Interobserver agreement and consensus over the esthetic evaluation of conservative treatment for breast cancer

Twenty-four experts from 13 different countries were asked to evaluate photographs taken of 60 women following conservative breast cancer treatment. The esthetic result of each case was classified as poor, fair, good or excellent. Agreement was evaluated using the kappa (k) and weighted kappa (wk) statistics, for all observers, male and female participants, those younger and older than 50 years, those seeing more than 250 cases a year, and those with previous publications in this area. Consensus was obtained by way of a modified Delphi approach, when more than 50% of participants provided the same classification. In a second round, consensual cases were disclosed and a revised opinion was asked in non-consensual ones. Agreement between all participants was fair (k=0.24, wk=0.37) and remained within the same range (k=0.20-0.31, wk=0.31-0.45) in the subgroups analyzed. First round consensus was obtained in 46 out of 60 cases (77%) and in the second round in 59 out of 60 cases (98%). Evaluation of the esthetic results of conservative treatment for breast cancer is only fairly reproducible when performed by experts working in different geographical areas. Consensus is obtainable if a relatively low threshold of agreement is considered acceptable.     

Brazilian-Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer

BACKGROUND: The University of Washington Quality of Life (UW-QOL) questionnaire is an English-language survey instrument used worldwide to assess the quality of life of patients with head and neck cancer. To be used in other cultures, such instruments require careful translation and psychometric validation in other languages. METHODS: The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients with at least 1 year of disease-free survival after treatment for squamous cell carcinoma of the upper aerodigestive tract, recruited from October 2004 to January 2005 from a tertiary cancer center hospital. Eligible subjects were invited to complete the Portuguese version of the UW-QOL questionnaire during routine clinical consultation and complete it again within 15 days. They also completed a validated Portuguese version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and a questionnaire to evaluate anxiety and depression symptoms (Hospital Anxiety and Depression Scale [HADS]). RESULTS: A Portuguese version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 109 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha [alpha] of 0.744) and test retest reliability (intraclass correlation coefficient [ICC] of 0.882). Construct validity was supported by statistically significant relationships between the SF-36 and HAD questionnaires and the translated UW-QOL questionnaire. CONCLUSIONS: The Brazilian-Portuguese version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid. This version is a valuable tool to evaluate accurately the quality of life of Brazilian patients with head and neck cancer.     

Support Vector Machine Learning Model for the Prediction of Sentinel Node Status in Patients With Cutaneous Melanoma

Background: Currently, approximately 80% of melanoma patients undergoing sentinel node biopsy (SNB) have negative sentinel lymph nodes (SLNs), and no prediction system is reliable enough to be implemented in the clinical setting to reduce the number of SNB procedures. In this study, the predictive power of support vector machine (SVM)-based statistical analysis was tested. Methods: The clinical records of 246 patients who underwent SNB at our institution were used for this analysis. The following clinicopathologic variables were considered: the patient’s age and sex and the tumor’s histological subtype, Breslow thickness, Clark level, ulceration, mitotic index, lymphocyte infiltration, regression, angiolymphatic invasion, microsatellitosis, and growth phase. The results of SVM-based prediction of SLN status were compared with those achieved with logistic regression. Results: The SLN positivity rate was 22% (52 of 234). When the accuracy was ≥80%, the negative predictive value, positive predictive value, specificity, and sensitivity were 98%, 54%, 94%, and 77% and 82%, 41%, 69%, and 93% by using SVM and logistic regression, respectively. Moreover, SVM and logistic regression were associated with a diagnostic error and an SNB percentage reduction of (1) 1% and 60% and (2) 15% and 73%, respectively. Conclusions: The results from this pilot study suggest that SVM-based prediction of SLN status might be evaluated as a prognostic method to avoid the SNB procedure in 60% of patients currently eligible, with a very low error rate. If validated in larger series, this strategy would lead to obvious advantages in terms of both patient quality of life and costs for the health care system.     

Skin infection due to Alternaria species in kidney allograft recipients: report of a new case and review of the literature

A kidney allograft recipient developed a cutaneous infection 29 months after transplantation, due to the dematiaceous fungus Alternaria infectoria on his right forearm and left leg. Since the lesions were too large to be excised, the patient was treated only with systemic itraconazole and a reduction of the immunosuppressive therapy. After 4 months, the lesions were completely healed, and no relapses were observed at follow-up of 22 months. Twenty-seven other cases of cutaneous alternariosis have been described so far in renal transplant recipients. All types of immunosuppressive treatment can be associated with Alternaria infection, for which predisposing factors are jobs with frequent contact with earth, diabetes mellitus and skin trauma. In 70% of cases the infection occurred within the first year after transplantation. More frequently the lower limbs were involved and the lesions were multiple. Alternaria alternata was the commonest causative agent, followed by Alternaria tenuissima,Alternaria infectoria and Alternaria chartarum. The treatment is far from being standardized, but the best results are obtained with the surgical excision of the lesion(s) associated with systemic antifungal therapy. Since relapses are possible, strict control of the patients over time is essential.     

Estimation of the parameters of cardiac function and of blood volume by arterial thermodilution in an infant animal model

BACKGROUND: Experimental studies in adults and in animals have reported that estimation of the intracardiac volumes by arterial thermodilution is a more reliable method of blood volume estimation than pressure measurement. The objective of this study has been to analyze the values of cardiac function and blood volume in an infant animal model using the arterial thermodilution technique. METHODS: A total of 202 measurements of cardiac output were performed by femoral arterial thermodilution in 38 Maryland piglets weighing between 8 and 16 kg, to determine the normal values of blood volume obtained by arterial thermodilution (PiCCO method) in an infant animal model. The following parameters were measured: blood volume [global end-diastolic volume index (GEDVI), total intrathoracic blood index (ITBI), extravascular lung water index (ELWI), systolic volume index (SVI)] and parameters of cardiac and vascular function [systolic volume index (SVI), cardiac function index (CFI), left ventricular contractility (Dp/dtmax), and systemic vascular resistance index) (SVRI)]. RESULTS: The cardiac index, 4.3 +/- 1.2 l x min(-1) x m(2), was within the normal range. The GEDVI, 198 +/- 48.6 ml x m(2), and ITBI, 574.1 +/- 113.4 ml x m(2), were lower than the normal values reported in adults, whereas the ELWI, 16.3 +/- 5.2 ml x kg(-1), was higher. CONCLUSIONS: Intrathoracic and intracardiac volume values obtained by arterial thermodilution are lower than those considered normal in the adult, whereas the extravascular lung water is higher. These values must be taken into account when the PiCCO method is used in small children.     

Construct validity of the incontinence severity index

AIMS: To assess the construct validity of the incontinence severity index (ISI) by testing its correlation with two health-related quality of life measures, the short forms of the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7), in women with urodynamic stress incontinence. MATERIALS AND METHODS: A cohort of 170 women with the urodynamic stress incontinence who underwent corrective surgery completed the ISI, IIQ-7, and the UDI-6 both pre- and post-treatment. We correlated the pre- and post-treatment responses between the ISI, the IIQ-7, the UDI-6 and their subscales. We also assessed the sensitivity of the ISI to change by correlating the percent change in score between the three instruments. The results were analyzed using a non-parametric test of correlation, the Spearman's rho. RESULTS: The ISI scores were generally not well correlated with the pre-treatment IIQ-7 and UDI-6 scores (r < 0.40). The post-treatment scores and percent change from pre- to post-treatment of the ISI, however, were highly correlated with that of the IIQ-7 and UDI-6 (r's > 0.70, P < 0.001). The ISI was most highly correlated with the UDI-6 stress symptoms subscale and most poorly correlated with the UDI-6 obstructive/discomfort subscale. CONCLUSIONS: This study provides valuable insight into the construct validity of the ISI. Evidence of its convergent validity is found in the high correlation with the stress symptoms subscales of the UDI-6, while the poorer correlation with the obstructive subscale provides evidence of its divergent validity. These data also suggest that the ISI is highly sensitive to change seen with treatment.     

Age-related variations of varicose veins anatomy

BACKGROUND: Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age. METHODS: The study included 100 varicose limbs in 82 patients aged < 30 years and 238 limbs in 183 patients aged > 60 years. Veins were designated as saphenous veins (SVs), tributaries of the SVs (STVs), and veins not connected with the SVs (NSVs). Four main anatomic patterns were comparatively evaluated: (1) varicose changes only along SVs, (2) varicose changes along SVs and STVs, (3) varicose changes only in STVs, and (4) varicose changes only in NSVs. RESULTS: SVs were normal in 44% of varicose limbs. In most limbs from young subjects, varicose changes afflicted only SVTs (25%) and NSVs (36%). Varicose SVs were more frequent in the older group (62%) than in younger one (39%) owing to a higher prevalence of limbs with combined SV and STV varicosities (respectively, 59% and 37%). In the older group, varicosities in the STVs were more frequently observed in association with incompetence of the SV trunks. CONCLUSION: The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis.     

A prospective, randomized comparison between the popliteal and subgluteal approaches for continuous sciatic nerve block with stimulating catheters

In this prospective, blinded study, we randomized 56 patients undergoing hallux valgus repair to receive continuous sciatic nerve block using a subgluteal (n = 28) or a posterior popliteal approach (n = 28) with a perineural stimulating catheter. Postoperatively, the stimulating catheter was connected to a patient-controlled analgesia pump with 0.0625% levobupivacaine (basal infusion rate of 3 mL/h, patient-controlled bolus dose of 3 mL, and lockout time of 20 min). Both approaches provided similar postoperative analgesia; however, local anesthetic consumption was larger in the popliteal group (4.9 +/- 1.4 mL/h) compared with the subgluteal group (3.8 +/- 1.1 mL/h; P < 0.05). We conclude continuous postoperative analgesia using stimulating catheters was effective at both injection sites; however, a subgluteal approach reduced the overall amount of local anesthetic.