Experiences of implant loss after immediate implant-based breast reconstruction: qualitative study.

BACKGROUND: Immediate implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK, but almost one in ten women experience implant loss and reconstructive failure after this technique. Little is known about how implant loss impacts on patients' quality of life. The first phase of the Loss of implant Breast Reconstruction (LiBRA) study aimed to use qualitative methods to explore women's experiences of implant loss and develop recommendations to improve care. METHODS: Semistructured interviews were conducted with a purposive sample of women who experienced implant loss after immediate IBBR, performed for malignancy or risk reduction across six centres. Interviews explored decision-making regarding IBBR, and experiences of implant loss and support received. Thematic analysis was used to explore the qualitative interview data. Sampling, data collection and analysis were undertaken concurrently and iteratively until data saturation was achieved. RESULTS: Twenty-four women were interviewed; 19 had surgery for malignancy and five for risk reduction. The median time between implant loss and interview was 42 (range 22-74) months. Ten women had undergone secondary reconstruction, two were awaiting surgery, and 12 had declined further reconstruction. Three key themes were identified: the need for accurate information about the risks and benefits of IBBR; the need for more information about 'early-warning' signs of postoperative problems, to empower women to seek help; and better support following implant loss. CONCLUSION: Implant loss is a devastating event for many women. Better preoperative information and support, along with holistic patient-centred care when complications occur, may significantly improve the experience and outcome of care.

ANTECEDENTES: La reconstrucción mamaria inmediata con prótesis (implant-based breast reconstruction, IBBR) es el procedimiento reconstructivo más utilizado en el Reino Unido, pero casi una de cada diez mujeres presentará pérdida de la prótesis y fallo del procedimiento reconstructivo tras esta técnica. Se sabe poco de cómo la pérdida de la prótesis afecta la calidad de vida de las pacientes. La primera fase del estudio LiBRA tuvo como objetivo explorar la percepción de las mujeres ante la pérdida de la prótesis, utilizando métodos cualitativos, y proponer una serie de medidas para mejorar la atención sanitaria de estas pacientes. MÉTODOS: Se realizaron entrevistas semiestructuradas en una muestra de mujeres que padecieron la pérdida de la prótesis tras una IBBR inmediata, realizada por neoplasia o como procedimiento de reducción de riesgo, en seis centros. Las entrevistas analizaron la toma de decisiones con respecto a la IBBR inmediata, así como la percepción ante la pérdida del implante y el soporte recibido. Se utilizó un análisis por temas para examinar los datos de la entrevista cualitativa. El muestreo, la recopilación de datos y el análisis se realizaron de forma simultánea e iterativa hasta que se logró la saturación de datos. RESULTADOS: Se entrevistaron 24 pacientes; 19 en las que la indicación quirúrgica fue por cáncer y 5 por reducción de riesgo. La mediana del tiempo entre la pérdida del implante y la entrevista fue de 42 (rango 22-52) meses. Diez mujeres se habían sometido a una reconstrucción secundaria; dos estaban a la espera de la cirugía y 12 habían rechazado la reconstrucción posterior. Se identificaron tres temas clave, siendo las necesidades de: i) información precisa sobre los riesgos y beneficios de la IBBR, ii) más información sobre los signos de "alarma precoz" de las complicaciones postoperatorias que permitiesen a las mujeres buscar ayuda, y iii) mejor soporte tras la pérdida de la prótesis. CONCLUSIÓN: La pérdida de una prótesis es una complicación catastrófica para muchas mujeres. Una mejor información y apoyo preoperatorios, junto con una atención holística centrada en la paciente cuando se presentan las complicaciones, podrían mejorar significativamente la experiencia y el resultado de la atención.

Differences between anticipated and perceived difficulty and insertion duration of labor epidural techniques among anesthesiologists, nurses and patients.

BACKGROUND: Difficulty with the labor epidural technique has been described using a variety of criteria, but remains inadequately defined. We sought to determine the reasons cited for difficulty with the insertion of labor epidural techniques among anesthesiologists, nurses, and patients. We hypothesized that the perception of procedural difficulty would correlate among participants and with the elapsed duration of the insertion attempt. METHODS: A total of 140 participant sets (i.e. anesthesiologist, nurse and patient) were asked to complete a questionnaire on procedural difficulty, immediately before (i.e. anticipated) and after (i.e. perceived) a standardized epidural technique. Procedural duration, using specified start and end times, was recorded in seconds by an independent co-investigator. Demographic data for all groups were recorded. RESULTS: Perceived difficulty with the epidural technique was similar among all groups (range 10-14%; P=0.29) and correlated with anticipated difficulty (anesthesiologist P=0.0004; nurse P=0.00001; patients P=0.006) and procedural duration (all groups P <0.001). The most common reasons cited for perceived difficulty were procedural duration (anesthesiologist P=0.58), number of attempts (nurse P=0.02), and pain experienced (patient P=0.035). CONCLUSIONS: Difficulty with the epidural technique is associated with anticipated difficulty and procedural duration. The reasons for perceived difficulty differ among anesthesiologists, nurses and obstetric patients, with patients most commonly citing pain experienced.

An ex utero intrapartum treatment procedure in a patient with a family history of malignant hyperthermia.

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 µg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.

Emergency interventions for hyperkalaemia.

BACKGROUND: Hyperkalaemia occurs in outpatients and in between 1% and 10% of hospitalised patients. When severe, consequences include arrhythmia and death. OBJECTIVES: To review randomised evidence informing the emergency (i.e. acute, rather than chronic) management of hyperkalaemia SEARCH STRATEGY: We searched MEDLINE (1966-2003), EMBASE (1980-2003), The Cochrane Library (issue 4, 2003), and SciSearch using the text words hyperkal* or hyperpotass* (* indicates truncation). We also searched selected journals and abstracts of meetings. The reference lists of recent review articles, textbooks, and relevant papers were reviewed for additional potentially relevant titles. SELECTION CRITERIA: All selection was performed in duplicate. Articles were considered relevant if they were randomised, quasi-randomised or cross-over randomised studies of pharmacological or other interventions to treat non-neonatal humans with hyperkalaemia, reporting on clinically-important outcomes, or serum potassium levels within the first six hours of administration. DATA COLLECTION AND ANALYSIS: All data extraction was performed in duplicate. We extracted quality information, and details of the patient population, intervention, baseline and follow-up potassium values. We extracted information about arrhythmias, mortality and adverse effects. Where possible, meta-analysis was performed using random effects models. MAIN RESULTS: None of the studies of clinically-relevant hyperkalaemia reported mortality or cardiac arrhythmias. Reports focussed on serum potassium levels. Many studies were small, and not all intervention groups had sufficient data for meta-analysis to be performed. On the basis of small studies, inhaled beta-agonists, nebulised beta-agonists, and intravenous (IV) insulin-and-glucose were all effective, and the combination of nebulised beta agonists with IV insulin-and-glucose was more effective than either alone. Dialysis is effective. Results were equivocal for IV bicarbonate. K-absorbing resin was not effective by four hours, and longer follow up data on this intervention were not available from RCTs. AUTHORS' CONCLUSIONS: Nebulised or inhaled salbutamol, or IV insulin-and-glucose are the first-line therapies for the management of emergency hyperkalaemia that are best supported by the evidence. Their combination may be more effective than either alone, and should be considered when hyperkalaemia is severe. When arrhythmias are present, a wealth of anecdotal and animal data suggests that IV calcium is effective in treating arrhythmia. Further studies of the optimal use of combination treatments and of the adverse effects of treatments are needed.

Feasibility of paramedic treatment and referral of minor illnesses and injuries.

BACKGROUND: Approximately 40% of Hennepin County Medical Center's (HCMC's) ambulance runs are for minor medical conditions as defined by billing criteria ["ALS minor," i.e., no advanced life support (ALS) procedures done in the field]. Current metropolitan guidelines mandate that all such patients must be transported to a hospital unless they refuse this service. It has been proposed that some patients with minor medical conditions could be better served by treatment in the field by paramedics and referred to a clinic or hospital for early follow-up care. It is proposed that this approach would save costs and improve paramedic availability for patients with more serious conditions. OBJECTIVE: To evaluate the feasibility and safety of implementing such a program by identifying high-volume, low-complexity groupings of cases. Such high-volume, low-complexity cases would serve as the topics for curriculum development for paramedic training in field treatment and referral. METHODS: Data were obtained from ambulance run sheets and emergency department (ED) records for all patients transported by the HCMC ambulance service in 1996 who were covered by the Metropolitan Health Plan (MHP) and who were categorized for billing purposes as "ALS minor" transports. The data included demographic information, vital signs, presenting problem, diagnoses in the ED, and procedures, laboratory studies, or x-rays done in the ED. Patients were classified as "potentially treatable" in the field if they were treated and discharged from the ED without undergoing any procedures or diagnostic studies. Patients who required more extensive evaluation in the ED, or who were admitted, were classified as likely too "complex" to be treated at the scene and then referred for early follow-up. The data were analyzed to find the most common presenting problems and the numbers, characteristics, and dispositions of "potentially treatable" and "complex" patients in each group. This information was used to determine what, if any, types of patients could potentially be treated safely and effectively according to this scheme. RESULTS: The study group comprised 1,103 patients, representing 127 different presenting medical problems. There were 523 (47%) "potentially treatable" patients and 580 (53%) "complex" patients. The 127 medical problems were grouped and the 15 most common presenting problem groups were identified. Within these groups there was no single medical problem with high volume. Each of these 15 most common problem groups contained a substantial proportion of "complex" patients, ranging from 24% to 100%. CONCLUSIONS: None of the 15 most frequently encountered problem groups consisted of a high enough proportion of "potentially treatable" cases to serve as a high-volume, low-complexity category for paramedic treatment in the field with early follow-up. Without any identified high-volume, low-complexity categories, a treatment and referral program as proposed in this article would require a substantial investment in development of appropriate criteria and in training paramedics to apply the criteria for numerous clinical entities. This would limit any cost saving, and require great care to avoid compromising patient safety accompanied by substantial professional liability exposure.

Prehospital sedation with intramuscular droperidol: a one-year pilot.

OBJECTIVE: Combative patients pose a threat to themselves and prehospital personnel, and are at risk for sudden death. Droperidol is an antipsychotic and sedative agent that might be effectively utilized by paramedics to assist in the management of uncontrollably violent patients. METHODS: A prospective observational study of patients requiring sedation was conducted in an urban third-service emergency medical services system (55,000 calls per year). Patients were scored by paramedics on a five-point agitation scale with 5 being extremely combative (continuous, vigorous fighting against restraints) and 1 being somnolent (sleeping or sleepy). Eligible (score 4-5) patients received 5 mg of intramuscular droperidol on direct physician order. Data including vital signs and agitation scores were recorded at 5-minute intervals until hospital arrival. Adverse effects were also recorded. RESULTS: Fifty-three patients received droperidol (51 patients received 5 mg; two received 2.5 mg) during the study period. The average predrug agitation score was 4.7 (+/- 0.1 SD). The average 5-minute postdrug score was 3.9 (+/- 0.1 SD, 95% CI 3.7-4.1. The average 10-minute postdrug score was 3.3 (+/- 0.1 SD, 95% CI 3.1-3.6). The average hospital arrival score was 2.8 (+/- 0.1 SD, 95% CI 2.5-3.1). One patient became obtunded and required supplemental oxygen; no other patient experienced an adverse event after receiving droperidol. Sedation was ineffective in seven patients, three of whom had head injuries, and one of whom received 2.5 mg of droperidol per physician order. Paramedics sustained no needlestick exposures. CONCLUSION: Intramuscular droperidol contributed to effective and rapid prehospital sedation in this observational series of 53 combative patients.

Acute metabolic alkalosis enhances response of C3H mouse mammary tumors to the weak base mitoxantrone.

Uptake of weak acid and weak base chemotherapeutic drugs by tumors is greatly influenced by the tumor extracellular/interstitial pH (pH(e)), the intracellular pH (pH(i)) maintained by the tumor cells, and by the ionization properties of the drug itself. The acid-outside plasmalemmal pH gradient in tumors acts to exclude weak base drugs like the anthracyclines, anthraquinones, and vinca alkaloids from the cells, leading to a substantial degree of "physiological drug resistance" in tumors. We have induced acute metabolic alkalosis in C3H tumor-bearing C3H/hen mice, by gavage and by intraperitoneal (i.p.) administration of NaHCO(3). (31)P magnetic resonance spectroscopic measurements of 3-aminopropylphosphonate show increases of up to 0.6 pH units in tumor pH(e), and 0.2 to 0.3 pH units in hind leg tissue pH(e), within 2 hours of i.p. administration of NaHCO(3). Theoretical calculations of mitoxantrone uptake into tumor and normal (hind leg) tissue at the measured pH(e) and pH(i) values indicate that a gain in therapeutic index of up to 3.3-fold is possible with NaHCO(3) pretreatment. Treatment of C3H tumor-bearing mice with 12 mg/kg mitoxantrone resulted in a tumor growth delay of 9 days, whereas combined NaHCO(3)--mitoxantrone therapy resulted in an enhancement of the TGD to 16 days.

Lateral intermetatarsal angle: a useful measurement of metatarsus primus elevatus?

The lateral intermetatarsal angle, a measurement of the sagittal plane angular divergence between the dorsal cortices of the first and second metatarsals of lateral weightbearing foot radiographs, was compared in 30 normal and 30 hallux limitus feet. The results suggest that the angle may be measured reliably and that although the measured angles are relatively small, a significant difference exists between the normal and hallux limitus subjects studied. Accordingly, the lateral intermetatarsal angle may prove to be a useful radiographic measurement to assist the podiatric physician in the clinical assessment of hallux limitus.

Enhancement of chemotherapy by manipulation of tumour pH.

The extracellular (interstitial) pH (pHe) of solid tumours is significantly more acidic compared to normal tissues. In-vitro, low pH reduces the uptake of weakly basic chemotherapeutic drugs and, hence, reduces their cytotoxicity. This phenomenon has been postulated to contribute to a 'physiological' resistance to weakly basic drugs in vivo. Doxorubicin is a weak base chemotherapeutic agent that is commonly used in combination chemotherapy to clinically treat breast cancers. This report demonstrates that MCF-7 human breast cancer cells in vitro are more susceptible to doxorubicin toxicity at pH 7.4, compared to pH 6.8. Furthermore 31P-magnetic resonance spectroscopy (MRS) has shown that the pHe of MCF-7 human breast cancer xenografts can be effectively and significantly raised with sodium bicarbonate in drinking water. The bicarbonate-induced extracellular alkalinization leads to significant improvements in the therapeutic effectiveness of doxorubicin against MCF-7 xenografts in vivo. Although physiological resistance to weakly basic chemotherapeutics is well-documented in vitro and in theory, these data represent the first in vivo demonstration of this important phenomenon.

Factors influencing hospital transport of patients in continuing cardiac arrest.

STUDY OBJECTIVE: Prior research has established the futility of continued resuscitation efforts for patients in cardiac arrest who fail to respond to out-of-hospital advanced cardiac life support. Determination of both medical and nonmedical factors resulting in the transport of patients in continuing cardiac arrest to the hospital may encourage the development of new systems or strategies to increase the appropriateness of these transports. METHODS: The attending paramedic completed a prospective survey after unsuccessful resuscitation efforts in our urban, hospital-based, two-tier emergency medical services (EMS) system. All nontraumatic adult arrests were included unless they were clearly noncardiac in nature. RESULTS: Paramedics responded to 259 cardiac arrests between September 12, 1996, and April 31, 1997. Seventy-nine patients were pronounced dead without resuscitation efforts. Of the remaining 180 patients, 44 had return of spontaneous circulation and were transported to the hospital, 68 were pronounced dead in the field, and 68 were transported to the hospital in continuing cardiac arrest. The 68 patients transported while in cardiac arrest are the focus of this study. Rare problems with field termination were identified. Reasons for transport of the 68 patients in continuing cardiac arrest included arrest in ambulance or going to ambulance (n = 6), arrest in a public place (n = 17), environmental factors (n = 6), road hazard to paramedics (n = 1), possible reversible cause (n = 4), persistent ventricular dysrhythmia (n = 5), no intravenous access (n = 5), airway difficulties (n = 5), family unable to accept field termination (n = 3), cultural or language barrier (n = 1), EMS physician ordered transport (n = 1), and obesity (n = 1). A protocol allowing pronouncement of death in the ambulance and transport of the body to a designated area could have prevented lights-and-siren transport to the emergency department in 24 of the 68 cases. CONCLUSION: Factors other than medical ones often influence the decision to transport patients in continuing cardiac arrest. In our urban system, physician, medical examiner, and paramedic education and protocols were needed to aid decision-making in this situation.

Preimplantation genetic testing for Marfan syndrome.

Marfan syndrome (MFS) is an autosomal dominant disease that affects the skeletal, ocular and cardiovascular systems. Defects in the gene that codes for fibrillin (FBN-1) are responsible for MFS. Here we report the world's first use of preimplantation genetic testing (PGT) to achieve a clinical pregnancy and live birth of a baby free of a Marfan mutation. One or two blastomeres from each embryo were tested for a CA repeat within the FBN-1 gene. The prospective mother is homozygous for the CA repeat (2/2) and has two normal copies of the FBN-1 gene, while the prospective father is heterozygous for the CA repeat (1/2), and is affected with the Marfan syndrome. In the father's family, allele 2 segregates with the mutated FBN-1 gene. For PGT, any embryo diagnosed as heterozygous for the CA repeat (1/2) would be presumed to have inherited normal FBN-1 genes from the father and the mother and be unaffected. One in-vitro fertilization (IVF) cycle yielded 12 embryos for preimplantation testing; six of the embryos were heterozygous for the CA repeat (1/2) and presumed to be free of the Marfan mutation. Five of the six embryos were subsequently transferred into the uterus. The fetus was tested by chorionic villus sampling and found to be free of the Marfan mutation by the same linkage analysis, had a normal fetal echocardiogram, and was normal at birth.

Proprioceptive responses under rising and falling BACs: a test of the Mellanby effect.

This study examined proprioceptive responses under equivalent rising and falling blood alcohol concentrations (BAC), using a repeated-measures design. Seven volunteer subjects, 21 to 35 years of age, participated in the study. After alcohol consumption, BAC readings were obtained every 5 minutes, and the proprioceptive responses were measured at the following BAC levels (in %): 0 (baseline), rising 0.05, 0.075, 0.1, falling 0.075, and 0.05. The analysis focused on the comparisons of these measures at the equivalent rising and falling 0.05% and at the 0.075% BACs. Results showed that the proprioceptive response was less accurate during the rising than the falling BACs.

The effects of high and low BACs on the Hoffmann reflex.

The purpose of this study was to measure and assess the magnitude and latency of the H-reflex and M-response between pre- and post-alcohol consumption. Also of interest was the comparison of the H-reflex and M-response between the rising and falling curves of BAC. Seven male volunteer subjects participated in this study. Testing started with pre-alcohol BAC and EMG recordings from the tibial nerve following an electrical stimulation. After alcohol consumption, BAC readings were obtained every five minutes, and the EMGs were recorded at the following BAC levels (in mg/dl): 75, 100, and falling 75. H-latency, H-amplitude, and M-response were identified within the EMG signals. The analysis focused on the comparisons of these measures between each of the BAC levels and the baseline, as well as between the rising and falling BACs. Results showed that, overall, the H-reflex and M-response were depressed following alcohol consumption. In addition, the depression of H-reflex appeared to be greater during the rising curve than the falling curve.

Rheumatologic disease and associated ocular manifestations.

BACKGROUND: Ocular involvement is a common manifestation of rheumatic disease. Recognition of associated systemic findings strengthens our diagnostic armamentarium. METHODS: The previous ophthalmic and medical literature was reviewed and synthesized into a focused review of rheumatoid arthritis, systemic lupus erythematosus, polyarteritis nodosa; the seronegative spondyloarthropathies, including ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, ulcerative colitis and Crohn's disease. RESULTS: New and improved diagnostic and therapeutic measures have added a great deal to our understanding of the ocular manifestations of rheumatologic disease and the systemic management of rheumatologic disease. CONCLUSIONS: Optometry can fill an important role in the health care of patients with rheumatologic disease. Regular optometric care and coordination with the patient's rheumatologist can significantly benefit the patient's care.

A proposed classification code for farm and agricultural injuries.

A fundamental problem with classifying agriculturally related injury is that there is neither a rational nor a comprehensive scheme for grouping incidents into categories describing actual exposures encountered on farms and in agricultural work. Current surveillance systems are unable to differentiate between work that is related to farm production and work that is not, and to include all exposed persons in the surveillance. The proposed Farm and Agricultural Injury Classification Code is a step toward overcoming these problems. When it was applied to previously analyzed fatality data, 40% of cases previously identified as farm production work were reclassified into other categories.

Psychomotor and visual performance under the time-course effect of alcohol.

This study examined reaction time (RT), anticipation time (AT), and visual performance under the influence of blood alcohol concentration (BAC), using a repeated-measures design. Subjects (8 men and 8 women), 21 to 40 yr. of age, participated in both single- and double-dose sessions, in which they drank approximately 2.3 oz. and 4.6 oz. of 86-proof vodka, respectively. The breath BAC was measured at 5-min. intervals. The RT, AT, and visual performance were tested every 20 min. for 140 min. in both sessions. In general, results indicated that RT, AT, and stereoscopic vision were impaired more in the rising BAC curve than the falling BAC curve. In addition, the impairment tended to be greater for the double-dose than the single-dose session. The far and near visual acuities were not affected by the BAC.

Predicting alcohol impairment: perceived intoxication versus BAC.

The purpose of this study was to report the relationship among perceived intoxication, performance impairment, and actual blood alcohol concentration (BAC) levels. Fifteen subjects, aged 21 to 40, completed both single- and double-dose sessions of alcohol consumption. BACs, reaction and anticipation time, and perceived intoxication data were collected during both sessions. Analysis of data showed that perceived intoxication was significantly related to performance impairment, but the actual BAC was not.

Variability in behavioral impairment involved in the rising and falling BAC curve.

The purpose of this pilot study was to measure variability in behavior impairment at specific levels of the rising and falling blood alcohol concentration (BAC) curve. Behavior impairment was measured for anticipation and reaction time in addition to a variety of visual skills. Also of interest was the variability in impairment involved at specific BAC levels under single-dose and double-dose conditions. The experimental design was a variation on a 2 x 2 factorial with repeated measures on the dose of alcohol. All subjects took part in two experimental sessions, single-dose and double-dose. Sixteen (8 male and 8 female) paid subjects ages 21-40 participated in the study. Testing procedures included repeated measures on reaction time, anticipation time, perceptual vision acuity and depth perception. Breath-alcohol measures were sampled continuously at 5-minute intervals and used to plot absorption time, peak BAC and elimination time. Results showed that the average peak BAC for the double-dose was significantly higher than that of the single-dose condition. However, there were no significant differences between the single-dose and double-dose condition in either absorption time or elimination time. The performance pattern for reaction time, anticipation time and depth perception showed more impairment in the rising BAC limb than in the falling BAC limb. It is noteworthy that specific individuals exhibited different levels of impairment at a given BAC level, depending on whether the session was single- or double-dose, suggesting that one's current BAC level is less a measure of impairment than is the total quantity of alcohol consumed. A follow-up procedure to examine practice effects was conducted on eight volunteer students. Identical testing procedures, using no alcohol, produced no significant practice effects after a 3-hour period.