Lipid-associated sialic acid levels in human breast cyst fluids

Summary Benign mammary gross cystic disease is the most common breast lesion. Women with apocrine changes of epithelium lining the cysts are at higher risk for developing breast cancer than the normal female population. Sialic acid has drawn considerable interest because of carbohydrate aberrations in malignant cells. The current investigation determined the concentrations of lipid-associated sialic acid (LASA) in 62 breast cyst fluids and sera. Data analyses show a significant increase in the mean values of LASA in metabolically active apocrine cysts when compared to the cysts with Na⁺/K⁺>3 (flattened cysts) (p<0.001). The greater LASA levels in cyst fluids with lower intracystic Na⁺/K⁺ ratios could represent an altered expression of biosynthetic activity of the surrounding apocrine cell surface sialoglycolipid metabolism, providing a possible explanation of why women with apocrine cysts may be at greater cancer risk and being useful in further studies on functional stage changes in the cysts and their relationship to breast cancer.     

Effect on the development of ankle edema of adding delapril to manidipine in patients with mild to moderate essential hypertension: a three-way crossover study

BACKGROUND: Use of the combination of an angiotensin-converting enzyme inhibitor (ACEI) and a calcium channel blocker (CCB) is considered a rational approach in patients whose hypertension is not controlled by monotherapy, providing better blood pressure (BP) control than the individual components with a lower incidence of adverse effects. In particular, such combinations have been found to reduce the incidence of ankle edema, the most common adverse effect of dihydropyridine annhypertensives. OBJECTIVE: The present study was undertaken to evaluate the effect on the development of ankle edema of adding the ACEI delapril to the CCB manidipine in patients with mild to moderate essential hypertension. METHODS: Patients between the ages of 30 and 70 years who had mild to moderate hypertension (diastolic BP [DBP] >90 and <110 mm Hg) were included in the study. After a 4-week placebo run-in period, eligible patients were randomized to receive 6 weeks each of manidipine 10 mg/d, delapril 30 mg/d, and both in a crossover fashion. There was a 2-week washout period between treatments. Ankle edema was assessed based on ankle-foot volume (AFV) and pretibial subcutaneous tissue pressure (PSTP). Sitting BP, AFV, and PSTP were measured at the end of the placebo run-in period and the end of each active-treatment period. RESULTS: The study enrolled 40 patients with previously untreated hypertension (21 women, 19 men). Both manidipine and delapril monotherapy were associated with significant reductions from baseline in systolic BP (SBP) (mean [SD], -17.3 [4] and -14.8 [4] mm Hg, respectively; both, P<0.01) and DBP (-14.6 [3] and -12.9 [3] mm Hg; both, P<0.01). Compared with monotherapy, the combination of manidipine and delapril was associated with greater reductions from baseline in SBP (-21.8 [5] mm Hg; P<0.001) and DBP (-18.6 [4] mm Hg; P<0.001). Manidipme monotherapy was associated with significant increases from baseline in both AFV (7.9%; P<0.001) and PSTP (36.6%; P<0.01). Compared with manidipine alone, the combination of manidipine and delapril was associated with less pronounced increases in AFV (3.3%; P<0.05) and PSTP (10.4%; P<0.05). Ankle edema was clinically evident in 3 patients after receipt of manidipine monotherapy and in 1 patient after receipt of combination treatment. CONCLUSION: In these patients with mild to moderate essential hypertension, the addition of delapril to manidipine partially counteracted the manidipine-induced microcirculatory changes responsible for ankle edema.     

Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: review and evaluation of the long-term results of 52 cases

This study was undertaken to determine the efficacy of delayed surgical treatment in cases of persistent radial nerve paralysis after fractures of the middle third of the humerus. We have limited this study to patients who had absolutely no functional recovery of the radial nerve 3 to 4 months after middle third humeral fractures. The fractures were treated by a variety of orthopaedic methods, conservative and surgical, in other departments and hospitals. Surgical exploration of the radial nerve was carried out 3 to 4 months after primary orthopaedic treatment. The outcome of this study concurs with data in the literature in showing that delayed nerve surgery (neurolysis or nerve grafts) in the absence of functional recovery of the radial nerve after humeral fracture can be useful in achieving good functional recovery and subjectively satisfying results.     

Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care

OBJECTIVE: This study compared the effectiveness and cost/utility ratio between a heart failure (HF) management program delivered by day-hospital (DH) and usual care in chronic heart failure (CHF) outpatients. BACKGROUND: Previous studies showed that about 50% of readmissions for CHF can be prevented by a multidisciplinary approach. However, the performance, effectiveness, and cost/utility ratio of a process of HF outpatient management related to evidence-based medicine have not been considered. METHODS: A total of 234 prospective patients discharged by a HF Unit were randomized to two management strategies: 122 patients to usual community care and 112 patients to a HF management program delivered by the DH. Management (rate of readmissions, therapeutic interventions), functional parameters (New York Heart Association [NYHA] functional class, left ventricular diameters, and ejection fraction, deceleration time of early diastolic mitral flow, peak oxygen uptake, and mitral regurgitation) and hard outcomes (cardiac death and urgent cardiac transplantation) were evaluated. The cost/utility ratios of the two strategies were compared. RESULTS: After 12 +/- 3 months of follow-up, the individual rate access in DH was 5.5 +/- 3.8 days. The DH subjects were readmitted to the hospital less frequently than were the usual-care group patients (13 vs. 78, p < 0.00001). Patients allocated to usual-care management showed heterogeneous changes in NYHA functional class (13% improved and 16% worsened p = NS); In contrast, the DH group showed significant changes in NYHA functional class (23% improved and 11% worsened, p < 0.009). Hard cardiac events in the one-year follow-up occurred in 25/234 (10.6%) patients; cardiac death occurred in 21/122 (17.2%) of the community group and in 3/112 (2.7%) in the DH group (p < 0.0007). One DH patient underwent urgent transplantation. Comparison of the two managerial models by Cox regression analysis showed that DH management significantly protected against the appearance of hard events (relative risk [RR] 0.17; confidence interval [CI] 0.06 to 0.66). The cost/utility ratio of the two management strategies was similar (usual care $2,409 vs. DH $2,244). The incremental analysis revealed a cost savings of $1,068 for each quality-adjusted life year gained. The cost/utility ratio for the integration of DH management of CHF was $19,462 (CI $13,904 to $34,048). CONCLUSIONS: A heart failure outpatient management program delivered by a DH can reduce mortality and morbidity of CHF patients. This management strategy is cost-effective and has an equitable value from a societal point of view.     

Negative pressure wound therapy using gauze and foam: histological, immunohistochemical and ultrasonography morphological analysis of the granulation tissue and scar tissue. Preliminary report of a clinical study

Negative pressure wound therapy (NPWT) is becoming routine for the preparation of wounds prior to grafting for wound closure. We have been using both foam- and gauze-based NPWT to prepare wounds for closure prior to skin grafting and have obtained similar proportions of closed wounds; 7/7 for wounds treated with gauze-based NPWT and 11/11 for wounds treated with foam-based NPWT. In our follow-up consultations we observed that skin grafts on the foam-treated patients were less pliable than those on the gauze-treated patients. To assess what the mechanism of this effect might be, we compared the specific details of the treatments of both 11 foam and 7 gauze patients, including depth, location, patients' age and co-morbidity; biopsies of granulation and scar tissue were taken and stained with haematoxylin-eosin and by Masson's trichrome staining and conducted ultrasound analysis of the closed wounds, to see if there were features which explained those effects. All foam patients were treated at -125 mm Hg for an average of 25·9 days before skin grafts were applied. All gauze patients were treated at -80 mm Hg for an average of 24·7 days before skin grafts were applied. Biopsies of granulation tissue prior to skin grafting from five foam and four gauze-based NPWT patients did not reveal any obvious histological differences between the treatments. Ultrasound analysis of the skin-grafted wounds showed an average depth of scar tissue of 18 mm in the wound beds of the foam-treated wounds and 7 mm in the gauze-treated ones. Biopsies taken on the scar tissue after treatment with the gauze showed a minor tissue thickness and disorganisation and less sclerotic components. The findings of this preliminary analysis suggest that foam-based NPWT may induce a thicker layer of scar tissue beneath skin grafts than gauze-based NPWT which might explain a reduced pliability of the reconstructed bed. At present it is unclear which mechanism might be responsible for the difference in pressure (-125 versus -80 mm Hg), either the length of the time taken to reconstruct the wound bed or the intrinsic nature of the foam or gauze on the tissue surface. Prospective studies are necessary to investigate whether these preliminary observations are confirmed and to investigate what the mechanism might be.     

Quantification of prostate-specific antigen immunoreactivity in human breast cyst fluids

Summary The frequency of gross cystic breast disease in premenopausal women and its possible association with in-creased breast cancer risk emphasises the importance of investigations relating to breast cyst fluid composition. In order to contribute to a better analysis of this medium, we have measured the presence of prostate-specific antigen immuno-reactivity in sixty-four human breast cyst fluids. Data analyses show that 35% of samples presented a level of this antigen < 0.05 µg/L, whereas 42 out of 64 cysts show a significant increase in the mean value of metabolically active apocrine cysts when compared to flattened cysts (p < 0.01). We report the first evidence that breast epithelium of gross cysts produces, secretes, and accumulates large amounts of prostate-specific antigen, a glycoprotein produced by prostatic tissue but recently detected in breast tumours, normal tissues, and during pregnancy. The production and intracystic accumulation of this serine protease in biosynthetically active apocrine type cyst can play a feasible role in the natural history of gross cystic breast disease as well as in the mechanism of cyst formation, enlargement, and transformation.     

Angioma of a finger: the usefulness of a graft from the hypothenar eminence for covering the defect]

Skin grafting remains the simplest option when bone is not exposed in soft tissue losses of the digits of the hand. As opposed to traditional donor sites, a split-thickness skin graft from the hypothenar eminence provides specialized skin similar to the one to be replaced. The graft remains elastic and soft in follow-up, without hyperpigmentation, hyperkeratosis, fissuring and hypertrophic scarring at the margins. As well as in acute trauma situations, the use of split-thickness skin grafting from the hypothenar eminence can also be extended to resurfacing defects in elective hand surgery. As an example, we describe a case of an ulcerated capillary hemangioma on the dorsal surface of the fifth digit at the distal interphalangeal joint.