Skin Toxicity in Early Breast Cancer Patients Treated with Field-In-Field Breast Intensity-Modulated Radiotherapy versus Helical Inverse Breast Intensity-Modulated Radiotherapy: Results of a Phase III Randomised Controlled Trial.

AIMS: Skin toxicity is a common adverse effect of breast radiotherapy. We investigated whether inverse-planned intensity-modulated radiotherapy (IMRT) would reduce the incidence of skin toxicity compared with forward field-in-field breast IMRT (FiF-IMRT) in early stage breast cancer. MATERIALS AND METHODS: This phase III randomised controlled trial compared whole-breast irradiation with either FiF-IMRT or helical tomotherapy IMRT (HT-IMRT), with skin toxicity as the primary end point. Patients received 50 Gy in 25 fractions and were assessed to compare skin toxicity between treatment arms. RESULTS: In total, 177 patients were available for assessment and the median follow-up was 73.1 months. Inverse IMRT achieved more homogeneous coverage than FiF-IMRT; erythema and moist desquamation were higher with FiF-IMRT compared with HT-IMRT (61% versus 34%; P < 0.001; 33% versus 11%; P < 0.001, respectively). Multivariate analysis showed large breast volume, FiF-IMRT and chemotherapy were independent factors associated with worse acute toxicity. There was no difference between treatment arms in the incidence of late toxicities. The 5-year recurrence-free survival was 96.3% for both FiF-IMRT and HT-IMRT and the 5-year overall survival was 96.3% for FiF-IMRT and 97.4% for HT-IMRT. CONCLUSIONS: Our study showed significant reduction in acute skin toxicity using HT-IMRT compared with FiF-IMRT, without significant reduction in late skin toxicities. On the basis of these findings, inverse-planned IMRT could be used in routine practice for whole-breast irradiation with careful plan optimisation to achieve the required dose constraints for organs at risk.

Neurocognitive dysfunction after coronary artery bypass surgery: a systematic review.

OBJECTIVE: Substantial, albeit scattered, evidence suggests that coronary artery bypass grafting may impair cognitive function. As methods and definitions differ greatly across studies, the reported incidence of cognitive decline after coronary bypass surgery varies widely as well. The aim of the present study was to systematically review those studies on cognitive decline that are relatively comparable and meet with certain quality criteria. METHODS: Four electronic databases and the references of several abstract books and earlier reviews were used to identify relevant literature. Stringent criteria, based in part on the 1994 consensus meeting on assessment of neurobehavioral outcomes after cardiac surgery, were used to assess the studies that were found. In total, 256 different titles were found, of which 23 met with the formulated selection criteria. RESULTS: Twelve cohort studies and eleven intervention studies were evaluated. A pooled analysis of six highly comparable studies yielded a proportion of 22.5% (95% confidence interval, 18.7%-26.4%) of patients with a cognitive deficit (a decrease of at least 1 standard deviation in at least two of nine or ten tests) 2 months after the operation. CONCLUSIONS: Neurocognitive dysfunction is a frequently occurring complication of coronary artery bypass grafting. The etiologic contribution of cardiopulmonary bypass to this complication will remain unclear until a randomized trial that directly compares off-pump and on-pump bypass surgery is carried out.

[Endovascular embolization in gastrointestinal hemorrhage]. / Endovasculaire embolisatie bij gastro-intestinale bloedingen.

The indications, the technique and the choice of materials for transcatheter embolisation in three patients are described. A 73-year-old woman with Henoch-Schönlein vasculitis was admitted with haematemesis and melaena. Angiography showed active haemorrhage in a branch of the pancreaticoduodenal artery. The common hepatic artery was catheterised up to the pancreaticoduodenal artery and superselective transcatheter embolisation was accomplished using polyvinyl alcohol (PVA) particles of 0.3-0.5 mm diameter. A 82-year-old woman with chronic cardiac decompensation developed serious haematemesis after a papillotomy. With the help of PVA particles the bleeding A. pancreaticoduodenalis inferior ramus posterior was embolised. Several days after a pancreaticoduodenectomy for a carcinoma of the papilla of Vater a 75-year-old man went into shock. The angiogram revealed haemorrhage of the right hepatic artery. With the combination of microcoils and a coaxial balloon catheter proximal of the bifurcation of the hepatic artery haemorrhage could be arrested. Haemorrhage did not recur and all patients could be discharged in good condition. When local anatomy has been changed by earlier surgery or when patients in bad general condition are concerned, transcatheter embolisation can offer the solution in active haemorrhage.

Thermodynamics of the charge recombination in photosystem II.

The temperature dependence of the electric field-induced chlorophyll luminescence in photosystem II was studied in Tris-washed, osmotically swollen spinach chloroplasts (blebs). The system II reaction centers were brought in the state Z(+)P(+)-QA (-)QB (-) by preillumination and the charge recombination to the state Z(+)PQAQB (-) was measured at various temperatures and electrical field strengths. It was found that the activation enthalpy of this back reaction was 0.16 eV in the absence of an electrical field and diminished with increasing field strength. It is argued that this energy is the enthalpy difference between the states IQA (-) and I(-)QA and accounts for about half of the free energy difference between these states. The redox state of QB does not influence this free energy difference within 150 µs after the photoreduction of QA. The consequences for the interpretation of thermodynamic properties of QA are discussed.

Resection of the rectum with preservation of continence by means of a transanal anastomosis.

Resection of the rectum with restoration of continuity via a transanal side-to-side anastomosis is a relatively simple and safe surgical technique for the treatment of tumours localized 9 cm or more from the anus. Even a temporary artificial anus is superfluous. In none of the six patients thus treated was any complication observed, all are normally continent. The technique used is described in detail.

Splenic vein thrombosis with oesophageal varices: a late complication of umbilical vein catheterization.

On the basis of observations made on three infants, a description is given of a late complication of umbilical vein catheterization not hitherto reported. The children showed the symptoms of thrombosis of the splenic vein with secondary splenomegaly and marked gastric and/or esophageal varices, while the portal vein showed no abnormality. The diagnosis was preoperatively established by means of selective angiography of the superior mesenteric artery and the splenic artery. Treatment in these three cases consisted of splenectomy, with good clinical and radiological results.