Endotoxemia and bacteremia in patients following ultrasonic lithotripsy

Summary The incidence of endotoxemia was studied in 17 patients who underwent ultrasonic lithotripsy (USL), and compared with the incidence in 11 patients who underwent transurethral resection (TUR) and in 8 patients who underwent other operations. Fourteen of 17 patients (82%) who underwent ultrasonic lithotripsy had endotoxemia. The incidence of endotoxemia after USL was significantly higher than that after TUR (9%) or after other operations (12.5%). Only 2 of the 17 patients (12%) who underwent USL had bacteremia. The organisms isolated were P. mirabilis and S. sanguis, respectively. Six of the 14 patients with endotoxemia after USL suffered high fever. These data suggest that endotoxemia is a factor which causes high fever after USL.     

Effects of graded mechanical compression of rabbit sciatic nerve on nerve blood flow and electrophysiological properties

Entrapment neuropathy is a frequent clinical problem that can be caused by, among other factors, mechanical compression; however, exactly how a compressive force affects the peripheral nerves remains poorly understood. In this study, using a rabbit model of sciatic nerve injury (n = 12), we evaluated the time-course of changes in intraneural blood flow, compound nerve action potentials, and functioning of the blood–nerve barrier during graded mechanical compression. Nerve injury was applied using a compressor equipped with a custom-made pressure transducer. Cessation of intraneural blood flow was noted at a mean compressive force of 0.457 ± 0.022 N (±SEM), and the compound action potential became zero at 0.486 ± 0.031 N. Marked extravasation of Evans blue albumin was noted after 20 min of intraneural ischemia. The functional changes induced by compression are likely due to intraneural edema, which could subsequently result in impairment of nerve function. These changes may be critical factors in the development of symptoms associated with nerve compression.     

Metaphyseal‐Loading Anterolaterally‐Flared Femoral Stem in Cementless Total Hip Arthroplasty: Five‐ to Eleven‐Year Follow‐Up Evaluation

Using a nonlinear three‐dimensional finite element analysis simulating loading conditions, we designed a new type of proximal‐fitting, anterolaterally‐flared, arc‐deposit hydroxyapatite‐coated anatomical femoral stem (FMS‐anatomic stem; Japan Medical Materials, Osaka, Japan) for cementless total hip arthroplasty (THA) for Japanese patients with dysplastic hip osteoarthritis. The aim of the present study was to analyze the clinical and radiographic outcomes of the new stem. We reviewed 143 consecutive patients (164 hips; 13 men, 14 hips; 130 women, 150 hips; age at surgery, 56.6 ± 7.6 years, mean ± SD, range, 30–74) who underwent cementless THA using the FMS‐anatomic stem at a single institution, with a follow‐up period of 7.6 ± 1.6 years (range, 5.3–11.0). Harris Hip score improved from 46.1 ± 12.6 before surgery to 90.0 ± 8.9 points post‐THA. The 7.6‐year survival rate of the stem was 99.0% after revision for aseptic loosening. Radiographs at follow‐up confirmed the stability of the femoral stems within the femoral canal in all cases, with sufficient bone ingrowth. None of the patients had subsidence of the stem exceeding 2.0 mm within the femoral canal or changes in varus or valgus position of more than 2.0°. The FMS‐anatomic stem provided excellent results in patients with dysplastic hip osteoarthritis. Our analysis confirmed reduced radiolucency around the stem in Gruen zones, minimal subsidence, appropriate stress shielding, and promising medium‐term stability within the femoral canal in our patients.     

Comparison of breast cancer detection by diffusion-weighted magnetic resonance imaging and mammography

PURPOSE: Breast cancer-detecting ability of diffusion-weighted magnetic resonance imaging (DW-MRI) was investigated by comparing the breast cancer detection rates of DW-MRI and mammography (MMG). MATERIALS AND METHODS: The subjects were 48 women who had breast cancer (53 cancer lesions) who underwent DW-MRI before surgery. Altogether, 41 lesions were invasive ductal carcinoma (IDC), 7 were noninvasive ductal carcinoma (NIDC) and 5 were "others." RESULTS: The breast cancer detection rates by MMG and DW-MRI were 84.9% and 94.3% (P < 0.001), respectively. In each classification of histology and size, the detection rate by DW-MRI was higher than that by MMG. In relation to the mammary gland density, the detection rates of fatty, scattered, heterogeneously dense, and extremely dense mammary glands were 100%, 100%, 92.0%, and 83.3%, respectively. The mean apparent diffusion coefficient values of the histologic types were 1.07 +/- 0.17 x 10(-3), 1.50 +/- 0.24 x 10(-3), 1.12 +/- 0.25 x 10(-3), and 2.01 +/- 0.29 x 10(-3) mm(2)/s for IDC, NIDC, others, and normal breast, respectively, showing that the values of IDC and NIDC were significantly different from that of the normal breast (P < 0.001 each). A significant difference was also noted between IDC and NIDC (P < 0.001). CONCLUSION: DW-MRI may be useful for detecting breast cancer in a wide age group of women, including young women with dense mammary glands.     

Phyllodes tumor of the breast: stromal overgrowth and histological classification are useful prognosis-predictive factors for local recurrence in patients with a positive surgical margin

BACKGROUND: The local recurrence rate of phyllodes tumors is high and ensuring a sufficient surgical margin is considered important for local control. However, the preoperative diagnosis rate of phyllodes tumors is low and we often encounter cases in which a sufficient surgical margin is not achieved, since in routine medical practice the lesion may not be diagnosed as phyllodes tumor until postoperative biopsy of a mammary mass. Furthermore, there are no established therapeutic guidelines for surgical stump-positive phyllodes tumors. We reviewed the outcomes of excision of phyllodes tumors to investigate factors involved in local recurrence and to determine the indication for re-excision in stump-positive cases. METHODS: The subjects were 45 patients treated for phyllodes tumors at our institution from January 1980 to July 2005. Age, tumor size, surgical method, stromal cellular atypia, mitotic activity, stromal overgrowth, histological classification and surgical stump status were analyzed. RESULTS: Median age was 45 years old (range 28-75) and tumor size was 1-17 cm (median 3.5 cm). Pathologic diagnoses were benign, borderline and malignant in 31, five and nine cases, respectively, and the surgical stump was negative in 27 lesions and positive in 15. Median follow-up was 101 months (range 1-273), with local recurrence in six cases and distant metastasis in one. The local recurrence-free rate was 88, 88 and 84% and the disease-free rate was 85, 85 and 81% after 5, 10 and 15 years, respectively. Overall 10-year survival was 97%. In univariate analysis, a positive surgical margin, stromal overgrowth and histological classification were predictive factors for local recurrence after breast-conservation surgery (P = 0.0034, 0.0003, 0.026). A positive surgical stump was the only independent predictor of local recurrence in multivariate analysis (RR 0.086; 95% CI 0.01-0.743, P = 0.012). Stromal overgrowth was a predictive factor for local recurrence in cases with a positive surgical margin (P = 0.0139). CONCLUSION: Wide excision is the preferred therapy for phyllodes tumor and preoperative diagnosis is important for good local control. Re-excision is recommended in cases with a positive surgical margin and stromal overgrowth and malignancy.     

Immunohistochemical expression of hormone receptors and the histological characteristics of biochemically hormone receptor negative breast cancers

Background  Most of the discordant cases between biochemical and immunohistochemical (IHC) assays for hormone receptor (HR) status in breast cancers are due to negative findings from the biochemical assay but positive IHC findings. However determining HR status based on IHC only in biochemically HR negative breast cancers has never been studied. The aim of this study is to examine the histological characteristics in immunohistochemically HR positive but biochemically HR negative breast cancers. Methods  IHC staining for HRs in 345 biochemically HR-negative breast cancers was done. The relationship between HR status by IHC and the histological characteristics was assessed. Results  In 345 cancers, 105 (30.4%) were estrogen receptor- (ER) or progesterone receptor- (PR) positive by IHC. The enzyme-immunoassay (EIA) HR titer was higher in immunohistochemically HR-positive tumors (ER: 2.7 fmol/mg protein; PR: 0.8 fmol/mg protein) than in negative tumors (0.6 fmol/mg protein in both HRs). IHC-assessed ER positivity on histological sections was high in some tumor types, such as mucinous carcinoma (77.8%), invasive micropapillary carcinoma (66.7%), and infiltrating ductal carcinoma of no special type with abundant stroma (60.2%). Among infiltrating ductal carcinomas of no special type, low nuclear grade tumors were all ER positive and high nuclear grade tumors showed low ER positivity by IHC, even in biochemically HR negative cancers. Conclusion  The IHC-assessed HR status may reflect tumor cell behavior, such as overall and disease-free survival and endocrine response, better than HR status as assessed by the enzyme-immunoassay method. Immunohistochemically HR-positive but biochemically HR-negative breast cancers include infiltrating ductal carcinomas of no special type with low nuclear grade and some tumor types with high stromal content. We can assess the true HR status by IHC especially these tumors.     

Epidermal inclusion cyst of the breast

Epidermal inclusion cysts are uncommon in the breast, but the consequences can be severe when these cysts occur in the breast parenchyma. Here, we report two such cases. The patient in case 1 was an 85-year-old woman with a 3-cm palpable mass in the right breast. Mammography revealed a round and smoothly outlined mass, which indicated a benign tumor, and sonography showed an irregularly shaped and heterogeneous hypoechoic mass. Breast cancer was suspected on the basis of the sonographic findings and the age of the patient, but excisional biopsy revealed an epidermal inclusion cyst. The patient in case 2 was a 45-year-old woman with a 9-cm lesion in the left breast. Mammography revealed a round, dense, smoothly outlined mass, and sonography showed a well-defined, central hyperechoic mass. A phyllodes tumor or a giant fibroadenoma was suspected on the basis of clinical and imaging findings, but the resected specimen revealed an epidermal inclusion cyst.     

Recent topics of health outcomes research in oncology

This article reviews recent topics in health outcomes research. First, we discuss the concept and importance of 'subjective' assessment of quality of life (QOL), and introduce new guidance, by the respective medical product regulatory authorities in Europe and the United States, for labeling claims of medical products that are assessed for outcomes related to QOL. Second, we address the application of item response theory (IRT) in developing and assessing QOL measures to compensate for several drawbacks of the classical psychometric approach, which has been commonly used to verify the reliability and validity of QOL instruments. Third, the relevance and determination of the minimally clinically important difference (MID) of QOL scores is discussed. Finally, we address the so-called 'response shift' which may affect the reliability of analysis results of QOL scores in longitudinal studies such as randomized clinical trials.