocrinologists (7) with that of residents and specialist ophthalmologists, in terms of sensitivity, specificity and level of “loss of chance.”