In many patients, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients would not be expected to benefit from completion axillary lymph node ...dissection (CALND). This study evaluated the factors that may determine the likelihood of additional positive nodes in the axilla in the presence of sentinel node metastasis. A total of 618 breast cancer patients underwent SLN biopsy based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peritumourally. This was followed by standard axillary node clearance at the same operation. Of the 201 patients with a positive SLN, 105 (52%) patients had no further positive nodes in the axilla, 96 (48%) patients had additional metastasis in non-sentinel lymph nodes (NSLN) upon CALND. In patients with a positive SLN, increasing tumour size and tumour grade significantly increased the frequency of additional positive nodes on univariate analysis. The number of SLNs removed and the number of negative SLNs were significant negative predictors. Increasing tumour burden in the sentinel nodes (determined by the number of positive SLNs) was significantly associated with increasing likelihood of positive NSLNs. Multivariate analysis revealed that the rest of the axilla is more likely to be positive if there are more positive than negative SLNs removed and more likely to be negative otherwise. A group of cases from one centre (Cardiff) were subjected to further detailed analysis. Tumour burden in the positive SLN was assessed by measuring the size of metastasis, percentage replacement of the SLN by tumour and by documenting extracapsular extension (ECE) around the SLN. Of the 64 patients with a positive SLN, 34 (53%) patients had no further positive nodes in the axilla, 30 patients (47%) had additional metastasis in NSLNs upon CALND. Increasing tumour burden in the SLN was associated with additional positive nodes in the axilla. Multivariate analysis revealed that size of the SLN metastasis is the most important predictor of involvement of only the SLN. Overall, in patients with a positive SLN, the difference in the number of positive and negative SLNs removed and size of the metastasis in the SLN, all predicted the frequency of additional positive nodes.
At the risk of not toeing the Journal of Clinical Epidemiology party line, I am far from impressed with the number needed to treat (NNT) as a measure for practical use. ...it comprises values of ...1/theta that are not consistent with the observed data.
Osteoporotic fractures in older people are a major and increasing public health problem. We examined the effect of vitamin D supplementation on fracture rate in people living in sheltered ...accommodation.
In a pragmatic double blind randomised controlled trial of 3 years duration, we examined 3,440 people (2,624 women and 816 men) living in residential or care home. We used four-monthly oral supplementation using 100,000 IU vitamin D(2) (ergocalciferol). As a main outcome measure, we used the incidence of first fracture using an intention to treat analysis. This was a multicentre study in 314 care homes or sheltered accommodation complexes in South Wales, UK.
The vitamin D and placebo groups had similar baseline characteristics. In intention-to-treat analysis, 205 first fractures occurred in the intervention group during a total of 2,846 person years of follow-up (7 fractures per 100 people per year of follow-up), with 218 first fractures in the control group over 2,860 person years of follow-up. The hazard ratio of 0.95 (95% confidence interval 0.79-1.15) for intervention compared to control was not statistically significant.
Supplementation with four-monthly 100,000 IU of oral vitamin D(2) is not sufficient to affect fracture incidence among older people living in institutional care.
OBJECTIVES To determine whether physiotherapy can improve mobility in chronic multiple sclerosis and whether there is a difference between treatment at home and as a hospital outpatient? METHODS A ...randomised controlled crossover trial was undertaken in patients with chronic multiple sclerosis who had difficulty walking and were referred from neurology clinics: allocation was to one of six permutations of three 8 week treatment periods separated by 8 week intervals: treatments consisted of physiotherapy at home, as an outpatient, or “no therapy”. The main outcome measures were based on independent assessments at home and included mobility related disability (primary outcome: the Rivermead mobility index), gait impairments, arm function, mood, and subjective patient and carer ratings. Therapy was assessed by recording delivery, achievement of set targets, patient and carer preference, and cost. RESULTS On the Rivermead mobility index (scale 0–15) (primary outcome) there was a highly significant (p<0.001) treatment effect of 1.4–1.5 units favouring hospital or home based therapy over no therapy: this was supported by other measures of mobility, gait, balance, and the assessor's global “mobility change” score: there was no major difference between home and hospital. Carers preferred home treatment but neither they nor patients discerned greater benefit there. Estimated costs of home physiotherapy were £25/session and those at hospital were £18 (including £7 patient travel costs). CONCLUSION A course of physiotherapy is associated with improved mobility, subjective wellbeing, and improved mood in chronic multiple sclerosis compared with no treatment but benefit may only last a few weeks: there is little to choose between home and hospital based therapy but the first is more costly, mainly due to skilled staff travelling time.
To analyse the factors affecting the clinical performance and those influencing the survival of resin-retained bridgework provided at a UK dental teaching hospital between 1994 and 2001.
A ...prospective analysis of restorations provided at a single centre using case notes with all patients invited for review to corroborate findings.
Department of Restorative Dentistry, University of Bristol Dental Hospital and School, Bristol, United Kingdom.
Between January 1994 and December 2001, data regarding 1,000 consecutive resin-retained bridges provided at Bristol Dental Hospital and School were recorded. Data was available for 805 patients at the time of the study. Following invitation, 621 patients attended for a review appointment. Life table and Kaplan-Meir survival analysis were carried out for all restorations provided.
The five-year and ten-year survival rates estimated by the life-table method are 80.8% (95% confidence interval 78.0-83.6%) and 80.4% (95% confidence interval 77.6-83.2%) respectively. The median survival cannot be estimated for this study as the survival probability remains above 80% even at the longest follow-up. Analysis of clinical variables influencing survival revealed that design of the restoration and experience of the operator providing the restoration were significant factors. Resin-retained bridges made with minimal tooth preparation are shown to be superior in terms of longevity than those for which other types of tooth preparation is made. Patient satisfaction with their treatment was high.
Abstract Objectives There has been a monumental increase in the consumption of soft drinks, fruit juices and sport drinks in the UK, the US, and many other countries. Previous investigations have ...demonstrated the erosive nature of these acidic soft drinks. The aim of this investigation was to determine the protective effects of an experimental fluoride-based toothpaste, containing sodium hexametaphosphate, against an erosive challenge on tooth enamel. Methods The erosion of enamel by orange juice compared the experimental toothpaste with a benchmark sodium fluoride paste and negative control, water, in a 15-day in situ model; and the same in an in vitro enamel erosion model. Flat, polished human enamel samples with a surface profile of ±0.1 μm, were exposed to the three regimens in the single blind, crossover clinical study mimicked in vitro . Depths of the resulting eroded areas were measured using a profilometer. Results There was significantly more erosive damage on the specimens exposed to the benchmark paste and water compared to the test paste in both the in situ and in vitro studies. Conclusions The data provide further support for tooth brushing before meals. Results of this study further suggest the sodium hexametaphosphate containing paste could be used to provide significant erosion protection in susceptible individuals over that provided by conventional fluoride products.
Hydrogen and helium trapping in polycrystalline tungsten under simultaneous He+–H+ and He+–D+ irradiation was measured by thermal desorption spectroscopy. At 300K: He retention and release are ...affected very little by the presence of H, closely following He+-only irradiations; He is trapped within ∼30nm of the surface. D retention is similar to D+-only levels but the presence of He enhances D trapping in the near surface, while limiting D diffusion into the bulk; D is trapped within ∼30–35nm of the surface possibly at interstitial sites surrounding He–vacancy defects. At 700K: He retention and release are again similar to He+-only cases; He is trapped within ∼30nm of the surface while no D is observed.
Elevated plasma homocysteine is a risk factor for arteriosclerosis, but a cause-and-effect relationship remains to be fully established. Endothelial dysfunction, an early event in the atherogenic ...process, has been shown to be associated with hyperhomocysteinemia in experimental and human studies. To further establish a direct relationship between changes in plasma homocysteine and endothelial dysfunction, we investigated whether moderate hyperhomocysteinemia induced by an oral methionine load would acutely impair flow-mediated endothelium-dependent vasodilatation in healthy adults.
Twenty-four healthy volunteers completed a randomized crossover study in which an oral methionine load (0.1 g/kg) was administered on 1 of 2 study days, 7 days apart. At each visit, plasma homocysteine and brachial artery endothelium-dependent and -independent dilatation were measured at baseline and at 4 hours. To further elucidate the temporal relationship between methionine, homocysteine, and endothelial function, an oral methionine load was administered in 10 subjects on a separate visit, and the time courses of plasma methionine, homocysteine, and flow-mediated brachial artery dilatation were measured at baseline and after 1, 2, 3, 4, and 8 hours. After oral methionine, plasma homocysteine increased from 7. 9+/-2.0 micromol/L at baseline to 23.1+/-5.4 micromol/L at 4 hours (P<0.0001, n=24) and was associated with a decrease in flow-mediated brachial artery dilatation from 0.12+/-0.09 to 0.06+/-0.09 mm (P<0. 05). The time course of the impairment of flow-mediated vasodilatation mirrored the time course of the increase in homocysteine concentration.
Oral methionine loading raises plasma homocysteine and impairs flow-mediated endothelium-dependent vasodilatation. This supports the view that homocysteine may promote vascular disease by inducing endothelial dysfunction.
Summary Background Prevalence surveillance methodology is the systematic observation of the occurrence and distribution of healthcare-associated infections (HCAIs) so that appropriate actions can be ...taken. Aim The objectives of a prevalence survey with an international validated methodology were to determine the prevalence of HCAIs for the first time in Argentina, and to provide data which could be used for international benchmarking. Methods In 2008, an HCAI prevalence survey was carried out in 39 hospitals in seven of 23 provinces in Argentina, with methodology identical to that employed by the Hospital Infection Society in the third prevalence survey of HCAIs in acute hospitals in the British Isles. Data collected were processed and analysed at the Northern Ireland Healthcare-Associated Infection Surveillance Centre at Belfast. Findings A total of 4249 patients were surveyed; 480 of these had at least one HCAI, resulting in a prevalence of 11.3% of patients. Male prevalence was 13.6% and female 9.0%. The most common HCAIs were pneumonia (3.3%), urinary tract infection (3.1%), surgical site infection (2.9%), primary bloodstream infection (1.5%), and soft tissue infections (1.2%). Among the 1027 patients who underwent surgery, the prevalence of surgical site infection was 10.2%. The prevalence of meticillin-resistant Staphylococcus aureus was 1.1%, accounting for 10.0% of all HCAI isolates. The results for Argentina show higher HCAI rates compared with corresponding findings for England, Wales, Northern Ireland and South Africa. Conclusion This survey will contribute to the prioritization of resources and help to inform Departments of Health and hospitals in the continuing effort to reduce HCAIs.
Abstract Objectives A product comparison study to compare the short term clinical efficacy of a strontium acetate/silica toothpaste with an arginine/calcium carbonate paste for pain reduction in ...dentine hypersensitivity. Methods The study was examiner blind of two arm parallel design. Eighty healthy adult subjects from general dental practice with ≥2 sensitive teeth but otherwise good oral health, were enrolled and randomised to 1 of 2 toothpaste treatments, schedule provided by the sponsor. Almost equal numbers received each treatment. Tooth sensitivity was measured in three ways; evaporative (Schiff score; Visual Analogue Scale) and tactile stimuli (Yeaple probe), prior to and immediately after subjects’ self application of a single pea sized dose of toothpaste, and following subsequent twice daily brushing for three days with the paste. Results All 80 subjects completed the study. Results confirm that for both treatments, pain was reduced immediately and relief was sustained after 3 days use. For all 3 measures, benefit was similar between the two pastes, with no statistical or clinical difference demonstrated, apart from response to evaporative stimulus at 3 days, where Schiff scores were significantly lower in the arginine group, p = 0.02. Conclusions It can be concluded that both desensitising, occluding toothpastes provided reduction of pain from dentine hypersensitivity on a short term basis: toothpastes appearing to be clinically similarly effective both after a single subject dab on application and post twice daily brushing for three days. National Research Ethics Service register number 09/H020/57.
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