Can breast self-examination continue to be touted justifiably as an optional practice?

In 2003, the revised American Cancer Society guidelines recommended that breast self-examination (BSE) be optional. Of 822 women diagnosed with breast cancer in our hospital from 1994 to 2004, sixty four (7.7%) were 40 years of age or younger. Forty four (68.7%) of these young women discovered their breast cancers on BSE, 17 (18%) by mammography, and 3 (4.7%) by clinical breast examination by medical professionals. Of 758 women over 40 years of age diagnosed with breast cancer, 382 (49%) discovered their cancer by mammography, 278 (39%) by BSE, and 98 (14%) by a clinical breast examination. Lymph node metastases in the older women was one-half that in the younger women (21% versus 42%), and a higher percentage of younger women presented with more advanced disease. In response to increasing breast cancer in young women under 41 years of age, encouragement of proper breast self-examination is warranted and should be advocated.

What we have learned about cachexia in gastrointestinal cancer.

It is appreciated widely by clinicians that significant malnutrition accompanies malignant processes in approximately 50% of patients and eventually leads to severe wasting which accounts for approximately 30% of cancer-related deaths overall, 30-50% of deaths in patients with gastrointestinal tract cancers, and up to 80% of deaths in patients with advanced pancreatic cancer. The body wasting known as cancer cachexia is a complex syndrome characterized by progressive tissue depletion and decreased nutrient intake that is manifested clinically as inexplicable, recalcitrant anorexia and inexorable host weight loss. Decreased nutritional intake, increased metabolic expenditure and dysfunctional metabolic processes, including hormonal and cytokine-related abnormalities, all appear to play roles in the development of cancer cachexia. Although this condition of advanced protein-calorie malnutrition, sometimes described as the cancer anorexia-cachexia syndrome, is not entirely understood, it appears to be multifactorial, is a major cause of morbidity and mortality in cancer patients, and ultimately leads to death. Therapeutic interventions have met with little success, and, regardless of tremendous efforts throughout the decades, the exact nature of the mediators responsible for cancer cachexia remain elusive. The pathogenesis of cancer cachexia appears to be related to proinflammatory cytokines, alterations in the neuroendocrine axis and tumor-derived catabolic factors. Despite trials of conventional and/or aggressive nutritional support by a myriad of feeding techniques, patients with cancer cachexia have failed to gain consistent significant benefits in terms of weight gain, functional ability, quality of life or survival. Additionally, attempts to ameliorate the abnormal clinical and metabolic features of cancer cachexia with a variety of pharmacologic agents have met with only limited success. Either until cancer of the gastrointestinal tract can be cured or until it is possible to identify the exact causes and mechanisms of the cancer cachexia syndrome, the most realistic and practical options currently are directed toward minimizing adverse gastrointestinal side effects or complications of the malignant process and/or therapy, as well as increasing appetite, food intake and nutrient utilization in an effort to enhance quality of life and improve survival.

Early passive mobilization after digital nerve repair and grafting in a fresh cadaver.

In the clinical management of combined tendon and nerve injuries, there are competing treatment strategies. Isolated tendon injuries should be rapidly mobilized after repair to prevent adhesion formation, whereas isolated nerve repairs are usually immobilized to prevent disruption and to allow axon regrowth. Recommendations in the published literature for the management of combined tendon and nerve injuries are vague and advise up to 3 weeks of immobilization. The goals of this study were to determine which length of nerve gap resulted in rupture of a repair following postoperative mobilization with the modified Duran protocol and with unrestricted motion and to determine whether nerve grafts are at risk of rupture after mobilization. A total of 100 digital nerves from 10 cadaver hands were tested with the modified Duran and the unsplinted protocols. Each digital nerve on each hand was sequentially resected and repaired at five progressively larger gap lengths after testing with both protocols. The mean nerve gaps at which disruption occurred were significantly different between the splinted (9.7 +/- 0.8 mm, n = 100) and unsplinted (7.3 +/- 1.9 mm, n = 100) protocols (t test, p < 0.001). One hundred percent of repairs remained intact, with up to 5 mm of resection with the modified Duran protocol (n = 100) and with up to 2.5 mm of resection with the unsplinted protocol (n = 100). All nerve grafts remained intact after mobilization within a dorsal-blocking splint (n = 100). Considering mechanical integrity of the nerve repair only, these data suggest that early mobilization with tendon protocols may be considered after a nerve injury to avoid the detrimental tendon sequelae that result from immobilization. The adequacy of functional recovery of mobilized nerves is yet to be determined.

Nd:YAG laser surgery for the excision of pilonidal cysts: a comparison with traditional techniques.

BACKGROUND AND OBJECTIVE: Nd:YAG laser photothermal ablation has been accepted as a treatment modality for hemorrhoidal disease. There is little reported on its use in treating pilonidal disease. We hypothesized that laser would be an excellent tool for pilonidal cystectomy, facilitating improved outcome and patient satisfaction. STUDY DESIGN/MATERIALS AND METHODS: A 5-year retrospective study was performed comparing Nd:YAG laser to the standard surgical technique. A telephone questionnaire addressing the length of time the cyst was debilitating both preoperatively and postoperatively as well as length of convalescent time before return to work was administered. Pain was assessed by using an analog pain scale. RESULTS: Operative time for the traditional pilonidal cystectomy was 20 minutes longer than Nd:YAG laser cystectomy. Postoperative hospital stay was similar. Laser patients returned to work an average of 2.4 days earlier, and their postoperative pain was less than those treated traditionally. CONCLUSION: In an era when the medical consumer makes decisions based on the efficacy of treatment by using criteria such as pain, length of hospitalization, and speed of return to work, Nd:YAG lasers have emerged as a surgical tool that can fulfill these criteria for certain procedures. Patient postoperative satisfaction after laser excision was greater when compared with those who had traditional excisions. Postoperative pain was less, as was the pain experienced during the first week of recovery. Cost for both was comparable.

The efficacy of X-rays after chest tube removal.

BACKGROUND: The insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management. MATERIALS AND METHODS: A 5-year retrospective study of 73 patients with tube thoracotomies was performed in a level II trauma center's intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected. RESULTS: Of the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patient's clinical appearance rather than on the x-ray findings. CONCLUSION: Chest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.

Are chest X-rays mandatory following central venous recatheterization over a wire?

Exchange of a central venous catheter (CVC) over a guidewire is a frequent clinical procedure, especially in surgical intensive care units. At most hospitals, a chest X-ray (CXR) is obtained routinely after recatheterization to confirm accurate catheter placement and to rule out complications such as pneumothorax. We hypothesized that the incidence of complications after central venous recatheterization over a guidewire is too low to justify automatic performance and the associated expense of a routine postprocedure CXR. Initially we undertook a retrospective study of a total of 295 patients with a Swan-Ganz catheter (SGC), of which 92 SGCs were exchanged over a guidewire for a CVC between July 1, 1994, and June 30, 1996, at a university-affiliated community hospital. Age, gender, duration of SGC placement, type of central catheter used for exchange with the SGC, and CXRs and their reports were noted. From July 1, 1996, to October 1, 1997, the study has been continued prospectively. Thus far, in this ongoing investigation, we have identified 505 patients (201 prospective) who had a SGC placed, 210 (116 prospective) of whom had their SGC removed electively, leaving the SGC introducer in place for advancement of a guidewire, and subsequent replacement by a CVC. Of all the patients with a SGC, 40 per cent had the SGC replaced with a CVC over a guidewire, and follow-up CXRs and their reports confirmed that all exchanged triple lumen catheter tips were appropriately positioned in the superior vena cava with zero complications. With the advent of managed care, a savings of $115/CXR (one view X-ray and reading cost at our hospital) would be gained without the added risk of radiation exposure to the patient if a CXR were not mandatory after an uncomplicated guidewire replacement of a central line. It appears from these data that a CXR is not justified as a routine study after replacement of all CVCs over a wire from the standpoints of both patient risk and expense. Conscientious physical examination together with good clinical acumen and judgement in evaluating patients after replacement of a CVC over a guidewire are likely to obviate the currently mandated postprocedure CXR, reserving its use for selected patients.

Routine chest radiographs following central venous recatheterization over a wire are not justified.

BACKGROUND: Subclavian vein central venous catheterization and the subsequent exchange of subclavian catheters over a guidewire are frequently performed procedures. We hypothesized that the policy of obtaining a routine postprocedure chest radiograph to confirm appropriate catheter placement and to rule out complications after exchanging central venous catheters over a wire was no longer justifiable. METHODS: A retrospective study of 295 patients with Swan-Ganz catheters (SGC) was performed between July 1, 1994 and June 30, 1996. One hundred fourteen of these SGCs were exchanged over a guidewire for a central venous catheter (CVC). Postexchange chest radiograph and associated radiologist's report, as well as age, gender, and duration of catheter placement were all recorded. Since July 1996, this study has been extended prospectively. RESULTS: Of the 380 documented over-a-wire exchanges, none has resulted in a complication, including catheter malposition. CONCLUSION: We conclude from these data that a routine chest radiograph following the replacement of a CVC over a guidewire is not necessary when good clinical judgment and discrimination are used in a monitored setting.