Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction.

BACKGROUND: The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients. METHODS: A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage. RESULTS: Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence). CONCLUSION: Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome.

INTRODUCTION: The optimal timing of breast reconstruction is controversial. Immediate breast reconstruction (IBR) has been gaining in popularity due to the aesthetic and psychological benefits, although its role is less certain when postoperative radiotherapy may be required. There is some evidence that long term cosmetic outcome of IBR using the autologous latissimus dorsi (ALD) flap may be impaired if the reconstruction is subjected to postoperative radiotherapy. We compared the long term cosmetic outcome and patient satisfaction between a group of patients who underwent IBR with postoperative radiotherapy and a group who underwent delayed ALD reconstruction. METHODS: Patients who underwent ALD breast reconstruction between 1997 and 2000 were invited to attend a research clinic. At the clinic up-to-date photographs were obtained and a quality of life questionnaire was completed. Cosmetic outcome was assessed by a panel of judges including surgeons, nurses and lay people. RESULTS: Thirteen patients who had IBR and postoperative radiotherapy and 11 patients who had delayed reconstruction attended for follow up. In the long term both groups fell within an acceptable cosmetic outcome range. However, there was a trend towards a better outcome in patients undergoing delayed reconstruction, with the volume and contour of the upper pole being most affected in the irradiated reconstructions. Patient satisfaction was similar between the two groups, however most patients in retrospect would have preferred an immediate reconstruction. CONCLUSIONS: Immediate ALD breast reconstruction, even in the setting of postoperative radiotherapy, yields satisfactory results. We continue to offer it to patients undergoing mastectomy operations, even when postoperative radiotherapy is likely to be required.

Immediate breast reconstruction does not lead to a delay in the delivery of adjuvant chemotherapy.

Immediate breast reconstruction (IBR) has been considered by some to lead to a delay in the delivery of adjuvant chemotherapy. Our aim was to determine whether IBR led to a delay when compared to conservation surgery and non-reconstructive mastectomy. Ninety-five cases of IBR receiving chemotherapy were reviewed. These were compared to 95 consecutively treated patients undergoing conservation surgery and 95 undergoing non-reconstructive mastectomy. Our data shows that IBR does not lead to a delay in the delivery of adjuvant chemotherapy when compared to standard non-reconstructive surgery and should not adversely affect breast cancer outcome.

The pharmacokinetics of once-daily oral 400 mg ofloxacin in patients with peritonitis complicating continuous ambulatory peritoneal dialysis.

Seven patients with end-stage renal disease requiring support by continuous ambulatory peritoneal dialysis received once-daily 400 mg oral ofloxacin for 7 days for the treatment of bacterial peritonitis. Serum and peritoneal dialysis fluid (PDF) were collected for assay throughout the course of the study and for 5 days thereafter. Ofloxacin, desmethyl ofloxacin and ofloxacin-N-oxide accumulated over the course of therapy and could still be detected in serum and PDF 5 days after the end of therapy. The mean elimination half-life of ofloxacin in serum was 32 +/- 7 h, desmethyl ofloxacin 45 +/- 26 h and for ofloxacin-N-oxide 44 +/- 15 h. The total mean recovery of ofloxacin and its metabolites from the PDF was 15.4%. This regimen results in serum and PDF concentrations likely to be effective for the treatment of infection for at least 10 days.

Is alcohol hepatotoxic in the baboon?

The baboon is the only animal in which alcoholic fibrosis and cirrhosis of the liver has been produced with a nutritionally adequate diet. Zinc deficiency is associated with alcoholic liver disease and may contribute to liver damage. We have therefore investigated whether zinc supplementation would reduce liver damage in ten baboons receiving ethanol and an adequate diet. Eight received ethanol at up to 25 g/kg/day (70% of calories) for up to 60 months (four were supplemented with 50 mg zinc/day). All animals gained weight, and blood concentrations of ethanol were 63-342 mg/dl. Changes in liver blood tests were slight. Liver histology only showed fatty change in six animals, severe in two, and minor inflammatory changes but no significant fibrosis or cirrhosis. In one of the animals with severe fatty change there were also degenerative changes in parenchymal cells. There was thus no significant hepatic fibrosis or cirrhosis in baboons given large amounts of ethanol and an adequate diet for up to 5 years.

Perinatal mortality in the Greater Harare Obstetric Unit area.

There were 1,563 known perinatal deaths among 45,343 births during 1983 in the Greater Harare Obstetric Unit area. The perinatal mortality rate was 34.5/1,000 for infants weighing greater than or equal to 500 g, and 26.9/1,000 for infants weighing greater than or equal to 1,000 g. The perinatal mortality rate for booked patients was 20.9/1,000 for infants weighing greater than or equal to 1,000 g. All the perinatal deaths were analysed. Immaturity was the leading known cause of perinatal death, accounting for 19.3% of the cases. Areas requiring further study to establish preventable factors in perinatal deaths are highlighted.

A review of perinatal mortality in an urban situation in a developing country.

Perinatal deaths occurring within the City of Harare, Zimbabwe, during 1983 were studied. Data were collected from all known deliveries within the city. This included exact numbers from three central maternity hospitals, and from referring midwife-run maternity clinics. An estimate was made of the number of births and perinatal deaths occurring within the city, but outside these official maternity facilities. All perinatal deaths were reviewed. The birthweight, the cause of death, and the antenatal care registration status of the mother were established. There were 2103 perinatal deaths from an estimated 53,665 total births. Deliveries include 50,138 (93.4%) in hospitals or clinics, 972 (1.8%) before arrival to the maternity service, and an estimated 2555 (4.8%) outside the city maternity services. One thousand seven hundred and fourteen (81.5%) perinatal deaths occurred in hospital or clinic delivered babies, and 134 (6.4%) from babies delivered before arrival at medical services. An estimated 255 (12.1%) of deaths occurred elsewhere. A total of 6380 (12%) patients did not register for antenatal care. There were 909 (43.2%) perinatal deaths in this unregistered group of patients. The overall perinatal mortality rate (PNMR) for infants weighing 500 g or more was 39.2/1000. For registered patients the PNMR was 25.3/1000 and for unregistered patients, 142.5/1000. For infants weighing 1000 grams or more the PNMR was 31.6/1000. The causes of death in the 2103 perinatal deaths were established and classified by clinical cause and by a simple pathological grouping with breakdown by birthweight.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: The survey purpose was to review as far as possible all of the perinatal deaths occurring in Harare, Zimbabwe. The maternity services within Harare consist of 3 maternity hospitals together with municipality-operated urban maternity clinics in the residential suburbs. All births taking place within the maternity services during 1983 were analyzed. An estimate of the number of patients giving birth within the city but outside these services was made after consultation with the City Medical Officer. All cases of perinatal deaths were analyzed to assess the cause of death, the registration status of the mother, and the birth weight of the baby. An estimate of perinatal deaths occurring outside the maternity services also was made from the City Medical Officer's annual report, newspaper reports of baby dumping, and after consultation with the City Social Services and the police. There were an estimated 53,665 total births and 2103 perinatal deaths in Harare during 1983. 94% of the births were delivered within the hospitals or clinics; 1.8% were born before arrival (BBA) to the maternity service. 4.8% were not born within the city maternity services. 1714 (18.5%) perinatal deaths occurred from babies born in the hospitals or clinics, and 134 (6.4%) from babies born before arrival at maternity services. An estimated 255 (12.1%) of deaths occurred elsewhere. Those infants born before arrival made up 1.8% of the total births and accounted for 6.4% of the total perinatal deaths. Of the 53,665 births within the City of Harare during 1983, 47,285 (88%) were booked for antenatal care at either a municipal clinic or hospital. 6380 (12%) patients did not register for antenatal care, and 909 (43.2%) perinatal deaths occurred in the unregistered groups of patients. The overall perinatal mortality rate (PNMR) was 39.2/1000. For registered patients the PNMR was 25.3/1000; it was 142.5/1000 for unregistered patients. 1685 (80.1%) perinatal deaths were in infants weighing 1000 g or more; 418 (19.9%) perinatal deaths occurred from infants weighing less than 1000 g. Unexplained stillbirth, immaturity, intrapartum asphyxia, and antepartum hemorrhage were the principal cause of death accounting for almost 60% of the total perinatal mortality.

The effects of hospital admission for bed rest on the duration of twin pregnancy: a randomised trial.

212 women with twin pregnancies were randomly allocated either to receive advice to rest in hospital from 32 weeks' gestation until delivery, or to be part of a control group in which hospital admission was offered selectively (and, on average, 5 weeks later). Preterm delivery was more common among women admitted routinely for bed rest than among controls, and this difference was unlikely to have occurred by chance. There is at present no scientifically acceptable evidence that this common, disruptive, and expensive obstetric policy does more good than harm.

Controlled trial of external cephalic version.

A prospective randomized, controlled trial involving 640 singleton breech presentations after 30 weeks gestation was conducted to assess the value of external cephalic version. In 310 patients external cephalic version was attempted; the other 330 patients in whom version was not attempted constituted a control group. There were three perinatal deaths directly attributable to external cephalic version. No significant differences were found between the study and control groups respecting the incidence of vaginal breech delivery, caesarean section rate, perinatal mortality and morbidity. Our results suggest that there is no place for external cephalic version before 36 weeks gestation.

Placental handling of zinc in the guinea pig.

The distribution of zinc between the mother and the fetoplacental unit, and its placental transfer, were studied using stable and isotopic zinc in unanaesthetized pregnant guinea pigs and an in situ perfusion preparation. The concentration of stable zinc in fetal plasma and skeletal muscle was higher than that in the maternal tissues: 2.0 compared with 1.4 micrograms/ml and 84 with 49 ng/mg dry weight, respectively. The placenta and maternal and fetal liver had similar zinc concentrations: 90, 75 and 88 ng/mg dry weight, respectively. The ability of the placenta to concentrate 65Zn, measured 1 h after a single intravenous injection into the unanaesthetized mother, was comparable with that of the maternal liver. Maternal-fetal mass transfer of zinc was directly related to maternal plasma zinc concentrations from 0.7 to 24.1 micrograms/ml (b = 2 ng X min-1 X g-1 X microgram-1, r = 0.92). At physiological plasma levels, the calculated transfer would supply the fetus with 0.12 mg zinc/day, similar to the accretion rate over the last trimester. Placental transfer of zinc was not influenced by the concentration of zinc in the placental perfusate. Extraction of zinc from the perfusate was also slow, and partly by absorption. Maternofetal transfer of zinc was directly related to both uterine and umbilical blood flows. The high concentration of zinc in the syncytium, relative to both maternal and fetal plasma levels, suggests active uptake at the maternal surface, combined with a slow release into the fetus, down a concentration gradient.

Clearance and non-invasive determination of the hepatic extraction of indocyanine green in baboons and man.

1. The disposition of an intravenous bolus of indocyanine green (ICG) has been studied in healthy man and baboons using a novel analysis of a two compartment pharmacokinetic model. 2. This analysis enabled the hepatic extraction ratio (ER) of dye to be determined solely from the plasma disappearance curve, and the ER determined did not differ from that measured by hepatic vein catheterization. 3. When compared with clearance measured at steady state, the two compartment model gave a significantly more accurate determination of plasma clearance than did the conventional one compartment model. 4. It is concluded that, in health, liver blood flow may be calculated accurately and non-invasively after a single intravenous injection of ICG.

Perspectives in obstetric care for Zimbabwe.

PIP: This is an examination of the following 4 aspects of obstetric care in Zimbabwe: 1) maternal health; 2) fetal health; 3) family planning; and 4) infertility. Largely at the insistence of voluntary organizations, the medical director of the colony of Rhodesia in 1926 accepted the idea that the state must play a role in providing maternity services. Western medicine was still provided only in urban areas; traditional medicine and midwives held sway in the rural areas. A comparison of mortality statistics illustrates the state of Zimbabwean health services today. While the maternal mortality rate for women in Britain was .1/1000 in the 1970s and the rate for white women in Zimbabwe was .2/1000, the rate for the African population was 3.3/1000. The rate for African women booked into hospitals for obstetric care was only .59/1000. While infection, hemorrhage, and hypertensive disease, the main causes of mortality in Britain in the 1930s, have been controlled there, infection still plays a major role in maternal mortality in Zimbabwe. The perinatal mortality rate of 45/1000 in Zimbabwe recently compares to a rate of 10-15/1000 in Britain. As with maternal mortality, perinatal mortality was much higher among unbooked patients. A program to control the spread of venereal diseases could help in eliminating the congenital abnormalities which account for much perinatal mortality. There is still low acceptance of abortion and sterilization as legitimate means of fertility control in Zimbabwe. The modern health care establishment must train and incorporate traditional workers also.^ieng

Aetiological factors in pelvic inflammatory disease in urban Blacks in Rhodesia.

Pelvic inflammatory disease is the main reason for the admission of patients to the Gynaecological Unit at Harari Hospital. Some epidemiological and microbiological aspects of the disease have been studied. Gonococcus was isolated infrequently from inpatients, but there appears to be a pool of potential pathogens, both aerobic and anaerobic, which are able to invade the upper genital tract under certain circumstances. Mycoplasmas were isolated from a high percentage of patients.

An assessment of the criteria for selection of patients for an obstetric intensive care unit.

Intensive care monitoring of the fetus during labour improves perinatal conditions in 'high-risk" Black women. If the available facilities and staff are to be used with maximal efficiency, a system of priorities is necessary. It would appear that patients with meconium staining of the liquor, with cephalopelvic disproportion, or with two or more indications for monitoring, should have priority for admission to our intensive care unit. Hypertension and antepartum haemorrhage are of less importance, but there are two other problems which need investigation. There is a group of patients in labour who arrive too late to be monitored. They have a considerable perinatal mortality and the reasons for their late arrival need to be ascertained. There is a second group of patients who begin labour before term and deliver babies with a high risk of perinatal death. These problems require further investigation.