Patient reported outcomes of autologous fat grafting after breast cancer surgery.

INTRODUCTION: Autologous fat grafting (AFG) can be used as an adjunct in breast cancer surgery to improve contour defects. Few previous studies have assessed patient reported outcomes (PROs) for AFG. This study analysed AFG use and assessed PROs in terms of physical and psychosocial well-being. MATERIALS AND METHODS: All patients undergoing AFG were identified from a prospective database and asked to complete the validated BREAST-Q questionnaire and a tool to assess patient-perceived change after AFG (5-point Likert-type scale). Descriptive statistics were computed for all BREAST-Q and perceived change subscales. Independent sample t-tests were conducted to compare scores on each of the BREAST-Q and perceived change subscales by type of breast cancer surgery and radiotherapy status. RESULTS: 156 AFG sessions were performed over 4 years on 119 breasts in 88 patients. Fifty-seven patients received AFG after reconstruction and 19 after breast conserving surgery. Forty-six patients (52%) completed the questionnaire. BREAST-Q scores (out of 100) and patient-perceived change after AFG (out of 5) were respectively: 54 and 4.0 for Breast satisfaction, 69 and 3.3 for Physical well-being and 60 and 3.6 for Psychosocial well-being. Radiotherapy status and type of surgery made little difference. Number of AFG procedures positively correlated with perceived improvement. DISCUSSION: Autologous fat grafting was associated with improved patient satisfaction despite small volumes transferred. BREAST-Q scores were comparable with previously published series on reconstructive breast surgery. Perceived change after AFG was no different in patients receiving radiotherapy.

The importance of prediction model validation and assessment in obesity and nutrition research.

Deriving statistical models to predict one variable from one or more other variables, or predictive modeling, is an important activity in obesity and nutrition research. To determine the quality of the model, it is necessary to quantify and report the predictive validity of the derived models. Conducting validation of the predictive measures provides essential information to the research community about the model. Unfortunately, many articles fail to account for the nearly inevitable reduction in predictive ability that occurs when a model derived on one data set is applied to a new data set. Under some circumstances, the predictive validity can be reduced to nearly zero. In this overview, we explain why reductions in predictive validity occur, define the metrics commonly used to estimate the predictive validity of a model (for example, coefficient of determination (R(2)), mean squared error, sensitivity, specificity, receiver operating characteristic and concordance index) and describe methods to estimate the predictive validity (for example, cross-validation, bootstrap, and adjusted and shrunken R(2)). We emphasize that methods for estimating the expected reduction in predictive ability of a model in new samples are available and this expected reduction should always be reported when new predictive models are introduced.

Energy balance measurement: when something is not better than nothing.

Energy intake (EI) and physical activity energy expenditure (PAEE) are key modifiable determinants of energy balance, traditionally assessed by self-report despite its repeated demonstration of considerable inaccuracies. We argue here that it is time to move from the common view that self-reports of EI and PAEE are imperfect, but nevertheless deserving of use, to a view commensurate with the evidence that self-reports of EI and PAEE are so poor that they are wholly unacceptable for scientific research on EI and PAEE. While new strategies for objectively determining energy balance are in their infancy, it is unacceptable to use decidedly inaccurate instruments, which may misguide health-care policies, future research and clinical judgment. The scientific and medical communities should discontinue reliance on self-reported EI and PAEE. Researchers and sponsors should develop objective measures of energy balance.

Numerical study of stretched smectic-A elastomer sheets.

We present a numerical study of stretching monodomain smectic-A elastomer sheets, computed using the finite element method. When stretched parallel to their smectic layer normal the smectic layers are unstable to a transition to a buckled state. We model macroscopic deformations by replacing the microscopic energy with a coarse grained effective free energy that accounts for the fine-scale layer buckling. We augment this model with a term to describe the energy of deforming buckled layers, which is necessary to reproduce the experimentally observed Poisson ratios postbuckling. We examine the spatial distribution of the microstructure phases for various stretching angles relative to the layer normal and for different length-to-width aspect ratios. When stretching parallel to the layer normal the majority of the sample forms a bidirectionally buckled microstructure, except at the clamps where a unidirectionally buckled microstructure is predicted. When stretching at small inclinations to the layer normal the phase of the sample is sensitive to the aspect ratio of the sample, with the bidirectionally buckled phase persistent to large angles only for small aspect ratios. We relate these theoretical results to experiments on smectic-A elastomers.

Negative Poisson's ratio and semisoft elasticity of smectic-C liquid-crystal elastomers.

Models of smectic-C liquid-crystal elastomers predict that they can display soft elasticity, in which the shape of the elastomer changes at no energy cost. The amplitude of the soft mode and the accompanying shears are dependent on the orientation of the layer normal and the director with respect to the stretch axis. We demonstrate that in some geometries the director is forced to rotate perpendicular to the stretch axis, causing lateral expansion of the sample-a negative Poisson's ratio. Current models do not include the effect of imperfections that must be present in the physical sample. We investigate the effect of a simple model of these imperfections on the soft modes in monodomain smectic-C elastomers in a variety of geometries. When stretching parallel to the layer normal (with imposed strain) the elastomer has a negative stiffness once the director starts to rotate. We show that this is a result of the negative Poisson's ratio in this geometry through a simple scalar model.

Legionella longbeachae serogroup 1 infections linked to potting compost.

Four cases of legionellosis caused by Legionella longbeachae serogroup (sg) 1 were identified in Scotland from 2008 to 2010. All case patients had exposure to commercially manufactured growing media or potting soils, commonly known as multipurpose compost (MPC), in greenhouse conditions, prior to disease onset. Two patients had been using the same brand of MPC but the clinical isolates were distinct genotypically by amplified fragment length polymorphism (AFLP) analysis. However, an indistinguishable AFLP profile was also found in an environmental isolate from the supply of MPC used by each patient. The third patient was diagnosed by immunofluorescent antibody serology only; however, the MPC to which this patient was exposed contained L. longbeachae sg 1 in large quantities (80 000 c.f.u. g(-1)). The fourth patient was L. longbeachae sg 1 culture-positive, but L. longbeachae was not identified from 10 samples of garden composting material. As compost is commonly used, but L. longbeachae infection seemingly rare, further work is required to ascertain (i) the prevalence and predictors of L. longbeachae in compost and (ii) the conditions which facilitate transmission and generate an aerosol of the bacteria. As most cases of legionellosis are diagnosed by urinary antigen that is Legionella pneumophila-specific and does not detect infection with L. longbeachae, patients in cases of community-acquired pneumonia with a history of compost exposure should have serum and respiratory samples sent to a specialist Legionella reference laboratory for analysis.

Determining the direction to a sound source in air using vector sound-intensity probes.

This paper is concerned with probes for measuring vector sound intensity in air using the minimum number of sound-pressure sensors. The probes consist of an arrangement of four small microphones at the vertices of a regular tetrahedron. They are connected to a digital signal processor, which determines the sound-intensity vector, using the cross-spectral formulation based on finite-difference approximations. Determining the direction of a sound source is an obvious application. To do this accurately the probes should be omnidirectional. This implies that the microphones in the probe have to be omnidirectional and to have the same response. Results in the paper show that the direction of a sound source can be determined with an accuracy of a few degrees. Two types of probes are described. One measures the sound-intensity vector in three-dimensional space. The other measures the vector in a half space such as would occur above the ground or in front of a wall.

Preventing glycaemic relapse in recently controlled type 2 diabetes patients: a randomised controlled trial.

AIMS/HYPOTHESIS: After achieving glycaemic control, many type 2 diabetic patients relapse to clinically significant levels of hyperglycaemia. We sought to determine the optimal frequency of telephone contact by nurse practitioners that was necessary to prevent glycaemic relapse. METHODS: This parallel, randomised controlled trial ran from June 2002 to February 2006 at an academic medical centre, studying 164 type 2 diabetic patients who had recently achieved glycaemic control. Participants were randomly assigned by sequential, concealed, computer-generated allocation to a 2 year maintenance strategy consisting of: (1) routine follow-up (n = 54); (2) routine follow-up and quarterly telephone contact (n = 55); or (3) routine follow-up and monthly telephone contact (n = 55). Blinding was not possible. The primary outcome was cumulative incidence of glycaemic relapse, defined as an increase in HbA(1c) of > or =1%; all participants were analysed. Cumulative incidence and prevalent proportions were compared. Weight change and hypoglycaemia were also assessed. RESULTS: All participants randomised were included in the analyses. The study was completed by 90% of participants and intervention fidelity was high. At 24 months, the cumulative incidence of relapse was 41%. At 12 months, prevalent proportions of relapse were 20%, 14% and 15% for control, quarterly contact and monthly contact, respectively. At 24 months, they were 25%, 21% and 29%, respectively. There was no statistically significant difference in cumulative incidence or prevalent proportions of relapse among the study arms. Adverse events did not differ between study arms. CONCLUSIONS/INTERPRETATION: This first randomised controlled trial to test an intervention to prevent glycaemic relapse found that regularly scheduled telephone contact by a nurse practitioner was no more effective than routine follow-up care in preventing glycaemic relapse.

Factors associated with balance deficits on admission to rehabilitation after traumatic brain injury: a multicenter analysis.

OBJECTIVE: To evaluate how demographics, measures of injury severity, and acute care complications relate to sitting and standing balance in patients with traumatic brain injury (TBI). DESIGN: Multicenter analysis of consecutive admissions to designated TBI Model Systems of Care (TBIMS). SETTING: Ten National Institute for Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. PARTICIPANTS: 908 adults with TBI were included in the study. MAIN OUTCOME MEASURES: Sitting and standing balance were assessed within 72 hours of admission to inpatient rehabilitation. RESULTS: Age less than 50 years had a significant association with normal sitting and standing balance (P =.001 and.05, respectively). Measures of severity of traumatic brain injury, including admission Glasgow Coma Score, length of posttraumatic amnesia (PTA), length of coma, and acute care length of stay were each significantly related to impaired sitting and standing balance ratings (P <.01). Initial abnormalities in pupillary response had a significant relationship with impairment of sitting (P =.009) but not standing balance. Incidence of respiratory failure, pneumonia, soft tissue infections, and urinary tract infections were all related to impaired sitting balance (P <.01). Presence of intracranial hemorrhages did not have a significant relationship with either sitting or standing balance. Intracranial compression had a significant relationship with standing (P =.05) but not sitting balance. A discriminant function analysis, which included neuroradiological findings, injury severity, and medical complications, could not accurately predict impaired balance ratings. CONCLUSIONS: This study demonstrated that rehabilitation admission balance ratings have a significant relationship with age, multiple measures of severity, and acute care medical complications after TBI. Prospective studies are indicated to evaluate the role balance at rehabilitation admission plays in the functional prognosis of patients with TBI.

Detection and characterisation of integrons in Salmonella enterica serotype enteritidis.

Integrons have been widely described among the Enterobacteriaceae including strains of multi-resistant Salmonella enterica serotype Typhimurium DT104; however, information with respect to the presence of integrons among S. enterica serotype Enteritidis strains is limited. Multi-resistant isolates of Enteritidis were screened for the presence of integrons using a PCR protocol. One integron was detected in all isolates that were resistant to sulfonamide and streptomycin. Characterisation of these isolates indicated an integron which ranged in size between 1000 and 2000 bp and which harboured a gene cassette encoding the ant(3")-Ia gene specifying streptomycin and spectinomycin resistance. Further studies revealed the integrons to be located on large conjugative plasmids. This appears to be the first report of plasmid-borne integrons in Enteritidis.

Knee version associated with anterior knee pain.

Version of the knee in the presence and absence of anterior knee pain was evaluated by computed tomography in this study. Version of the knee is defined as the static rotation of the tibia with respect to the femur in full knee extension. Fourteen patients in whom conservative management for anterior knee pain failed were compared with 14 volunteers with no symptoms. Computed tomography images of the femoral condyles and tibial plateau were obtained with the knee extended. The angle between the bicondylar and posterior tibial axes was measured. This angle, representing external rotation of the tibia relative to the femur, was increased significantly in patients with symptoms (7 degrees) compared with volunteers with no symptoms (1 degree). This increased knee version identifies a unique morphologic characteristic of the knee with anterior pain.

An out-of-home care system in crisis: implications for African American children in the child welfare system.

An out-of-home care system that is itself in crisis lacks adequate resources to provide the services needed by families and children in distress. Increasingly, these families are composed of people of color, particularly African Americans. Using current child welfare statistics and a review of the literature, this article examines the nature of the crisis in child welfare, and how poverty and an array of social problems, as well as problems specific to the child welfare system, increase the overrepresentation of African American children and families in the out-of-home care system. Implications for child welfare practice and advocacy are also discussed.

Suboptimal progesterone production in pathologic pregnancies.

Serum progesterone (P) levels were determined at the time of routine prenatal registration (227 patients) or upon presentation for evaluation of vaginal bleeding and/or abdominopelvic cramping/pain (135 patients). P associated with a normal intrauterine gestation was 24.63 +/- 4.19 (SD) ng/mL as compared with 6.29 +/- 2.43 ng/mL and 6.02 +/- 2.39 ng/mL for spontaneous abortions and ectopic gestations, respectively. Further, P differed between asymptomatic (11.92 +/- 9.61 ng/mL) and symptomatic patients (4.81 +/- 3.92 ng/mL) who were subsequently shown to have an abnormal gestation. By establishing a P cutoff point of < or = 14.2 ng/mL and < or = 10.5 ng/mL in asymptomatic and symptomatic patients, respectively, 100% screening sensitivity was reached, and therefore no abnormal gestations would escape detection in our study population. P was either in the normal or abnormal range as early as four weeks' estimated gestational age and persisted as such through the luteal-to-placental shift and up to the time of pregnancy loss or 12 weeks' estimated gestational age. Although there was no significant correlation between P and chorionic gonadotropin levels and pregnancy outcome, the binding constant for native chorionic gonadotropin was 15-52 times lower in 12 of 41 cases of spontaneous abortion but not ectopic gestation, suggesting a possible molecular basis for suboptimal P production. P is therefore an excellent adjunctive marker for prediction of early pregnancy outcome, and in some cases qualitative abnormalities in chorionic gonadotropin may dictate its production.

The relationship between health beliefs, adherence, and metabolic control of diabetes.

There is evidence that an individual's health beliefs influence performance of health behaviors. The purpose of this study was to determine whether health beliefs in persons with diabetes could be modified during a clinical education program and whether the health beliefs were related to adherence to self-care instructions and metabolic control of diabetes. Health beliefs and HbA1c were measured at baseline in 189 adult outpatients with diabetes. Diabetes educators then attempted to modify health beliefs that were not conducive to positive health behaviors. Following education, some health beliefs were modified in a positive direction. Modest, but statistically significant increases in perceived severity of diabetes, perceived ability to carry out recommended behaviors, and perceived benefits of treatment were observed. Although HbA1c improved significantly in a subgroup of patients, this improvement could not be directly associated with any health belief or with self-reported adherence by the measures used in this study.

Dropout and relapse during diabetes care.

OBJECTIVE: To determine factors associated with dropout and relapse during chronic diabetes care. RESEARCH DESIGN AND METHODS: Private practice outpatient treatment-education program for adult diabetes was surveyed. Retrospective analysis was done, involving 422 patients for up to 3 yr. RESULTS: Of the patients in the study, 12% dropped out after the initial visit, and 33% of the residual cohort dropped out during each subsequent 6-mo period. Factors associated with dropout included distance from home to clinic > 100 miles, lack of insulin treatment, and cigarette smoking. In patients who remained in follow-up, a significant decrease in HbA1C occurred during the first 6 mo, but 40% of the patients relapsed between 6 and 12 mo. Frequency of relapse declined as time passed. Relapse was more frequent in women. CONCLUSIONS: Dropout from treatment and relapse after temporary improvement account for a substantial amount of uncontrolled diabetes, and overcoming the obstacles of dropout and relapse has potential for significant improvement in diabetes care.

Ubiquitin, PGP 9.5 and dense body formation in trimethyltin intoxication: differential neuronal responses to chemically induced cell damage.

Ubiquitin in normal cells may be important in degrading or transferring short-lived or aberrant proteins to lysosomal dense bodies. To examine its role in degrading proteins produced by a chemical insult, changes in the distribution of ubiquitin and the carboxy-terminal hydrolase, PGP 9.5, have been studied in rat hippocampal neurons and cerebellar Purkinje cells in trimethyltin intoxication. Here tubulovesicular dense bodies (TVBs) form from 12h onwards associated with vacuolation of the Golgi apparatus. Striking accumulations of lysosomal dense bodies follow in hippocampal pyramidal cells but not in cerebellar Purkinje cells; many of the hippocampal neurons later die, while the Purkinje cells generally survive. Ubiquitin immunoreactivity was diffusely increased in hippocampal pyramidal and Purkinje cells 6 h after dosing. By 12 h both diffuse and granular ubiquitin immunoreactivity was present that intensified over 24 and 48 h. Both by light and electron microscopy TVBs showed ubiquitin immunoreactivity, but dense bodies in hippocampal perikarya did not stain with an anti-ubiquitin antibody. PGP 9.5 immunoreactivity was not altered in hippocampal cells at any time, while Purkinje and Golgi cell dendrites and perikarya showed intensified labelling at 3 h that reached a peak of 12 h. At 48 h Western blot analysis of hippocampal homogenates showed significant increases in high molecular weight (HMW) ubiquitin conjugates, while cerebellar homogenates showed an increase in ubiquitin-histone conjugates. Northern blot analyses showed no change in ubiquitin or PGP9.5 gene expression in hippocampus or cerebellum. These findings suggest that the material in the TVBs in hippocampal cells is not being degraded by the ubiquitin system but passes ubiquitinated into the lysosomal system, while material in Purkinje cell TVBs is degraded by the ubiquitin system, suggesting it may have a different composition in each type of neuron.