A multidisciplinary team approach minimises prophylactic mastectomy rates.

BACKGROUND: Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making. METHODS: We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded. RESULTS: Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%). DISCUSSION: MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Hemifacial mass with extensive intralesional ossification and fat.

The imaging appearance of neurofibromas is well described; however, macroscopic fat in a neurofibroma has been sparsely reported and intralesional ossification has only been documented twice in the literature. We describe a diffuse neurofibroma presenting as a hemifacial mass, atypical for the presence of extensive intralesional ossification and fat; the diagnosis was suggested on identification of other associated radiological features of neurofibromatosis.

Isolated left innominate vein aneurysm: a rare cause of mediastinal widening.

Mediastinal widening in an adult is mostly nodal in origin. Occasionally vascular aneurysms may be the underlying cause, in which case the aorta or its branches are most frequently involved. Thoracic venous aneurysms, on the other hand, have been reported only in anecdotes, with fusiform aneurysm of the superior vena cava being the commonest. Isolated aneurysms involving the brachiocephalic/innominate vein are extremely rare. We describe detection of a saccular aneurysm of the innominate vein, as the underlying cause of mediastinal widening seen on a chest radiograph in a 42-year-old asymptomatic woman. The characteristic radiological findings of thoracic venous aneurysms are described with particular reference to the importance of multiplanar computed tomography in such settings. Also discussed is the role of imaging in the diagnosis and guiding the management of this rare entity.

Design of a donor-driven data collection strategy for operational improvement of blood donation process.

BACKGROUND: Prior studies have noted that donor retention may be negatively impacted by the total time it takes to complete the blood donation process. STUDY DESIGN AND METHODS: To gain a comprehensive understanding of the blood donation process and examine opportunities for operational improvements, an educational partnership established between a blood bank and a university designed and implemented a donor-driven data collection strategy. RESULTS: A large amount of real-time, comprehensive, donor-reported data was collected as donors navigated the process, which has enabled a thorough analysis of the process and its potential improvements. CONCLUSION: In this paper, we describe the design and implementation efforts, examine the challenges in operationalizing a donor-driven data collection approach, and present insights and recommendations for its application in similar settings.

Multiple intracranial tubercular abscesses in a child.

2 Year old girl presented with fever and cough for 4 months. Neurological examination revealed right sided hemiplegia. Contrast enhanced computed tomography of brain showed multiple hypodense ring enhancing lesions. Pus on aspiration of intracranial abscess showed positive polymerase chain reaction for Mycobacterium tuberculosis. A possibility of tuberculosis though not commonly recognised may be considered in any child presenting with prolonged fever and multiple intracranial abscesses.

Anesthetic management for emergency cesarean section in a patient with severe valvular disease and preeclampsia.

Wider selection of young patients for prosthetic valve replacement for valvular heart disease has resulted in an increase in number of women with heart disease reaching childbearing age. Such patients presenting in labor for emergency cesarean section require special consideration. We present a report of a parturient who presented at 36 weeks of gestation with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia. The goals of our anesthetic management included (1) careful airway management (2) maintaining stable hemodynamics (3) optimizing fluid status, and (4) preventing seizures. Issues related to management of patients with severe valvular disease, prosthetic valves and complications due to anticoagulant therapy during pregnancy are discussed.

Bilateral hematogenous Pseudomonas aeruginosa endophthalmitis after lung transplantation.

Pseudomonas aeruginosa commonly colonizes the airways of patients with cystic fibrosis (CF). However, the occurrence of bacteremia with metastatic infection to the eye causing endogenous endophthalmitis is very rare. In the setting of lung transplantation, the significance of P. aeruginosa bacteremia in patients with CF whose airways are colonized before transplantation is unknown. We report a case of bilateral P. aeruginosa endogenous endophthalmitis in a patient with CF after lung transplant without documented bacteremia. The patient presented with acute eye symptoms in the presence of a left atrial thrombus and the disease followed a rapidly progressive course requiring aggressive medical-surgical treatment. Typically P. aeruginosa endophthalmitis has been associated with a poor visual prognosis. However, with combined medical-surgical management this patient retained useful vision in one eye without having retinal detachment or requiring enucleation. Endogenous endophthalmitis should be considered in the differential diagnosis of ocular complaints in patients with CF after lung transplant.

Measurement of alpha particle energy using windowless electret ion chambers.

Electret ion chambers are inexpensive, lightweight, robust, commercially available, passive, charge-integrating devices for accurate measurement of different ionizing radiations. In an earlier work a chamber of dimensions larger than the range of alpha particles having aluminized Mylar windows of different thickness was used for measurement of alpha radiation. Correlation between electret mid-point voltage, alpha particle energy, and response was developed and it was shown that this chamber could be used for estimating the effective energy of an unknown alpha source. In the present study, the electret ion chamber is used in the windowless mode so that the alpha particles dissipate their entire energy inside the volume, and the alpha particle energy is determined from the first principles. This requires that alpha disintegration rate be accurately known or measured by an alternate method. The measured energies were within 1 to 4% of the true values for different sources (230Th, 237Np, 239Pu, 241Am, and 224Cm). This method finds application in quantitative determination of alpha energy absorbed in thin membrane and, hence, the absorbed dose.

Negative ion fragmentations of deprotonated peptides: backbone cleavages directed through both Asp and Glu.

The collision-induced spectra of [M - H](-) ions of a variety of natural and synthetic amphibian peptides containing Asp and/or Glu exhibit characteristic gamma backbone cleavage ions that identify the positions of these residues in the peptide. A theoretical study suggests that the Glu cleavage involves an S(N)i reaction of the carboxylate anion from the Glu alpha side chain to form a deprotonated cyclic lactone. The presence of either Asp or Glu or other residues that effect pronounced side-chain cleavages (e.g. Ser or Thr) results in the normal alpha and beta backbone cleavages being reduced in comparison to those cleavages which originate from side chains.

The search for charge-remote reactions of even-electron anions derived from 1,3-disubstituted adamantanes in the gas phase. Retro Diels-Alder and Norrish II processes.

The collision induced decompositions of 3-substituted adamantane carboxylate anions have been studied with a view to uncovering charge-remote fragmentations of the 3-substituent. The 3-substituent is chosen so that it cannot approach the anion site, and so any fragmentations of that substituent should proceed independently of the charged centre, viz. charge-remote reactions. The following systems have been studied (i) the 3-cyclohexenyl system shows no charge-remote retro Diels-Alder fragmentation (DeltaH = +157 kJ mol(-1)), instead, charge-remote loss of the cyclohexenyl radical is noted, (ii) the 3-isobutyl ketone system shows no Norrish II cleavage (loss of C(3)H(6), DeltaH = +18 kJ mol(-1)), instead, the competitive losses of CO(2) from the charged carboxyl centre, together with charge-remote radical loss of the 3-substituent are observed, and (iii) the corresponding 3-isopropyl ester does show the "Norrish II" loss of C(3)H(6), together with competitive losses of CO(2) and the 3-substituent. It is concluded for cases (ii) and (iii), that an adamantane carboxylate anion system with a carbonyl group directly attached at the 3-position is not a suitable model system for studying charge-remote reactions.

Oro-facial granulomatosis: a laryngeal presentation.

We report the first case of oro-facial granulomatosis (OFG) presenting in pregnancy with laryngeal manifestations.

Electret ion chambers for estimating alpha particle energy.

Electret ion chambers (EICs) are inexpensive, lightweight, robust, commercially available, passive, charge-integrating devices for measuring different radiations. At Florida International University's Hemispheric Center for Environmental Technology (FIU-HCET), EIC performance was evaluated with the goal of providing the U.S. Department of Energy (DOE) with a low-cost, low-risk means of alpha contamination monitoring using an existing commercial technology. During this evaluation, sensitivity of electrets in 960-mL hemispherical ion chamber (radius: 7.6 cm) was observed to increase with alpha particle energy because alpha particles expended their entire energy in the chamber volume. This observation prompted us to explore another EIC application: estimation of alpha particle energy. Correlation between electret mid-point voltage, alpha particle energy, and response was developed for the 960-mL EIC and was used to determine energy of an unknown source. The response (change in voltage per disintegration) is the ratio of the change of voltage per unit time and alpha particle activity. Since an EIC measures only the change in voltage per minute, to determine the alpha particle energy, the source activity should be accurately determined by another method.

Potential interstellar molecules. Formation of neutral C(6)CO from C(6)CO(-*) in the gas phase.

Computations at the RCCSD(T)/aug-cc-pVDZ//B3LYP/6-31G* level of theory indicate that neutral C(6)CO is a stable species. The ground state of this neutral is the singlet cumulene oxide :C=C=C=C=C=C=C=O. The adiabatic electron affinity and dipole moment of singlet C(6)CO are 2.47 eV and 4.13 D, respectively, at this level of theory. The anion (C(6)CO)-* should be a possible precursor to this neutral. It has been formed by an unequivocal synthesis in the ion source of a mass spectrometer by the S(N)2(Si) reaction between (CH(3))(3)Si-C(triple bond)C-C(triple bond)C-C(triple bond)C-CO-CMe(3) and F(-) to form (-)C(triple bond)C-C(triple bond)C-C(triple bond)C-CO-Me(3) which loses Me(3)C* in the source to form C(6)CO(-)*. Charge stripping of this anion by vertical Franck-Condon oxidation forms C(6)CO, characterised by the neutralisation-reionisation spectrum (-NR(+)) of C(6)CO(-*), which is stable during the timeframe of this experiment (10(-6) s).