Patient-reported outcome measurement compared with professional judgment of cosmetic results after breast-conserving therapy.

Background: In the present study, we set out to compare patient-reported outcomes with professional judgment about cosmesis after breast-conserving therapy (bct) and to evaluate which items (position of the nipple, color, scar, size, shape, and firmness) correlate best with subjective outcome. Methods: Dutch patients treated with bct between 2008 and 2009 were analyzed. Exclusion criteria were prior amputation or bct of the contralateral breast, metastatic disease, local recurrence, or any prior cosmetic breast surgery. Structured questionnaires and standardized six-view photographs were obtained with a minimum of 3 years' follow-up. Cosmetic outcome was judged by the patients and, based on photographs, by 5 different medical professionals using 3 different scoring systems: the Harvard scale, the Sneeuw questionnaire, and a numeric rating scale. Agreement was scored using the intraclass correlation coefficient (icc). The association between items of the Sneeuw questionnaire and a fair-poor Harvard score was estimated using logistic regression analysis. Results: The study included 108 female patients (age: 40-91 years). Based on the Harvard scale, agreement on cosmetic outcome between the professionals was good (icc: 0.78). In contrast, agreement between professionals as a group compared with the patients was found to be fair to moderate (icc range: 0.38-0.50). The items "size" and "shape" were identified as the strongest determinants of cosmetic outcome. Conclusions: Cosmetic outcome was scored differently by patients and professionals. Agreement was greater between the professionals than between the patients and the professionals as a group. In general, size and shape were the most prominent items on which cosmetic outcome was judged by patients and professionals alike.

Efficacy of localization of non-palpable, invasive breast cancer: Wire localization vs. Iodine-125 seed: A historical comparison.

BACKGROUND: To achieve radical tumour excision in non-palpable breast cancer accurate tumour localization is essential. Historically, this has been achieved by wire localization (WL). Recently, new techniques like Iodine-125 seeds (IL) have become available. The aim of this study was to determine whether the results in case of IL are better than when WL is used. METHOD: A consecutive series of patients operated on because of non-palpable breast cancer was analysed. Between January 2007 and April 2011 WL was method of choice. From April 2011 till January 2013 IL was introduced and became the standard procedure. PRIMARY OUTCOMES WERE: success rate of (peri-) operative localization and radicality of the excision. Secondary outcomes were duration of operation and volumes of the excised tissue specimen. RESULTS: A total of 236 women were included; 149 women underwent WL and 87 women IL. The overall success rate for WL was 93.3%. In 10 patients (6.7%) WL failed because of peri-operative dislocation of the wire compared to only one failure to locate the seed in de postoperative specimen in the IL-group (1.1%, p = 0.098). Radical resection was obtained in 126/149 (84.6%) of the WL-patients, in comparison with 81/87 (93.1%) in the IL-group (p = 0.054). Median operation time and volume of the specimen was not significantly different between both groups. CONCLUSION: Localization of non-palpable breast cancer using Iodine-125 seeds is, at least, as good as the standard wire localization procedure.

Cisplatin and oxaliplatin surface contamination in intensive care units (ICUs) and hospital wards during attendance of HIPEC patients.

PURPOSE: The aim of this pilot study was to evaluate surface contamination by platinum drugs in the environment of patients in ICUs and wards treated by hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: The monitoring included 12 HIPEC treatments from four hospitals during the following 3 days after perfusion. A total of 33 urine and 33 drainage fluids from HIPEC patients and 160 wipe samples from several surfaces (urine/drainage bags, floors, gloves) were taken during the study period. RESULTS: In urine, the highest platinum concentrations were measured on the first day after perfusion. Median platinum concentrations were 1260 ng/ml for patients after cisplatin perfusion and 11,000 ng/ml for oxaliplatin treatment. Concentrations decreased until day three to 413 ng/ml cisplatin and 529 ng/ml oxaliplatin, respectively. In drainage liquids, platinum concentrations were generally lower. Platinum concentrations from surfaces of bags and floors ranged from 0.01 to 439 pg/cm(2) (median: urine bag 2.77 pg/cm(2), drainage bag 0.22 pg/cm(2), floor left 0.14 pg/cm(2), floor right 0.24 pg/cm(2)), with the highest contamination found on the outer surface of the urine bags. Samples from nurses' protective gloves ranged between 0.03 and 12 pg/cm(2) (median: 0.2 pg/cm(2)). CONCLUSIONS: High platinum-drug concentrations in urine and drainage liquids are the main source of contamination. Therefore, safe handling of these liquids is the best way to avoid cross-contamination on surfaces in wards and ICUs. Our results show that it is possible to take care of HIPEC patients without high contaminations during the first 3 days.

Retrosternal dislocation of the clavicle.

Retrosternal dislocation of the clavicle is an uncommon injury which may affect the mediastinal structures in a life-threatening way. Therefore, computed tomography is mandatory. Manipulation in the acute situation is the treatment of choice. In case of failure or old dislocation, open reduction with stabilization of the joint is required. The literature on this subject has been reviewed and an additional two cases are reported.

Cicatricial hernia after bone grafting from the iliac crest.

Herniation of the abdominal wall is seldom encountered after harvesting cancellous bone from the iliac crest. The case history is presented of a patient with the symptoms, diagnostic work-up and repair of the hernia using a Goretex sheet.

Periampullary and pancreatic head carcinoma: facts and factors influencing mortality, survival, and quality of postoperative life.

From September 1983 to December 1985 40 patients from a total of 55 with periampullary and pancreatic head carcinoma underwent resectional surgery in our department. Following a policy of precise evaluation of each patient's operative findings, six patients underwent a Whipple duodenopancreatectomy, 29 patients underwent regional subtotal pancreatectomy, and five underwent regional total pancreatectomy. Five patients underwent vascular reconstruction of their regional vascular structures after transection of the invaded segments of their vessels and eight had positive lymph nodes. Lymph node involvement was confined to the regional area. Patients with distant lymph node involvement (paraaortic) were not considered eligible to resection. Three patients died and 10 required reoperation. Thirty-one had radical resection, one palliative and eight equivocal resection. From the survived patients (n = 37) 33 are alive and doing well at the time of this report (overall mean survival 18 months). The results of this study demonstrate that a radical approach based on a precise evaluation of operative findings of the individual patient might well offer a higher resectability rate and is probably the only chance for radical resection and for a longer survival in patients with periampullary and pancreatic head carcinoma.

A new surgical approach for the management of carcinoma of the junction of the main hepatic ducts.

In the present study we discuss our early results and some technical aspects of a new surgical approach in dealing with high-lying malignant biliary obstruction. After transection of the common bile duct we proceed through a cephalad reflection of its proximal end in a meticulous dissection of the intrahepatic biliary tree. During dissection we follow the intrahepatic course of the right and left portal vein, which leads us to follow the respective course of the main right and left hepatic ducts and to reach the levels of their subsequent consecutive segmental bifurcations. By transecting at high levels, we excise completely or partially the tumor with the confluence of common hepatic duct. We reconstruct the biliary tree by multiple intrahepatic cholangiojejunostomies by use of a Roux-Y jejunal loop and a varied number of segmental hepatic ducts. Transanastomotic tubes were used only temporarily. Fifteen patients underwent operations by the described surgical approach without mortality. All were relieved of their jaundice completely and in all the tumor was either completely (5) or partially (10) removed. All patients had a good quality of postoperative life without being obliged to carry transanastomotic tubes and the complications and problems associated with them.

Absence of muscle capillary basement membrane thickening and retinopathy in patients with myocardial infarction and impaired i.v. glucose tolerance.

We have investigated the possible contribution of an early capillaropathy to the increased incidence of myocardial infarction (MI) in patients who had impaired glucose tolerance (IGT) during an i.v. glucose tolerance test (IVGTT). In lieu of the myocardium, biopsies from the quadriceps femoris muscle were studied for muscle capillary basement membrane (MCBM) thickening. Fluorescence angiography was performed to detect capillary retinopathy. Plasma growth hormone (GH) concentrations were determined during IGT. Data were obtained from 14 male patients with MI and IGT on IVGTT. Nine healthy subjects served as controls. MCBM thickness was similar in patients and controls (1,107 +/- 55 vs 1,067 +/- 88 A). None of the patients had signs of capillary retinopathy, and plasma GH concentrations were not higher in the patients as compared to control subjects. It is concluded that, in patients with IGT on IVGTT, MCBM thickening is probably not a factor for the development of MI.

[Cardiac arrhythmias and other complications in patients after myocardial infarction during a long term training program]. / Ventrikuläre Rhythmusstörungen und andere Komplikationen bei Patienten nach Myokardinfarkt während eines langfristigen dosierten Trainings.

In 85 patients with myocardial infarction undergoing a physical training on a bicycle ergometer 3 times a week over a period of 18 months beginning 5 weeks after the acute infarction, telemetric and haemodynamic investigations were made. The telemetry was done during ergometer training, dynamic and isometric gymnastics and during work at home. The diastolic pulmonary arterial pressure under exercise was registered in 43 patients before the beginning of the training program; in 16 of these patients a control heart catheterization was made after a training period of 4 months. During the ergometer training program 32% of all patients had ventricular premature beats more than 1:10, 6% had paroxysmal ventricular tachycardias, 1 patient had supraventricular tachycardias and 1 patient died at home after having a tachycardia of unknown origin. During dynamic or isometric gymnastics or under work at home the patients had not more arrhythmias than in the telemetric controls during the ergometer training. Arrhythmias and other complications are very often found in patients with high diastolic pulmonary arterial pressure in the exercise test.

[Use of nifedipine and nitroglycerin during exercise therapy in patients with myocardial infarct. Clinical and hemodynamic studies]. / Anwendung von Nifedipin und Nitroglyzerin während eines dosierten Trainings bei Patienten mit Herzinfarkt Klinische und hämodynamische Untersuchungen.

The hemodynamic effects of nitroglycerin and nifedipin and the application of both substances during a long term training program in patients with angina pectoris, myocardial infarction, and myocardial dysfunction (=48) were studied. Cardiac output, heart rate, and arterial blood pressure showed no significant changes after application of nitroglycerin and nifedipin. After nitroglycerin, however, there were significant drops of pulmonary arterial pressure and right atrial pressure during rest and exercise, whereas no changes were seen after nifedipin. With the application of nitroglycerin (but not with nifedipin) prior to the daily physical training program on a bicycle ergometer, all patients with angina pectoris and myocardial dysfunction showed an increasing training effect during the long term program and their angina pectoris improved.

[Nitroglycerin, furosemide and ethacrynic acid effect on hemodynamics in rest and during ergometric load in coronary disease patients]. / Wirkung von Nitroglycerin, Furosemid und Ethacrynsäure auf die Hämodynamik in Ruhe und unter ergometrischer Belastung bei Patienten mit koronarer Herzerkrankung

The haemodynamic effects of intravenous injections of furosemide and ethacrynic acid as well as those of peroral administration of nitroglycerin were studied in 32 patients (4-12 weeks after acute myocardial infarction) during rest and exercise. Cardiac output, heart rate and arterial blood pressure showed no significant changes after administration of nitroglycerin, furosemide and ethacrynic acid (fig 3). A few minutes after application of nitroglycerin or furosemide there were significant falls of pulmonary arteria diastolic pressure and right atrial pressure (fig. 1 and 2), whereas no changes were seen after injection of ehtacrynic acid. This initial effect of furosemide as well as the effect of nitroglycerin is primarily of vascular origin, causing an increased peripheral venous capacitance. Ethacrinic acid failed to exhibit any direct vascular effect. Therefore during pulmonary oedema nitroglycerin together with furosemide should be given.

[Haemodynamic effects of furosemide and ethacrynic acid (author's transl)]. / Vergleichende hämodynamische Untersuchungen über die extrarenale Wirkung von Furosemid und Ethacrynsäure

The haemodynamic effects of intravenous injections of furosemide and ethacrynic acid were studied in 12 patients during rest and exercise. Cardiac output, heart rate and arterial blood pressure showed no significant changes after injection of furosemide or ethacrynic acid. Few minutes after injection of furosemide there were significant falls of pulmonary artery diastolic pressure and right atrial pressure, whereas no changes were seen after injection of ethacrynic acid. This initial effect of furosemide apparently is of primarily vascular origin, causing an increased peripheral venous capacitance. Ethacrynic acid failed to exhibit any direct vascular effect.

Myocardial hypertrophy, myocarditis, and myocardial fibrosis in a long term experiment.

In a long term experiment, a systematic analysis was made of the cellular reaction of the myocardium and the lymphatic system to application of antigenic substances. Several groups of mice received single or repeated injections of human serum, serum from rabbits with antiheart antibodies, mouse spleen cells immunized to myocardium, and human or mouse cardiac homogenate with and without incomplete or complete Freund's adjuvant. After injection of human and mouse heart homogenate, hypertrophy of myocardial cells was the first alteration seen; then followed focal myocarditis and after 10 months, interstitial fibrosis. Simultaneously, in the lymphorecticular tissue, there was marked proliferation of reticulum cells, lymphocytes, and plasma cells, as well as an enlargement of secondary follicles. All the animals produced antibodies to the injected antigens. Following injection of human serum or serum from rabbits with cardiac specific antibodies or spleen cells, no morphological changes were seen in the hearts.

Age-dependent changes of heart valves and heart size.

The mode and extent of the regressions of heart valves, valvular rings, and tendon chords, as well as the size of atria and ventricles in 316 hearts of different age groups (macroscopically normal at autopsy), were studied. With increasing age, the valves showed marked thickening and loss of elasticity. Deposition of lipoids and calcification occur to a variable extent in the valvular tissue and rings; Valve size shows a change of minor degree, but tendon chords and papillary muscles shorten in old age. The diameters of the atria, mitral, tricuspid, pulmonary, and aortic rings increase continuously up to the 9th decade of life. The width and length of the ventricles show minor alterations in size. In old age, heart weight increases.