Meta-analysis of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer.

BACKGROUND: Women with breast cancer are more frequently being treated with preoperative neoadjuvant chemotherapy. The reliability of sentinel lymph node biopsy (SLNB) following chemotherapy has not been determined. This was a meta-analysis of studies that examined the results of SLNB after preoperative chemotherapy. METHODS: Included articles had to meet two criteria. First, patients had to have had operable breast cancer and to have undergone SLNB after preoperative chemotherapy and, second, patients had to have undergone subsequent axillary lymph node dissection. Meta-analyses were performed in which Bayesian hierarchical models were created to estimate the identification rate (IR) and sensitivity of SLNB in this setting. RESULTS: Twenty-one studies were identified that included a total of 1273 patients. The IRs reported ranged from 72 to 100 per cent, with a pooled estimate of 90 per cent. The sensitivity of SLNB ranged from 67 to 100 per cent, with a pooled estimate of 88 (95 per cent confidence interval 85 to 90) per cent. Meta-analyses performed using Bayesian modelling resulted in (posterior) estimates for IR and sensitivity of 91 (95 per cent credible interval 88 to 94) and 88 (95 per cent credible interval 84 to 91) per cent respectively. CONCLUSION: SLNB is a reliable tool for planning treatment after preoperative chemotherapy.

A pilot study for a screening trial of cervical fluorescence spectroscopy.

Fluorescence spectroscopy is a promising technology for detection of epithelial precancers and cancers. In preparation for a multicenter phase II screening trial, a pilot trial was conducted to test data collection and patient examination procedures, use data forms, time procedures, and identify problems with preliminary data analysis. Women 18 years of age and older underwent a questionnaire, a complete history, and a physical examination, including a pan-colposcopy of the lower genital tract. A fiber-optic probe measured fluorescence excitation-emission matrices at 1-3 cervical sites for 58 women. The data collection procedures, data forms, and procedure times worked well, although collection times for all the clinical data take an average of 28 min. The clinical team followed procedures well, and the data could be retrieved from the database at all sites. The multivariate analysis algorithm correctly identified squamous normal tissue 99% of the time and columnar normal tissue only 7%. The assessment of ploidy from monolayer samples was not accurate in this small sample. The study was successful as a pilot trial. We learned who participated, who withdrew, how often abnormalities were present, and that algorithms that have worked extremely well in previous studies do not work as well when a few study parameters are changed. The current algorithm for diagnosis identified squamous normal tissue very accurately and did less well for columnar normal tissue. Inflammation may be an explanation for this phenomenon. Fluorescence spectroscopy is a promising technology for the detection of epithelial precancers and cancers. The screening trial of fluorescence and reflectance spectroscopy was successful.

A new carbon monoxide occupational dosimeter: results from a worker exposure assessment survey.

The LBNL/QGI occupational carbon monoxide (CO) dosimeter (LOCD), a new, inexpensive CO passive sampler, was field-validated in an occupational exposure assessment study in the Moscone Convention Center (MCC) in San Francisco, CA in January, 1997. The LOCD measures time-weighed-average (TWA) CO exposures from 10 to 800 parts per million hours (ppm h; accuracy +/- 20%; precision 10 ppm h). This device represents a major improvement over currently available low-cost personal CO monitors. At the MCC, over 1000 workers set up and remove exhibitions. Forty propane-powered forklifts moved materials throughout the 42,000 m2 of exhibit halls. Diesel truck emissions enter the building via three internal underground loading docks. The LOCD was used to measure 154 worker exposures on 3 days. Sampler performance was compared to a standard method at 15 fixed sites. The geometric mean (GM) of all 154 exposures was 7 ppm (geometric standard deviation (GSD) = 1.6); 10% of the exposures was 10 ppm or more. Dock Walkers and Forklift Operators had the highest exposures (maximum = 34 ppm) with GM (GSD) of 9 (1.7) and 9 (1.6) ppm, respectively. Attendants and Installer/Decorators had the lowest exposures with GMs of 6 (1.6) and 7 (1.4), respectively. The Cal/OSHA personal exposure limit for CO is 25 ppm time-weighted average (TWA).

Patient self-assessment of tibial plateau fractures in 40 older adults.

This retrospective study examined the outcome of 40 patients 50 or more years of age treated between September 1988 and September 1993 for tibial plateau fractures. Our analysis was based on a review of the medical records of all patients as well a patient self-assessment questionnaire. The 22 women and 18 men studied had a mean age of 60 (range, 50 to 76 years) at the time of injury. A satisfactory overall outcome (based on patients' self-assessment) was observed in only 14 (35%) of the 40 cases. Unsatisfactory outcomes were observed in 23 (72%) of 32 cases treated operatively and 3 (38%) of 8 cases treated nonoperatively. No significant difference in outcome was observed between the 27 patients with AO type B fractures and the 13 patients with AO type C fractures. Similarly, no significant difference in outcome was observed in patients with fractures involving the lateral plateau only, those with fractures involving the medial plateau only, and those with bicondylar fractures. There was no significant relationship between the adequacy of fracture reduction and overall clinical outcome, although a trend of more favorable outcomes was noted in patients with excellent or satisfactory reductions. The results suggest that patients of 50 or more years of age have a high rate of unsatisfactory clinical outcomes regardless of how their tibial plateau fractures are treated.

Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty.

A hospital-based computer system was used to compare the inpatient costs of performing bilateral simultaneous sequential, staged, and unilateral total hip and knee arthroplasties. Bilateral simultaneous sequential total knee arthroplasty was 36% less costly than 2 unilateral total knee arthroplasties. Bilateral simultaneous sequential total hip arthroplasty saved 25% over the costs of performing 2 unilateral hip arthroplasties. Prosthetic costs range between 28% and 43% of the total costs of hospitalization. There was a significant correlation between hospital length of stay, morbidity, and total costs, but no correlation with patient age and sex except in the unilateral knee patients. Bilateral simultaneous sequential joint arthroplasty can save more than $10,000 for each total knee patient and more than $8,000 for each total hip patient.

Alcohol and drug use in adult patients with musculoskeletal injuries.

This study reviewed trauma registry data for information on the prevalence of alcohol and drug use in adult patients with fractures and dislocations admitted to Hermann Hospital, Houston, Texas, from January 1992 to December 1994. Of the 1776 adult patients aged 18 years or older, 1126 (63%) were tested for blood alcohol concentration, and 873 (49%) had their urine screened for a panel of 58 drugs. Of the patients tested, 467 (41%) had positive blood alcohol concentrations, and 335 (30%) were legally intoxicated (blood alcohol concentration > or = 0.10%). Of the patients providing urine specimens, 191 (22%) had samples that were positive for one or more drugs. Overall, 9% of the patients tested were positive for both alcohol and drugs, and 54% were positive for either alcohol or drugs. The highest prevalence of alcohol use was in patients aged 21 to 33 years, and men were intoxicated more often than women. Alcohol use was more commonly associated with motor vehicle accidents, pedestrian or bicycle accidents, and gunshot wounds; intoxification was associated with a higher incidence of tibia fractures. The average injury severity score was higher, the duration of stay was longer, and total hospital charges were higher for the alcohol-positive group. Patients testing positive for alcohol or drugs were more likely to lack insurance coverage.

Comparison of general and epidural anesthesia in patients undergoing primary unilateral THR.

One hundred ninety-five consecutive patients underwent 195 primary unilateral total hip arthroplasties between January 1988 and December 1993. Patients were divided into three groups based on the type of anesthesia utilized for their procedure. Group I consisted of 108 patients (59 women and 49 men; average age 56 years) who had general endotracheal anesthesia alone. Group II consisted of 70 patients (41 women and 29 men, average age 58 years) who had general endotracheal anesthesia with epidural augmentation intraoperatively and postoperatively. Group III consisted of 17 patients (6 women and 11 men, average age 62 years) who had epidural anesthesia only. Data were analyzed by anesthesia group to compare a variety of clinically relevant factors. No statistically significant differences among groups were noted regarding average age at surgery, the underlying diagnoses leading to joint replacement, the number of preexisting medical conditions, length of hospitalization, nonsurgical operating room time, intraoperative blood transfusions, intraoperative femur fractures, deep venous thrombosis, deep infections, death, or the prevalence of postoperative urinary tract infections. Postoperative urinary tract infections correlated with duration of Foley catheterization, but not the duration of epidural catheterization. Significant differences among anesthesia groups were observed for two factors: 1) estimated intraoperative blood loss was highest for Group I (P < .05) and was primarily a function of surgical time (P < .0001), and 2) postoperative Hemovac output (over the first and second postoperative 24-hour periods) was greatest for Group II (P < .05). Epidural anesthesia appears to be a safe modality in patients undergoing primary unilateral total hip replacement.

Primary noncemented total hip arthroplasty in patients with ankylosing spondylitis. Clinical and radiographic results at an average follow-up period of 6 years.

Twenty consecutive primary noncemented total hip arthroplasties performed on 12 men with ankylosing spondylitis were available to be studied clinically and radiographically at an average follow-up period of 75 months (range, 27-121 months). The average patient age at the time of surgery was 35 years (range, 23-53 years). Harris hip scores averaged 48.4 before surgery and 89.1 at the most recent follow-up examination. Significant improvements in pain, function, and range of motion were observed following total hip arthroplasty. No hip has required a surgical revision or reoperation. Heterotopic ossification was observed in 6 of 14 hips (43%) in the ankylosing spondylitis patients who had not had any perioperative prophylaxis for heterotopic bone formation. By contrast, 43 of 49 hips (88%) demonstrated heterotopic bone formation in a well-defined control group of 45 men with other diagnoses undergoing the same procedure by the same group of surgeons at the same institution. During the same period using the same implants. A thorough review of the literature and data from the institution does not support the notion that ankylosing spondylitis patients are necessarily predisposed to form heterotopic ossification. The use of routine perioperative prophylaxis for heterotopic ossification may not be warranted in all patients with ankylosing spondylitis undergoing routine primary noncemented total hip arthroplasty.

Demographic biases found in scoring instruments of total hip arthroplasty.

Four hip scoring systems were used in evaluating 200 adult subjects who had no prior history of injury, pathologic condition, or treatment of the hips, knees, lower extremities, or spine. All subjects were in the age range typical of a total hip arthroplasty candidate (average age, 65 years; range, 50-100 years). In addition to a physical examination, complete demographic data were collected on each subject. Data were recorded on standardized flow sheets so that hip scores could be calculated; scores were normalized by dividing the observed scores by the maximum possible score. The average normalized total hip scores were Harris hip score, 90.8%; modified Harris hip score, 91.9%; Merle D'Aubigne score, 93.9%; and Hospital for Special Surgery hip rating 87.5%. Demographic variables that had a significant negative correlation with hip scores included advanced age (particularly past age 85), an income below the poverty level, and the presence of two or more major medical conditions. Differences in hip scores between different study groups that have not been matched for various clinically relevant factors ("case mix") are at least as likely to represent differences in the patient populations as differences in surgical technique or implant design. Hip scores may decline over the course of a 10- to 20-year follow-up period due to the change in a patient's age and/or medical condition rather than any factor relating to the hip arthroplasty.

Inpatient cost of primary total joint arthroplasty.

The financial and medical records of 98 patients undergoing either primary total hip or total knee arthroplasty were analyzed to determine the inpatient cost of their surgery. Eleven patients were excluded, leaving a total of 87 patients available for analysis who underwent 50 primary total hip and 37 primary total knee arthroplasties. Ten separate cost centers such as implant, anesthesia/operating room, nursing/hospital room, physical therapy, and laboratory were included in the evaluation. Correlations between total cost and demographic parameters such as patient sex, age, and length of stay were determined. Seventy-six percent of the inpatient cost of all total joint procedures consisted of implant, anesthesia/operating room, and nursing/hospital room costs. Reductions in the cost of these components represent a potential for cost containment. The strongest correlate for total cost was hospital length of stay (P < .0005). Unfortunately, there is evidence that length of stay has reached a plateau and cannot be reduced further without affecting the quality of care and the incidence of complications.

Comparison of febantel tablets and Vercom paste against gastrointestinal nematodes of dogs.

Thirty adult dogs with naturally acquired gastrointestinal nematode infections were assigned at random to ten replicates and treated daily for 3 days with either a combination febantel/praziquantel (Vercom) paste, febantel tablets or placebo tablets. Numbers of hookworm and whipworm eggs after treatment were reduced similarly for both drug formulations when compared with pretreatment egg counts, whereas these counts increased in the controls. Vercom paste reduced the hookworm egg count by 99.9% and the whipworm egg count by 99.6%. The febantel tablet decreased the hookworm egg count by 99.9% and the whipworm egg count by 100%. As determined at necropsy, the controlled test efficacy against adult hookworms and whipworms was similar for the Vercom paste and the febantel tablets. The controlled test efficacies of Vercom paste against Ancylostoma caninum, Ancylostoma braziliense, and Trichuris vulpis were, respectively, 99.7%, 100% and 95.8% and those of febantel tablets were 98.2%, 100% and 99.7%. These results indicate that the nematocidal efficacy of febantel against these nematodes remains unchanged in these two formulations. No adverse reactions to either febantel tablets or to Vercom paste were observed.

Resonance Raman studies on the blue-green-colored bovine adrenal tyrosine 3-monooxygenase (tyrosine hydroxylase). Evidence that the feedback inhibitors adrenaline and noradrenaline are coordinated to iron.

Tyrosine 3-monooxygenase (tyrosine hydroxylase) is a non-heme iron, tetrahydropterin-dependent enzyme which catalyzes the rate-limiting step in the biosynthesis of catecholamines. The highly purified bovine adrenal enzyme contains an unusual blue-green chromophore with lambda max at around 700 nm (epsilon = 1.3 (mM subunit enzyme)-1 cm-1). On excitation at 605.2 nm, resonance-enhanced Raman vibrations are observed at 454, 494, 527, 604, 635, 835, 1130, 1271, 1320, 1426, and 1476 cm-1. The excitation profiles of the modes of 1276 and 1476 cm-1 (from 488 to 620 nm) follow the contour of the 700 nm absorption band. The vibrations observed strongly indicate the presence of a bidentate catecholamine-Fe(III) complex in the enzyme as isolated which gives rise to the characteristic charge-transfer transitions. This is further supported by the release of 0.11 +/- 0.04 mol of noradrenaline and 0.25 +/- 0.06 mol of adrenaline per mol of enzyme subunit on denaturation of the enzyme. The energies of the catecholate to Fe(III) charge-transfer transitions indicate a mixture of histidines and carboxylate(s) coordinated to the iron center in tyrosine hydroxylase. At neutral pH, the enzymatic activity was inhibited more than 50% by 10 microM dopamine, noradrenaline, and adrenaline. The high affinity of the catecholamines to the nonphosphorylated form of tyrosine hydroxylase may have significance in vivo since catecholamines are potent feedback inhibitors of the enzyme.

Anthelmintic efficacy of febantel combined with praziquantel against Ancylostoma tubaeforme, Toxocara cati, and Taenia taeniaeformis in cats.

Forty cats, each harboring 2 or 3 parasitic infections (Ancylostoma tubaeforme, Toxocara cati, and/or Taenia taeniaeformis), were used to titrate the anthelmintic efficacy of a paste containing 3.4% febantel and 0.34% praziquantel. The cats were allotted into 4 groups (10 cats/group). For 3 consecutive days, the cats were given febantel/praziquantel at 5/0.5 mg/kg/day, 10/1 mg/kg/day, 15/1.5 mg/kg/day, or a blank paste vehicle (control) at 0.29 g/kg of body weight. The recommended dosage of 10 mg of febantel and 1 mg of praziquantel/kg cleared greater than or equal to 98% of the 3 helminth species.

Toxicology studies conducted in laboratory animals and cattle with coumaphos flowable formulation.

A new flowable formulation containing coumaphous, an organophosphate compound, will be used as an insecticide on cattle. It was evaluated for human and cattle safety. The oral LD50 for female rats was 37 mg of formulation/kg and the dermal LD50 for male rabbits was 500 mg/kg. The inhalation LC50 in female rats was 303 micrograms/L. Dermal sensitization in guinea pigs or eye irritation in rabbits were not observed. The formulation was a mild dermal irritant on rabbits, but the erythema reversed itself within 7 days. Spray safety evaluations in cattle included a single application, 2 treatments at 14 day interval, and 2 treatments at 28-day intervals with both 0.5 (highest label rate) and 2.5% (5X) concentrations. Dip vat treatments of cattle included 2 applications at a 7-day interval in 0.3% (highest label rate) and single applications with 0.6% (2X) and 1.2% (4X) concentrations. The cattle did not show significant clinical signs of toxicity nor did trends develop in clinical pathology. The lowest whole blood cholinesterase mean value for cattle sprayed once with a 0.5% concentration was 80% of the pretreatment value at 14 days post-treatment. The cattle receiving 2 dip vat treatments of a 0.3% concentration at a 7 day interval had their lowest cholinesterase reading (53% of pretreatment value) 10 days after the second treatment. Cholinesterase depression in cattle receiving higher than use rate treatment was related to the concentration applied.

Efficacy of praziquantel against immature Echinococcus multilocularis in dogs and cats.

Efficacy of an injectable formulation of praziquantel (given IM at a dosage of 5 mg/kg of body weight) against immature Echinococcus multilocularis was studied in 18 experimentally infected dogs and 22 experimentally infected cats. There were no worms recovered at necropsy from any of the treated hosts. However, whereas E multilocularis worms were recovered from all nontreated control dogs (n = 9; min-max 15-1,840, mean 483), such tapeworms were recovered from only k6 of the 11 nontreated control cats (min-max 2-820; overall mean 123.4). The study demonstrates 100% clearance of E multilocularis by praziquantel in experimentally infected dogs and cats, and shows that cats are not as suitable as experimental hosts for this parasite as are dogs.

Praziquantel for control of Hymenolepis nana in mice.

Praziquantel was blended into ground mouse feed at 35, 70, and 140 ppm in one replicate and at 140, 210, and 280 ppm in a second replicate. Mice naturally infected with Hymenolepis nana were provided this diet for 7 consecutive days. Reduction of Hymenolepis nana in mice receiving medicated feed when compared to mice receiving nonmedicated feed was 48.9, 73.2, and 87.1%, respectively in replicate 1, and 100% in all three groups in replicate 2. These data suggest that praziquantel blended into the feed at 140 ppm for 7 consecutive days will provide efficacious (87.1-100%) control of Hymenolepis nana in mice. Higher dosages may be necessary for complete elimination of this parasite.