Premalignant diseases of the breast.
The importance of identifying women at increased risk for developing breast cancer is obvious. Environmental and host factors as well as breast histology are reviewed in this article.
Adult↗
Biomedical subjects
F E Gump
Publications and source records attributed to F E Gump.
The psychological impact of immediate breast reconstruction for women with early breast cancer.
Twenty-five patients were evaluated, 13 who had immediate breast reconstruction and 12 who had delayed breast reconstruction for early breast cancer. Data were elicited about the psychological impact of the cancer, the mastectomy, and the reconstruction. Our results support the conclusion that immediate breast reconstruction is accompanied by a lower incidence of psychological morbidity postoperatively, and we recommend that immediate breast reconstruction be offered as an alternative to women with early breast cancer.
Adult↗
Trauma and hemorrhage.
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Anesthesia, General↗
The effect of parenteral nutritional repletion on muscle water and electrolytes. Implications for body composition.
Nutritional depletion and repletion are associated with changes in the size of the extracellular and intracellular fluid compartments. Although the effect of nutrition on whole body composition is well established, the distribution of changes among the various body tissues is not. This study correlates changes in skeletal muscle composition with whole body electrolyte and nitrogen balance in an attempt to establish the contribution made by skeletal muscle to the changes in whole body fluid and electrolyte composition. Total parenteral nutrition was administered to ten patients for 16 to 25 days. Oxygen consumption, CO2 production, and balances of N, Na, and K were measured daily. Muscle biopsies were taken prior to administration of TPN, in the middle, and at the end of the nutritional regimen. Prior to administration of parenteral nutrition, muscle concentrations of water, sodium, and chloride were significantly higher than normal. With institution of the nutritional support regimen, all three concentrations decreased. The calculated loss in muscle water could account, at most, for only one-sixth of the loss in total body water. Muscle Na loss could account for approximately one-half of the whole body change. Potassium concentrations in the depleted patients were not significantly decreased from normal values and showed a negligible increase with TPN. Since the ratio of K to dry fat-free solids in muscle was constant, most of the whole body changes could be accounted for by assuming that nearly all N is deposited in muscle. Nutritional support results in restoration of cell mass with a contraction of the extracellular fluid (ECF) compartment. The changes in the ECF must occur in tissues other than muscle, while the restoration of cell mass occurs primarily in muscle.
Adult↗
The response to TPN. A form of nutritional assessment.
Malnutrition in surgical patients is associated with an increased incidence of postoperative mortality and morbidity. Preoperative nutritional support has been shown to be efficacious in reducing the incidence of these complications, although the postoperative complication rate in these patients continues to be greater than in their wellnourished counterparts. This study attempts to determine whether the postoperative course can be either influenced by or predicted from the preoperative response to nutritional support. Thirty-two patients with nutritional depletion who received an average of 1 week of total parenteral nutrition prior to a major abdominal operation were studied. These patients were followed for postoperative complications. Of the 16 patients who exhibited the characteristic response to early nutritional support, diuresis of the expanded extracellular fluid compartment with a resultant loss of weight (127.9 +/- 5.7 to 124.6 +/- 5.8 (SEM) lbs, p less than .001) and rise in serum albumin (3.21 +/- 0.14 to 3.46 +/- 0.15 gms%, p less than 0.001), only one developed a complication in the postoperative period. The other 16 patients did not exhibit this response. They retained additional fluid, gained weight (119.3 +/- 8.1 to 121.3 +/- 8.2 lbs, p less than .025), and showed a decrease in serum albumin levels (3.14 +/- 0.14 to 3.00 +/- 0.14%), p less than 0.01). Eight of these patients developed a total of 15 postoperative complications (p less than 0.01). This study demonstrates that the response to preoperative TPN is an important factor in assessing operative risk and morbidity. The need to individualize preoperative nutritional support and the timing of surgical intervention is clearly demonstrated.
Aged↗
Effect of an anabolic steroid on nitrogen balance and amino acid patterns after total hip replacement.
The effect of an anabolic steroid, nandrolone decanoate, on nitrogen balance and plasma and muscle amino acid concentrations was studied in patients undergoing total hip replacement and receiving daily postoperative infusions of 5% dextrose and 3.5% amino acids. An intramuscular injection of 200 mg immediately after operation resulted in a nitrogen balance of -48 mg N/kg . day for the first 3 days, as compared to 102 mg N/kg . day in noninjected controls. After steroid injection there was also an attenuation of trauma-induced changes in amino acid concentrations in muscle but not in plasma. This suggests that nandrolone decanoate may act directly on muscle to reduce the protein catabolism which follows a major form of operative trauma.
Aged↗
Serum albumin levels as an index of nutritional support.
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Adult↗
Kinetics of energy substrates.
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Carbon Dioxide↗
Lipoprotein lipase activity in surgical patients: influence of trauma and infection.
Hypertriglyceridemia commonly accompanies clinical sepsis and may be caused by increased hepatic production or decreased clearance of triglyceride from the bloodstream. In contrast, enhanced lipid clearing capacity is usually seen after uncomplicated trauma. The purpose of the study was to determine the role of lipoprotein lipase (LPL) in effecting the above changes. Enzyme activity was assayed in skeletal muscle and adipose tissue biopsy samples from 11 normal subjects and from 17 injured and 11 infected surgical patients. Normal subjects after 4 days of 5% dextrose infusion (D5) showed a significant decrease in adipose tissue LPL activity but no change in skeletal muscle activity. Trauma patients after several days of D5 had higher activity in adipose tissue and higher plasma insulin levels than diet-matched control subjects but showed no change in skeletal muscle activity. Infected patients with high plasma triglyceride levels had significantly decreased LPL activity in both tissues. A linear relationship was found between insulin concentration and adipose tissue LPL activity in normal subjects. We conclude that: (1) low tissue LPL activity in sepsis may result in diminished lipid clearance and contribute to hypertriglyceridemia, (2) after trauma, changes in tissue LPL activity as well as other factors such as altered hemodynamics play a role in determining in vivo lipid clearance, and (3) adipose tissue LPL activity is related to the plasma insulin concentration in normal subjects.
Adipose Tissue↗
Metabolic and endocrine effects of fasting followed by infusion of five-percent glucose.
Isotonic glucose is often the sole nutrient provided to hospitalized patients with varying degrees of protein calorie malnutrition. To study the effects of such diets uncomplicated by illness, normal human subjects were fasted (6 to 14 days) before receiving an infusion of 5% dextrose (5 to 7 days). Norepinephrine excretion rose steadily-to six times control values-during the first 6 days of the fast and changed little thereafter. It remained high during the first 3 days of glucose infusion and subsequently returned toward normal. The rate of NTau-methylhistidine excretion changed little during the fast but decreased abruptly with glucose infusion. The magnitude of NTau-methylhistidine excretion indicated that undirectional muscle protein degradation was about equal to nitrogen excretion during the fast, and that the decrease in muscle protein degradation could account for the abrupt decrease in nitrogen excretion (from 91 to 30 mg N/kg . day) after glucose infusion. This suggests that the conservation of muscle protein caused by glucose infusion in this setting is affected by decreased degradation rather than by increased synthesis. Changes in NTau-methylhistidine excretion and total nitrogen excretion were more rapid than, and therefore not mediated by, changes in insulin concentration or norepinephrine excretion.
Adult↗
Fibromatosis of the breast.
We have reviewed the Columbia-Presbyterian Hospital experience with fibromatosis of the breast, a most uncommon lesion that frequently mimics carcinoma. Very few examples of this rare lesion have been reported previously, and the lack of follow-up data has made it difficult to evaluate treatment. Five patients were cared for at the Columbia Presbyterian Medical Center and an additional 12 patients were reviewed after slides were sent for consultation. Complete clinical information and follow-up data were obtained in a total of 13 patients, three of whom had recurrences. There were no histologic features that served to distinguish those patients who had a recurrence from those who did not. While there were no recurrences when adequate excision was carried out, it is worth noting that we found one instance of spontaneous regression as well as two patients who did well despite the fact that tumor was found at the margin of the specimen. The results of this review suggest that the major problem facing the surgeon, once the diagnosis has been made, relates to the difficulty in defining the extent of the tumor in the breast. Careful orientation of the specimen and repeated use of frozen sections should make it possible to perform a complete excision and, at the same time, remove a minimum amount of breast tissue. Since fibromatosis is a benign process, the cosmetic impact of surgical therapy certainly deserves careful consideration.
Adolescent↗
The effect of carbohydrate intake on the lipolytic rate in depleted patients.
The effect of intravenous carbohydrate intake on glycerol turnover and fat metabolism was estimated in six nutritionally depleted surgical patients requiring total parenteral nutrition. Two diets were given. Nitrogen intake was the same in both diets. The calorie intake, adjusted by varying glucose intake, provided either 72% or 128% of the measured resting energy expenditure. Glycerol turnover was measured during administration of 5% dextrose solutions before starting total parenteral nutrition, and again after 4 days on each diet. Turnover rates of glycerol were closely correlated with plasma concentrations. However, fractional turnover rates were only two-thirds of normal values, indicating decreased clearance possibly due to decreased hepatic blood flow. Glycerol turnover, plasma free fatty acid concentrations, and rate of fat oxidation declined progressively with increased glucose intake. When compared with these results, previous studies of injured and septic patients showed: higher values for glycerol turnover, FFA concentrations, and fat oxidation; poor corrlation between glycerol turnover and concentration; inhibition of lipogenesis at high glucose intake; and high rates of norepinephrine excretion. The data suggest that in severe injury, counter regulatory hormones may almost completely block the effects of insulin on hormone sensitive lipase but have less influence on insulin stimulation of FFA esterification and inhibition of ketone body synthesis.
Aged↗
Some metabolic effects of fat infusions in depleted patients.
Severely depleted surgical patients were given total parenteral nutrition, providing an average of 34.6 kcal and 266 mg nitrogen/kg body weight. Two diets were used, one with glucose as sole source of nonprotein energy, the other with a fat emulsion, Liposyn 10%, substituted isocalorically for one-third of the glucose. The two diets were given alternately, for 1 wk at a time, to each patient. N balance, at zero energy balance, was estimated to average 50 mg nitrogen/kg, indicating that energy intake in excess of expenditure is not required to restore lean body mass in depleted patients. Nitrogen (N) balance was equally good with either diet. Respiratory quotients and carbohydrate oxidation were lower, and fat oxidation was higher with the fat-containing diet. Amino acids and glucose were infused continuously over each 24-hr period and fat was given for only 6--8 hr. During the period of fat infusion, fat oxidation was significantly higher, and carbohydrate oxidation and RQ were lower than at other times of day.
Aged↗
Influence of total parenteral nutrition on fuel utilization in injury and sepsis.
Total parenteral nutrition with hypertonic glucose/AA solutions given to eighteen nutritionally depleted patients resulted in a rise in the respiratory quotient (RQ) from 0.83 to 1.05 (p less than .001), while oxygen consumption (VO2) increased only 3%. Excess glucose in depleted patients was converted to fat as evidenced by an RQ greater than 1.0. Administration of a similar glucose load to fourteen hypermetabolic patients (injury/infection) resulted in a rise in RQ from 0.76 to 0.90 while VO2 increased 29% (p less than .001) In hypermetabolic patients, even with administration of glucose in quantities above energy expenditure, there was still ongoing utilization of fat for energy, resulting in a RQ significantly less than 1.0. Excess glucose under these circumstances is apparently converted to glycogen while fat stores are utilized to partially meet energy needs. Septic and injuried man seems to preferentially utilize endogenous fat as an energy source. Administration of a large glucose load to hypermetabolic patients does not totally suppress the net fat oxidation as it does in depleted patients. Rather there is an increase in VO2, continuing oxidation of fat and apparently an increase in the conversion of glucose to glycogen.
Adult↗
Muscle and plasma amino acids after injury: hypocaloric glucose vs. amino acid infusion.
This study examines the effect of three different hypocaloric diets on the patterns of muscle and plasma amino acids in patients undergoing total hip replacement. Group I (seven patients) received 90 g/day of glucose, Group II (seven patients) received 70 g/day of amino acids, Group III (eight patients) received both 90 g of glucose and 70 grams of amino acids per day. Utilizing the percutaneous biopsy technique of Bergström, free amino acid patterns in muscle and plasma were analyzed pre- and postoperatively (day 4). The postoperative pattern of amino acids was characterized by elevated levels in muscle and plasma of the branched chain amino acids, phenylalanine, tyrosine and methionine. There was a marked decrease in muscle glutamine and smaller decreases in the basic amino acids in both muscle and plasma. Muscle:plasma concentration ratios increased for the neutral amino acids, decreased for glutamine and the basic amino acids and were unchanged for the acidic amino acids. The patterns seen after hip replacement are almost identical to those seen after colectomy or accidental injury. There was little effect of diet on amino acid concentrations in muscle. In plasma, concentrations of leucine, isoleucine, valine and proline were higher in Group II in the absence of glucose intake, than in the other groups. Lysine was lower in Group I with no amino acid intake than in the other groups. Thus, there is a unique amino acid pattern associated with operative trauma which is relatively unaffected by hypocaloric, intravenous nutrition.
Amino Acids↗
Muscle and plasma amino acids following injury. Influence of intercurrent infection.
The present study was undertaken to determine intracellular amino acid patterns in patients with multiple trauma, whether or not complicated by sepsis and during convalescence. A percutaneous muscle biopsy was performed three to four days following major accidental injury in ten patients and analyzed for muscle free amino acids. Venous blood was drawn at the time of the biopsy and analyzed for plasma free amino acids. Five patients developed sepsis and a repeat biopsy was performed on days 8 to 11. In five of the patients a biopsy was performed during the late convalescent period (anabolic phase). A marked depletion of nonessential amino acids in muscle occurred in both injury and sepsis due to a decrease (50%) in glutamine, which was equally marked in both states. The essential amino acids in muscle increased in injury. During sepsis, a further increase was observed with a return toward normal in the convalescent period. In injury, the most marked rise was in the branched-chain amino acids, phenylalanine, tryosine and methionine. With sepsis, a further rise in muscle branched-chain amino acids, phenylalanine and tryosine occurred, while plasma levels remain unchanged. During convalescence, muscle glutamine, arginine, histidine and plasma branched-chain amino acids were below normal, whereas muscle phenylalanine and methionine were elevated. The muscle free amino acid pattern observed after major trauma was essentially the same as earlier described following elective operation. This suggests a common response of intracellular amino acids irrespective of the degree of injury, and may indicate that the pump settings which regulate amino acid transport follow the "all or none" rule. The high intracellular levels of branched-chain amino acids in sepsis suggest that the energy deficit of this state is due to an impairment of substrate use rather than intracellular availability. The high concentrations of the aromatic amino acids and methionine may be due to altered liver function. During the late convalescent period (anabolic phase) the low levels of certain key amino acids suggests inadequate nutrition. The difficulties in nourishing the injured or septic patient are well recognized. The period following these catabolic states may be an important period for the application of an optimal, aggressive nutritional regimen.
Abdomen, Acute↗
Use of the ventilatory equivalent to separate hypermetabolism from increased dead space ventilation in the injured or septic patient.
Normal subjects and surgical patients were studied with a noninvasive canopy-spirometer system which provides prolonged measurements of gas exchange and pattern of breathing. Values for normal subjects agreed with published values. Twenty-nine patients undergoing uncomplicated elective operation had a mean preoperative minute ventilation of 3.44 +/- 0.84 L/min/m2, a VO2 of 0.132 +/- 0.022 L/min/m2, and VCO2 of 0.105 +/- 0.017 L/min/m2, and the postoperative values on the third to fifth day were not statistically different. The ventilatory equivalent (V.E.CO2) or the liters of air moved per liter of CO2 excreted has been used instead of the dead space/tidal volume (VD/VT) ratio for the indication of levels of minute ventilation, which are excessive for the associated metabolic demands for gas exchange. Thirty-eight runs on 18 acutely ill surgical patients showed mean increases in minute ventilation of 85%; the associated increases in metabolism averaged 17%. Therefore, their V.E.CO2 increased from a normal of 31 +/- 6 to 50.7 +/- 8, indicating a sharp increase in dead space ventilation. The additional clinical information provided by the serial graphic presentation of V.E.CO2 supplements what is learned from successive numbers representing the trend in VD/VT.
Bacterial Infections↗
Anemia in surgical patients.
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Acute Disease↗