Absence of capsular contracture in 319 consecutive augmentation mammaplasties: Dependent drains as a possible factor

Capsular contracture is one of the major complications of augmentation mammaplasty. A review of 638 augmented breasts in 319 consecutive patients who underwent primary augmentation, with an average follow-up of 17.2 months and without a single case of capsular contracture of any degree to date, is presented, along with a discussion of the surgical technique and complications, and an analysis of measures used to prevent capsular contraction. Each patient received a pair of smooth saline-filled implants (Mentor, USA) placed in the submuscular space through an inframammary incision. In all operated breasts, many of the known measures commonly used for capsular contracture prevention were implemented. As well, a dependent drain was used as the final hemostatic step to prevent blood accumulation in the pocket. Leaving a dependent drain in the dissected pocket overnight, as one of the sequence of measures aimed at eliminating blood accumulation, is believed to be a contributing factor in capsular contracture prevention.     

Diuretic treatment in those dying from a myocardial infarction

The relative risk of dying from a myocardial infarction according to diuretic therapy was estimated in a case control study for 189 cases, 144 dead controls and 349 living controls. The controls were matched for age (±2.5 years), sex and general practice. The study was community-based; the cases were identified from death certificates and the death certificates of the dead controls had no mention of ischaemic heart disease. The relative risk was estimated from the odds ratio and was similar whether dead or living controls were considered. Against all controls combined, the odds ratio for dying while taking a potassium-losing diuretic at 1 month prior to death (R₁) was 1.5 (95 per cent CI 0.9, 2.4) and for a combined potassium-losing + sparing diuretic (R_L+S) was 2.0 (95 per cent CI 1.1, 3.4). Potassium-sparing diuretics may be given more frequently to patients at greater risk of dying, thus masking a benefit, but the data could not provide evidence for a benefit from the addition of a potassium-sparing diuretic.     

Age-related effects of placebo and active treatment in patients beyond the age of 60 years: the need for a proper control group

The age-related response to placebo and active antihypertensive treatment was evaluated in 742 elderly hypertensive patients who were followed in the double-blind placebo-controlled trial conducted by the European Working Party on High blood pressure in the Elderly (EWPHE). In the two treatment groups, the fall in systolic and diastolic blood pressures after 3 months was negatively correlated with age (P less than 0.02), indicating that the hypotensive effect of placebo and active treatment was more pronounced in older patients. Further comparison of the two treatment groups failed to demonstrate any statistical differences in the slopes of the hypotensive effect on age. These conclusions were not altered by cumulative adjustments for baseline blood pressure, pulse rate, serum creatinine and the presence of cardiovascular complications at entry. In conclusion, in the present study, a similar blood-pressure-lowering action which increased with age was observed on active and placebo treatment; thus, proof that an observed age-related hypotensive effect is caused by a particular drug requires comparison with a control group on placebo.     

Evidence for a curvilinear relation between blood pressure and urinary sodium in men

With the use of a linear model, the relation between urinary sodium and blood pressure has been reported to be positive, non-significant, or negative. The hypothesis that this relationship is more complex than linear was investigated in two different study populations, which were independently recruited and examined by different observers. In 1,071 men randomly selected from the general population and in an unrelated sample of 1,209 military men, systolic and diastolic blood pressure were correlated with urinary sodium following a model, which included both the linear and quadratic terms of urinary sodium. In both groups of men, these second order models, adjusted for age and body mass index, provided a better fit (P less than 0.05) than the relationships with only the linear term of urinary sodium. The quadratic models explained from 0.35 to 1.10% of the blood pressure variance. Third order models, which in addition included the cubic term of urinary sodium, did not further improve the correlations between systolic and diastolic blood pressure and urinary sodium in men. In 1,010 women drawn from the general population and in 499 military women, neither the first nor the second order correlations between systolic and diastolic blood pressure and urinary sodium were statistically significant. In conclusion, the present results, reproducible in two different study populations, suggest that a second order model is more appropriate than a simple linear correlation to describe the weak relationship between blood pressure and urinary sodium in men. However, recommendations for the prevention of hypertension must not be changed, until the present findings are confirmed by intervention studies.     

Understanding patient acceptance and refusal of HIV testing in the emergency department

Background  

Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.     

Interventional radiology virtual simulator for liver biopsy

Purpose

   Training in Interventional Radiology currently uses the apprenticeship model, where clinical and technical skills of invasive procedures are learnt during practice in patients. This apprenticeship training method is increasingly limited by regulatory restrictions on working hours, concerns over patient risk through trainees’ inexperience and the variable exposure to case mix and emergencies during training. To address this, we have developed a computer-based simulation of visceral needle puncture procedures.

Methods

   A real-time framework has been built that includes: segmentation, physically based modelling, haptics rendering, pseudo-ultrasound generation and the concept of a physical mannequin. It is the result of a close collaboration between different universities, involving computer scientists, clinicians, clinical engineers and occupational psychologists.

Results

   The technical implementation of the framework is a robust and real-time simulation environment combining a physical platform and an immersive computerized virtual environment. The face, content and construct validation have been previously assessed, showing the reliability and effectiveness of this framework, as well as its potential for teaching visceral needle puncture.

Conclusion

   A simulator for ultrasound-guided liver biopsy has been developed. It includes functionalities and metrics extracted from cognitive task analysis. This framework can be useful during training, particularly given the known difficulties in gaining significant practice of core skills in patients.     

Antihypertensive therapy in patients above age 60. Third interim report of the European Working Party on High blood pressure in Elderly (EWPHE).

Three hundred forty nine hypertensive patients above the age of 60 have entered the double-blind multicentre trial of the European Working Party on High blood pressure in the Elderly (EWPHE). After stratification and randomisation half were treated with one or two capsules containing 25 mg hydrochlorothiazide and 50 mg triamterene and if blood pressure control was insufficient methyldopa was added up to 2 g daily; the other half received matching placebo. No significant differences between the groups were present prior to randomisation. A significant blood pressure difference of 25/10 mm Hg was obtained between the groups and maintained during two years of follow-up. No major disturbances in serum potassium or serum sodium were noted with the present drug combination. However, during the initial phase an increase in serum creatinine and serum uric acid was noted in the actively treated group, which was maintained for two years. Also glucose tolerance was impaired after 2 years in the actively treated group. A favourable influence on prognosis by active treatment can be expected on the basis of the blood pressure reduction and in the absence of major electrolytes disturbances. But this benefit must be proven by observed statistical differences in terminating events between the groups. Therefore the patients are being followed for a longer period of time and more patients are admitted into the trial.     

Biallelic neutrophil Na-antigen system is associated with a polymorphism on the phospho-inositol-linked Fc gamma receptor III (CD16)

Neutrophils express two distinct types of receptor for the Fc region of IgG, FcRII and FcRIII, in amounts of 10,000 to 20,000 FcRII (40 Kd) and 100,000 to 200,000 FcRIII (50 to 80 Kd) per neutrophil. We showed that the FcRIII exhibits genetically determined heterogeneity, detectable by differences in electrophoretic mobility with sodium dodecyl sulfate (SDS) as well as by reaction with antibodies against the biallelic neutrophil-specific antigen system NA. FcRIII was precipitated with an FcRIII-specific monoclonal antibody (MoAb) from the neutrophils of 35 donors. NA1NA1 donors expressed an FcRIII with a molecular weight (mol wt) of 50 to 65 Kd, NA1NA2 donors expressed an FcRIII with a mol wt of 50 to 80 Kd, and NA2NA2 donors expressed an FcRIII with a mol wt of 65 to 80 Kd. Statistical analysis showed that the electrophoretic heterogeneity corresponds with the NA polymorphism (k = 1). Sequential immunoprecipitation with a MoAb against NA1 and a MoAb against anti- FcRIII, followed by SDS-polyacrylamide gel electrophoresis (PAGE), showed that NA1-FcRIII is distinct from NA2-FcRIII. Moreover, immunoprecipitation with a MoAb against NA1 yielded a protein of 50 to 65 Kd, and immunoprecipitation with human anti-NA2 sera or an MoAb against NA2 yielded a protein of 65 to 80 Kd. Preincubation of NA1NA2 neutrophils with F(ab')2 fragments of an MoAb against anti-NA1 reduced binding of IgG dimers to these cells with about 50%, whereas it completely prevented binding of the dimers to NA1NA1 neutrophils. Inhibition experiments with the MoAb against NA2 yielded the same results for NA1NA2 cells, whereas binding of IgG dimers to NA2NA2 cells was completely prevented. Thus, the products of both NA alleles bind IgG. Immunoprecipitation from the medium of neutrophils either stimulated with formyl- methionyl-leucyl-phenylalanine (FMLP) or treated with glycosyl-phosphatidyl-inositol-specific phospholipase C (GPI- PLC) showed that both the NA1-FcRIII and the NA2-FcRIII are released from the cell surface, indicating that both forms of FcRIII have some structural features in common. Deglycosylation of FcRIII from homozygous donors yielded material that showed several bands on SDS- PAGE. GPI-PLC treatment of neutrophils indicated that all of this material is phosphatidyl-inositol linked.