Breast Conservation After Neoadjuvant Chemotherapy

Background Tumor downstaging by preoperative neoadjuvant chemotherapy in patients with locally advanced breast tumors allows breast conservation in women who were previously candidates for mastectomy. Nevertheless, lumpectomy success in such cases cannot be fully achieved. The aim of this study was to create a quantitative tool for preoperative evaluation of the success of breast conservation in such patients.Methods The study population included 100 consecutive patients with stage II and III breast cancer who were designated for lumpectomy and 19 patients who were designated for mastectomy. All patients received neoadjuvant therapy. Breast-conserving surgery was offered in accordance with clinical and esthetic criteria. Demographic details and clinical, imaging, and pathologic information were collected from medical files. A decision protocol for classifying patients to lumpectomy or mastectomy was built by using the Classification and Regression Trees procedure based on preoperative characteristics.Results Three factors were found to be the main predictors for successful breast conservation: absence of diffuse microcalcifications as seen in the pretreatment mammogram, a postchemotherapy tumor size of < 25 mm, and the existence of a circumscribed lesion on mammography.Conclusions The use of these criteria as a basis for decision on the type of surgery may decrease the performance of unnecessary procedures.     

The effect of growth hormone on the development of diabetic kidney disease in rats.

BACKGROUND: Nephropathy is the most severe complication of diabetes mellitus. We investigated the effect of exogenous growth hormone (GH) administration on renal function and matrix deposition in the streptozotocin (STZ) model of type I-diabetic rat. METHODS: Adult female STZ-diabetic rats (D), non-diabetic control rats injected with saline (C) and control and diabetic rats injected with bovine GH for 3 months (CGH and DGH, respectively) were used. RESULTS: The usual renal hypertrophy seen in D animals was more pronounced in the DGH group. Creatinine clearance increased only in the D rats, but not in the other groups, including DGH. Albuminuria was observed in the D animals but was significantly elevated in the DGH group. Glomeruli from DGH animals showed more extensive matrix accumulation (manifested as an increase in mesangial/glomerular area ratio). Renal extractable insulin-like growth factor (IGF-I) mRNA was decreased in the D and DGH groups, but renal IGF-I protein was not significantly increased. Renal IGF binding protein-1 was increased in the D groups and further increased in the DGH group, at both the mRNA and protein levels. CONCLUSIONS: GH-treated diabetic rats had less hyperfiltration and more albuminuria, concomitant with more glomerular matrix deposition, when compared with regular diabetic animals. This was associated with a significant increase in renal IGFBP-1, and dissociated from IGF-I changes. Thus, in this model, GH exacerbates the course of diabetic kidney disease.     

Management Trends and Early Mortality Rates for Acute Type B Aortic Dissection: A 10-Year Single-Institution Experience

This study was undertaken to assess trends in management over time and to determine predictors of early mortality for acute type B aortic dissection. Fifty-three consecutive patients with acute type B aortic dissection over a 10-year period were reviewed. Baseline demographics as well as in-hospital data regarding symptoms, type of initial management, surgical indications, type of surgical intervention, and early mortality rates were collected. Independent predictors of early mortality were determined by logistic regression. Forty-one of 53 (77.4%) patients were initially managed medically with a total of 26 (49.1%) ultimately undergoing surgical repair during hospitalization. Crude early mortality was 30.8% in the surgical group vs. 14.8% in the medical group (p = 0.20). Improvements in early mortality were observed over time for surgery (58.3%, first half vs. 7.1%, second half; p = 0.019) and medical therapy (21.4%, first half vs. 7.7%, second half; p = 0.64). Early mortality was 50% in 16 patients having open aortic surgery vs. 0% in 10 patients undergoing endovascular stent graft repair (p < 0.005). Independent predictors of early mortality included only renal dysfunction (odds ratio [OR] 7.39), aortic rupture (OR 8.72), and date of admission during the study period (OR 0.712). Despite improvements over time in early mortality that appear associated with the increasing use of endovascular stent grafts, patient-specific factors are still the most important independent predictors of early mortality in acute type B aortic dissection.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, IL, June 7, 2003.     

Should testing be initiated prior to amoxicillin challenge in children?

Amoxicillin is the most common antibiotic prescribed in children with increasing use over time. While up to 10% of children are labelled as amoxicillin allergic, most children can tolerate amoxicillin after allergy evaluation. It is well documented that the label of amoxicillin allergy in children is associated with adverse health outcomes such as antibiotic‐resistant infections. However, it remains controversial how best to assess children for amoxicillin allergy. While in general it is recommended that skin testing be done prior to drug provocation test in the evaluation of amoxicillin allergy, there is increasing evidence that drug provocation testing could be done in lower risk children without skin testing prior. The goal of this article as a narrative review is to review the strengths and limitations of skin testing prior to drug provocation test in children who have a history of either immediate or non‐immediate, reactions to amoxicillin.