Comparison of breast cancer recurrence and outcome patterns between patients treated from 1986 to 1992 and from 2004 to 2008.

PURPOSE: To determine whether the patterns of relapse according to estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status changed in the contemporary era. PATIENTS AND METHODS: Female patients referred to the British Columbia Cancer Agency with biopsy-proven stage I to III breast cancer (BC), diagnosed between 1986 and 1992 (cohort 1 [C1]) and between mid-2004 and 2008 (cohort 2 [C2]), and with known ER and HER2 status were eligible. Data were prospectively collected. C2 patients were matched to C1 patients for stage, grade, and ER and HER2 status. The primary end point was hazard rate of relapse (HRR) for BC by study cohort according to biomarker status. Secondary outcomes included HRR according to stage, grade, and age and hazard rate of death (HRD). RESULTS: After matching, 7,178 patients were included (3,589 patients in each cohort). BC subtype distribution was as following ER positive/HER2 negative, 70.8%; ER positive/HER2 positive, 6.9%; ER negative/HER2 positive, 6.6%; and ER negative/HER2 negative, 15.8%. For the overall population, the HRR approximately halved in all yearly intervals to year 9 in C2 compared with C1. Differences in HRR between cohorts were greater in the initial five intervals for HER2-positive and ER-negative/HER2-negative BC. The HRR decreased in C2 compared with C1 for all disease stages and grades. The HRD in C2 also decreased compared with C1, although to a lesser extent. CONCLUSION: Although the pattern of relapse remains similar, there has been a significant improvement in BC relapse-free survival. Outcomes have improved for all BC subtypes, especially HER2-positive and ER-negative/HER2-negative BC, with the early spike in disease recurrence markedly decreased. These contemporary hazard rates are important for treatment decisions, patient discussions, and planning clinical trials of early BC.

Variation in access to community rehabilitation services and length of stay in hospital following a hip fracture: a cross-sectional study.

OBJECTIVES: To assess variation in access to and use of community rehabilitation services for patients with a hip fracture, and whether this affects length of stay in hospital. DESIGN: Cross-sectional study using administrative patient-level data from Hospital Episode Statistics (HES) and organisational survey data. SETTING: A regional health economy in South West England served by four acute National Health Service (NHS) hospital trusts and six former Primary Care Trusts (PCTs). POPULATION: 1230 hip fracture patients treated in an acute hospital between 1 April 2011 and 29 February 2012. MAIN OUTCOMES: Information about access to community rehabilitation services for each acute hospital and PCT, reported by organisational survey. Rates of patients transferred from acute hospital to community rehabilitation hospitals (CRH) across eight groups with varying access; determined by acute hospital and PCT. Median lengths of stay in the acute hospital, and in the acute hospital plus CRH combined. Associations between the rate of transfer to a CRH and median lengths of stay assessed using Spearman's rank correlation coefficient (rs). RESULTS: Access to community rehabilitation services varied, including the number of CRH inpatient beds, formal access criteria and waiting times. In one PCT, no home-based rehabilitation service was available. The percentage of patients transferred to a CRH ranged from 2.1% to 54.7%. A higher transfer rate was associated with a shorter median length of stay in the acute hospital (rs=-0.8; p=0.01), but a longer median combined length of stay in the acute hospital and CRH (rs=+0.7; p=0.04). CONCLUSIONS: Within one geographical area, there was wide variation in availability and use of community rehabilitation services for patients discharged from an acute hospital following a hip fracture. Reliance on transfers to community rehabilitation hospitals was associated with a longer length of stay in the NHS.

Group A streptococcal fasciitis after submental tumescent liposuction.

Tumescent liposuction is a procedure with a good safety record. Local infection is rare but can result in devastating consequences. We report a rare case of group A streptococcal fasciitis complicating tumescent liposuction and highlight the importance of early diagnosis and treatment of this condition. A 62-year-old woman presented 8 days after submental liposuction and a platysmal plication procedure with signs and symptoms of cervical fasciitis. Microbiological analysis confirmed a group A streptococcal infection. By using early aggressive medical and surgical treatments, the disease was arrested before the onset of any necrotizing process. A high index of suspicion is required to make an early diagnosis of this potentially disfiguring and life-threatening infection.

Nasal alar necrosis.

OBJECTIVE: To describe an unrecognized clinical entity, nasal alar necrosis, and propose recommendations regarding the diagnosis, pathophysiology, and management of these cases. STUDY DESIGN: Retrospective review of four patients with this condition. METHODS: Histories, treatments, and outcomes were evaluated using office and hospital chart data. RESULTS: We noted that three patients had prior trauma or surgery, other than to the nose, in the head and neck region. All four patients had comorbidities such as diabetes, hypothyroidism, depression, or tobacco abuse. Three patients had sensory deficits over the distribution of the maxillary nerve, and three volunteered that they had a habit of picking the crusted wound. Two patients improved over several months with aggressive wound care. One patient refused treatment and another underwent successful reconstruction. CONCLUSIONS: After malignant and granulomatous diseases were ruled out, our evaluations suggested that the pathogenesis was multifactorial including several factors alone or in combination, such as, hypoesthesia, self-mutilation, and an inadequate blood supply. Deficits in vascularity and sensory innervation must be considered as potential obstacles in reconstruction. Psychological problems causing factitious wounding may complicate therapeutic interventions.

Betahistine increases vestibular blood flow.

Betahistine is used for treatment of several vestibular disorders. Despite the accepted use of this histamine-like substance, its mechanism of action is not well understood. The purpose of this study was to assess the possibility that one of the activities of betahistine is increasing blood flow in the peripheral vestibular end organs. Using a novel surgical approach, we identified the posterior semicircular canal ampulla of guinea pigs and placed a laser Doppler probe in position to obtain blood flow measurements from the posterior semicircular canal ampulla. Blood pressure, heart rate, and vestibular blood flow were continuously recorded. Concentration-response curves were obtained for betahistine (2.5, 5, 7.5, and 10 mg/kg) and control-vehicle (0.15 mol/L NaCl) infusions. A separate group of subjects was pretreated with the competitive selective H3 agonist, thioperimide maleate, before betahistine treatment. Increases in vestibular blood flow and decreases in blood pressure were observed in response to betahistine infusions. Pretreatment with thioperamide maleate abolished these changes at low doses of betahistine and attenuated the responses at higher doses of betahistine. These results show that betahistine administration induces increases in vestibular blood flow. These findings support the potential use of betahistine for treatment of vestibular disorders, which may be caused by compromised circulation.

Volume-length impact of lateral jaw resections on complication rates.

OBJECTIVE: To study the relationship between soft tissue volume loss and bone resection length following lateral segmental mandibulectomy with plate reconstruction and complication rates. DESIGN: Retrospective case review of 31 patients (1989-1996), with average follow-up of 37.2 months, who were treated by lateral composite resection for oral cavity and/or oropharyngeal malignancy with primary reconstruction by defect-bridging plates. SETTING: Academic tertiary care referral center. INTERVENTIONS: Thirty patients had stainless steel and 1 patient a vitallium reconstruction plate to restore mandibular continuity. Soft tissue defects were repaired with pectoralis myocutaneous flaps (n = 25), skin grafts (n = 4), a radial forearm free flap (n = 1), or primary closure (n = 1). All patients received preoperative (n = 6) or postoperative (n = 25) radiation therapy. MAIN OUTCOME MEASURES: Overall and hardware-related complications. RESULTS: All 31 initial soft tissue repairs were successful. Subsequent complications occurred in 14 patients (45%), which included plate exposure (29%), loosened screws requiring hardware removal (29%), fistula (14%), local wound infection (14%), osteomyelitis (7%), and plate fracture (7%). Average time to complication was 7.7 months. Complication rates were 81% for bone defects greater than 5.0 cm, and 7% for those less than 5.0 cm. Bivariate analysis indicated bone resection lengths greater than 5.0 cm to be a significant predictor of both hardware-related (P = .02) and overall complications (P = .005), whereas soft tissue volume resections greater than 240 cm3 were found only to be marginally significant (P = .04) for overall complications. CONCLUSION: Extirpative losses involving more than 5 cm of bone, or tissue volume greater than 240 cm3, are associated with unacceptably high complication rates when reconstructed with solid screw stainless steel plates and this warrants consideration of alternative techniques for long-term stability.

Atrial natriuretic peptide participates in the regulation of vestibular blood flow.

Atrial natriuretic peptide (ANP) is a cardiac hormone which exerts natriuretic, diuretic and vasorelaxant effects. Among the many organs and vascular beds populated with ANP receptors (Genest and Cantin, 1988) are the vestibular and auditory organs of the inner ear (Lamprecht and Meyer zum Gottesberge, 1988). The purpose of the current study was to assess the potential influence of ANP on vestibular blood flow in the guinea pig. The inner ear was exposed with a posterior-lateral approach medially through the mastoid cortex. The laser Doppler probe was placed adjacent to the ampulla of the posterior semicircular canal. Baseline measurements of mean blood pressure (BP), heart rate (HR) and vestibular blood flow were established. ANP dissolved in physiologic saline was infused intravenously at concentrations of 15, 150 or 300 ng/kg/min at 10 microliters/min for 30 min. Measurements were recorded during the infusion and for a recovery period of 65 min. The control group was treated equivalently and infused with 0.15 M NaCl. Baseline BP and HR for all animals were 40.1 +/- 6.67 and 190 +/- 15.7, respectively. BP, HR and vestibular blood flow remained stable during the baseline, control and recovery conditions of saline infused subjects. Infusion of ANP (15 ng/kg/min) induced a mild elevation of BP followed by a small decrease in pressure during the post-infusion period. Vestibular blood flow showed a decrease to approximately 20% below baseline during infusion and stabilized at this level during the recovery period. Infusion of higher concentrations of ANP (150 and 300 ng/kg/min) induced a similar pattern of BP change in a dose-dependent manner. Vestibular blood flow, however, evidenced significant elevations during the post-infusion periods for both concentrations. These increases (22% and 26%, for 150 and 300 ng/kg/min, respectively) were significantly different from vestibular blood flow changes in the saline and low dose groups. The HR remained stable for baseline, infusion and recovery periods for each of the ANP infused subjects. This investigation demonstrates the systemic and local effects of ANP suggest a possible role for ANP in local regulation of vestibular blood flow.