Ipsilateral microcalcifications after breast-conserving surgery: is it possible to differentiate benign from malignant calcifications?

AIM: To analyse stereotactic biopsies of microcalcifications in patients with previous ipsilateral breast-conserving surgery (BCS) to identify the positivity rate, assess for an association between the patient's primary cancer or mammographic appearances of the microcalcifications, and the risk of recurrence. MATERIALS AND METHODS: Relevant patients from 2018-2020 were identified via a retrospective review of the prospectively maintained radiological procedure database. Clinicopathological features of the patients' primary tumour and new calcifications were obtained from the hospital electronic patient record system and the national integrated medical imaging system. RESULTS: Thirty-one percent of recurrences post-ipsilateral BCS presented as isolated microcalcifications on mammography. Fifty-three percent of patients undergoing stereotactic biopsy of ipsilateral calcifications had recurrence. A positive margin status was associated with new or recurrent malignancy. There was no significant correlation between oestrogen-receptor status, sentinel lymph node status, adjuvant radiotherapy or chemotherapy and the risk of recurrence. Calcifications within the tumour bed were more likely to be benign while calcifications within the same quadrant but remote from the tumour bed were more likely malignant. All coarse calcifications were benign while 67% of fine linear/fine linear branching and 89% of fine pleomorphic calcifications were malignant. CONCLUSION: Increased time since diagnosis, positive margin status, fine pleomorphic and fine linear calcifications in the same quadrant as the tumour bed were associated with malignancy. Patients with coarse calcifications and calcifications within the tumour bed may avoid stereotactic biopsy and undergo short-interval surveillance.

Adherence to clinical guidelines and the potential economic benefits of admission avoidance for acute uncomplicated diverticulitis.

BACKGROUND: The treatment paradigm for acute diverticulitis is changing. There is an increasing trend towards managing patients with uncomplicated diverticulitis in the community. AIMS: The aim of this study was to analyse how acute diverticulitis is managed in our institution and also to analyse national data pertaining to treatment of acute diverticulitis. METHODS: A prospective database of all patients admitted to our institution over a 2-year period (2014-2016) with acute diverticulitis was maintained. Severity of disease, treatment received and average length of stay (LOS) were analysed for all patients. Contemporaneous hospital inpatient enquiry (HIPE) data was interrogated to analyse current management for acute diverticulitis at a national level. RESULTS: One hundred twenty-six patients were admitted to our institution with acute diverticulitis during the study period (inpatient stay = €1277/night). Of patients, 59.5% had uncomplicated diverticulitis while 40.5% had complicated disease. The median LOS was 4 (range 1-34) days and 8 (range 2-51) days in the uncomplicated and complicated group, respectively. Based on HIPE data, there were 11,357 patients with uncomplicated diverticulitis and 526 patients with complicated diverticulitis admitted to Irish hospitals in the year 2015. Nationally, the median LOS for those with uncomplicated diverticulitis was 3 (range 1-142) days and for those with complicated diverticulitis the median LOS was 7 (range 1-308) days. Projected total cost for hospital stay nationally for uncomplicated diverticulitis amounted to €43.5 million for the year 2015. CONCLUSIONS: At present, uncomplicated diverticulitis in Ireland is not being managed as per evidence-based guidelines. Changing practice could result in significant cost savings for surgical departments.

Magnitude of non-operative surgical emergency admissions; service implications for surgical and radiological practice.

BACKGROUND: Financial sustainability is an area of sharp ongoing focus across the broad spectrum of the Irish Health Service. Recent attention has been drawn to the financial implications of non-operative surgical admissions, suggesting that some of these may be unnecessary. AIMS: In this study, we aim to determine the volume of emergency surgical admissions to Mayo University Hospital (MUH), in particular, to identify the scale of non-operative admissions and to assess the wider inherent implications for acute hospital services. METHODS: An electronic handover system for emergency surgical admissions was introduced in MUH in September 2014. All surgical admissions from September 1st 2014 to August 31st 2015 were identified from this prospectively maintained database. HIPE (Hospital Inpatient Enquiry) data were not used in this study. Theatre logbooks confirmed those patients who required operative intervention. RESULTS: 1466 patients were admitted as emergencies during the study period. 58 % (850) were male and median age was 48 years (0-100). Average length of stay was 5 days (range 1-125). 327 patients (22.3 %) required operative intervention. The most commonly performed procedure was appendicectomy (52.5 %). 48 (3.3 %) patients were transferred to other hospitals. 131 (8.9 %) admissions related to the acute urological conditions. Of the 1466 admissions, 546 underwent a CT scan, while 342 patients proceeded to ultrasound. CONCLUSION: Almost 80 % of all surgical emergency admissions were discharged without undergoing a formal operative procedure while generating a significant workload for the radiology department. Changes in working practices and hospital network structures will be required to reduce the burden of non-operative emergency admissions.

Post-chemotherapy retroperitoneal lymph node dissection in the management of metastatic testis cancer: the 16-year experience in an Irish setting.

INTRODUCTION: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important tool in the management of advanced germ cell testis cancer, particularly non-seminoma. AIM: We present the 16-year experience with PC-RPLND in a single Irish tertiary referral centre, and compare our results to the major speciality centres worldwide. METHODOLOGY: All 78 patients undergoing PC-RPLND for the treatment of metastatic testis cancer between January 1996 and December 2011 were included. Medical records were reviewed and up to date follow-up obtained from primary referral centres, patient's GPs and individual patient interview. RESULTS: The mean age at diagnosis was 28.5 ± 7 years. Initial pathology included non-seminoma 62.8 %, seminoma 6.4 % and combined 19.2 %. All patients underwent pre-operative chemotherapy. The resection template utilised was bilateral infra-hilar in 29.5 %, unilateral infra-hilar in 46.2 % and supra-hilar in 20.5 %. Complete abdominal remission was achieved in all but one patient. Additional procedures were required in 38.5 % of patients (n = 30). Clavien Dindo grade three or four complications were seen in 8.9 %, including five patients who required early reoperation. Histology of RPLND specimen showed mature teratoma (41 %) and active cancer (11.5 %). Follow-up data were available for 66 patients (85 %). Median follow-up was 101 (11-207) months. Nine patients relapsed with median time to relapse 15 (8-60) months. Overall 5-year survival rate was 95.2 % (four deaths). CONCLUSION: In this relatively small series due to small population and low disease incidence, we have shown acceptable peri-operative course, morbidity and oncological outcomes with PC-RPLND compared to major international centres.

Incidence rate of type 2 diabetes is >50% lower in GrassrootsHealth cohort with median serum 25-hydroxyvitamin D of 41 ng/ml than in NHANES cohort with median of 22 ng/ml.

Higher serum 25-hydroxyvitamin D [25(OH)D] concentrations have been associated with lower risk of type 2 diabetes. This study compared incidence rates of type 2 diabetes among participants aged ≥20 years in two U.S. cohorts with markedly different median 25(OH)D concentrations. The median 25(OH)D concentration in the GrassrootsHealth (GRH) cohort was 41 ng/ml (N=4933) while in the 2005-6 National Health and Nutrition Examination Survey (NHANES) it was 22 ng/ml (N=4078) (P<0.0001). The adjusted annual incidence rate of type 2 diabetes was 3.7 per 1000 population (95% confidence interval=1.9, 6.6) in the GRH cohort, compared to 9.3 per 1000 population (95% confidence interval=6.7, 12.6) in NHANES. In the NHANES cohort, the lowest 25(OH)D tertiles (<17, 17-24 ng/ml) had higher odds of developing diabetes than the highest tertile (OR: 4.9, P=0.02 and 4.8, P=0.01 respectively), adjusting for covariates. Differences in demographics and methods may have limited comparability. Raising serum 25(OH)D may be a useful tool for reducing risk of diabetes in the population.

Early results of the use of collagenase in the treatment of Dupuytren's contracture.

INTRODUCTION: In recent years, the enzyme collagenase has been developed for the percutaneous treatment of Dupuytren's contracture, allowing management of the condition as an outpatient. We present early results on the treatment of Dupuytren's contracture using injectable collagenase. METHODS: Patients awaiting Fasciectomy for Dupuytren's Contracture were selected for enrolment. Contracture cords were then marked and injected with collagenase in the outpatients department. Twenty-four hours later, patients returned for an extension procedure, performed under regional anaesthesia. Hand therapy was then commenced as for surgical release. Contracture angles were measured pre-injection and at follow-up. RESULTS: Thirteen fingers were treated in 10 patients with a mean age of 66 years. Eight little fingers and five ring fingers were treated. Four fingers had isolated metacarpophalangeal joint (MCPJ) contracture, one finger had isolated proximal interphalangeal joint (PIPJ) contracture and the remainder had combined contractures. Mean pre-treatment MCPJ contracture was 58.6° and the mean pre-treatment PIPJ contracture was 39°. Post-treatment contracture was 4.23° and 9° for the MCPJ and PIPJ, respectively. All patients were satisfied with their results. COMPLICATIONS: Significant post-injection bruising occured in one patient. Skin tears occurred in 11 digits, and in all cases healed without intervention. No tendon rupture occurred. CONCLUSIONS: Collagenase is a safe and effective outpatient-based treatment for Dupuytren's contracture, which may be useful in controlling surgical waiting lists. We recommend its use as first-line treatment in patients who are unsuitable more invasive treatment alternatives.

Chronic dietary fiber supplementation with wheat dextrin does not inhibit calcium and magnesium absorption in premenopausal and postmenopausal women.

This placebo-controlled, randomized, crossover clinical study examined the effect of chronic wheat dextrin intake on calcium and magnesium absorption. Forty premenopausal and post menopausal women (mean ± SD age 49.9 ± 9.8 years) consumed wheat dextrin or placebo (15 g/day) for 2 weeks prior to (45)calcium ((45)Ca) and (26)magnesium ((26)Mg) absorption testing. After a standardized breakfast, serial blood and urine samples were obtained. The mean ± SD area under the curve from 0 to 9 h for (45)Ca specific activity was 0.81 ± 0.21 for wheat dextrin and 0.82 ± 0.22 for placebo, showing that wheat dextrin had no effect on calcium absorption. The mean ± SD percentage excess of (26)Mg/(24)Mg was 7.8% ± 2.1% for wheat dextrin and 7.9% ± 2.6% for placebo, showing that wheat dextrin had no effect on magnesium absorption. In conclusion, chronic wheat dextrin consumption did not inhibit calcium or magnesium absorption from the gastrointestinal tract in women.

Variability in the measured response of bone to teriparatide.

UNLABELLED: Apparent failures of bone mineral density (BMD) response to teriparatide at spine or hip occur even in a high compliance context (15% spine and 55% hip). Apparent non-responders nevertheless show good biomarker response, suggesting that apparent BMD non-response is due to measurement imprecision. Calcium intake may be an important determinant of hip response. INTRODUCTION: Individuals vary in response to bone active agents, but that variability is poorly quantified and its basis is not well understood. The study included 203 postmenopausal women with moderately severe osteoporosis, all treated with teriparatide, calcium, and vitamin D. The study was performed at the Creighton University Medical Center, a single site. METHODS: This is a prospective study of change in bone mineral density and resorption biomarkers over a 12-month treatment period. BMD response at spine and total hip was quantified by computing slopes for each participant's values, and biomarker change by the difference in values across the 12-month study period. RESULTS: Of the total number of participants, 85.2% exhibited a significant spine BMD response, while only 44.8% had a significant change at the hip. However, mean biomarker response was marginally larger for the BMD non-responders at either site than for the responders, indicating biological, if not measurable densitometric, activity of teriparatide in essentially all participants. CONCLUSIONS: Occasional apparent failures of BMD response in patients receiving teriparatide are probably not due to failure of response at the level of the bone remodeling apparatus, but instead reflect a combination of measurement imprecision and variable bone remodeling balance. The reason for the latter remains unclear.

Diagnosis and treatment of vitamin D deficiency.

The recent discovery--in a randomised, controlled trial--that daily ingestion of 1100 IU of colecalciferol (vitamin D) over a 4-year period dramatically reduced the incidence of non-skin cancers makes it difficult to overstate the potential medical, social and economic implications of treating vitamin D deficiency. Not only are such deficiencies common, probably the rule, vitamin D deficiency stands implicated in a host of diseases other than cancer. The metabolic product of vitamin D is a potent, pleiotropic, repair and maintenance, secosteroid hormone that targets > 200 human genes in a wide variety of tissues, meaning it has as many mechanisms of action as genes it targets. A common misconception is that government agencies designed present intake recommendations to prevent or treat vitamin D deficiency. They did not. Instead, they are guidelines to prevent particular metabolic bone diseases. Official recommendations were never designed and are not effective in preventing or treating vitamin D deficiency and in no way limit the freedom of the physician--or responsibility--to do so. At this time, assessing serum 25-hydroxy-vitamin D is the only way to make the diagnosis and to assure that treatment is adequate and safe. The authors believe that treatment should be sufficient to maintain levels found in humans living naturally in a sun-rich environment, that is, > 40 ng/ml, year around. Three treatment modalities exist: sunlight, artificial ultraviolet B radiation or supplementation. All treatment modalities have their potential risks and benefits. Benefits of all treatment modalities outweigh potential risks and greatly outweigh the risk of no treatment. As a prolonged 'vitamin D winter', centred on the winter solstice, occurs at many temperate latitudes, < or = 5000 IU (125 microg) of vitamin D/day may be required in obese, aged and/or dark-skinned patients to maintain adequate levels during the winter, a dose that makes many physicians uncomfortable.

Calcium fortificants: overview and strategies for improving calcium nutriture of the U.S. population.

Despite more than 20 y of awareness of the importance of calcium to health, U.S. calcium intakes remain suboptimal. Fortification of foods with shortfall nutrients is probably the optimal strategy for dealing with widespread nutrient deficiencies, as it has the best chance of reaching the population segments most at risk, as contrasted with attempts at changing individuals' food choices or relying on voluntary supplement taking. Given the wide array of potential calcium fortificants and fortification levels, there is not much to guide manufacturers interested in improving the nutritional value of their products. In this review, we assemble the calcium salts/complexes that have been used or proposed for use as fortificants and describe certain of their measured characteristics that relate to incorporation into foods, particularly what is known of their absorbability. The calcium salts most commonly used as supplements or fortificants exhibit similar absorbability when tested in pure chemical form. Choice of salt will depend mainly upon cost, compatability with the manufacturing process, and consumer acceptability. However, interaction with food, tablet, or beverage matrices can degrade intrinsic absorbability substantially. As a consequence, each product must be explicitly tested to establish the degree to which its calcium is available to consumers.

Vitamin D inadequacy among post-menopausal women: a systematic review.

BACKGROUND: Vitamin D inadequacy has been studied extensively, due to concerns about ageing populations, associations with osteoporosis and other disorders (including non-musculoskeletal), and high prevalence. AIM: To review recent reports on the prevalence of vitamin D inadequacy among post-menopausal women with and without osteoporosis and/or other musculoskeletal diseases. DESIGN: Systematic review. METHODS: We reviewed publications in the past 10 years reporting prevalence estimates for vitamin D inadequacy, reported as serum 25(OH)D values below various levels. Thirty published studies in the English language were identified, from January 1994 through April 2004. RESULTS: In osteoporotic populations, the prevalence of 25(OH) vitamin D concentration <12 ng/ml ranged from 12.5% to 76%, while prevalence rates reached 50% to 70% of patients with a history of fracture(s) using a cut-off of 15 ng/ml. In post-menopausal women, the prevalence of 25(OH) vitamin D concentrations