Papillomas of the breast 15 mm or smaller: 4-year experience in a community-based dedicated breast imaging clinic.

PURPOSE: To determine the significance of small, often mammographically occult and asymptomatic papillomas of the breast 15 mm and smaller. METHODS: Four-year retrospective review of papillomas of the breast in a community-based dedicated breast imaging center, with a selected cohort of 179 papillomas 15 mm or smaller in 147 patients, all completing image-guided core biopsy followed by surgical excision. RESULTS: Of 179 papillomas 15 mm or smaller, 36 % were abnormal (24 % atypia; 12 % cancer). Twenty-one percent had a surgical upgrade diagnosis. One hundred forty-six benign papillomas by core biopsy yielded 7 (4.7 %) cancers and 25 (17 %) atypias (atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma-in situ) at surgical excision. Seven of 34 (14 %) of very small papillomas (5 mm or smaller) showed cancer. Twelve of 72 (11 %) and 8 of 36 (13 %) papillomas showed cancer in normal-risk and high-risk patients, respectively. Increasing age (70+ years) associated strongly with increasing risk of papillomas with cancer (10 of 35, 29 %). Thirteen unsuspected papillomas in 10 patients with new nonpapillary breast cancers yielded 3 atypias and 3 additional cancers, changing surgical management in half of these patients. Breast ultrasound identified 44 % of papillomas as incidental findings, all mammographically occult and asymptomatic. CONCLUSIONS: There is no size threshold below which a papilloma of the breast can be safely watched or ignored without risking a missed diagnosis of atypia or cancer. Identification of papillomas in patients with new nonpapillary breast cancers can change patient management in up to half of these patients. Finally, breast ultrasound significantly enhances identification of unsuspected papillomas.

Frequency of Monitoring Hemoglobin A1C and Achieving Diabetes Control.

OBJECTIVES: The American Diabetes Association recommends measuring hemoglobin A1C levels (A1C) at least semiannually in diabetic patients who have stable glycemic control and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. These guidelines were based on expert consensus without reference to actual clinical data. The main objective of this study was to assess association between meeting a target A1C level of <7% and adherence to monitoring guidelines. Secondary objectives were to determine the proportion of diabetic patients in the authors' practice who met the A1C monitoring guidelines and to assess whether meeting the target A1C level is associated with other information easily abstracted from patients records, namely age, gender, and types of therapy. METHODS: This study employed a case control design. Records of 193 type 2 diabetic patients seen over a 6-month period in a rural family medicine clinic were analyzed. Assessment of diabetes control was based on the most recent A1C level, with <7% considered controlled. Adherence to guidelines was assessed by determining frequency of testing during the preceding 12-month period. RESULTS: Ninety-eight patients (51%) adhered to the American Diabetes Association guidelines on frequency of monitoring A1C. Median levels of adherent and nonadherent patients differed significantly (6.5 vs 7.3, P < .001, Mann-Whitney test). Logistic regression analysis showed that "diabetes control" based on the A1C level is positively associated with adherence to the guidelines, negatively associated with intensity of therapy, and not associated with gender or age. CONCLUSION: This study supports the usefulness of American Diabetes Association practice guidelines on the frequency of monitoring A1C levels in diabetic patients.

Malignant transformation in perianal fistulas of Crohn's disease: a systematic review of literature.

INTRODUCTION: Malignant transformation of perineal fistula in Crohn's disease has rarely been reported. The aim of this study is to define the patient's characteristics and clinical presentation of this rare disease. METHODS: A systematic review of case series and reports published in English language between 1950 and 2008 was conducted. All cases with malignancy in low pelvic/perineal fistula in patients with Crohn's disease were included. All selected cases were then analyzed with respect to age, gender, duration of Crohn's disease and fistula, location of fistula, presenting symptoms, method of diagnosis, delay in diagnosis, histopathology, treatment, and outcome. Data analyses were done using chi-squared or Fisher's exact test and the Mann-Whitney test. RESULTS: Literature review revealed 61 cases of carcinomas arising in perineal fistulas in Crohn's disease. Sixty-one percent (37) of the patients were females. Females were significantly younger than males at the time of diagnosis of cancer (47 vs. 53 years, P < 0.032). Males were also noted to have significantly longer duration of Crohn's disease compared to females (24 vs. 18 years, P = 0.005). However, females were noted to have the fistula for significantly shorter duration prior to cancer transformation when compared to males (8.3 vs. 16 years, P = 0.0035). On initial examination, malignancy was suspected and proven only in 20% of patients (n = 12). Adenocarcinoma was the most common histology (59%, n = 36), followed by squamous cell carcinoma (31%, n = 19). In most patients (59%, n = 36), the fistula was rectal in origin. CONCLUSIONS: A high suspicion for malignancy in chronic perineal fistulas associated with Crohn's disease should be maintained in spite of negative biopsies. Especially in women, the shorter duration of Crohn's fistulas prior to malignant degeneration necessitates an aggressive approach to rule out cancer.

Motor and cognitive development at one-year follow-up in infants with torticollis.

BACKGROUND: Clinical experience suggests infants with torticollis are at risk for developmental delay. AIMS: To examine gross motor (GM) skills at presentation in infants with torticollis; report first-year GM and cognitive outcomes; examine relationship between types of torticollis and above outcomes. STUDY DESIGN: Prospective follow-up study. SUBJECTS: Infants referred to 2 regional child development centers from April 2001-December 2002 with torticollis/head tilt and no perinatal complications syndromes were studied. OUTCOME MEASURES: GM function was measured using the Alberta Infant Motor Scale and classified as normal (>10%), suspect (5-10% inclusive), or abnormal (<5%). Cognitive function was measured at follow-up using CAT-CLAMS-r Developmental Assessment. Follow-up data obtained between 8 and 15 months of age. RESULTS: One hundred and one infants with torticollis were seen for initial assessment at mean age 2.9 (SD 1.5) months. Eighteen had sternomastoid tumor, 47 muscular torticollis and 36 postural torticollis. At presentation, 35 (35%) of the 101 infants had suspect or abnormal GM function. 19/66 children with normal GM and 17/35 with suspect or abnormal GM function had postural torticollis (p=0.054). All children received physical therapy. Follow-up assessment of 83 participants, mean age 12.8 (SD 3.6) months, showed 75 had normal GM function and 8 had suspect or abnormal GM function; 11/83 still had torticollis. Cognitive assessment on 66 infants, mean age 14.4 (SD 4.8) months, revealed 57 (87%) had normal cognitive function and 9 (13%) were either delayed or significantly delayed. CONCLUSIONS: Infants with torticollis are at increased risk for early GM delay but most normalize by one year. Torticollis is not associated with delays in early cognitive function.

Intracellular trafficking and degradation of unassociated proalpha2 chains of collagen type I.

Procollagen I is a trimer consisting of two proalpha1(I) chains and one proalpha 2(I) chain. In certain cases of mild osteogenesis imperfecta, abnormal proalpha1(I) chains are degraded very soon after synthesis. As a consequence, the cells produce excess proalpha2(I) chains, which cannot form trimers and are not secreted. The objective of this work was to determine the intracellular fate of unassociated proalpha2(I) chains. Mov13 mouse fibroblasts, which do not synthesize proalpha1(I) mRNA, but do produce proalpha2(I) mRNA, were incubated with radioactive amino acids using pulse-chase protocols, and proteins were analyzed by gel electrophoresis, autoradiography, and Western blotting. Mov13 cells produced proalpha2(I) chains that were degraded intracellularly within 30 min. Degradation was inhibited when cells were treated with brefeldin-A, which blocks transit from endoplasmic reticulum to Golgi. Fixed cells exposed to various immunofluorescence markers and imaged by confocal laser scanning microscopy showed that proalpha2(I) chains colocalized with Golgi and lysosome markers. Degradation was inhibited and chains were secreted when cells were treated with wortmannin, which blocks trafficking to lysosomes. These results demonstrate that unassociated proalpha2(I) chains leave the endoplasmic reticulum, transit the Golgi, and enter lysosomes where they are degraded.

A simplified diagnostic approach to dizziness in children.

The objective of the study was to validate the effectiveness of a questionnaire and computer-assisted algorithm in diagnosing children with dizziness or vertigo. Dizziness and vertigo are common complaints in children, causing an extensive, often unnecessary evaluation. A pediatric "dizziness questionnaire" was designed and a computer-assisted algorithm was developed to facilitate the diagnostic task. A retrospective medical record review was conducted on all children presenting to the clinic for dizziness or vertigo throughout a 2-year period. The information was used by one investigator to complete the questionnaire and by the other, the algorithm. The two diagnoses thus obtained were compared by the third investigator to the medical record diagnosis. Sixty-two records were reviewed. The final diagnoses were migraine (39%), benign paroxysmal vertigo (15%), vestibular neuronitis (14%), and anxiety (13%). In 57 patients (92%), the questionnaire-derived diagnosis was identical to the medical record diagnosis. In 52 patients (84%), the algorithm-derived diagnosis matched the medical record diagnosis. The questionnaire and computer-assisted algorithm are reliable diagnostic screening tools for children with dizziness or vertigo. When these tools combined provide a clear-cut diagnosis, no further evaluation is necessary.