Axillary Reverse Mapping: A Prospective Study in Women with Clinically Node Negative and Node Positive Breast Cancer

Background

The primary aim of axillary reverse mapping (ARM) is to prevent lymphedema by preserving arm versus breast axillary lymphatics. Concerns regarding feasibility and oncologic safety have limited the adoption of the technique. This prospective study was undertaken to investigate ARM in clinically node negative and node positive breast cancer patients.

Methods

A total of 184 patients underwent 212 ARM procedures: 155 sentinel lymph node biopsies (SLNB) without axillary lymph node dissection (ALND) (group 1) and 57 ALNDs with/without SLNB (group 2). ARM lymphatics were not preserved if they were a SLN, directly entered a SLN, or were within ALND boundaries during ALND.

Results

SLN with radioisotope alone was successful in 92 % of procedures (181 of 197). ARM identification was 47 % (73 of 155) in group 1. Criteria were met in 30 % (47 of 155) for preservation, and 25 % (38 of 155) were preserved. Of those who met preservation criteria, 81 % (38 of 47) were preserved. In group 2, ARM identification was 72 % (41 of 57); 7 met criteria for preservation and were preserved. Of the ARM nodes, 10 % (22 of 212) were SLNs (crossover). ARM nodes contained metastatic disease in one crossover and two nonsentinel ARM nodes in clinically node positive patients with N2/N3 disease.

Conclusions

ARM is a feasible technique for identification and preservation of axillary arm lymphatics with an acceptable incidence of SLN crossover. A larger sample size is needed to determine if ARM can reduce the incidence of lymphedema in patients undergoing SLNB alone and to confirm the absence of ARM metastases in clinically node negative patients undergoing ALND.     

Multi-society guideline for reprocessing flexible gastrointestinal endoscopes

Summary  Flexible gastrointestinal endoscopy is a valuable diagnostic and therapeutic tool for the care of patients with gastrointestinal and pancreaticobiliary disorders. Compliance with accepted guidelines for the reprocessing of gastrointestinal endoscopes between patients is critical to the safety and success of their use. When these guidelines are followed, pathogen transmission can be effectively prevented. Increased efforts and resources should be directed to improve compliance with these guidelines. Further research in the area of gastrointestinal endoscope reprocessing should be encouraged. The organizations that endorsed this guideline are committed to assisting the FDA and manufacturers in addressing critical infection control issues in gastrointestinal device reprocessing.     

Predictors of Treatment Outcomes for Substance-Abusing Women: A Retrospective Study

This study examined whether client characteristics at admission predict Retention, Abstinence, and utilization of Required Services and Specialized Services for pregnant women in outpatient and residential substance abuse treatment. Retrospective data were collected with the Psychosocial History (PSH), a structured clinical interview that is an expansion of the Addiction Severity Index, designed specifically to assess substance abusing women. The PSH was administered at intake for 183 pregnant women admitted to outpatient (n = 133) or residential (n = 50) treatment. Factor analysis reduced predictors to five factors with composite scores, and multiple regression procedures determined client characteristics that predict treatment outcomes. The findings suggest the complexity of predicting treatment outcomes for pregnant women. Significant predictors were composites of variables that encompassed all aspects of women's personal and family lives including medical and psychiatric needs, family and parenting issues, housing, victimization, and clients' perceived needs for treatment and assistance in all of these areas. The results suggest the need for a holistic approach to substance abuse treatment and continued exploration of a broad range of psychosocial assessments at intake in order to develop substance abuse treatment programs that effectively address multiple aspects of women's lives.     

Early corrective reactions of the leg to perturbations at the torso during walking in humans

The contribution of afferent feedback to the regulation of locomotion in humans is not well understood. Animal experiments have suggested that loading of the leg during the stance phase may enhance the magnitude of extensor burst activity and delay the onset of swing phase. The aim of the present study was to determine whether transient loading of the leg at the end of stance would enhance extensor-muscle activity and delay the onset of swing in walking humans. To test this hypothesis, we applied loads to the hips of subjects so that the load was applied along the long axis of the leg at the end of stance (down-back unsupported, DBU). This resulted in an unexpectedly complex reaction characterised by rapid co-contraction of antagonist pairs of muscles around the ankle and knee and a prolongation of the stance phase. We speculated that the complexity of the reaction was, in part, due to a disturbance in equilibrium. To address this possibility, two additional perturbation paradigms were tested: (1) subjects held a rail during the loading paradigm (down-back supported, DBS), or (2) subjects received only a posteriorly directed perturbation of the hips, which added no additional load to the leg (backward unsupported, BU). As predicted, the DBS perturbation resulted in an enhancement of the ongoing soleus-muscle activity, and the unexpected tibialis anterior burst that was observed during the DBU paradigm was absent. Allowing the subjects to hold a rail substantially reduced the change in the timing of the step cycle observed in the DBU paradigm. The BU perturbation prolonged the stance phase duration and, as expected, resulted in a burst of activity in tibialis activity. This was usually accompanied by a reduction in the ongoing soleus activity. Two important conclusions are drawn from the present study. First, loading of the leg at the end of stance phase enhances the ongoing extensor-muscle activity. We suggest that afferent feedback responding to the increase load supported by the leg leads to rapid enhancement of the active extensor muscles to compensate for the increased load and prevent collapse of the leg. Interestingly, the duration of the stance phase was only marginally increased when loading was applied without a postural disturbance (DBS). Second, posterior perturbation of the centre of mass at the end of stance phase evokes an "automatic postural response" in tibialis anterior. Of particular interest, this evoked postural response can occur simultaneously with an enhanced activation of soleus. This indicates that the DBU perturbation employed in this study elicited two responses, one to prevent the collapse of the leg and the other to stabilise the centre of mass.     

Long-term results of abdominal sacrocolpopexy

OBJECTIVE: Our purpose was to determine the long-term results after abdominal sacrocolpopexy. STUDY DESIGN: Computer-coded procedure logs identified women who had an abdominal sacrocolpopexy performed from 1985 to 1992. Subjects answered a validated, condition-specific symptom questionnaire, a sexual function questionnaire, and a demographic survey. Failures were defined by reoperation or symptoms. The data were analyzed with use of the Student t test and the Fisher exact test. RESULTS: At the time of surgery the subjects (n=38) had a mean age of 59.2 years (range 40-77 years), parity 4.03 (1-9), BMI 26.5 (18.6-40.2), and stage of prolapse 2.56 (0-4). The mean follow-up interval was 13.7 years (10-17 years). The total number of failures was 10 (26.3%), 4 (10.5%) because of reoperation and 6 (16%) because of symptoms. Symptom distress scores were low and similar between failures and successes. Twelve subjects were available for examination and most defects were noted in the anterior wall. CONCLUSION: This long-term outcome analysis of abdominal sacrocolpopexy found the procedure to be durable with a 74% success rate at a mean follow-up of 13.7 years.