A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND: Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited. METHODS: A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70. RESULTS: We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up. CONCLUSIONS: IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

Linking breeding and wintering ranges of a migratory songbird using stable isotopes.

We used the natural abundance of stable isotopes (carbon and hydrogen) in the feathers of a neotropical migrant songbird to determine where birds from particular breeding areas spend the winter and the extent to which breeding populations mix in winter quarters. We show that most birds wintering on western Caribbean islands come from the northern portion of the species' North American breeding range, whereas those on more easterly islands are primarily from southern breeding areas. Although segregated by breeding latitude, birds within local wintering areas derive from a wide range of breeding longitudes, indicating considerable population mixing with respect to breeding longitude. These results are useful for assessing the effects of wintering habitat loss on breeding population abundances and for predicting whether the demographic consequences will be concentrated or diffuse.

Multiscale assessment of patterns of avian species richness.

The search for a common cause of species richness gradients has spawned more than 100 explanatory hypotheses in just the past two decades. Despite recent conceptual advances, further refinement of the most plausible models has been stifled by the difficulty of compiling high-resolution databases at continental scales. We used a database of the geographic ranges of 2,869 species of birds breeding in South America (nearly a third of the world's living avian species) to explore the influence of climate, quadrat area, ecosystem diversity, and topography on species richness gradients at 10 spatial scales (quadrat area, approximately 12,300 to approximately 1,225,000 km(2)). Topography, precipitation, topography x latitude, ecosystem diversity, and cloud cover emerged as the most important predictors of regional variability of species richness in regression models incorporating 16 independent variables, although ranking of variables depended on spatial scale. Direct measures of ambient energy such as mean and maximum temperature were of ancillary importance. Species richness values for 1 degrees x 1 degrees latitude-longitude quadrats in the Andes (peaking at 845 species) were approximately 30-250% greater than those recorded at equivalent latitudes in the central Amazon basin. These findings reflect the extraordinary abundance of species associated with humid montane regions at equatorial latitudes and the importance of orography in avian speciation. In a broader context, our data reinforce the hypothesis that terrestrial species richness from the equator to the poles is ultimately governed by a synergism between climate and coarse-scale topographic heterogeneity.

Detection of macro-ecological patterns in South American hummingbirds is affected by spatial scale.

Scale is widely recognized as a fundamental conceptual problem in biology, but the question of whether species-richness patterns vary with scale is often ignored in macro-ecological analyses, despite the increasing application of such data in international conservation programmes. We tested for scaling effects in species-richness gradients with spatially scaled data for 241 species of South American hummingbirds (Trochilidae). Analyses revealed that scale matters above and beyond the effect of quadrat area. Species richness was positively correlated with latitude and topographical relief at ten different spatial scales spanning two orders of magnitude (ca. 12,300 to ca. 1,225,000 km2). Surprisingly, when the influence of topography was removed, the conditional variation in species richness explained by latitude fell precipitously to insignificance at coarser spatial scales. The perception of macro-ecological pattern thus depends directly upon the scale of analysis. Although our results suggest there is no single correct scale for macro-ecological analyses, the averaging effect of quadrat sampling at coarser geographical scales obscures the fine structure of species-richness gradients and localized richness peaks, decreasing the power of statistical tests to discriminate the causal agents of regional richness gradients. Ideally, the scale of analysis should be varied systematically to provide the optimal resolution of macro-ecological pattern.

The utility of trained arthritis patient educators in the evaluation and improvement of musculoskeletal examination skills of physicians in training.

OBJECTIVE: To determine the level of examination skills of internal medicine residents and to assess whether an intervention by trained persons with arthritis could have a greater impact on their examination skills than participation in an ambulatory care training experience. METHODS: Twenty-seven residents attended a 6-week ambulatory care rotation that included didactic teaching as well as attendance at an outpatient arthritis clinic with supervision by rheumatologists. Sixteen residents were randomly assigned to have a training encounter with an arthritis educator along with the standard experience in the arthritis clinic, whereas 11 residents received training in the arthritis clinic only. Arthritis educators evaluated the musculoskeletal examination skills of each resident during the first week of the rotation. The 16 residents in the intervention group received instruction on joint examination techniques by the arthritis educator immediately following their evaluation. At the end of the 6-week rotation, the groups were re-evaluated by a different arthritis educator. A group of 21 rheumatologists was also asked to perform a comprehensive musculoskeletal examination on individual arthritis educators. The arthritis educators assessed the examination of the rheumatologists using the same evaluation instrument that was used to assess the residents. RESULTS: Initially, internal medicine residents carried out the musculoskeletal examination poorly (34.2 +/- 0.09% correct, n = 27). By contrast, the rheumatologists carried out a significantly greater amount of the examination correctly (54.5 +/- 0.05%). The musculoskeletal examination skills of the residents who received additional training from an arthritis educator were significantly greater at the end of the rotation than the group who did not receive this intervention (50.5 +/- 0.10% versus 41.9 +/- 0.14% correct, P = 2.15 x 10(-5). CONCLUSION: Internal medicine residents carried out the musculoskeletal examination poorly. However, an intervention by arthritis educators improved the musculoskeletal examination skills of internal medicine residents significantly and more effectively than the standard clinical teaching in a rheumatology outpatient clinic. The impact of the arthritis educator intervention persisted for at least 5 weeks.

Role of postnatal penicillin prophylaxis in prevention of neonatal group B streptococcus infection.

This prospective study was designed to identify the role of postnatal penicillin prophylaxis in the prevention of neonatal group B streptococcus (GBS) infection. We studied 10 998 infants. Of these, 5389 were in the penicillin prophylaxis group (PP) and 5609 infants did not receive penicillin prophylaxis (NPP). Infants were allocated to treatment by month of birth, alternating 3-mo blocks or 2-mo blocks to the two groups after the first block was randomly assigned. The use of PP reduced the incidence of clinical sepsis (1.7% PP versus 2.5% NPP, p < 0.01), GBS infection (0.4% PP versus 0.9% NPP, p < 0.001) and deaths from sepsis (0.1% PP versus 0.3% NPP, p < 0.05). We conclude that the routine use of postnatal penicillin prophylaxis appears to be effective in reducing the incidence of clinical sepsis and death from sepsis in neonates.

Long-term outcome of infants at the margin of viability.

The outcome of babies at extremely short gestational age (22 to 26 weeks) effects our clinical decisions regarding their care. We looked at survival and presence of disability at 25 +/- 11 months of age in 246 of these infants born at our hospital between 1992 and 1996 who were average weight for gestational age. Babies were evaluated in our follow up clinic by a pediatrician, and a physical therapist for cerebral palsy, blindness and deafness, and by a psychologist with the Bayley II. Chances for survival without disability exceeded 50% of live born infants at 25 weeks gestation or a birth weight of 700 to 800 grams. Chances for survival exceeded 50% of live born infants at 24 weeks gestation or a birth weight of 600 to 700 grams. Chances for intact survival reached 50% of survivors at 23 weeks gestation or a birth weight of 400 to 500 grams.

Intravenous t-PA for acute ischemic stroke: therapeutic yield of a stroke code system.

Subsequent to publication of the NINDS t-PA Stroke Study results, we sought to determine the proportion of patients eligible for and receiving intravenous tissue plasminogen activator (t-PA) at an active acute stroke treatment center. Over a 12-month period there were 185 stroke code activations. Of these, 134 involved patients with ischemic stroke, and 48 of these (36%) were potentially eligible for treatment with t-PA by the time criterion (i.e., interval from stroke onset to hospital presentation < 3 hours). Nine of the 48 potentially eligible patients (19%) and 9 of 134 ischemic stroke patients (7%) overall received t-PA. In our patient population only a small proportion of all patients with acute ischemic stroke presently are eligible for treatment with t-PA.

MRI findings in headbangers.

Magnetic resonance imaging (MRI) findings in a mentally retarded adult female who exhibits headbanging behavior are presented. Radiographic changes include enlargement of the diploic space in the parietal and occipital bones, and gray matter loss adjacent to the bony changes. This pattern of injury is compared with skull changes previously reported in headbangers, and neuronal injury seen in boxers (dementia pugilistica) and Minimata disease.

Immunogenicity of hepatitis B vaccine in healthy very low birth weight infants.

We studied the immunogenic response to hepatitis B vaccine of infants weighing < or = 1500 gm at birth. Infants were divided into two groups: those weighing < or = 1000 gm (n = 22) and those weighing 1001 to 1501 gm (n = 28). When immunized early (3 days of age, n = 25), these infants had a response rate (defined as antibody to hepatitis B surface antigen titer > 10 mIU/ml) of 68%, whereas when the first vaccine was given at 1 month of age (n = 25), a 96% response rate was noted, irrespective of birth weight and weight at the time of immunization (p < 0.02).

Calciphylaxis in a patient with Crohn's disease in the absence of end-stage renal disease.

Calciphylaxis is a rare and life-threatening condition of progressive cutaneous necrosis secondary to small and medium-sized vessel calcification previously described in patients with end-stage renal disease and hyperparathyroidism. Early diagnosis may be important in improving the poor outcome in these patients since early intervention may forestall the development of life-threatening complications. We describe a patient with Crohn's disease complicated by short-bowel syndrome and modest renal insufficiency (not requiring renal replacement therapy) who developed calciphylaxis. It appears that longstanding Crohn's disease and the short-bowel syndrome accelerated the development of calciphylaxis as the chronic renal disease was not end stage. Considering the possibility of calciphylaxis in this setting may avoid delaying the diagnosis and its consequences.

Effect of birth order on incidence of periventricular-intraventricular hemorrhage in very low birth weight twins.

The purpose of the study was to determine whether the incidence of periventricular-intraventricular hemorrhage (PV-IVH) is significantly different between the firstborn and secondborn of very low birth weight twins. The firstborn and secondborn of 102 sets of twins were compared by incidence of PV-IVH, mode of delivery, birth weight, 5-minute Apgar score, pH, duration of oxygen therapy, duration of ventilator support, and occurrence of patent ductus arteriosus, air leak, bronchopulmonary dysplasia, or hyaline membrane disease. PV-IVH was graded by the Papile classification. Statistical data were analyzed by either the paired t test or McNemar's test. Major PV-IVH (grades III and IV) occurred in 11 firstborn and 14 secondborn infants. Minor PV-IVH (grades I and II) occurred in 11 firstborn and 8 secondborn twins. Neither these findings nor those from other measured variables showed a statistically significant difference.

The use of isotope tracers for identifying populations of migratory birds.

To determine whether stable isotopes can be used for identifying the geographic origins of migratory bird populations, we examined the isotopic composition of hydrogen (deuterium, δD), carbon (δ13C), and strontium (δ87Sr) in tissues of a migratory passerine, the black-throated blue warbler (Dendroica caerulescens), throughout its breeding range in eastern North America. δD and δ13C values in feathers, which are grown in the breeding area, varied systematically along a latitudinal gradient, being highest in samples from the southern end of the species' breeding range in Georgia and lowest in southern Canada. In addition, δD decreased from east to west across the northern part of the breeding range, from New Brunswick to Michigan. δ87Sr ratios were highest in the Appalachian Mountains, and decreased towards the west. These patterns are consistent with geographical variation in the isotopic composition of the natural environment, i.e., with that of precipitation, plants, and soils for δD, δ13C, and δ87Sr, respectively. Preliminary analyses of the δD and δ13C composition of feathers collected from warblers in their Caribbean winter grounds indicate that these individuals were mostly from northern breeding populations. Furthermore, variances in isotope ratios in samples from local areas in winter tended to be larger than those in summer, suggesting that individuals from different breeding localities may mix in winter habitats. These isotope markers, therefore, have the potential for locating the breeding origins of migratory species on their winter areas, for quantifying the degree of mixing of breeding populations on migratory and wintering sites, and for documenting other aspects of the population structure migratory animals - information needed for studies of year-round ecology of these species as well as for their conservation. Combining information from several stable isotopes will help to increase the resolution for determining the geographic origins of individuals in such highly vagile populations.

Postnatal penicillin prophylaxis and the incidence of group B streptococcal sepsis in neonates.

We conducted a retrospective chart review of infants, born over a 3-year period, who had positive urine latex agglutination and/or positive blood culture for group B streptococci (GBS). Infants routinely received intramuscular aqueous penicillin for the first half of the study period, and no penicillin was given for the subsequent 18 months. Overall, infants who received penicillin prophylaxis had a decreased incidence of clinical sepsis and positive blood culture for GBS (4.8/1,000 versus 8/1,000 and 1.3/1,000 versus 5.4/1,000, respectively). The incidence of GBS sepsis during the time of penicillin prophylaxis was not different from that in previously reported studies. When analyzed by weight groups, no difference in clinical sepsis or positive blood cultures for GBS was seen in the subset of infants weighing < or = 2,500 g at birth. There were fewer positive blood cultures in the infants who received penicillin and met the criteria for clinical sepsis. Mortality from GBS sepsis was unchanged during these two study periods in all weight groups.

Relationship of cranial midline shift to outcome of very-low-birth-weight infants with periventricular hemorrhagic infarction.

The purpose of this study was to determine the relationship of a cranial midline shift accompanying periventricular hemorrhagic infarction to subsequent handicap in very-low-birth-weight infants. A study group of 44 infants with intraventricular hemorrhage and an associated periventricular hemorrhagic infarction was retrospectively selected from 1,080 very-low-birth-weight infants evaluated by cranial sonography. A cranial midline shift is defined sonographically as displacement of the septum pellucidum (or cavum septi pellucidi) more than 3 mm from the spatial midline. The midline is measured as half the distance between the right and left inner tables on an anterior coronal view. Other sonographic data recorded were the size of the lateral ventricle, the intracranial hemisphere, and the periventricular hemorrhagic infarction. Also noted was the appearance of the area of infarction at the time of initial detection of a midline shift. After discharge, the infants were periodically evaluated for major handicap in vision, hearing, cognition, and motor activity. A midline shift was identified in 29 (66%) of 44 infants with periventricular hemorrhagic infarction. Seven (24%) of the 29 infants with midline shift and 3 (20%) of the 15 infants without a midline shift died. In all of the 22 surviving infants with a midline shift and in 3 (25%) of 12 survivors without a midline shift, a handicap developed (p < 0.01). As a predictor of handicap, midline shift showed a sensitivity of 88% and a specificity of 100%. Predictability was not improved by combining midline shift with the size of the parenchymal infarct.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal salvage by week's gestation in pregnancies complicated by HELLP syndrome.

OBJECTIVE: For clinical management and counseling purposes, we determined the neonatal salvage by weeks' gestation and birth weight of pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). METHODS: All patients who delivered with a diagnosis of HELLP syndrome between January 1, 1980 and December 31, 1991 at a single tertiary care medical center were evaluated for neonatal outcome and survival. The syndrome was diagnosed in the presence of severe preeclampsia/eclampsia accompanied by laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. RESULTS: During the study interval, 58,670 live-born deliveries occurred, of which 527 (0.11%) had HELLP syndrome. In this population, 143 patients delivered fetuses at less than 30 weeks' gestational age. Based upon gestational age intervals, neonatal salvage was 0% at 23 weeks in 13 deliveries, 17% (intact salvage 8.5%) at 24 weeks, 31% (intact salvage 15%) at 25 weeks, 75% (intact salvage 65%) at 26 weeks, 80% (intact salvage 70%) at 27 weeks, and 83% at 28 and 29 weeks (intact salvage 70 and 76%). Based on birth weight intervals, neonatal salvage was 0% at less than 600 g, 34% at 600-700 g (intact salvage 17%), 69% at 700-800 g (intact salvage 53%), and 84% or more at greater than 800 g. These pregnancy outcomes are similar to those in this institution in patients without HELLP syndrome. Disease severity was distributed evenly among the 143 patients at less than 30 weeks' gestation. Apart from gestational age, there was no significant relation between the severity of the HELLP disease process and ultimate neonatal salvage. CONCLUSIONS: Intact neonatal salvage in pregnancies complicated by HELLP syndrome is poor at weights less than 700 g and gestation of 25 weeks or less, but is more optimistic in pregnancies of greater than 700 g and 26 weeks' gestation or later. Aggressive efforts to enhance perinatal outcome, by operative delivery if indicated for fetal compromise, appear especially appropriate in gestations of greater than 700 g and 26 weeks' gestation or later, provided that adequate intensive care nursery facilities and neonatal expertise are available.