The Effect of Lumpectomy and Cavity Shave Margin Status on Recurrence and Survival in Breast-Conserving Surgery.

BACKGROUND/OBJECTIVE: Cavity shave margins (CSMs) decrease rate of positive margins and need for re-excision. Recurrence data following breast-conserving surgery (BCS) are not always available in large cancer registries. We sought to define our recurrence and survival data in BCS with routine excision of CSMs. METHODS: A single institution, 10-year retrospective review of breast cancer patients who underwent BCS with routine CSMs was conducted. Cavity shave margin technique was standard. Cox proportional hazard analyses and the Kaplan-Meier method were used to estimate recurrence and survival. RESULTS: Breast-conserving surgery with CSM was performed in 839 patients. Re-excision rate to achieve negative margins was 8.5%. Fifty-two patients (75%) underwent margin re-excision vs 18 patients (25%) underwent salvage mastectomy. Positive margin rate stratified by tumor histology was highest for invasive lobular carcinoma followed by mixed invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS), followed by pure DCIS and lowest for IDC. Length of follow-up was (4.7 ± 2.6, years). Overall recurrence rate (locoregional and systemic) was 4.3%: highest in patients with negative lumpectomy margin but positive CSM (L-S+ = 15%) followed by positive lumpectomy and CSMs (L+S+ = 14%), followed by patients with positive lumpectomy margin but negative CSMs (L+S- = 13%) and lowest for negative lumpectomy and CSM (L-S- = 5%), (P = .0008). There was no difference in 5-year breast cancer-specific survival between the 4 subgroups: 96% for L-S-, 86.7% L-S+, 94.7% L+S+ and 90% L+S- (P = .094). CONCLUSIONS: Recurrence following BCS with CSMs can be stratified based on both lumpectomy and cavity shave margin positivity. Routine excision of CSMs allows identification of these patient subsets.

Impact of Implementing Welcoming Clinic Space Indicators on Sexual and Gender Minority Patients' Health Care Experience.

It has been well established that those identifying as a member of the sexual and gender minority (SGM) have difficulties accessing health care services. This is strongly associated with the desire to avoid discriminatory health care practices and prejudicial providers that many SGM individuals have encountered. Implementation of specific welcoming clinic space indicators (WCSIs) has been recommended to mitigate prior health care alienation experienced by SGM individuals. The project supported three HIV clinical care sites in Louisiana to implement and maintain identified SGM WCSIs as one of its interventions to improve sexually transmitted infection screening, testing, and treatment in people with and at-risk of HIV. This project found that SGM WCSIs had a positive impact on SGM individuals and were predominately unnoticed by those that were non-SGM-identifying individuals. Further, across the entire sample, the SGM WCSIs had an extremely low (<1%) level of negative impact, eliminating the misconception that SGW WCSI implementation may offend non-SGM individuals. There were differences in the implementation of the SGM WCSIs across the three sites associated with their governance structure and priority community. Implementation of SGM WCSIs should be considered as an important component of assuring culturally competent health care for SGM individuals.

Biofilm Formation on Central Venous Catheters: A Pilot Study.

INTRODUCTION: Central line-associated bloodstream infection is a complication with serious consequences and biofilm development is thought to play a role. This study evaluated the impact of sterilization technique on central venous catheter (CVC) biofilm formation. MATERIALS AND METHODS: This pilot study was conducted in the surgical intensive care unit of a tertiary care facility. All CVCs were inserted with chlorhexidine preparation (CHG). CHG-only CVCs were compared to the use of CHG with chlorhexidine gluconate-impregnated sponge (CHGIS). After removal, a punch biopsy of the CVC was taken at the noted skin level. Scanning electron microscopy identified the stage of biofilm. Confocal laser scanning microscopy with SYPRO stain confirmed the presence of glycocalyx and a volumetric analysis was completed. RESULTS: Twenty four CVCs were collected. Indications for line placement were similar, with 42% placed for sepsis in the CHGIS group and 33% in the CHG group. There were no positive line cultures or bacteremia and 2/12 CHGIS patients had candidemia. CHGIS lines were in place for a mean of 91 h, compared to 60 h with CHG alone (P = 0.19). The interior of CVCs had lower stage biofilms than the exterior and lacked stage 4 biofilms. Stage 4 biofilms were present externally on 50% of CVCs (8/12 CHG and 4/12 CHGIS). Stage 3 biofilms were present on 7/12 CHG and 6/12 CHGIS interior samples. Volume analysis found an increase in biofilm and glycocalyx in CHGIS compared to CHG samples. CONCLUSIONS: This study identified biofilms on both surfaces of CVCs. No significant difference in biofilm formation was found based on a sterilization technique.

Effect of the endOclear® Device on Biofilm in Endotracheal Tubes.

BACKGROUND: Organisms trapped in biofilms cause more than 80% of medical infections. Significant investments are being made to develop methods of removing these biofilms. The endOclear® device is reported to remove biofilm from endotracheal tubes (ETTs) and to decrease pneumonia rates and ventilator time. METHODS: This was an observational study performed at a university Level 1 trauma center intensive care unit. A series of 40 ETTs were collected at extubation, with half of the patients having been treated daily with the endOclear® device. Biofilms were quantified from a standardized point on the distal ETT. The patients' standard and biofilm cultures were reviewed. RESULTS: The mean hours of intubation for the control group was 135 and for the device group 138. This difference was not statistically significant (p = 0.91). Eleven patients in the device group were found to have pneumonia compared with six in the control group (p = 0.34). Ventilator data after device use showed a mean increase of 29.9 cc in tidal volume and a mean decrease in peak pressures of 0.39 cm H2O. Comparisons between biofilm stage or hours of intubation and a diagnosis of pneumonia found no correlation. Only nine of 40 ETTs had congruence between the microbiata of the biofilm and standard bronchoalveolar lavage (BAL) fluid, a divergence rate of 78%. CONCLUSIONS: Comparison of the endOclear® group and controls demonstrated a trend toward a higher pneumonia rate in the former. Additionally, the device achieved very small, clinically insignificant, changes in ventilator settings, and no difference was seen in the time on the ventilator. Comparisons between biofilm and standard BAL cultures continue to show the biofilm is more diverse than previously thought. In this study, no statistical significance was found between biofilm stage and the pneumonia rate. This study provides additional evidence that there is no correlation between biofilm stage and duration of intubation.

Wr u txting b4 u crashed?

BACKGROUND: Texting has become popular, particularly among young adults. Texting while driving has been identified as a factor in accidents. Literature is lacking about the overall attitudes and utilization of texting. PURPOSE: Understand attitudes and behaviors surrounding texting. METHODS: A survey to evaluate attitudes and behaviors concerning texting was developed in conjunction with a social scientist. The survey (2009) was administered to university freshmen via an anonymous, web based program. The study was approved by the IRB. RESULTS: 426 university freshmen completed the survey. 67% reported texting was more useful than speaking by phone. 53% report they text more than 50 times per day. 24% report they text more than 100 times per day. 73% report they text while driving, though only 9% responded they do so frequently. 92% believe texting affects their concentration while driving. 84% reported they are passengers when the driver texts and 75% report they do not feel safe in the car when the driver is texting. 77% disagreed with the statement "It is no big deal to text while driving." 53% reported they can not safely text and drive and 60% agreed texting while driving should be illegal. 92% reported texting was less safe then talking on the cell phone while driving. CONCLUSIONS: Texting is commonly used by young adults, though many believe texting while driving decreases concentration and is unsafe. A majority report to texting while driving. Injury prevention and awareness programs are needed to decrease this behavior.

Advanced endotracheal tube biofilm stage, not duration of intubation, is related to pneumonia.

BACKGROUND: Biofilms are complex communities of living bacteria surrounded by a protective glycocalyx. Biofilms have been implicated in the development of infections such as dental caries and hardware infections. Biofilms form on endotracheal tubes (ETT) and can impact airway resistance. The lifecycle of a biofilm has four stages. We hypothesize that there is a relationship between the stage of biofilm on the ETT and development of pneumonia. METHODS: Thirty-two ETT were analyzed for biofilms and staged. Staging was performed by a microbiologist blinded to all patient information. Data included development of pneumonia, duration of intubation, comorbidities, and microbiology. Pneumonia was defined as presence of fever, WBC >12 K or <4 K, infiltrate on chest X-ray, and purulent sputum with +lower airway culture (bronchoalveolar lavage or brush). Statistics were performed by a biostatistician; p < 0.05 defined significance. RESULTS: There were 11 women and 21 men with a mean age of 50 years. Mean intensive care unit days were 13 (standard deviation ± 9.9) and mean length of intubation was 7.4 days (standard deviation ± 5.0). Half (16 of 32) the patients developed pneumonia while intubated. Eight of 10 patients with a stage IV biofilm had pneumonia. There was a relationship between increasing biofilm stage with the incidence of pneumonia (p < 0.05). Stage IV biofilms were associated with pneumonia (p < 0.02). There was no relationship to duration of intubation, patient age or hospital stay and biofilm stage. CONCLUSIONS: Advanced biofilm stage (stage IV) is associated with pneumonia. Duration of intubation does not predict biofilm stage.

Increases in endotracheal tube resistance are unpredictable relative to duration of intubation.

BACKGROUND: Accumulated secretions after intubation can affect the resistance of an endotracheal tube (ETT). Our objective was to measure extubated patient tubes and size-matched controls to evaluate differences in resistance. METHODS: New ETTs, with internal diameters of 7.0 through 8.5 mm, were tested as controls to establish the resistance of each size group as measured by pressure drop. Measurements were obtained using a mass flowmeter and pressure transducer. Pressure drop was measured at three flow rates. Seventy-one patient ETTs were evaluated after extubation by an identical method and compared with controls. RESULTS: In each control group, pressure drop was tightly clustered with low variation and no overlap between sizes. A total of 73 to 79% of the patient ETTs had a pressure drop of > 3 SDs of size-matched controls at all flow rates. Pressure drop in 48 to 56% (across three flow rates) of extubated tubes was equivalent to the next smaller size of controls. At 60 and 90 L/min, 10% and 15% of patient tubes, respectively, had the pressure drop of a control tube three sizes smaller. The pressure drop was unpredictable relative to the duration of intubation. CONCLUSIONS: Organized secretions can significantly increase resistance as measured by the pressure drop of ETTs. The degree of change was highly variable, occurs in all sizes, and was unrelated to the duration of intubation. The performance of an ETT may be comparable to new tubes one to four sizes smaller. This may impact the tolerance of ventilator weaning.

Endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting: first reported case.

Endoscopic vessel harvesting has become a widely used modality for harvesting venous and arterial conduits for coronary artery bypass grafting. Specifically, it has been used to harvest the greater saphenous vein, internal thoracic artery, and the radial artery. A case of endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting is reported.