Percutaneous microductectomy with a directional vacuum-assisted system guided by ultrasonography for the treatment of breast discharge: experience in 63 cases

Background: Vacuum-assisted devices are becoming a useful tool in the diagnosis and treatment of breast pathology. Recent publications show good results in percutaneous removal of benign lesions.

Purpose: To discuss our experience in percutaneous excision of ductal lesions with a vacuum-assisted, ultrasound-guided directional system.

Material and Methods: From January 2003 to July 2006, 63 patients with pathological nipple discharge and intraductal lesion identifiable on imaging were studied at two reference centers. Percutaneous excision with a vacuum-assisted device was offered as an alternative to surgery.

Results: A total of 71 lesions were diagnosed in 63 patients with a mean age of 52 years. All the patients presented nipple discharge. Mammography was normal in 65 cases (92%). Galactography showed an intraductal lesion in 67 cases (94%). Mean lesion size on ultrasonography was 7.4 mm (2-26 mm). Percutaneous excision was performed in 45 lesions (63%), while surgical excision was indicated in 26 lesions. The histopathological results in the 45 lesions biopsied demonstrated intraductal papilloma in 30 cases, dilated duct with papillomatous projections in 11, ductal ectasia with no papillary lesion in three, and a nonspecific benign result in one. Excision was considered complete in 41 lesions (91%). Clinical signs of discharge were resolved in 39 patients (95% of cases treated percutaneously). Mild complications occurred in four cases.

Conclusion: Percutaneous excision of ductal lesions with an ultrasound-guided, vacuum-assisted device is a safe procedure with high diagnostic and therapeutic value for the management of breast discharge.     

腺苷A1受体对新生鼠离体延髓脑片呼吸节律性放电的影响

目的 探讨腺苷A₁ 受体在基本呼吸节律产生和调节中的可能作用。方法 制作新生大鼠离体延髓脑片标本,主要包含面神经后核内侧区(the medialregion of the nucleus retrofacialis,mNRF),并保留舌下神经根的完整,以改良Kreb’s液灌流脑片,稳定记录舌下神经根呼吸节律性放电(respiratory rhythmical discharge activity, RRDA)。在灌流液中先分别单独给予腺苷A₁ 受体的特异性拮抗剂8-环戊-1,3-二丙基黄嘌呤(8-cyclopentyl-1,3-dipropylxa nthine, DPCPX)和特异性激动剂R-苯异丙基-腺苷(R-phenylisoprpyl-adeno sine,R-PIA);再分别先后给予R-PIA和R-PIA+ DPCPX,观察RRDA的变化,进一步探讨腺苷A1受体对其的调节作用。结果 给予腺苷A₁ 受体拮抗剂DPCPX后,呼气时程和呼吸周期明显缩短,吸气时程和积分幅度未出现显著性变化;给予腺苷A₁ 受体激动剂R-PIA后,吸气时程,积分幅度显著性降低,呼吸周期和呼气时程明显延长,且R-PIA的呼吸抑制作用可部分被DPCPX逆转。结论 腺苷A₁ 受体参于了哺乳动物基本呼吸节律的产生和调节中起着重要的作用。     

Bloody nipple discharge in children: possible etiologies and selection of appropriate therapy

An understanding of underlying causes of bloody nipple discharge (BND) is necessary to be able to advise treatment guidelines of this rare symptom in the pediatric age group. Of 11 patients with 14 breasts that had BND, data regarding age, sex, side and duration of BND, physical examination findings, laboratory values, culture reports, ultrasonography (US) findings, treatment approach, histopathologic details, and outcomes were obtained, and also, literature was reviewed. The patients were between 3 months and 12 years of age. There were six males and five females. The BND was located in the right breast in six patients, in the left in two, and it was bilateral in three. On physical examinations, seven patients had palpable cystic nodules located at the areolar area and three had a diffuse breast enlargement without skin findings. Laboratory investigations showed normal hormone levels in all patients. At US examinations, seven breasts had cystic lesions, three had hypoechoic tissue in the subareolar region, and others had normal US findings. In a girl with positive culture for Staphylococcus aureus, BND resolved after oral antibiotics. Two cases resolved spontaneously, with 6 months and 4 months follow-up periods, respectively. Surgical intervention was performed for the remaining eight patients, and mean time to operation after onset of symptoms was 10 months (range=1–34 months). Histopathologic findings showed that the underlying cause of BND was duct ectasia in five breasts, gynecomastia in three, and fibrocystic change in two. Their follow-up periods ranged between 3 months and 6 years, and no recurrences were observed. Classification of breasts with BND for selecting appropriate therapy on the basis of results of careful physical examination, with an US evaluation in selected cases, is effective, and prevents unnecessary investigations.     

Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom

OBJECTIVE: To compare gestational age at discharge between infants born at 30-34(+6) weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom. DESIGN: Prospective observational cohort study. SETTING: Fifty four United Kingdom, five California, and five Massachusetts NICUs. SUBJECTS: A total of 4359 infants who survived to discharge home after admission to an NICU. MAIN OUTCOME MEASURES: Gestational age at discharge home. RESULTS: The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI -1.2 to 3.0) days earlier in Massachusetts. CONCLUSIONS: Infants of 30-34(+6) weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.     

Length of stay. How short should hospital care be?

BACKGROUND: Reducing length of hospital stay (LOS) is a policy aim for many health care systems and is thought to indicate efficiency. METHODS: A MedLine search was undertaken for articles relating to 'LOS', 'early discharge' or 'patient discharge' between 1983 and 1997 and a selective search was undertaken for material published before 1983. RESULTS: Routine data showed that there were variations in LOS between countries, regions and hospitals. The trends in LOS showed a decrease over time in all regions. Research consistently fails to show an adverse effect on health outcomes of reducing LOS, but there may nevertheless be an ethical or moral minimum LOS. Two recent examples illustrate this. There has been an outcry at some ultrashort stays, for example 'drive-through mastectomy' and 'lunchtime abortion' and these are discussed in the review. CONCLUSIONS: There are a number of reasons for the perceived lack of relationship between LOS and health outcomes. Clearly reducing days of care at the low-intensity end of a hospital stay may not necessarily affect health outcomes. There is a case to be made for tailoring care more exactly to an individual's needs by looking at the actual components of care rather than the place of care--within or outside hospital walls.     

早产儿母亲出院准备度现状及影响因素分析

目的 探讨早产儿母亲出院准备度现状,并分析影响因素,为提高产妇出院准备水平提供参考.方法 选取青岛市3所三级甲等医院NICU早产儿母亲257名,住院期间实施三阶段干预培训母亲照护技能;采用出院准备度量表、领悟社会支持量表、儿科护士与患儿父母伙伴关系量表进行调查,分析影响因素.结果 257名早产儿母亲出院准备度总分83.31±9.44,社会支持总分48.38±5.42,早产儿母亲与护士的伙伴关系总分146.55±15.65.是否具有育儿经验、不同受教育程度的早产儿母亲出院准备度得分差异有统计学意义(P＜0.05,P＜0.01);出院准备度总分与早产儿母亲和护士的伙伴关系、社会支持总分呈正相关(均P＜0.01);育几经验、社会支持水平、伙伴关系水平是早产儿母亲出院准备的主要影响因素(均P＜0.01).结论 医护人员可从影响早产儿母亲出院准备度的主要因素着手,给予早产儿母亲足够的社会支持同时制定策略加强其与护士的伙伴关系,从而提高其出院准备水平.     

To reduce technology prior discharge from intensive care – important but difficult? A grounded theory

Aim: The aim of this study was to provide a deeper understanding of the experience of intensive care staff regarding the reduction in the use of medical technology prior to patients’ transfer from the ICU. Background: The goal of ICU transitional care, provided for intensive care patients before, during and after the transfer from the ICU to another care unit, is to ensure minimal disruption and optimal continuity of care for the patient. To smooth this transition, there is a need to prepare for a less technological environment and therefore also a need for a gradual reduction in the use of monitoring equipment. Method: Group interviews and individual interviews, together with participant observations, were conducted with ICU staff in two hospitals in Sweden. The data were analysed using classic grounded theory. Results: The main concern was the ICU staff’s ambiguity regarding whether and how to reduce the use of medical technology devices. Insecurity about weaning patients from medical equipment combined with a lack of standardized routines made it difficult for staff to reduce the technical support. The core category describes how the ambiguity was solved primarily by ‘prioritizing control’. However, this often caused the ICU staff to use advanced technology while the patients were in the ICU until the ward staff arrived, even if this should have been handled otherwise. Why and how the ICU staff used the strategy of ‘prioritizing control’ is further explained in the categories ‘being affected by cultural/contextual aspects’, ‘searching for guidance and a shared understanding’ and ‘weighing advantages with more v s less technology’. Conclusion: It is important to consider ICU staff ambiguity concerning the reduction in technology and to establish strategies for a safe and structured transitional phase with step‐down procedures in which technology and monitoring is gradually reduced prior to transfer from ICU.     

Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy

AIM: To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge.METHODS: About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study.RESULTS: Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms.CONCLUSION: The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.     

Novel Oscillatory Mechanisms in the Cholinergic Control of Guinea Pig Sino‐Atrial Node Discharge

Oscillatory Mechanisms in Sinus Node Cholinergic Control. Introduction: The role of the oscillatory after‐potential V_os and pre‐potential ThV_os in cholinergic control of discharge was studied in sino‐atrial node (SAN). Methods and Results: A microelectrode technique was used in isolated guinea‐pig SAN superfused in vitro in high [K⁺]_o to visualize V_os and ThV_os. The cholinergic agonist carbachol (CCh) decreased the amplitude and slope of V_os and ThV_os at a time when there was no increase in maximum diastolic potential. The slowing in SAN rate was due to slower and smaller ThV_os that missed intermittently the threshold and occurred gradually later in diastole, but not to a decrease in the intrinsic rate of ThV_os. Eventually, quiescence followed. Larger CCh concentrations quickly induced a hyperpolarization that altogether prevented the occurrence of oscillatory potentials. During CCh washout, ThV_os reappeared and consistently reinitiated discharge. Lower [Ca²⁺]_o also decreased slopes and amplitude of V_os and ThV_os, thereby slowing and stopping SAN discharge, as CCh did. Overdrive temporarily offset the negative chronotropic effects of CCh and of low [Ca²⁺]_o. Cesium (a blocker of hyperpolarization‐activated current I_f) did not abolish CCh inhibitory effects on oscillatory potentials. Conclusions: The cholinergic agonist CCh: (1) slows SAN discharge by decreasing the amplitude of V_os and ThV_os, but not the rate of ThV_os; (2) can cause hyperpolarization that altogether suppresses the oscillatory potentials; (3) is mimicked in its effects by low [Ca²⁺]_o; (4) is antagonized by procedures that increase cellular calcium; and (5) modifies the oscillatory potentials independently of I_f. (J Cardiovasc Electrophysiol, Vol. 22, pp. 71‐80, January 2011)