Relationship between mammographic screening intervals and size and histology of ductal carcinoma in situ.

OBJECTIVE: The objective of this study was to determine how the length of time between mammographic screenings is related to the size, grade, and histology of mammographically detected ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: We retrospectively reviewed 166 consecutive mammograms of women evaluated for DCIS with (n = 24) and without (n = 142) microinvasion. The size of the DCIS was determined by the maximum diameter as measured on the mammogram. After pathologic analysis, DCIS was classified by histologic architecture, nuclear grade, presence of microinvasion, and presence of multifocality. Four screening intervals were defined: annual (6-17 months), biennial (18-29 months), triennial (> or = 30 months), and first time. Patients were grouped according to screening intervals. The average age of all groups was 55 years. RESULTS: The annual group (mean size of DCIS, 1.69 cm) had significantly smaller DCIS than did the biennial (mean size, 2.27 cm), triennial (mean size, 3.49 cm), or first time groups (mean size, 3.29 cm) (p = .003). Comedo histology was more frequently observed in patients screened biennially (73.7%) than in those screened annually (46.8%) (p = .05). High-grade nuclear histology was more commonly seen in the biennial (76.3%) than in the annual (48.1%) screening group (p = .008). We found no significant correlation between screening interval and the incidence of microinvasion and multifocality. CONCLUSION: Small, low-grade noncomedo DCIS was more common in the annual mammographic screening group than in the biennial screening group. A direct relationship was found between DCIS size and length of screening interval: DCIS detected at annual screening was smaller than that found at biennial screening, which in turn was smaller than DCIS revealed at triennial screening. This study provides inferential support for annual screening mammography for DCIS detection and management.

Skull roentgenography in the evaluation of head injury.

The role of skull roentgenograms in determining choice of therapy, hospital admission, and length of hospitalization was evaluated in 106 consecutive patients with head injury. Thirty patients were discharged from the emergency room after initial evaluation and had uneventful recovery. Seventy-six were admitted and discharged without operative treatment one to ten days later. Only five had pathologic skull findings roentgenographically. Of these, one was discharged from the emergency department; the remaining four were admitted because of abnormal neurologic findings. All five recovered uneventfully. Another patient who had a normal roentgenographic evaluation required subsequent admission for craniotomy. Skull roentgenograms were an unimportant factor in the management of head injury patients and did not eliminate the need for complete and serial neurologic evaluation.

Noninvasive cerebrovascular evaluation: a prerequisite for angiography?

Results of cerebrovascular evaluation were reassessed in 768 patients to determine whether angiography performed in unselected patients was safe and economically efficient, and whether previous noninvasive screening was sensitive enough and effective in increasing the yield of subsequent angiography. In 543 patients undergoing angiography without previous noninvasive screening, positive results were obtained in 21 percent. Complications included hemorrhage (2.4 percent), neurologic deficit (2.2 percent), and death (0.2 percent). Of 225 patients undergoing previous screening with Doppler, ophthalmoplethysmography, and carotid phonoangiography, none with negative screening results had subsequent cerebrovascular complications. Of 82 patients having positive noninvasive test results, 53 underwent angiography with a 74 percent yield of positive results. Twenty-nine had no angiography or corrective therapeutic action. Of these, 3 percent died after a cerebrovascular accident, and 21 percent developed complete stroke (mean follow-up 3 years). Noninvasive screening reliably eliminated necessity for angiography in 64 percent of patients while increasing the angiographic yield from 21 to 74 percent. Therefore, performance of cervicoencephalic angiography is asymptomatic and unselected patients cannot be condoned any longer. Likewise, positive noninvasive screening results should not be ignored because in the absence of treatment, death (3 percent) and permanent neurologic deficit (21 percent) occur over a 3 year period.

Recurring cystosarcoma phyllodes associated with breast carcinoma.

A 59-year-old patient, who had had recurring giant fibroadenomas and cystosarcoma phyllodes over a 36-year period, presented with cystosarcoma phyllodes and adenocarcinoma of the breast. Only seven other well documented instances of the coexistence of these lesions have been reported. The prognosis and treatment of adenocarcinoma was not affected by coexisting cystosarcoma phyllodes.

Ventricular cardiac arrhythmias during anesthesia: feasibility of preoperative recognition.

We investigated the occurrence of anesthetic ventricular cardiac arrhythmia (CA) in 104 systemically healthy consecutive patients undergoing general anesthesia, to evaluate the possibility of recognizing preoperatively those patients prone to CA. In 19 (18%) patients, control strips taken before anesthesia showed CA. During anesthesia CA developed in 34 (33%), including 16 during induction, ten during endotracheal intubation, and eight during both events. Older patients had a higher incidence of CA than younger ones (P less than 0.01), and patients with preoperative CA showed a greater trend toward anesthetic CA. There were no anesthetic deaths in this group. Early detection and treatment avoided complications and sequelae of CA. A second anesthetist in the operating room, to monitor the cardiac rhythm during induction and intubation, possibly contributed to early detection of CA and is strongly recommended.

Perineoscrotal gangrene: two-staged therapeutic approach.

With approximately 350 reported instances of Fournier's disease (fulminating gangrene of the scrotum) since its description in 1883, individual experience is largely anecdotal and treatment remains controversial. Clarification is specially indicated as to how extensive diagnostic evaluation should be, whether, surgical incision and drainage is justified as initial therapeutic therapy, and that the priorities should be in patients having both severe systemic disease and rapidly advancing gangrene. Of four patients with Fournier's disease, three survived; the fourth died postoperatively in septic shock, diabetic ketoacidosis, and coma. A thorough diagnostic search is necessary to detect and treat all predisposing causes, especially when colorectal lesions are suspected. Simple incision and drainage did not arrest progression of disease even when combined with intensive antibiotic therapy. Critically ill patients with rapidly progressing gangrene present a therapeutic dilemma of priorities because neither immediate operation in unprepared patients nor extensive delay to treat the systemic illness first has proved to be adequate. The role of hyperbaric oxygen therapy in preoperative preparation should be explored further.

Diagnosis of incipient reflux esophagitis: a new test.

Sensitivity and reliability of a new esophageal perfusion test was evaluated and compared with those of the standard hydrochloric acid (N/10 HCl) perfusion test. Sixty-four patients including 43 with biopsy-proven reflux esophagitis (group A) and 21 with negative esophageal biopsy and equivocal symptoms (Group B) had esophageal perfusion with N/10 HCl and with taurine bile salt conjugates in N/10 HCl (T-N/10 HCl) in a double-blind, randomized fashion. In group A, T-N/10 HCl perfusion led to 100% positive results as opposed to 70% with N/10 HCl perfusion. Moreover, response times were significantly shorter (9 +/- 4 min) and washout times longer (18 +/- 4 min) with T-N/10 HCl than with N/10 HCl perfusion (18 +/- 5 min, P less than .001; and 10 +/- 3 min, P less than .001, respectively). All (100%) group B patients had negative N/10 HCl perfusion tests, whereas eight (40%) had positive T-N/10 HCl tests. All patients with positive T-N/10 HCl tests improved with administration of antacids and bile salt binders, whereas none with negative T-N/10 HCl tests improved with such therapy. Accordingly, T-N/10 HCl perfusion was more sensitive than N/10 HCl perfusion for detection of reflux esophagitis. Since all biopsy-negative patients who responded to treatment normally reserved for reflux esophagitis had a positive T-N/10 HCl test, it is possible that this test was able to detect early incipient esophagitis, before histologic changes became apparent at biopsy.

Diagnosis of postoperative intra-abdominal abscess.

Clinical, laboratory, radiologic, and radionuclide findings of 40 patients with operatively proven intra-abdominal abscesses were evaluated to determine their degree of diagnostic accuracy. Correct preoperative diagnosis was established by clinical, laboratory, and simple radiologic technics in 24 (60%) patients, whereas more sophisticated imaging procedures were used in 16. Gallium citrate Ga 67 scan was done in nine and was positive in six, ultrasonic scan was positive in seven of 16, and computerized tomography in six of eight patients. In 12, two consecutive imaging procedures were used. Concordant results were obtained in eight, of which five were accurate and three inaccurate. Of the four remaining patients with discordant results, the second imaging procedure was incorrect in three and correct in one instance. Accordingly, sophisticated imaging procedures were done in only 40% of patients and were accurate in 75% of less of cases. Furthermore, addition of a second imaging procedure did not increase diagnostic accuracy. Therefore, these technics, while improving the previously existing diagnostic means, should be still considered less than perfect and their negative result should not exclude the need for diagnostic celiotomy when clinical findings are highly suggestive of intra-abdominal abscess.

Fatal respiratory distress in burned patients.

Of 167 patients with major burns, fatal respiratory distress developed in ten. Fluid overload caused fatal respiratory failure within 48 hours of admission in five patients with anuria, whereas late deaths were due to fluid overload and pulmonary sepsis. Three of the four patients who had a tracheostomy died of pulmonary sepsis, whereas all ten patients who had endotracheal intubation survived, p less than 0.05. Preventable causes of fatal respiratory distress were found in all ten patients. The use of colloid infusions during burn shock resuscitation and serial monitoring of pulmonary extravascular water was suggested for prophylaxis of fluid overload and respiratory distress syndrome. Aspiration pneumonia prophylaxis and avoidance of an early tracheostomy were suggested for prophylaxis of pulmonary sepsis. It is suggested that the concept of idiopathic burn lung syndrome be abandoned, and instead, a vigorous etiologic search to be instituted in order to prevent, to identify and to treat correctable causes of respiratory failure.

Sodium nitroprusside pharmacoangiography: arteriographic enhancement by local vasodilation.

Sodium nitroprusside (SNP) was injected intra-arterially into the right femoral artery of five dogs, to promote arteriographic enhancement with minimal systemic effects. Injection of 3 microgram/Kg SNP or more, produced tachycardia, hypotension and increased pulsatile arterial blood flow. a 36% pulsatile arterial flow increase, which lasted 25 seconds or less, was the most remarkable systemic change seen after intra-arterial injection of 2.5 microgram/Kg SNP. Small doses were followed by even lesser systemic changes but were ineffective in promoting arteriographic enhancement. Comparison of arteriograms obtained before and after 2.5 microgram/Kg SNP injection showed increased arterial diameter, greater architectural detail and extensive visualization of previously undetected smaller arteries in post-SNP angiograms. Thus, suggesting that 2.5 microgram/Kg was the optimal SNP dose for production of local arterial without remarkable systemic effects. Good results of SNP pharmacoangiography in this experimental series suggest that further research on this topic is warranted.

Subclavian-axillary venous thrombosis: role of noninvasive diagnostic methods.

The diagnosis of primary subclavian axillary venous thrombosis (SAVT) was evaluated in eight patients to compare the accuracy of clinical diagnosis and noninvasive vascular evaluation with phlebography. Clinical evaluation led to three misdiagnoses: lymphedema (1), and inflammatory breast carcinoma (2). Doppler ultrasound detection of venous flow performed on three patients detected SAVT in only one. Plethysmography also performed on three patients led to unquestionable diagnosis in only one. Plethysmography also performed on three patients led to unquestionable diagnosis in only one. Phlebography positively identified SAVT in all patients and showed bilateral disease in one. Two patients had pulmonary embolism, and in one, permanent sequelae developed, thus emphasizing the necessity for energetic treatment of SAVT. Because of the risks of therapy and the inaccuracy of other diagnostic methods, SAVT should be positively identified by phlebography if anticoagulation is considered. Doppler and plethysmography are useful to rule out concomitant leg phlebothrombosis, to evaluate the arterial sector, and to document venous hemodynamic recovery after SAVT.

Fatal pulmonary embolism in cancer patients: is heparin prophylaxis justified?

The incidence of fatal and nonfatal pulmonary embolism (PE) was evaluated in a series of 578 patients, to quantify the suspected higher risk in cancer patients of death from massive PE when compared with patients not having cancer. PE occurred in 13% and was fatal in 8% of noncancer patients. It occurred in 17% and was fatal in 14% (P less than .05) of cancer patients. Of these cases of PE, 75% occurred in patients with adenocarcinoma and 62% in those having tumors of the pancreas, breast, large bowel, prostate, lung, and ovary. One of every seven hospitalized cancer patients died not of cancer but of PE, and 60% of all patients who died of massive PE had localized cancer or limited metastatic disease which would have allowed for reasonably long survival in absence of lethal PE. Accordingly, we strongly suggest use of prophylactic anticoagulation in hospitalized cancer patients having otherwise good prospects for reasonably long survival.

Early diagnosis of anticoagulation failure: can recurrent pulmonary embolism be prevented?

Propagating thrombosis, occurring in spite of full anticoagulation, is an early indication of the failure of anticoagulation therapy. Its detection can be successfully accomplished by routinely monitoring all heparinized patients with serial fibrinogen uptake tests or serial Doppler ultrasound venous flow evaluation in selected lower extremity veins. If anticoagulation therapy failure is detected, it should be corrected immediately. In already fully anticoagulated patients who nevertheless develop propagating thrombosis, inferior vena cava interruption should be performed before potentially lethal pulmonary embolism occurs.

The rigid versus soft postoperative dressing controversy: a controlled study in vascular below-knee amputees.

Results of 52 consecutive below-knee amputations for lower extremity ischemia were evaluated to determine whether use of immediate fit prostheses (IPOP) instead of soft stump dressings had any bearing postoperative hospitalization time, functional recovery, postoperative pain, morbidity, and mortality in amputees. Of 34 patients receiving IPOP, 21 per cent developed stump necrosis, 21 per cent had wound infection, 26 per cent required major reamputation, and 12 per cent died within 30 days of operation. Of 18 patients treated with soft stump dressings, 17 per cent developed necrosis, 33 per cent infection, 44 per cent required reamputation, and 11 per cent died postoperatively. None of these differences was statistically significant. Mean hospitalization time and average narcotic requirements for analgesia were also similar in both groups. Fifty-six per cent of patients with IPOP and 22 per cent of those with soft dressings ultimately ambulated with prostheses (P less than 0.05). Whether or not IPOP was used had little if any effect on the early evolution of vascular amputees in this series.