Nalbuphine analgesia in the prehospital setting

Forty-six patients with moderate to severe pain caused by orthopedic injuries, burns, multiple trauma, or intraabdominal conditions were treated with intravenous (IV) nalbuphine hydrochloride (Nubain; DuPont Pharmaceuticals, Wilmington, DE) by paramedics before arrival at the hospital. Patients who weighed less than 60 kg received 15 mg nalbuphine, and patients weighing greater than 60 kg received 20 mg nalbuphine. Forty-one of 46 patients (89%) experienced pain relief from nalbuphine, with maximum relief occurring within 15 minutes after the administration of the drug. Two addicted patients received no pain relief. There were no untoward side effects following nalbuphine administration, and the patients' heart rates, mean arterial pressures, and respiratory rates remained constant and stable throughout the study period. Repeated assessment of the patient by paramedics in the field was not impaired by nalbuphine treatment. In summary, nalbuphine hydrochloride is a useful and safe analgesic drug for IV use by paramedics in the prehospital setting.     

Impact and Outcomes of Routine Microstaging of Sentinel Lymph Nodes in Breast Cancer: Significance of the pN0(i+) and pN1mi Categories

Background  In 2003, the American Joint Committee on Cancer (AJCC) initiated the 6th edition staging criteria, including pN0(i+) and pN1mi categories for breast cancer. However, the clinical significance of these categories is debated in the literature. Methods  A prospective registry was used to identify patients staged with sentinel lymph node (SLN) biopsy. SLN evaluation included routine serial sectioning and immunohistochemical stains. SLN biopsies performed before January 2003 were restaged according to the AJCC’s 6th edition criteria. Results  Of 954 SLN biopsies identified, on review, 491 N0i-, 86 N0i+, 73 N1mi, 146 N1a, 29 N2a, and 11 N3a patients were available for analysis with a median follow-up of 45.4 months. Significant prognostic and therapeutic differences existed between the groups. Differences in overall survival (OS) and recurrence-free survival (RFS) were only noted when the size of the metastases reached the N1a level. There were no statistically significant differences in OS or RFS between N0(i−) and N0(i+) or N1mi disease. Cases that were N0(i+) or N1mi were more likely to have other poor prognostic factors and to receive more aggressive therapy. Conclusion  SLN biopsy allows a more sensitive evaluation of lymph nodes for metastatic cells. This has led to the increased identification of very small axillary metastases. While the new microstaging categories are not yet clearly associated with a significantly decreased OS or DFS in this series, they are associated with other poor prognostic factors and more local/regional and systemic therapy. Further analysis of the microstaging categories is needed.     

Bilaterality and recurrence rates for lobular breast cancer: Considerations for treatment

Background: The purpose of this study was to evaluate the tumor biology with respect to bilaterality and recurrence rates for bilateral infiltrating lobular (IL) breast carcinoma in comparison with other histological types. Methods: A prospectively accrued data base containing 1,548 breast cancer cases as well as H. Lee Moffitt Cancer Center's cancer registry compiled during the same period were queried for specific features relating to bilaterality and recurrence. The 116 patients in this study had been treated at the Comprehensive Breast Cancer Clinic and had documented bilateral breast cancer (invasive in situ). Results: Eighty-two of the patients (70.7%) had metachronous breast cancer, and 34 (29.3%) had synchronous cancer. Although median follow-up times were short, the risk of developing breast cancer in the contralateral breast after the diagnosis of cancer in the ipsilateral breast was estimated to be 0.7% per patient-year of follow-up. Recurrence rates for IL cancers were compared with those for invasive ductal (ID) and for ID + IL cancers. IL cancers recurred 8.1% of the time, whereas ID cancers recurred at a rate of 7.8%. Recurrences were equally divided between local and distant sites. Conclusions: Although IL cancers have demonstrated insidious behavior, their incidence of bilaterality is only slightly higher than other histologies and their rates of recurrence are low when properly evaluated and treated. The risk to the opposite breast also appears to be low. These data do not support the routine use of blind contralateral biopsy or prophylactic mastectomy.     

Postoperative Performance of the Quartet® Left Ventricular Heart Lead

Promote^® Q CRT‐D and Quartet^® LV Lead Study . Introduction: The Quartet^® left ventricular (LV) lead is the first with 4 pacing electrodes (tip and 3 rings) that enables pacing from 10 different pacing vectors. Postoperative performance of this lead was evaluated in a prospective, nonrandomized, multicenter IDE study. Methods: Patients with standard indications for CRT‐D were enrolled. Electrical performance and presence of phrenic nerve stimulation (PNS) were assessed during pacing from each of 10 vectors at predischarge (within 7 days), 1 month, and 3 months postimplant. Results: The Quartet LV lead was implanted successfully in 170 patients (95.5% implant success rate, 68 ± 11 years, 68.5% male, LVEF: 25 ± 7%, NYHA class III: 98.3% and class IV: 1.7%). Mean follow‐up was 4.7 ± 1.9 months. Capture threshold and impedance for each of the 10 LV lead pacing vectors remained stable during follow‐up. LV lead dislodgement occurred in 6 (3.5%) patients and PNS was observed in 23 (13.5%) patients. PNS was resolved noninvasively in all 23 (100%) patients, either by reprogramming to pace from the additional LV lead pacing vectors alone (13 pts, 56.5%), reprogramming to pace from the additional LV lead pacing vectors and reprogramming pacing output (4 pts, 17.4%), or by reprogramming pacing output alone (6 pts, 26.1%). Conclusions: The Quartet LV lead electrical performance was stable and was associated with a high implant success and low dislodgement rate during 3‐month follow‐up. In all patients with PNS, the 10 pacing vectors combined with reduced output programming enabled the elimination of PNS noninvasively. (J Cardiovasc Electrophysiol, Vol. 24, pp. 449‐456, April 2013)     

Anthralin Therapy for Alopecia Areata

Abstract: Topical anthralin application producing a brisk irritant contact dermatitis has been reported to have therapeutic benefit in alopecia areata. A pilot clinical study was undertaken to determine whether topical anthralin application in doses low enough to produce only minimal contact dermatitis would produce a similar therapeutic response. None of the patients in the study received any benefit from this low-dose regimen. If anthralin is of benefit in the therapy of alopecia areata, a significant irritant contact dermatitis is apparently required.