Surgical treatment of children and youth with congenital melanocytic nevi: self- and proxy-reported opinions

The role of surgery in the management of congenital melanocytic nevi (CMN) is controversial. Data on surgical outcomes and predictors of satisfaction remain scarce. An online survey was employed following worldwide recruitment of youth aged 14–25 years (n = 44) and parents of children ≤ 18 years (n = 249) with CMN to query patterns of treatment and satisfaction with and opinions about the benefits of surgery. In proxy-reports, 121 of 249 (49%) and in self-reports 30 of 44 (75%) participants underwent CMN excision. The most common reasons for surgery were psychosocial determinants, aesthetic improvement, and melanoma risk reduction. The overall satisfaction with surgical management was good, although no predictors for satisfaction could be identified. Higher current age of the child was found to predict decision regret in proxy-reports. Most participants indicated that having a scar is more socially acceptable than a CMN. Opinions differed on whether surgery should be deferred until the child is old enough to be involved in the decision-making process. Whether and when to perform surgery in children with CMN is a multifaceted question. Awareness of common concerns as well as risks and benefits of surgery are essential to ensure critical reflection and balanced decision-making.     

Post-exercise response of the systolic blood pressure in the diagnosis of coronary artery disease: comparison of two exercise methods

We studied 81 angiographically documented coronary artery disease patients and 28 with normal coronary arteries, having paired exercise tests (the Bruce treadmill protocol and the jogging in place test) in order to investigate the value of the ratio of recovery systolic blood pressure to peak exercise systolic blood pressure (postexercise pressure ratio) compared to the classic ST depression. The postexercise pressure ratio was significantly higher in patients with coronary artery disease than in patients with normal coronary arteries for each of the 2 exercise tests (P < 0.001 − P < 0.00001). On the contrary, we obtained significantly lower sensitivities for the pathologic (> ± 2 SD of patients with normal coronary arteries) values of the post-exercise pressure ratio than for the positive electrocardiographic outcome 30% vs 58% (P < 0.00002) and 37% vs 64% (P < 0.0001) as well as lower accuracies 48% vs 63% (P < 0.03) and 52% vs 71% (P < 0.005), respectively.

Thus, we proved that the classic ST depression has much more diagnostic value than the post-exercise pressure ratio and this result is independent of the exercise methodology. Consequently this ratio is not recommended to replace the electrocardiographic exercise criteria.     

Sonobreast: predicting individualized probabilities of malignancy in solid breast masses with echographic expression

To create an individualized predictive tool for the risk of malignancy in solid breast masses, based on echographic and clinical characteristics. Research Ethics Committee approval and informed consent were obtained. This multi-center study included 1,403 solid breast masses prospectively. Each ultrasound feature was analyzed and compared with the definitive diagnosis. The ultrasound results, women's ages and family histories of breast cancer were included in a multivariate logistic regression model. Among the 1,403 lesions included in the study, 1,390 (99.1%) had a conclusive diagnosis: 343 malignant tumors (24.7%), and 1,047 benign masses (75.3%). The odds ratio (and confidence interval) for breast malignancy for each variable included in the model, as calculated by multivariate analysis, were as follows: irregular shape/noncircumscribed margins, 16.02 (7.75-33.09); heterogeneous echo texture, 4.50 (2.42-8.23); vertical orientation (not parallel to the skin), 2.23 (1.04-4.75); anterior echogenic rim, 2.62 (1.09-6.31); posterior shadowing, 2.38 (1.23-4.62); age more than 40 years, 2.19 (1.26-3.81); positive first-degree family history (mother, sister or daughter), 7.50 (2.65-21.18). There was no advantage in including the presence of internal vascularity, presence of thickened Cooper's ligaments or size of the mass, in the model. The predictive tool was named SONOBREAST and it is freely available for medical purposes on the internet site: http://www.sonobreast.com. The probability of malignancy in breast masses can be specified based on their ultrasound features, the woman's age and the family history of breast cancer.     

Risk of malignancy in solid breast nodules according to their sonographic features.

OBJECTIVE: The purpose of this study was to assess the risk of malignancy for each type of sonographic feature in solid breast nodules. METHODS: The study included 304 patients from the Department of Gynecology and Obstetrics of the Federal University of Goiás who had solid breast nodules. A medical trainee, working under the supervision of a preceptor, obtained the sonographic images of the breast, and the features were recorded in a questionnaire. Each sonographic feature was analyzed and compared with the anatomic and pathologic findings after the lesion was excised. RESULTS: Of the 304 patients included in the study, 292 (96%) had a conclusive diagnosis. Among these women, 216 (74%) had benign tumors and 76 (26%) had malignant tumors. The odds ratio of malignancy in breast nodules, as calculated by multivariate analysis, was as follows: lesions without circumscribed margins, 17.02 (95% confidence interval, 5.28-54.90); lesions with heterogeneous echo texture, 7.70 (2.99-19.84); lesions with thickened Cooper ligaments, 15.61 (1.08-225.10); nodules whose anteroposterior dimension was larger than their width, 3.29 (1.09-9.96); those with an anterior echogenic rim, 2.59 (0.80-8.40); and those with posterior shadowing, 1.57 (0.62-4.01). Among the 133 cases that had all the sonographic features of a benign lesion, 3 nodules (2.3%) had a histologic diagnosis of malignant. CONCLUSIONS: Sonography is a diagnostic method that can help establish the differentiation between benign and malignant solid tumors. A lack of circumscribed margins, heterogeneous echo patterns, thickened Cooper ligaments, and an increased anteroposterior dimension can indicate a higher probability of malignancy in solid breast nodules.     

Control of Mycobacterial Infections in Mice Expressing Human Tumor Necrosis Factor (TNF) but Not Mouse TNF

Tumor necrosis factor (TNF) is an important cytokine for host defense against pathogens but is also associated with the development of human immunopathologies. TNF blockade effectively ameliorates many chronic inflammatory conditions but compromises host immunity to tuberculosis. The search for novel, more specific human TNF blockers requires the development of a reliable animal model. We used a novel mouse model with complete replacement of the mouse TNF gene by its human ortholog (human TNF [huTNF] knock-in [KI] mice) to determine resistance to Mycobacterium bovis BCG and M. tuberculosis infections and to investigate whether TNF inhibitors in clinical use reduce host immunity. Our results show that macrophages from huTNF KI mice responded to BCG and lipopolysaccharide similarly to wild-type macrophages by NF-κB activation and cytokine production. While TNF-deficient mice rapidly succumbed to mycobacterial infection, huTNF KI mice survived, controlling the bacterial burden and activating bactericidal mechanisms. Administration of TNF-neutralizing biologics disrupted the control of mycobacterial infection in huTNF KI mice, leading to an increased bacterial burden and hyperinflammation. Thus, our findings demonstrate that human TNF can functionally replace murine TNF in vivo, providing mycobacterial resistance that could be compromised by TNF neutralization. This new animal model will be helpful for the testing of specific biologics neutralizing human TNF.