Recurrent eosinophilic mastitis

Systemic diseases rarely present with manifestations in the breast. Disorders such as sarcoidosis and pyoderma gangrenosum have been described to produce signs and symptoms in the breast. Peripheral eosinophilia is a systemic disease associated with a finite group of conditions including asthma, allergic or atopic disease, collagen vascular disease, and parasitic infection. In addition it has been described in association with several malignancies. A 50-year-old woman with a history of asthma and significant eosinophilia presented with an enlarging breast mass. Complete excision of the mass revealed eosinophilic mastitis. Two years later the patient again presented with a large mass in the same breast. Repeat excision demonstrated the same pathology. The clinical significance of this lesion is important because it presents as an enlarging, painless, dominant mass. Excision is necessary for management and to conclusively rule out malignancy. Its recurrence despite excision to negative margins, however, may indicate that control of the eosinophilia--and possibly the underlying disorder--is important to prevent further recurrence.     

Effect of massage technique on sentinel lymph node mapping for cancer of the breast

Sentinel lymph node (SLN) mapping has substantially changed the nature of surgery for cancer of the breast. Variables such as tracer type, volume, injection site, timing, and surgical experience have all been extensively evaluated. However, little attention has been paid to the technique of massage for SLN procedures. We sought to evaluate the effects of three different massage techniques on mapping success or accuracy of SLN mapping for breast cancer. All lymphatic mapping procedures for breast cancer at our tertiary-care center were performed by three experienced surgeons using both colloid and dye followed by a 5-minute massage. All data pertaining to SLN identification, histopathology, tumor characteristics, and patient demographics were entered into the Breast Care Center database. Consistent and uniquely differing massage techniques classified as resuscitative, buffer, or knead-like were each used by a specific surgeon. The last 25 consecutive cases performed by two surgeons and the last 24 by one surgeon were evaluated. The overall rate of SLN identification was 97 per cent, and the overall accuracy was 98.7 per cent. There was no statistically significant difference in the rate of SLN identification or accuracy between techniques. The proportions of blue-stained SLNs were similar, but the resuscitative technique yielded fewer hot SLNs (Fisher's exact test, P = 0.02). This method also yielded one false negative case. The three different massage techniques yielded a similar number of blue-stained SLNs. The resuscitative technique yielded fewer hot SLNs than the kneading and buffer methods. Our results failed to demonstrate a superior breast massage technique for identifying sentinel nodes. A larger randomized trial is needed to confirm these findings.     

Tissue oxygen monitoring during hemorrhagic shock and resuscitation: a comparison of lactated Ringer's solution,hypertonic saline dextran,and HBOC-201

BACKGROUND: The ideal resuscitation fluid for the trauma patient would be readily available to prehospital personnel, universally compatible, effective when given in small volumes, and capable of reversing tissue hypoxia in critical organ beds. Recently developed hemoglobin-based oxygen-carrying solutions possess many of these properties, but their ability to restore tissue oxygen after hemorrhagic shock has not been established. We postulated that a small-volume resuscitation with HBOC-201 (Biopure) would be more effective than either lactated Ringer's (LR) solution or hypertonic saline dextran (HSD) in restoring baseline tissue oxygen tension levels in selected tissue beds after hemorrhagic shock. We further hypothesized that changes in tissue oxygen tension measurements in the deltoid muscle would reflect the changes seen in the liver and could thus be used as a monitor of splanchnic resuscitation. METHODS: This study was a prospective, blinded, randomized resuscitation protocol using anesthetized swine (n = 30), and was modeled to approximate an urban prehospital clinical time course. After instrumentation and splenectomy, polarographic tissue oxygen probes were placed into the liver (liver PO2) and deltoid muscle (muscle PO2) for continuous tissue oxygen monitoring. Swine were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg over 20 minutes, shock was maintained for another 20 minutes, and then 100% oxygen was administered. Animals were then randomized to receive one of three solutions: LR (12 mL/kg), HSD (4 mL/kg), or HBOC-201 (6 mL/kg). Physiologic variables were monitored continuously during all phases of the experiment and for 2 hours postresuscitation. RESULTS: At a MAP of 40 mm Hg, tissue PO2 was 20 mm Hg or less in both the liver and muscle beds. There were no significant differences in measured liver or muscle PO2 values after resuscitation with any of the three solutions in this model of hemorrhagic shock. When comparing the hemodynamic effects of resuscitation, the cardiac output was increased from shock values in all three animal groups with resuscitation, but was significantly higher in the animals resuscitated with HSD. Similarly, MAP was increased by all solutions during resuscitation, but remained significantly below baseline except in the group of animals receiving HBOC-201 (p < 0.01). HBOC-201 was most effective in both restoring and sustaining MAP and systolic blood pressure. There was excellent correlation between liver and deltoid muscle tissue oxygen values (r = 0.8, p < 0.0001). CONCLUSION: HBOC-201 can be administered safely in small doses and compared favorably to resuscitation with HSD and LR solution in this prehospital model of hemorrhagic shock. HBOC-201 is significantly more effective than HSD and LR solution in restoring MAP and systolic blood pressure to normal values. Deltoid muscle PO2 reflects liver PO2 and thus may serve as an index of the adequacy of resuscitation in critical tissue beds.     

Time to deterioration of the elderly,anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality

BACKGROUND: Generally accepted guidelines regarding the care of the elderly, anticoagulated minor head injury patient do not exist within the trauma literature. METHODS: Charts were reviewed on all anticoagulated, minor head injury patients older than 65 years between January 1993 and May 2000. Postinjury course was examined for neurologic changes, times, coagulation/radiographic studies, reversal, operative intervention, and outcome. RESULTS: Thirty-two patients were identified. Twenty-four patients were discharged from the Emergency Department. Three of the remaining eight patients had initial Glasgow Coma Scale scores of 15, 15, and 14 but became comatose over a mean course of 3.83 hours. A fourth patient presented comatose 6 hours postinjury, down from "acting normal." Three of these four patients died. CONCLUSION: Elderly, anticoagulated patients with minor head trauma risk neurologic deterioration within 6 hours of injury, despite an initially normal neurologic examination. Early cranial computed tomographic scanning and close observation for a minimum of 6 hours are indicated.     

Renal hemodynamic and ureteral pressure changes in response to ureteral obstruction: the role of nitric oxide

PURPOSE: Triphasic changes in renal blood flow and ureteral pressure after unilateral ureteral obstruction have long been known. The contribution of nitric oxide to the decline in renal blood flow and ureteral pressure in unilateral ureteral obstruction was studied in this model using arginine infusion and by studying the effect of 2 inhibitors of nitric oxide synthase (NOS). MATERIALS AND METHODS: Left ureteral obstruction was created in dogs. Renal blood flow and ureteral pressure were monitored. Groups 1 to 4 underwent unilateral ureteral obstruction and group 5 dogs underwent sham operation. Groups 2 to 5 received an infusion of arginine at hour 18 of obstruction that was sustained for 1 hour. In addition, NOS inhibitors were administered to dogs in groups 3 (N-monomethyl-L-arginine) and 4 (triamcinolone diacetate). RESULTS: Arginine administration at 18 hours of obstruction caused a significant increase in renal blood flow and ureteral pressure compared to sham operated animals. Triamcinolone diacetate eliminated the increase in renal blood flow and ureteral pressure, whereas N-monomethyl-L-arginine did not, reflecting the competitive nature of its inhibition of NOS. CONCLUSIONS: Arginine infusion 18 hours after unilateral ureteral obstruction led to increases in renal blood flow and ureteral pressure that were not seen in control animals. These results suggest that the nitric oxide system of the kidney is activated in unilateral ureteral obstruction. Since the addition of arginine is accompanied by an increase in renal blood flow and ureteral pressure, it further suggests that a lack of availability of substrate for NOS may explain the decrease in renal blood flow and ureteral pressure in obstruction. Providing substrate may be a way of maintaining renal blood flow in unilateral ureteral obstruction.     

T-cell compartments of prediabetic NOD mice

Given the importance of the NOD mouse as a model of type 1 diabetes, there is a surprising lack of published information on the overall composition of the thymic and peripheral T-cell compartments. In this study, we revisited some earlier reports of T-cell abnormalities in this strain and examined a number of additional parameters to provide a global view of T-cells in prediabetic NOD mice. In some cases, we concur with past conclusions, but in other important areas, we find that NOD mice closely resemble nonautoimmune strains. Specifically, and contrary to published reports, the thymocyte subset distribution, the rate and composition of thymic export, and the composition of the peripheral T-cell pool, including the proportion of CD25(+)CD4(+) T-cells, are essentially normal in prediabetic NOD mice. These factors are therefore unlikely to be involved in the loss of tolerance that leads to autoimmunity within this strain.     

The Caregiver Vigilance Scale: application and validation in the Resources for Enhancing Alzheimer's Caregiver Health (REACH) project

This article reports on the measurement properties of Caregiver Vigilance, a four-item caregiver self-report of perceived oversight demand for Alzheimer's disease and related disorders family caregiving. The self-report uses data from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) project, a multisite National Institutes of Health (NIH) sponsored study of over 1,200 family caregivers. Results indicate that the items were clearly understood by the racially/ethnically diverse respondents; and, when responses were transformed into a summary scale and analyzed, unidimensionality was evident and internal consistency reliability favorably demonstrated. We suggest using the Caregiver Vigilance Scale in conjunction with traditional burden measures to systematically include the caregiving time associated with protectively watching over care recipients and the daily duration of this responsibility. We also highlight the practical utility of selected items for potential use in the caregiver assessment process.