Resolution of late-developing periprosthetic breast infections without prosthesis removal

Based on prior experience with implant exposure, an aggressive regimen to eradicate periprosthetic infections has proven successful in delayed gram-positive and gram-negative bacterial infections and in atypical microbacterial infections. The objective of the salvage procedure is to retain a prosthesis, to maintain breast contour, and to avoid psychological and physical consequences of prosthesis removal. The salvage procedure involves topical antisepsis, contracture release if needed, systemic and topical antibiotics with intermittent or continuous irrigation, and reinforcement of incision lines in selected cases using local tissue flaps.     

Clinical pharmacology of oral and intravenous 4-demethoxydaunorubicin

Summary The clinical pharmacology of 4-demethoxydaunorubicin (4-DMDNR) was studied in 28 patients with advanced breast cancer, using a sensitive reverse-phase HPLC technique. All patients had normal renal and hepatic function. The serum levels of 4-DMDNR after a single i.v. bolus injection followed a triple exponential decay curve (T1/2=9.6 min, T1/2=3.2 h and T1/2=34.7 h) and conformed to a three-compartment model. Comparison of the area under the curve (AUC) and urinary excretion for the oral and i.v routes suggests an oral bioavailability of approximately 24%. In patients treated with a schedule of weekly oral administration for periods of up to 12 months there was no significant alteration in either AUC or elimination half-life for the parent drug or its principal metabolite 13-OH4DMDNR. Moreover, there was no evidence of accumulation of the metabolite although measurable amounts were present 7 days after administration of 4-DMDNR.This work was supported by the Cancer Research Campaign and Farmitalia Carlo Erba Ltd     

The radiologic "lead band" revisited

After prolonged heavy metal exposure (e.g., lead) "lead bands" develop at the metaphyseal ends of growing bones. These "lead bands," while a constant finding, are used as additional laboratory evidence to diagnose plumbism. In this study, the role of the proximal fibula in distinguishing physiologic sclerosis from pathologic thickening of the zone of provisional calcification is assessed. In addition, laboratory values are compared to radiographic findings in a controlled fashion to establish levels at which "lead bands" appear. The former is a useful adjunct in the radiographic diagnosis of plumbism, while the minimum blood levels at which "lead bands" are seen is much lower than previously described.     

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England,Wales, Northern Ireland,and the Isle of Man

BackgroundTo determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates.MethodsUsing National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs.ResultsTen-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases.ConclusionUKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.     

Making the (Business) Case for Clinical Ethics Support in the UK

HEC Forum - This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when...     

Comparative pharmacokinetics of escalating doses of doxorubicin in patients with metastatic breast cancer

Summary Recombinant human granulocyte colony-stimulating factor (G-CSF) has been shown to reduce neutropenia following cytotoxic therapy, thereby enabling dose escalation to improve the response rate. It is important to know whether drug kinetics change as doses are increased. Doxorubicin was selected because of its broad spectrum of activity and its known efficacy in metastatic breast cancer. Doses of 75, 100, 125 and 150 mg/m² were given to 11 patients with metastatic breast cancer by infusion over 30 min. Serum concentrations of parent drug and metabolites were determined during the first 48 h following the infusion by high-performance liquid chromatography (HPLC). The serum concentration vs time curve decayed as a triple exponential function in four patients and as a double exponential function in seven. A four-compartment model, one central and three peripheral, would predict concentrations to within 1 SE of the observed values. Doxorubicinol was the principal metabolite, and doxorubicinone and 7-deoxydoxorubicinone were clearly identified. There was a linear increase in the AUC with dose. In addition, a small and transient increase in circulating levels of doxorubicinol and other important metabolites was observed 6 h following the administration of doxorubicin, which suggests the existence of an enterohepatic, or other, re-circulation mechanism. We conclude that in the dose range selected the kinetics of doxorubicin are linear and that the increase in toxicities seen with the higher doses of doxorubicin, following the second and third fortnightly administration, may be due to intracellular drug accumulation in tissues.     

Critical success in management development

Details the results of an attempt to identify the impact of a comprehensive management development programme on organizational effectiveness within the health service public sector. Concludes that management development programmes must have a prespecified set of strategically linked outcomes, identifying the benefits to the organization, and a set of critical success factor measures to determine their achievement or otherwise. Programmes which do not result in managers feeling empowered will be criticized in not impacting positively on the organization.     

Economics 101: exploring the land of costs

The word "cost" is a slippery, chameleon-like beast that changes its meaning to suit the occasion. The author's "economish" dictionary will help you survive the purchasing jungle.