Hematoma-Directed Ultrasound-Guided (HUG) Breast Lumpectomy

Background Needle localization breast biopsy (NLBB) is presently the primary means of localizing non-palpable lesions. Disadvantages of NLBB include vasovagal episodes, patient discomfort, and miss rates. Because hematomas naturally fill the cavity after vacuum-assisted breast biopsies (VABB), we hypothesized that ultrasound (US) could be used to find and accurately excise the actual biopsy site of non-palpable breast lesions without a needle. Methods This is a retrospective study from January 2000 to July 2005. Electronic chart review identified patients with non-palpable breast lesions detected by means of mammogram who then underwent lumpectomy via NLBB or the hematoma-directed ultrasound-guided technique (HUG). HUG involved localizing the hematoma with a 7.5-MHz US probe and using the “line of sight” technique straight down toward the chest wall. A block of tissue encompassing the hematoma was then excised. Results Localization procedures were performed in 186 patients—63 (34%) via needle localization and 123 (66%) via HUG. The previous VABB site in 100% of patients was successfully excised using HUG, 65 of 123 (53%) were benign and 58 of 123 (47%) were malignant; margins were positive in 13 of these 58 (22%). NLBB was successful in 100% of patients, 44 of 63 (70%) were benign and 19 of 63 (30%) were malignant; margins were positive in 14 of these 19 (73%). Margin positivity was significantly higher for NLBB than HUG (P = 0.0001, Fisher Exact). Conclusions This study suggests that HUG is more accurate in localizing non-palpable lesions than NLBB. By eliminating the additional procedure needed for NLBB, HUG may also be more time- and cost efficient. HUG makes VABB not only a less invasive diagnostic procedure, but also a localization procedure. Margaret Thompson: Supported by the Virginia Clinton Kelley/Fashion Footwear Association of New York Breast Cancer Research Fellowship Aaron Margulies: Supported by the Susan G. Komen Breast Cancer Clinical Fellowship     

Identification of hemodynamic compromise by cerebrovascular reserve and oxygen extraction fraction in occlusive vascular disease.

Cerebrovascular reserve (CVR) and oxygen extraction fraction (OEF) are used to identify hemodynamic compromise in symptomatic patients with carotid occlusive vascular disease, but evidence suggests that they are not equivalent. The authors studied the relationship between CVR and OEF to evaluate their equivalence and stages of hemodynamic compromise. Symptomatic patients (N = 12) with carotid occlusion were studied by stable xenon-computed tomography CBF after intravenous acetazolamide administration for CVR, followed within 24 hours by positron emission tomography (PET) for OEF. Middle cerebral artery territories were analyzed by hemisphere and level. Hemispheric subcortical white matter infarctions were graded with magnetic resonance imaging. Both hemispheric and level analysis of CVR and OEF showed a significant (P = 0.001), negative linear relationship [CVR (%) = -1.5 (OEF) + 83.4, (r = -0.57, P = 0.001, n = 24]. However, 37.5% of the hemispheres showed compromised CVR but normal OEF and were associated (P = 0.019) with subcortical white matter infarction. CMRO2 was elevated in stage II hemodynamic compromise (CVR < 10%, OEF > 50%). CVR and OEF showed a significant negative linear relationship in stage II hemodynamic compromise but revealed hemispheres in hemodynamic compromise by CVR but normal OEF that were associated with subcortical white matter infarction.     

Assisting nursing faculty through the crisis and resolution of student suicide

The statistics on suicide in the United States are noteworthy, with current estimates revealing that one suicide occurs every 17 minutes. Although minimally addressed in the nursing literature in the 1990s, nursing student suicide and its effects remain important topics to revisit. Nursing program administrators and faculty innately know how to assist surviving nursing students through a crisis such as this. However, the same attention and resolve do not appear to be focused on surviving nursing faculty and staff. This article profiles a crisis intervention approach that may be considered for implementation in nursing programs before a crisis (such as a nursing student suicide) occurs so that appropriate and systematic interventions are put into action for all who may be affected.     

Prevalence of exposure to occupational risks during pregnancy in Spain

Objectives

We describe reported exposures to main categories of occupational agents and conditions in Spanish pregnant workers.

Methods

Women were recruited at 12th week of pregnancy from main public gynaecological consults to be included in the INMA Spanish cohorts study (n?=?2,058). Through personal interviews with structured questionnaires, information on working situation and working conditions during pregnancy was obtained.

Results

Fifty percent of the women reported frequent exposure to physical load (standing, heavy lifting) and 45?% reported exposure to three or more indicators of job strain. Exposure to at least one physical agent (noise, vibrations, etc.) affected 25?% of the women. Exposure to chemicals was reported by 20?% of the women, mostly including solvents and cleaning products. Eight percent of the women worked at night shifts. Job strain was more prevalent in office workers and industrial operators. Industrial workers showed the highest prevalence of exposure to chemical and physical pollutants.

Conclusions

Our data suggest that working conditions of pregnant women may need increased control in Spain.     

Establishment of hormone reference intervals for infants born < 30 weeks' gestation

Objective

Preterm infants, especially those born very preterm (< 32 weeks' gestation), suffer a number of morbidities. Immaturity of the endocrine system and its potential impact on morbidity is the subject of numerous studies. Hormone concentrations are sometimes measured in very preterm infants, however there are little normative data available to be able to interpret the results. The aim of this study was to describe age appropriate hormone reference intervals for babies born less than 30 weeks' gestation.

Study design

Samples were collected at 1, 4, 7, 14, 21, 28 and 42 days after birth from babies born 23–29 weeks' gestation. The serum was analyzed for seven hormones by automated chemiluminescent immunoassay (Siemens Immulite 2000). Results from the 107 infants who survived beyond 40 weeks' corrected gestational age were included in the data analysis.

Results

Cortisol, dehydroepiandrosterone sulfate, growth hormone and progesterone levels were highest during the first seven days with levels up to 10,801 nmol/L; 26.6 μmol/L; 343 mU/L; and > 63.6 nmol/L respectively. Free thyroxine levels were as low as < 2.6 pmol/L for the first 28 days with the nadir at 7 days. Estradiol levels ranged from < 73 to 1626 pmol/L over the six weeks. Reference intervals for IGF-1 could not be established as the levels were below the analyzer's sensitivity. There were no differences in reference intervals between male and female infants.

Conclusions

We describe gestation appropriate reference intervals for six hormones measured in babies born < 30 weeks' gestation. Utilization of these reference intervals permits the correct and timely interpretation of results to the clinician.     

What coalition factors foster community capacity? Lessons learned from the Fighting Back Initiative.

Coalitions build community capacity by encouraging local organizations to expand services, programs, or policies (i.e., organizational capacity). The aim of the study was to identify coalition factors--resources, lead agency, governance, and leadership--that foster organizational capacity. Thirteen coalitions funded by Robert Wood Johnson Foundation's Fighting Back (FB) Initiative were examined in a multiple-site case study where coalition served as the unit of analysis. Organizational capacity was measured by creating a scale for each community based on changes in programs, services, or policies among eight types of organizations. Both qualitative and quantitative analyses were conducted to identify relationships among organizational capacity and coalition factors. FB sites with greater organizational capacity shared seven characteristics: received more funds for coalition building; delayed establishing new lead agencies; were housed in agencies supportive of FB; maintained stable, participatory decision-making bodies; cultivated active involvement of local government; practiced collaborative leadership; and had effective, long-serving project directors.     

Teamwork and social worker advocacy: Conflicts and possibilities

Consumer participation in mental health services has made professional activities, including teamwork, visible to increased examination of points of conflict that often focus on aspects of professional ethics. Social workers are ethically bound to serve as client advocates, which implies an adversary process not provided for in assumptions about teamwork. Social work generally is based on a consensus model and occurs in the absence of legitimate standards to assess competence. These factors are likely to be a negative influence on social workers' contributions to teamwork. An interprofessional procedure focused on client rights is suggested to increase explicit attention to conflict in teamwork.