Immediate breast reconstruction in two stages using anatomical tissue expansion.

Over the last four years, 43 modified radical mastectomies and 13 simple mastectomies were done for 56 patients with breast cancer followed by immediate reconstruction in two stages using anatomical tissue expansion. In 49 patients a permanent prosthesis was successfully implanted while three patients refused a further operation, and four required removal of the expander. Complications were seen in 21 cases, including infection (n = 4), Baker III-IV contractures (n = 5), radiodermitis with breast distorsion (n = 3), and seroma (n = 2). Four patients required removal of the expander, and no further attempts were made to reconstruct the breast. All 10 patients given radiotherapy developed some kind of complication. After a mean follow up of 2.5 years (range 6-48 months), the aesthetic result was rated 6.9 and patient satisfaction 7.8 on a 0-10 scale. We concluded that immediate breast reconstruction with anatomical tissue expansion gives predictable aesthetic results, which satisfied most patients. Although the complication rate is high, it does not exceed complication rates associated with mastectomy alone or delayed reconstruction. At present, only patients undergoing preoperative or postoperative radiotherapy and hesitant patients are not considered to be candidates for this procedure.     

Intermittent capture of the right ventricular outflow tract by atrial pacing in a patient with a dual-chamber pacemaker

We describe a previously unreported phenomenon of intermittent outflow right ventricular tract capture from the atrial lead of a dual-chamber pacemaker. This was more obvious at slower paced atrial rates and disappeared by decreasing the atrial pulses voltage. Electroanatomical mapping showed that the onset of activation was nearly simultaneous at the insertion site of the atrial lead and at an intermediate level of the right ventricular outflow tract. This exceptional finding might be erroneously diagnosed as due to pseudo-pseudo fusion beats.     

BTEX near real-time monitoring in two primary schools in La Rochelle,France

The present field campaign was conducted in two French primary schools for 5 weeks, where the experimental conditions were modified every week. During the first week, the classrooms were empty and not occupied, whereas the furniture was added the second week. For the three last weeks, the classrooms were normally occupied by students and various scenarios of ventilation were applied. BTEX concentrations were monitored by using novel portable pre-industrial prototypes with low gas and energy consumption, which worked continuously and operated in near real time with a time resolution of 10 min. The BTEX concentrations were compared to CO₂ measurements since the latter is commonly considered as a confinement indicator. In both schools, BTEX were not detected during the absence of students indicating that neither building materials nor furniture emit such compounds. Once the schools occupied by students, BTEX have been detected from time to time, and their concentrations ranged as follows: 0–12 ppb (benzene); 0–29 ppb (toluene), 0–4 ppb (ethylbenzene), 0–11 ppb (m/p-xylenes), and 0–10 ppb (o-xylene) excluding huge values due to paint emissions in one of the schools. Toluene was found to be strongly correlated to high levels of CO₂, showing that it was emitted by internal students activities scheduled at the end of mornings. On the contrary, benzene peak was not correlated to high values of CO₂, suggesting that it comes from external sources.     

Qualitative Research in Emergency Care Part I: Research Principles and Common Applications

Qualitative methods are increasingly being used in emergency care research. Rigorous qualitative methods can play a critical role in advancing the emergency care research agenda by allowing investigators to generate hypotheses, gain an in‐depth understanding of health problems or specific populations, create expert consensus, and develop new intervention and dissemination strategies. This article, Part I of a two‐article series, provides an introduction to general principles of applied qualitative health research and examples of its common use in emergency care research, describing study designs and data collection methods most relevant to our field, including observation, individual interviews, and focus groups. In Part II of this series, we will outline the specific steps necessary to conduct a valid and reliable qualitative research project, with a focus on interview‐based studies. These elements include building the research team, preparing data collection guides, defining and obtaining an adequate sample, collecting and organizing qualitative data, and coding and analyzing the data. We also discuss potential ethical considerations unique to qualitative research as it relates to emergency care research.     

Use of Chronic Care Management Codes for Medicare Beneficiaries: a Missed Opportunity?

Background

Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions.

Objective

Characterize use of the Chronic Care Management (CCM) code in New England in 2015.

Design

Retrospective observational analysis.

Participants

All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015.

Intervention

None.

Main measures

The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services.

Key results

Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model.

Conclusions

The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare’s most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.

     

Differential Activation of Peritoneal Cells by Subcutaneous Treatment of Rats with Cryptococcal Antigens

Previous studies in our laboratory have shown that the subcutaneous pretreatment of rats with heat-killed cells (HKC) of Cryptococcus neoformans emulsified in complete Freund adjuvant (CFA) promotes protective immunity against an intraperitoneal challenge with C. neoformans. In contrast, subcutaneous treatment with the capsular polysaccharide (PSC) emulsified in CFA exacerbates the cryptococcal infection. The purpose of this study was to analyze the mechanisms involved in these phenomena. Adherent peritoneal cells from rats treated with HKC-CFA showed upregulated ED2, CD80, and CD86 expression; an increase in the level of production of anticryptococcal metabolites; and the enhanced production of interleukin-12 (IL-12) in comparison with the findings for cells from rats treated with CFA-phosphate-buffered saline (PBS). Adherent peritoneal cells from rats treated with PSC-CFA, however, also presented upregulated ED2, CD80, and CD86 expression compared to the level of expression for peritoneal cells from controls, but these cells showed an increase in arginase activity and decreased levels of production of IL-12 and tumor necrosis factor (TNF) compared with the activity and levels of production by peritoneal cells from CFA-PBS-treated rats. In addition, treatment with HKC-CFA resulted in a rise in the phagocytic and anticryptococcal activities of adherent peritoneal cells compared to those for control rats. However, adherent peritoneal cells from rats treated with PSC-CFA presented a reduction in anticryptococcal activity in comparison with that for cells from animals treated with CFA-PBS. These results show the differential activation between adherent peritoneal cells from HKC-CFA- and PSC-CFA-treated rats, with this differential activation at the primary site of infection possibly being responsible, at least in part, for the phenomena of protection and exacerbation observed in our model.Infection by the encapsulated yeast Cryptococcus neoformans is one of the most common opportunistic infections in patients with impaired cell-mediated immunity, such as those with AIDS (19). The capsule represents the major virulence factor of this fungus, with the main component of this capsule, glucuronoxylomannan (GXM), being continuously released by C. neoformans during its replication (16, 17). GXM has been implicated in multiple deleterious effects to immune function (14, 66, 67). Furthermore, previous studies in our laboratory have provided strong cytometric, molecular, and morphological evidence demonstrating that purified GXM promotes cell death by apoptosis in spleen mononuclear cells (18).Full protection against C. neoformans is dependent on multiple factors, which include innate and acquired immunity (37, 50). The innate immune system has multiple components to provide resistance to C. neoformans infection, such as cytokines, various cell populations, chemokines, and adhesion molecules. In previous publications, different cytokines have been shown to be important in the control of infections caused by C. neoformans (2, 13, 39). For example, interleukin-12 (IL-12) plays a pivotal role in the induction of a Th1 immune response against this infection, which is essential for protection (24). In relation to this, treatment with IL-12 was found to reduce the fungal load and prolong the survival of mice infected with C. neoformans (20, 38). In addition, another proinflammatory cytokine, tumor necrosis factor alpha (TNF-α), is necessary during the early stage of infection with C. neoformans, since it promotes the maturation and migration of dendritic cells to the draining lymph node (9). Furthermore, TNF-α can also activate macrophages, leading to an increase in the capacity of these cells to phagocytose and kill C. neoformans yeast, with the neutralization of this cytokine resulting in the exacerbation of infection (21, 36). In contrast, Th2-related cytokines, such as IL-4 and IL-10, contribute to the progression of cryptococcal infection (41). IL-10 suppresses T-cell proliferation and downregulates the production of Th1 cytokines, which includes gamma interferon (IFN-γ), IL-12, and TNF-α (23, 47, 52). The role of transforming growth factor beta (TGF-β) in cryptococcosis is still debated. Studies by Shao et al. (61) demonstrated that the early, but not the late, administration of this cytokine during cryptococcal infection results in an increase in the lung fungal burden. In conclusion, the Th1-Th2 cytokine balance is critical for host immunity against infection with C. neoformans.Neutrophils, macrophages, dendritic cells, and natural killer T cells constitute the cellular effectors of innate immunity against C. neoformans (15, 40, 46, 68). Macrophages have been demonstrated histopathologically to be the predominant cell types after a transient influx of neutrophils into the lungs of rats infected with C. neoformans, which has suggested an important role of macrophages in host defenses against cryptococcal infection (30). These cells are capable of secreting an array of cytotoxic products, including reactive oxygen intermediates (ROI), such as hydrogen peroxide, and reactive nitrogen intermediates, such as nitric oxide (51). In addition, previous studies in our laboratory have shown that macrophages from infected rats appear to be able to kill C. neoformans principally by generating NO (58). Furthermore, other functions have been attributed to macrophages, including phagocytosis, the production of cytokines and chemokines, and antigen presentation (35, 43, 44, 65). On the other hand, alternatively activated macrophages (aaMac) can also appear. In this case, the macrophages have high levels of arginase activity and produce l-ornithine and urea. Other characteristics include increased fungal phagocytosis, decreased intracellular killing, and the promotion of fibrosis. Furthermore, alternative activation is also associated with a high level of expression of macrophage activation markers, such as major histocompatibility complex class II (MHC II), CD80 (B7-1), CD86 (B7-2), and CD163 (ED2 antigen), and low levels of TNF-α production (7, 28, 29, 32, 63).In previous studies, we have shown that subcutaneous treatment of rats with heat-killed cells (HKC) of C. neoformans emulsified in complete Freund adjuvant (CFA) provides protection against an intraperitoneal challenge with viable C. neoformans. In contrast, cryptococcosis is exacerbated in rats pretreated with capsular polysaccharide (CPS) emulsified in CFA (8). In the study described here, our objective was to evaluate the immunological bases of the protective and nonprotective responses induced by these treatments. For this purpose, given the importance of innate immunity against cryptococcosis and the central role of peritoneal cells in our model, due to the fact that it is in peritoneum where the first contact between the yeast and the host immune system is produced, we studied the activation state of adherent peritoneal cells induced by different treatments, before fungal challenge, which could be responsible for the protection or exacerbation of cryptococcal infection reported previously (8).     

Recording of high V1-V3 precordial leads may be essential to the diagnosis of Brugada syndrome during the ajmaline test

Sodium channel-blocking agents are routinely used to unveil the Brugada syndrome in patients in whom the typical electrocardiographic pattern is absent or doubtful. In this article, the authors report a patient with syncopal episodes of unknown origin in whom the conventional electrocardiographic result was normal and a negligibly small "saddle back" type repolarization was present in lead V2 recorded 2 intercostal spaces above the conventional site. Intravenous ajmaline (50 mg) did not elicit the type 1 pattern of the Brugada syndrome in the precordial leads obtained at their usual level, but a clear-cut coved-type repolarization was apparent in high right precordial leads. These findings indicate that high precordial leads should be routinely recorded while assessing the ajmaline test in patients suspected of having the Brugada syndrome.