Inaccuracies in patient medical histories.

Of patients who completed the same medical history questionnaire twice within a certain time period, 66% had at least 1 significant omission in their history. Consideration is given to the merits of a national medical history computerized database.

The effects of common and specific factors in short-term anxiety-provoking psychotherapy: a pilot process-outcome study.

This study attempted to identify the necessary and sufficient change factors in short-term anxiety-provoking psychotherapy (STAPP). Twenty patients were randomly assigned to either STAPP or a form of nondirective therapy almost devoid of psychodynamic elements but with common factors of psychotherapy intact. Both treatments were 20 sessions long, were manualized, and therapists in both conditions were experienced clinicians receiving manual-guided supervision. Most patients had a diagnosis of anxiety. Results showed that patients in both treatments improved greatly symptomatically and that no further gains were made after termination. Treatments were equally effective. The therapeutic alliance was a strong predictor of symptom improvement. The findings underscore the importance of common factors pertaining to the therapeutic relationship, and they may open to question, to some degree, the therapeutic effectiveness of psychodynamic technique factors in STAPP. The way in which specific and common factors can be brought together under the umbrella of the concept of affect attunement is discussed.

Preoperative prediction of open breast biopsy results.

BACKGROUND: The accuracy of a surgeon's clinical judgment dictates the need for interventional diagnostic procedures to identify breast carcinoma patients. Few studies exist in which such accuracy is determined. METHODS: A series of 2247 consecutive open breast biopsies in newly presenting patients is presented in which the author preoperatively predicted a benign or malignant condition. RESULTS: Positive predictive values for all patients, patients with breast lumps, and patients with abnormal mammograms were 0.49, 0.68, and 0.39, respectively, with the highest positive predictive value (0.89) found in women 50 years or older with a breast lump. Negative predictive values for all patients, patients with a breast lump, and patients with abnormal mammograms were 0.94, 0.94, and 0.93, respectively, with the highest values found in women younger than 30 years (0.98) and in women younger than 50 years (0.95). CONCLUSIONS: Negative predictive values are reliable enough in women younger than 50 years to justify initial clinical observation of many benign appearing breast conditions. Minimal interventional procedures and open breast biopsies have a tendency to be overutilized in an effort to avoid any delay in the diagnosis of breast carcinoma. Fear of failure to diagnose breast carcinoma in a "timely fashion" is a driving force for interventional procedures in many situations in which close clinical follow-up alone is justifiable.

Prevalence of recurring BRCA mutations among Ashkenazi Jewish women with breast cancer.

The BRCA1 mutations 185delAG and 5382insC and the BRCA2 mutation 6174delT have been detected in a significant proportion of Ashkenazi Jewish women with early-onset breast cancer. A group of 236 Jewish women with breast cancer was screened for the presence of these alterations. Mutations were detected in 25.0% (59/236). Among women with breast cancer diagnosed at or before the age of 45, the prevalence of these mutations was 29.1% (42/144). Among women diagnosed with breast cancer after age 45, mutations were noted in 18.5% (17/92). Among women with a family history of breast or ovarian cancer, the likelihood of detecting a mutation was 32.1% (53/165). BRCA1 185delAG was the most common mutation overall (40/236, 16.9%). The ratio of BRCA1 185delAG to BRCA2 6174delT was 4.0 in women with early-onset breast cancer and 1.3 in women with breast cancer diagnosed after age 45. Clinical features such as age at diagnosis, family history of breast or ovarian cancer, bilateral breast cancer, and personal history of breast and ovarian cancer increase the likelihood of detecting mutations among Ashkenazi women with breast cancer. The yield of testing is low in the absence of any of these features.

Breast MR imaging with commercially available techniques: radiologic-pathologic correlation.

PURPOSE: To evaluate the clinical utility of dynamic gadolinium-enhanced magnetic resonance (MR) imaging of the breast with commercially available techniques in patients scheduled for excisional biopsy. MATERIALS AND METHODS: A total of 91 breast abnormalities, 70 benign and 21 malignant, were evaluated. Thin-section three-dimensional gradient-echo images were obtained before and 2, 4, and 7 minutes after injection of contrast material. Three radiologists prospectively evaluated the mammograms and MR images. RESULTS: The areas under the receiver operating characteristic curves were 0.820 for mammography and 0.893 for MR imaging (P = .67). Sensitivity of MR imaging was 82.5%, compared with 74.6% for mammography. Specificity of MR imaging was 82.5%, compared with 79.1% for mammography. Enhancement profiles showed early intense enhancement in malignancies but considerable overlap with enhancement of benign disease. CONCLUSION: Breast MR imaging is a slightly more sensitive modality than mammography but not a highly specific technique for evaluating breast lesions. It has utility in several clinical situations but should not be used as a substitute for biopsy or general screening.

Symptom improvement and its temporal course in short-term dynamic psychotherapy. A growth curve analysis.

Using hierarchical linear model procedures, growth curve analyses were performed to examine the course, rate, and correlates of symptom improvement during short-term anxiety-provoking psychotherapy (STAPP) and a 2-year posttermination period. The Symptom Check-list-90 was used to measure general symptomatology. The sample consisted of 15 patients who were found suitable for STAPP. Most had a diagnosis of anxiety. Therapists were in postgraduate manual-guided STAPP training. Results showed that three of four patients made a reliable and clinically significant symptom improvement over the course of treatment. Patients improved at a steady rate during treatment as well as after treatment. Average improvement was large and significant during treatment, while small and marginally significant after treatment. Improvement rates varied significantly over the course of treatment and were faster for patients less rigid in their personality functioning.

Partial mastectomy and limited axillary dissection performed as a same day surgical procedure in the treatment of breast cancer.

A series of 133 patients treated for breast cancer with partial mastectomy and limited axillary dissection performed as a same day procedure is presented. For comparison purposes an additional 45 patients are presented who had the same operative procedure but stayed for 1 or more nights as an in-patient. Of those having the procedure on a same day basis complications included hematoma (0.8%), seroma (2.3%), infection (1.5%) and miscellaneous (0.8%). These results are similar to those for patients staying overnight. It is concluded that partial mastectomy and limited axillary dissection can be safely performed as a same day procedure with advantages to the patient of avoiding hospitalization, to the surgeon in avoiding excessive paperwork and in-hospital responsibilities, and to the third party insurers in reducing costs.

The significance of breast complaints as correlated with age and breast cancer.

A review is presented of 2,000 consecutive new, patients with breast complaints. Emphasis is placed on the specific complaint as correlated with patient age and the incidence of breast cancer. The initial complaints were a lump (50%), an abnormal mammogram (32%), other complaints (8%), breast pain (6%), and nipple discharge (4%). Follow-up information was available for 1,889 patients. The majority of the patients (68%) were under 50 years of age. Of 831 patients to whom a biopsy was recommended, 720 ultimately had a biopsy and 147 cancers were identified. Sixty-five per cent of the cancers were in women aged 50 years or greater. Of the patients aged 50 years or older, 16.1 per cent had breast cancer, while only 4.0 per cent of the patients less than 50 years and 0.8 per cent of the patients less than 30 years of age had breast cancer. The author concludes that the overwhelming majority of patients (92%) referred to a breast surgery practice do not have malignancy. Thus, primary physicians undoubtedly see even a smaller per cent of breast complaints ultimately result in the diagnosis of breast cancer. There is a need to better inform the public as to the significance of breast complaints and to establish more specific criteria for biopsy, particularly in the young, professional, liability threats not withstanding.

Dermatoglyphics in the identification of women either with or at risk for breast cancer.

Fingerprints and palm prints were studied in 78 breast cancer patients, 391 patients at increased risk for developing breast cancer, and 64 control patients for the purpose of finding a pattern that would identify those women with breast cancer or those who are predisposed to its development. A pattern of 6 or more digital whorls was identified more frequently in women with breast cancer than in those without the disease (P less than 0.01). This finding was independent of known risk factors for breast cancer and was present in 28% of the cancer patients. No correlation was noticed between palm prints and breast cancer. The positive predictive value of 6 or more digital whorls was comparable to that of mammography and that of breast biopsy. With increasing age there was an increase in the positive predictive value associated with 6 or more digital whorls. It is concluded that digital dermatoglyphics may have a future role in identifying women either with or at increased risk for breast cancer such that either risk reduction measures or earlier therapy may be instituted.

Parenteral nutrition in a pregnant cystic fibrosis patient.

This case report describes a 30-year-old pregnant woman with cystsic fibrosis who had marasmus as evidenced by clinical examination. The patient was maintained on central venous hyperalimentation for 18 days in her last trimester. The patient delivered a full-term infant via cesarian section with Apgar of 8 and 9, at 1 and 5 minutes, respectively, and adverse affects.

Specialized nutrition support: patterns of care.

A prospectively studied series of 1072 patients who received specialized nutritional support are presented to evaluate the patterns of such care in a large nonuniversity teaching center. Age, service, materials used, routes of administration, complications, assessment parameters, duration of treatment, diagnoses, and survival statistics are presented. Such patterns are considered to be of importance to medical scientists, basic researchers, hospital administrators, governmental agencies, and members of the health care insurance industry.

Parenteral nutrition complications in a voluntary hospital.

A prospective study analyzing the complications in 307 patients who had specialized nutrition support administered by their private practitioners was performed and compared to other series in which a nutrition support service exclusively provided such care of patients. The mechanical complication rate of 4.6%, septic complication rate of 2.9%, and metabolic complication rate of 4.2% compared favorably with the reported literature. A new category of complications, the judgmental complication, is described and was 12.7% in the reported series. The Saint Barnabas Medical Center experience suggests that individual practitioners can satisfactorily administer intravenous specialized nutrition support if in fact an involved nutrition support service functions administratively and supportively in the background.

Subclavian cannulation. Valuable dialysis access alternative.

The subclavian vein was used for temporary dialysis access in 67 patients. There were 733 dialysis treatments performed using a total of 87 catheters during the study period. The catheters were left in place for an average of 24.5 days per patient and 18.9 days per catheter. A mean of 10.9 dialysis treatments per patient, and 8.4 dialysis treatments per catheter were performed. Seven patients expired with their catheters indwelling. None of these deaths were related to the catheter. There were 21 associated catheter complications. Twelve of these catheter complications were corrected by changing the catheter over a guide wire. The technique for catheter insertion, proper catheter care including home care, and complications due to the catheters are discussed. Subclavian catheter dialysis access appears to be a valuable adjunct for dialysis and has replaced the use of Scribner shunts and repeated femoral catheterizations for temporary access in our institution.