Nipple-sparing mastectomy has gained popularity, but the question remains of whether it can be offered safely to women with a history of reduction mammaplasty or mastopexy. The authors present their ...experience with nipple-sparing mastectomy in this patient population.
Patients at the authors' institution who had reduction mammaplasty or mastopexy before nipple-sparing mastectomy were identified. Outcomes measured include nipple-areola complex viability, mastectomy flap necrosis, infection, presence of cancer in the nipple-areola complex, and breast cancer recurrence.
The records of the nipple-sparing mastectomy patients at the authors' institution from 2006 through 2012 were reviewed. The authors identified 13 breasts in eight patients that had nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Within this subset of patients, the mean age was 46.6 years and the mean body mass index was 25.1. Nine of 13 breasts had therapeutic resections, whereas the remaining four were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 51.8 months (range, 33 days to 11 years). In all cases, prior reduction mammaplasty/mastopexy incisions were used for nipple-sparing mastectomy. Ten breasts underwent reconstruction immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and two with immediate abdominally based free flaps. Complications included one hematoma requiring evacuation and one displaced implant requiring revision. There were no positive subareolar biopsy results, and the nipple viability was 100 percent. Mean follow-up time was 10.5 months.
The authors' experience demonstrates that nipple-sparing mastectomy can be offered to patients with a history of reduction mammaplasty or mastopexy with reconstructive outcomes comparable to those of nipple-sparing mastectomy alone.
Therapeutic, IV.
Background: Dogs with immune‐mediated hemolytic anemia (IMHA) and certain inflammatory diseases are at high risk of developing thromboembolic disease. The presence of anti‐endothelial cell ...autoantibodies (AECA) has been associated with an increased risk of thromboembolism in humans.
Hypothesis: AECA will be detected more often in dogs at risk of thromboembolism than in healthy control animals or dogs with diseases not associated with a higher risk of thromboembolism.
Animals: Ninety‐one sick dogs and 22 healthy control dogs.
Methods: Retrospective case‐controlled study. Serum was screened for the presence of AECA. Dogs were identified for the study based on the risk of thromboembolism as determined by clinical impression and the underlying disease process. Flow cytometry and normal canine endothelial cells were used to screen serum samples from sick and healthy control dogs for the presence of AECA. In addition, serum from dogs with confirmed thromboemboli was also screened for the presence of AECA by immunohistochemistry.
Results: AECA were detected in 2/91 sick dogs, both with infectious diseases, but were not found in healthy dogs. Anti‐endothelial antibodies were not detected in 21 dogs with IMHA and 20 dogs with systemic inflammatory response syndrome, sepsis, or both.
Conclusions: We conclude that AECA are rarely detectable in dogs considered at high risk of thromboembolism. These findings suggest that AECA may not play an important role in the pathogenesis of thromboembolism in dogs with IMHA and other inflammatory diseases.
Education leaders at the 2012 Academic Emergency Medicine Consensus Conference on education research proposed that dedicated postgraduate education scholarship fellowships (ESFs) might provide an ...effective model for developing future faculty as scholars. A formal needs assessment was performed to understand the training gap and inform the development of ESFs.
A mixed-methods needs assessment was conducted of four emergency medicine national stakeholder groups in 2013: department chairs; faculty education/research leaders; existing education fellowship directors; and current education fellows/graduates. Descriptive statistics were reported for quantitative data. Qualitative data from semistructured interviews and free-text responses were analyzed using a thematic approach.
Participants were 11/15 (73%) education fellowship directors, 13/20 (65%) fellows/graduates, 106/239 (44%) faculty education/research leaders, and a convenience sample of 26 department chairs. Department chairs expected new education faculty to design didactics (85%) and teach clinically (96%). Faculty education/research leaders thought new faculty were inadequately prepared for job tasks (83.7%) and that ESFs would improve the overall quality of education research (91.1%). Fellowship directors noted that ESFs provide skills, mentorship, and protected time for graduates to become productive academicians. Current fellows/graduates reported pursing an ESF to develop skills in teaching and research methodology.
Stakeholder groups uniformly perceived a need for training in education theory, clinical teaching, and education research. These findings support dedicated, deliberate training in these areas. Establishment of a structure for scholarly pursuits prior to assuming a full-time position will effectively prepare new faculty. These findings may inform the development, implementation, and curricula of ESFs.
Reconstruction in the setting of prior breast irradiation is conventionally considered a higher-risk procedure. Limited data exist regarding nipple-sparing mastectomy in irradiated breasts, a ...higher-risk procedure in higher-risk patients.
The authors identified and reviewed the records of 501 nipple-sparing mastectomy breasts at their institution from 2006 to 2013.
Of 501 nipple-sparing mastectomy breasts, 26 were irradiated. The average time between radiation and mastectomy was 12 years. Reconstruction methods in the 26 breasts included tissue expander (n=14), microvascular free flap (n=8), direct implant (n=2), latissimus dorsi flap with implant (n=1), and rotational perforator flap (n=1). Rate of return to the operating room for mastectomy flap necrosis was 11.5 percent (three of 26). Nipple-areola complex complications included one complete necrosis (3.8 percent) and one partial necrosis (3.8 percent). Complications were compared between this subset of previously irradiated patients and the larger nipple-sparing mastectomy cohort. There was no significant difference in body mass index, but the irradiated group was significantly older (51 years versus 47.2 years; p=0.05). There was no statistically significant difference with regard to mastectomy flap necrosis (p=0.46), partial nipple-areola complex necrosis (p=1.00), complete nipple-areola complex necrosis (p=0.47), implant explantation (p=0.06), hematoma (p=1.00), seroma (p=1.00), or capsular contracture (p=1.00).
In the largest study to date of nipple-sparing mastectomy in irradiated breasts, the authors demonstrate that implant-based and autologous reconstruction can be performed with complications comparable to those of the rest of their nipple-sparing mastectomy patients.
Can long-term subcutaneous venous (Mediport) catheters be safely inserted without routine chest X-ray (CXR) verification? An estimated 500,000 Mediport catheters are inserted yearly in the United ...States, and elimination of unnecessary radiographs would result in substantial savings of increasingly limited health care resources. A total of 513 consecutive Mediport catheters were inserted by a single surgeon over a 5-year period using a standardized protocol and selective indications for follow-up CXR that included unilateral chest pain, aspiration of air, decreased breath sounds, and difficult catheter insertion. The 513 catheters were inserted in 498 patients with 271 patients (53%) undergoing postprocedure CXR. Of the 513 catheters 461 (90%) were placed by percutaneous approach to the subclavian vein. Six pneumothoraces (1.2% incidence) occurred, all in patients who met criteria for immediate CXR. The overall complication rate was 3.1 per cent and included eight instances of catheter-tip malposition (seven of the eight were successfully repositioned by vascular radiology), one mediastinal hematoma, and one chest-wall hematoma. This largest single-surgeon-reported series demonstrates that Mediport insertion can be safely accomplished with minimal complications following a standardized protocol using selective radiologic evaluation.
Intravenous gene delivery using liposome-DNA complexes (LDC) has previously been shown to elicit antitumor activity, but only in rodent tumor models. Therefore, we conducted a study to determine in a ...large animal spontaneous tumor model whether intravenous infusions of LDC could target gene expression to cutaneous tumor tissues and whether repeated treatments had an effect on tumor growth or angiogenesis. A total of 13 dogs with cutaneous soft tissue sarcomas were enrolled in the study and were randomized to receive a series of 6 weekly infusions of LDC containing either canine endostatin DNA or DNA encoding an irrelevant gene (luciferase). Serial tumor biopsies were obtained to assess transgene expression, tumor microvessel density (MVD), and intratumoral leukocyte inflammatory responses. We found that intravenous infusion of LDC did not result in detectable gene expression in cutaneous tumor tissues. However, two of 13 treated dogs had objective tumor responses and eight dogs had stable disease during the treatment period. In addition, a significant decrease in tumor MVD was noted in six of 12 treated dogs at the completion of six treatments. These results suggest that intravenous infusions of LDC may elicit nonspecific antitumor activity and inhibit tumor angiogenesis.
CYP119 from Sulfolobus solfataricus, the first thermophilic cytochrome P450, is stable at up to 85 °C. UV-visible and resonance Raman show the enzyme is in the low spin state and only modestly shifts ...to the high spin state at higher temperatures. Styrene only causes a small spin state shift, but T1 NMR studies confirm that styrene is bound in the active site. CYP119 catalyzes the H2O2-dependent epoxidation of styrene, cis-β-methylstyrene, andcis-stilbene with retention of stereochemistry. This catalytic activity is stable to preincubation at 80 °C for 90 min. Site-specific mutagenesis shows that Thr-213 is catalytically important and Thr-214 helps to control the iron spin state. Topological analysis by reaction with aryldiazenes shows that Thr-213 lies above pyrrole rings A and B and is close to the iron atom, whereas Thr-214 is some distance away. CYP119 is very slowly reduced by putidaredoxin and putidaredoxin reductase, but these proteins support catalytic turnover of the Thr-214 mutants. Protein melting curves indicate that the thermal stability of CYP119 does not depend on the iron spin state or the active site architecture defined by the threonine residues. Independence of thermal stability from active site structural factors should facilitate the engineering of novel thermostable catalysts.
The reaction between metmyoglobin and hydrogen peroxide produces both a ferryl-oxo heme and a globin-centred radical(s) from the two oxidizing equivalents of the hydrogen peroxide. Evidence has been ...presented for localization of the globin-centred radical on one tryptophan residue and tyrosines 103 and 151. When the spin-trapping agent 5,5-dimethyl-1-pyrroline N-oxide (DMPO) is included in the reaction mixture, a radical adduct has been detected, but the residue at which that adduct is formed has not been determined. Replacement of either tryptophans 7 and 14 or tyrosines 146 and 151 with phenylalanine has no effect on the formation of DMPO adduct in the reaction with hydrogen peroxide. When tyrosine 103 is replaced with phenylalanine, however, only DMPOX, a product of the oxidation of the spin-trap, is detected. Tyrosine-103 is, therefore, the site of radical adduct formation with DMPO. The spin trap 2-methyl-2-nitrosopropane (MNP), however, forms radical adducts with any recombinant sperm whale metmyoglobin that contains either tyrosine 103 or 151. Detailed spectral analysis of the DMPO and MNP radical adducts of isotopically substituted tyrosine radical yield complete structural determinations. The multiple sites of trapping support a model in which the unpaired electron density is spread over a number of residues in the population of metmyoglobin molecules, at least some of which are in equilibrium with each other.
Physician reentry–A timely topic for emergency medicine Guth, Todd A; Luber, Samuel D.; Marcolini, Evie ...
Journal of the American College of Emergency Physicians Open,
December 2020, Letnik:
1, Številka:
6
Journal Article
Recenzirano
Odprti dostop
As physician workforce shortages persist, physician reentry is an important and timely issue for the specialty of emergency medicine. Physician reentry is defined as a return to clinical practice ...following an extended period of clinical inactivity not resulting from discipline or impairment. This review provides a general overview of the physician reentry published literature with a focus on the specialty of emergency medicine. Transition into a non‐clinical position, personal health, family issues, and career dissatisfaction all contribute to physicians leaving the workforce voluntarily. Previously, the majority of reentry physicians did not pursue additional training prior to returning to the workforce; however, regulatory agencies are now increasingly requiring additional training, standardized testing, and fitness to practice evaluations prior to restarting clinical work. The burden of proof is on the reentry physician to meet the appropriate requirements for licensure, certification, and credentialing prior to returning to clinical work.
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