Current Management of High-Risk Breast Lesions

Abstract

Purpose of review

The purpose of this review is to describe recent updates in the management of high-risk breast lesions. We review the various high-risk breast lesions and evaluate the collective literature regarding the rates of upgrade to invasive cancer or ductal carcinoma in situ with excisional biopsy as well as the increased risk for future breast cancer development that a diagnosis of a high-risk breast lesion may portend. For those lesions associated with an increased risk of breast cancer, we discuss the appropriate surveillance regimens as well as risk reduction opportunities available to patients.

Recent findings

Recent studies may suggest a role for close imaging observation in certain clinical settings when a benign intraductal papilloma or flat epithelial atypia is identified by core needle breast biopsy. Ongoing prospective clinical trials should reveal valuable data to help answer this question.

Summary

Clinical management of high-risk breast lesions identified and determined to be concordant after image-guided core needle biopsy varies and prospective data are needed to better guide management decisions. High-risk breast lesions require close radiologic-pathologic correlation when diagnosed by image-guided breast core needle biopsy. Excisional biopsy can exclude a higher-grade lesion such as DCIS or invasive cancer; however, in certain cases, close observation with follow-up may be appropriate. Additionally, women who have certain high-risk lesions such as lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia are at an increased risk for the future development of breast cancer and should undergo risk assessment and discussion of risk reduction measures. Ongoing and future prospective trials may provide data to better guide these management decisions and optimize patient care.

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Long-term follow-up in the endovascular treatment of intracranial aneurysms with flow-diverter stents: update of a single-centre experience

Abstract

Introduction

Flow-diverter stents are becoming a useful tool in treating patients with intracranial aneurysms with suitable anatomical feature. Purpose of this study was to evaluate effectiveness and safety of endovascular treatment with flow-diverting stents (FD) in unruptured intracranial aneurysms.

Methods

From May 2009 and May 2014, we treated 49 patients with a total of 58 aneurysms, with FD technique. All patients were treated electively, under general anesthesia and were administered single antiplatelet drug 5 days before the procedure and double antiplatelet therapy for 3 months afterwards. Fifteen of the patients were asymptomatic, eight had headache, thirteen patients presented symptoms due to mass effect of the aneurysm on CNS structures, twelve were treated due to a post-surgical relapse and one patient presented relapsing TIAs due to distal embolization from the aneurysm dome. Choice of FD treatment was done according to aneurysm anatomy (fusiform over saccular, dome/neck ratio < 2) and whenever conventional treatment (coil embolization) appeared difficult (eg. Large aneurysm neck, fusiform aneurysms or difficult sac catheterization). We considered a dome/neck ratio > 2 as the only exclusion criteria.

Results

Successful stent deployment was achieved in 50 procedures out of 52 (94.34%) while overall mortality was 2% (1/49). Forty-eight patients were evaluated at long-term follow-up for a total of 56 treated aneurysms. At 3 months, follow-up 75% (42/56) of the aneurysms were excluded from intracranial circulation, at 6 months 80.35% (45/56) and at 12 months 84% (47/56). Stent patency was observed in 100% of patients at short and long-term follow-up, with only two cases of intimal hyperplasia at 3 months, without any further complications.

Conclusions

According to our study FD repair of unruptured intracranial aneurysms appeared to be a safe and effective technique, especially in selected patients with hostile anatomy for traditional embolization.

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Multi-slice CT examinations of adult patients at Sudanese hospitals: radiation exposure based on size-specific dose estimates (SSDE)

Abstract

The aim of this study was to update the radiation exposure for adult patients undergoing multi-slice CT (MSCT) examinations using size-specific dose estimates (SSDE). Console, displayed CTDI_vol and scan parameters were retrospectively recorded for 423 adult patients in seven Sudanese hospitals. Patient torso diameters were measured using digital calipers on the scanner console. SSDE was determined based on transverse images (SSDE_trans) and scout radiographs (SSDE_sco). Size-specific conversion factors were used to translate the recorded CTDI_vol into SSDE according to the procedure described in the American Association of Physicists in Medicine (AAPM) Report 204. In chest CT, mean CTDI_vol, SSDE_trans and SSDE_sco ranged: from 4.3 to 47.5 mGy (average: 12.8), 5.5 to 70.3 mGy (average: 18.6) and 5.8 to 63.5 mGy (average: 18.7), respectively. In abdominal CT, mean CTDI_vol, SSDE_trans and SSDE_sco ranged: from 4.0 to 74.5 mGy (average: 16), 5.5 to 152.8 mGy (average: 23.9) and 6.0 to 151.3 mGy (average: 25.21), respectively. Our study highlights the relationships between CT dose and patient dimensions measured from scout and transverse CT images. The correlations between the patient size and dose based on scout images were less significant than that based on transverse images. High dose levels and dose variations among hospitals reveal the need for standardization of scanning protocols and staff training on adoption of scanners' dose reduction techniques.

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Intracranial arterial calcifications as a prognostic factor for subsequent major adverse cardiovascular events (MACE)

Abstract

Background

Intracranial arterial calcifications (ICAC) are often detected on unenhanced CT of patients with an age > 60. However, association with the subsequent occurrence of major adverse cardiovascular events (MACE) has not yet been evaluated.

Purpose

This study aimed at evaluating the association of ICAC with subsequent MACE and overall mortality.

Methods

In this retrospective, IRB approved study, we included 175 consecutive patients (89 males, mean age 78.3 ± 8.5 years) of age > 60 years who underwent an unenhanced CT of the head due to minor trauma or neurological disorders. Presence of ICAC was determined in seven intracranial arteries using a semi-quantitative scale, which resulted in the calcified plaque score (CPS). Clinical follow-up information was obtained by questionnaires and telephone interviews. MACE was defined as myocardial infarction or revascularization, stroke or death due to cardiovascular event.

Results

Mean follow-up time was 39.8 ± 7.8 months, resulting in 579.7 patient-years of follow-up. Overall, 36 MACE occurred during follow-up (annual event rate = 6.2%/year). Mean CPS was significantly higher in subjects with MACE during follow-up compared to subjects without MACE (p < 0.01). In 15 patients CPS was 0; in none of these patients MACE was registered. Kaplan–Meier-analysis revealed that patients with a low plaque burden (CPS < 5) had a significant longer MACE-free and overall survival than patients with a high plaque burden (CPS ≥ 5) (p < 0.01).

Conclusion

Patients with ICAC have an increased risk for future cardio- or cerebrovascular events. Therefore, ICAC might be a prognostic factor to determine the risk for these events in older patients.

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Subtle Imaging Findings Aid the Diagnosis of Adolescent Hereditary Spastic Paraplegia and Ataxia

Abstract

Purpose

Hereditary spastic paraplegia (HSP) and hereditary spastic ataxia (HSA) are a heterogeneous group of genetic disorders characterized by progressive lower limb spasticity resulting from pyramidal tract dysfunction. By identifying critical imaging findings within the clinical context of spasticity, radiologists are uniquely positioned to recommend specific genetic testing, and thus facilitate diagnosis.

Methods

We present two examples of HSP and HSA that had gone clinically unrecognized for years, and in which magnetic resonance imaging played a critical role in the diagnosis.

Results

Radiologists' awareness of HSP and HSA, combined with a critical review of the clinical history and characteristic imaging findings led to specific genetic testing and a definitive diagnosis.

Conclusion

Awareness of HSP and HSA among radiologists will expedite more accurate diagnosis, explanation of patient symptoms, recommendation for syndrome-specific treatment, and family planning considerations.

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Potts disease associated with large and multiple abscesses in a 30-year-old migrant from Chad

Description 

After a 1-year history of increasing mechanical back pain, a 30-year-old Chadian man with no medical record progressively developed a voluminous paravertebral mass (figure 1A). He described night sweats without fever for several months associated with a 20 kg weight loss (admission weight at 68 kg). Physical examination revealed no neurological defect. Laboratory tests showed a biological inflammatory syndrome with C reactive protein (CRP) plasmatic level at 80 mg/L and fibrinogen at 5.1 g/L. A vertebral MRI showed a T11–T12 vertebral osteomyelitis with a discal and corporeal abscess surrounded by important adjacent bone oedema, epiduritis causing mild spinal cord compression, as well as voluminous, prevertebral (12x8x5 cm), left psoas (9x8x8 cm) and retrovertebral (16x5x4 cm) liquid collections with peripheral contrast enhancement, suggestive of abscesses (figure 1B–D). Culture of the punctured collection of the retrovertebral abscess yielded multisusceptible Mycobacterium tuberculosis. Body scan revealed no other disease localisation. HIV serological test was negative and...

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Intravascular lymphoma presenting with postural hypotension

An 84-year-old woman presented with severe postural hypotension. Further assessment revealed weight loss, fatigue and fever at night. On examination, she had bilateral skin lesions on the inner thighs and skin biopsy revealed intravascular high grade B cell lymphoma. This was successfully treated with curative chemotherapy. The cause of the postural hypotension in this case was felt likely to be autonomic neuropathy caused by neurovascular infiltration by intravascular lymphoma. Treatment of the lymphoma has resolved the postural hypotension, although some symptoms of postural instability persist.

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Fuchs syndrome: a case of fever, mucositis and conjunctivitis

Description

A 5-year-old boy presented with fever and cough of 2 weeks’ duration, conjunctivitis and lip swelling with blistering for 6 days, and 1 day of skin rash. His past medical history was significant for incomplete Kawasaki disease (KD) at 3 years of age with no cardiac sequelae. Significant findings on physical examination included bilateral conjunctival injection with perilimbic sparing, red and cracked lips with crusting, oral mucositis and ulcerations of the buccal mucosae and tongue (figure 1), and a mild generalised maculopapular rash. He was systemically well otherwise, and there were no target lesions evident on his skin.

Figure 1

Oral mucositis with blistering of lips in a patient with Fuchs syndrome.

Differential diagnoses at that point included recurrent incomplete KD, Stevens-Johnson syndrome (SJS) and gingivostomatitis. However, oral mucositis was not consistent with KD. Furthermore, the absence of any skin...

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Cryptosporidium diagnosed on endoscopic biopsy in a paediatric patient with inflammatory bowel disease

Cryptosporidium, a parasitic infection commonly associated with diarrhoea, may be difficult to differentiate from a flare in patients with inflammatory bowel disease and can lead to unnecessary therapy and increase in morbidity and mortality. We report the case of a paediatric patient who had substantial stool output requiring significant fluid resuscitation and who was later diagnosed with cryptosporidium on endoscopic biopsy. Diagnostic work up for cryptosporidium should be strongly considered when a patient presents with a flare involving massive stool output.

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Segmental dilatation of small bowel presenting with severe anaemia: a diagnostic puzzle

A 7-year-old boy presented to Paediatric outpatient with worsening lethargy and tiredness. On examination he had extreme pallor. Blood investigations confirmed severe iron deficiency anaemia. He was started on iron supplements and received blood transfusion. However, the response to iron treatment was suboptimal, he therefore underwent extensive workup for the cause of iron deficiency anaemia. The barium meal showed dilated segments of ileum with two distal stenoses. The surgical resection of the involved segment was performed with end to end anastamosis. Histology of the resected segment was inconclusive of inflammatory bowel disease, malignancy or vascular malformation. The child has remained well since surgery with no further blood transfusion or iron therapy.

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Chronic incomplete non-puerperal uterine inversion due to huge submucous fibroid: diagnosis and management

Description

Incomplete non-puerperal uterine inversion is a rare complication that can arise secondary to the presence of submucous fibroid.1 In the majority of cases reported in the literature, the definitive diagnosis is usually made at the time of hysterectomy.2 In reported cases where hysterectomy was not done, Haultain procedure was done to correct the inversion.3 In the following case, the diagnosis was made preoperatively and the fibroid was resected vaginally by LigaSure.

A 31-year-old nulliparous woman presented to the emergency room with history of excessive bleeding for a few months. She also had urine retention for 1 day. On examination, she was pale. Vaginal examination showed a large mass distending the vagina with foul smell and moderate bleeding. Her haemoglobin was 6.2 g/L. Pelvic ultrasound scan was not conclusive in ascertaining the origin of the mass. MRI revealed the presence of a pedunculated,...

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New onset diabetes after nivolumab treatment

The authors describe a case of a life-threatening diabetic emergency 25 days after initiation of nivolumab (3 mg/kg) for stage 4 lung adenocarcinoma. She was admitted to the emergency department, with hyperglycaemia-related signs and symptoms, such as polyuria, polydipsia, weight loss, confusion, asthenia, dehydration, hypotension and Kussmaul respiratory pattern. Her body mass index was 21.9 kg/m² and she did not show acanthosis nigricans. Arterial blood gas determination revealed high anion gap metabolic acidaemia and blood tests showed hyperglycaemia (1060 mg/dL), hyperketonaemia (beta-hydroxybutyrate: 6.6 mmol/dL), elevated total serum osmolality (389 mOsm/kg), low serum and urinary C-peptide and positive antiglutamic acid decarboxylase antibodies. Since nivolumab was initiated a few days before, and due to its known immune-mediated endocrine adverse events, we assumed the diagnosis of new onset immune-mediated type 1 diabetes mellitus. After prompt and adequate treatment of diabetic ketoacidosis/hyperosmolar hyperglycaemic state, she was discharged improved on multiple daily injections of insulin.

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High Prevalence of Hypertension in Ethiopian and Non-Ethiopian HIV-Infected Adults

Objectives. Prevalence of hypertension has not been studied in the Ethiopian HIV-infected population, which represents 60% of the patients in our AIDS unit. Our aim was to identify risk factors and characterize the prevalence of hypertension in the population monitored at our unit. Methods. A retrospective chart review categorized subjects according to their blood pressure levels. Hypertension prevalence was determined and stratified according to variables perceived to contribute to elevated blood pressure. Results. The prevalence of hypertension in our study population was significantly higher compared to the general population (53% versus 20%, ) and was associated with known risk factors and not with patients’ viral load and CD4 levels. Ethiopian HIV-infected adults had a prominently higher rate of blood pressure rise over time as compared to non-Ethiopians (). Conclusions. The high prevalence of hypertension in this cohort and the rapid increase in blood pressure in Ethiopians are alarming. We could not attribute high prevalence to HIV-related factors and we presume it is part of the metabolic syndrome. The lifelong cardiovascular risk associated with HIV infection mandates hypertension screening and close monitoring in this population.

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Durable and Washable Antibacterial Copper Nanoparticles Bridged by Surface Grafting Polymer Brushes on Cotton and Polymeric Materials

To increase the durability of antibacterial coating on cotton and polymeric substrates, surface initiated grafting polymer brushes are introduced onto the substrates surface to bridge copper nanoparticles coatings and substrate. The morphologies of the composites consisting of the copper nanoparticles and polymer brushes were characterized with scanning electron microscopy (SEM). It was found that copper nanoparticles were uniformly and firmly distributed on the surfaces of the substrates by the polymer brushes; meanwhile, the reinforced concrete-like structures were formed in the composite materials. The substrates coated by the copper nanoparticles showed the efficient antibacterial activity against Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) even after washing by 30 cycles. The copper nanoparticles were tethered on the substrates by the strong chemical bonds, which led to the excellent washable fitness and durability. The change of the phase structure of the copper was analyzed to investigate the release mechanism of copper ions.

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Roles of NUCKS1 in Diseases: Susceptibility, Potential Biomarker, and Regulatory Mechanisms

Nuclear casein kinase and cyclin-dependent kinase substrate 1 (NUCKS1) is a 27 kD chromosomal, highly conserved, and vertebrate-specific protein. NUCKS1 gene encodes a nuclear protein and the conserved regions of NUCKS1 contain several consensus phosphorylation sites for casein kinase II (CK2) and cyclin-dependent kinases (Cdk) and a basic DNA-binding domain. NUCKS1 is similar to the high mobility group (HMG) family which dominates chromatin remodeling and regulates gene transcription. Meanwhile, NUCKS1 is a RAD51 associated protein 1 (RAD51AP1) paralog that is significant for homologous recombination (HR) and genome stability and also a transcriptional regulator of the insulin signaling components. NUCKS1 plays an important role in DNA damage response and metabolism, participates in inflammatory immune response, and correlates with microRNA. Although there is still not enough functional information on NUCKS1, evidences suggest that NUCKS1 can be used as the biomarker of several cancers. This review summarizes the latest research on NUCKS1 about its susceptibility in diseases, expression levels, and regulatory mechanisms as well as the possible functions in reference to diseases.

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Variability in Ultrasound Backscatter Induced by Trabecular Microstructure Deterioration in Cancellous Bone

To determine the relationship between the ultrasonic backscatter parameters and trabecular microstructural variations in cancellous bone, three erosion procedures were performed to simulate various changes in the cancellous bone microstructure. The finite difference time domain (FDTD) method was used to simulate the backscatter signal in cancellous bone. Ultrasonic backscatter properties were derived as functions of the porosity when the ultrasound incident directions were perpendicular and parallel to the major trabeculae direction (MTD), respectively. The variability in the apparent backscatter coefficient (ABC) and apparent integrated backscatter (AIB) due to the trabecular microstructure was revealed. Significant negative correlations between the backscatter parameters (ABC and AIB) and the porosity of the cancellous bone were observed. The simulations showed that the ABC and AIB were influenced by the direction of the trabecular microstructural variations. The linear regressions between the ultrasonic backscatter parameters (ABC and AIB) and the porosity showed significantly different slopes for three erosion procedures when they are ultrasonically perpendicular (for ABC, −1.22 dB, −0.98 dB, and −0.46 dB; for AIB, −0.74 dB, −0.69 dB, and −0.25 dB) and parallel (for ABC, −1.87 dB, −0.69 dB, and −0.51 dB; for AIB, −0.9 dB, −0.5 dB, and −0.34 dB) to the MTD. This paper investigated the relationship between ultrasonic backscatter and cancellous bone microstructure deterioration and indicated that the ultrasonic backscatter could be affected by cancellous bone microstructure deterioration direction.

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Maximum Wind Power Tracking of Doubly Fed Wind Turbine System Based on Adaptive Gain Second-Order Sliding Mode

This paper proposes an adaptive gain second-order sliding mode control strategy to track optimal electromagnetic torque and regulate reactive power of doubly fed wind turbine system. Firstly, wind turbine aerodynamic characteristics and doubly fed induction generator (DFIG) modeling are presented. Then, electromagnetic torque error and reactive power error are chosen as sliding variables, and fixed gain super-twisting sliding mode control scheme is designed. Considering that uncertainty upper bound is unknown and is hard to be estimated in actual doubly fed wind turbine system, a gain scheduled law is proposed to compel control parameters variation according to uncertainty upper bound real-time. Adaptive gain second-order sliding mode rotor voltage control method is constructed in detail and finite time stability of doubly fed wind turbine control system is strictly proved. The superiority and robustness of the proposed control scheme are finally evaluated on a 1.5 MW DFIG wind turbine system.

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Numerical Simulation of Unsteady Conjugate Heat Transfer of Electrothermal Deicing Process

A novel 3-D unsteady model of in-flight electrothermal deicing process is presented in this paper to simulate the conjugate mass and heat transfer phenomena of water film runback, phase change, and solid heat conduction. Mathematical models of water film runback and phase change are established and solved by means of a loosely coupled method. At the current time step, solid heat conduction, water film runback, and phase change are iteratively solved until the heat boundary condition reaches convergence, then the temperature distribution and ice shape at the moment are obtained, and the calculation of the next time step begins subsequently. A deicing process is numerically simulated using the present model following an icing tunnel experiment, and the results match well with those in the literatures, which validate the present model. Then, an in-flight deicing process is numerically studied to analyze the effect of heating sequence.

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Bargaining Power Choices with Moral Hazard in a Supply Chain

A supply chain contract is established using a dynamic, Nash bargaining game which determines the optimal bargaining power allocation for the manufacturer, retailer, and society in an environment affected by moral hazard and irreversible investment. The results found that the manufacturer’s choice was to hold all bargaining power; however, due to the remaining information problem, the retailer still had a profit; in contrast, the retailer was only willing to give up bargaining power if the manufacturer’s profit was reserved. The optimal bargaining power allocation was found to be strongly related to the ability to convert and monitor technology, with the bargaining power gradually shifting to the manufacturer as the technology improved. A numerical simulation is given to examine the theoretical results.

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Olfactory and gustatory functions after free flap reconstruction and radiotherapy for oral and pharyngeal cancer: a prospective follow-up study

Abstract

Background

The senses of smell and taste can be adversely affected by both tumour- and treatment-related factors amongst head and neck cancer patients. The consequences may negatively impact nutritional status as well as quality of life in this patient population.

Patients and methods

This prospective longitudinal follow-up study is consisted of 44 patients treated for oral cavity, oropharyngeal or hypopharyngeal cancer with tumour resection and microvascular free tissue transfer reconstruction at the Helsinki University Hospital, Helsinki, Finland. Thirty-nine (89%) of them also received radiotherapy. The senses of smell (odour detection, identification and threshold test) and taste (electrogustometry) and quality of life (UW-QOL) were evaluated preoperatively, and at 6 weeks, 3 months, 6 months and 12 months, postoperatively.

Results

There were higher scores in the odour detection values in the 6-week and 3-month tests compared with preoperative values for the tumour side. Other detection scores did not differ statistically from the preoperative values neither in the tumour nor the contralateral side. However, in the odour identification test, all posttreatment values were statistically significantly higher than pretreatment ones. In the olfactory threshold test, no statistically significant differences were found between pre- and posttreatment values. Electrogustometry values for the taste on the tumour side were statistically significantly impaired at 6 weeks (p < 0.05) and at 3 months (p < 0.01) compared with the pretreatment results. They were also impaired at 6 months and at 12 months, although the differences were not statistically significant. The quality of life was impaired after treatment in this patient series. However, the correlation between quality of life and sense of taste was found only at one time point (3 months) and only with contralateral side measurements.

Conclusions

We conclude that in oral and pharyngeal cancer patients the postoperative taste problems are related to the impairment on the taste sensation in the tongue but not with the sense of smell. Moreover, the impairment in the quality of life is not clearly related to the impaired sense of taste.

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Homelessness and public health

The number of people officially recorded as sleeping on the streets of England rose from 1768 in 2010 to 4751 in autumn 2017.1 Charities estimate the true figure to be more than double this.2 There...

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Low and middle income countries make up 82% of the global population, yet of the 10 top-cited articles ever publish… https://t.co/2FF47kCa6T

Low and middle income countries make up 82% of the global population, yet of the 10 top-cited articles ever publish… https://t.co/2FF47kCa6T

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Former USA Gymnastics team doctor sentenced for abusing hundreds of girl athletes

Larry Nassar, a former doctor with USA Gymnastics and Michigan State University (MSU) who sexually abused hundreds of young athletes under his care, has received a sentence of 40 to 175 years in...

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End non-essential use of antimicrobials in livestock

Tackling antimicrobial resistance (AMR) is a priority of the World Health Organization’s public health agenda, and in November 2017 the organisation launched guidelines on the use of medically...

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Use paracetamol for most acute sore throats, says NICE

Doctors should not prescribe antibiotics for most cases of acute sore throat, including pharyngitis and tonsillitis, says guidance from the National Institute for Health and Care Excellence.1The...

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Government postpones first ACOs to allow further consultation

The government will delay the formation of the first accountable care organisations in England while further consultation takes place, the health and social care secretary has said.In a letter to...

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