Richard B. Friedman

Accelerated superfractionated radiotherapy for inflammatory breast carcinoma: complete response predicts outcome and allows for breast conservation.

PURPOSE Chemotherapy and accelerated superfractionated radiotherapy were prospectively applied for inflammatory breast carcinoma with the intent of breast conservation. The efficacy, failure patterns, and patient tolerance utilizing this approach were analyzed. METHODS AND MATERIALS Between 1983 and 1996, 52 patients with inflammatory breast carcinoma presented to the Medical College of Virginia Hospitals of VCU and the New England Medical Center. Thirty-eight of these patients were jointly evaluated in multidisciplinary breast clinics and managed according to a defined prospectively applied treatment policy. Patients received induction chemotherapy, accelerated superfractionated radiotherapy, selected use of mastectomy, and concluded with additional chemotherapy. The majority were treated with 1.5 Gy twice daily to field arrangements covering the entire breast and regional lymphatics. An additional 18-21 Gy was then delivered to the breast and clinically involved nodal regions. Total dose to clinically involved areas was 63-66 Gy. Following chemoradiotherapy, patients were evaluated with physical examination, mammogram, and fine needle aspiration x 3. Mastectomy was reserved for those patients with evidence of persistent or progressive disease in the involved breast. All patients received additional chemotherapy. RESULTS Median age was 51 years. Median follow-up was 23.9 months (6-86) months. The breast preservation rate at the time of last follow-up was 74%. The treated breast or chest wall as the first site of failure occurred in only 13%, and the ultimate local control rate with the selected use of mastectomy was 74%. Ten patients underwent mastectomy, 2 of which had pathologically negative specimens despite a clinically palpable residual mass. Response to chemotherapy was predictive of treatment outcome. Of the 15 patients achieving a complete response, 87% remain locoregionally controlled without the use of mastectomy. Five-year overall survival for complete responders was 68%. This is in contrast to the 14% 5-year overall survival observed with incomplete responders. The 5-year actuarial disease-free survival and overall survival for the entire patient cohort was 11% and 33%, respectively. All patients tolerated irradiation with limited acute effects, of which all were managed conservatively. CONCLUSION Our experience demonstrates that induction chemotherapy, accelerated superfractionated radiotherapy, and the selected use of mastectomy results in excellent locoregional control rates, is well tolerated, and optimizes breast preservation. Based on our present results, we recommend that a patients response to induction chemotherapy guide the treatment approach used for locoregional disease, such that mastectomy be reserved for incomplete responders and avoided in those achieving a complete response.

The Computer-Assisted Postmortem Identification (CAPMI) System: A Computer-Based Identification Program

The Computer-Assisted Postmortem Identification (CAPMI) system was developed at the U.S. Army Institute of Dental Research to facilitate rapid identification of human remains. The increasing requirement for dental based identification of high-energy fatalities and decomposed remains has dovetailed with the development of computer capabilities permitting automation of most of the highly repetitive chart-by-chart screenings characteristic of traditional identification taskings. This report summarizes the concepts upon which CAPMI is based, describes how it works, and reviews suggested applications and limitations. CAPMI software is available to governmental, civic, or humanitarian organizations at no cost.

A new algorithm for use in computer identification.

On 9 May 1987, a Soviet-made IL-62M Polish airliner, LOT Flight 5055, crashed, exploded, and burned, killing the crew and 183 passengers. A forensic science team from the Armed Forces Institute of Pathology, comprised of 6 dental officers, 3 forensic pathologists, and 3 medical photographers, worked in concert with the Polish forensic science team. The small number of antemortem records and the extreme fragmentation of the remains presented a new scenario for computer use. Typically, the Computer-Assisted Postmortem Identification (CAPMI) software is used to compare remains against an antemortem database. Results are listed by the number of tooth-to-tooth matches based on restorative or other characteristics or both. The Polish disaster confounded this approach to some degree, however, and suggested a reconsideration of the theory on which the sort is made, that is, that the cases with maximum number of matches to preexisting dental records would be the most likely identification (ID) match. A hypothesis was constructed that, if searches were accomplished for fragments with a minimum number of mismatches, the correct matches would appear higher in the rank order. Six antemortem records (that had all dental information) were sorted against one hundred and twelve postmortem fragmented records. The resulting report was reordered so that records were listed by minimum number of mismatches. There was significant improvement in rank placement for all of the records. Thus it was accepted that in the situation of highly fragmented remains a different sorting based on the number of mismatches is indicated. Programming changes to make this option available have been implemented in the new version of CAPMI.

Oral hygiene following traumatic brain injury: a programme to promote dental health

Dental care and oral hygiene programmes for persons with traumatic brain injury (TBI) have been relatively ignored areas of clinical care and research. Data regarding the need for structured oral hygiene programmes with this population are sorely lacking. Further, evidence to support or contraindicate the efficacy of such interventions is negligible. The purpose of the present study was to address the need for ongoing dental follow-up and oral hygiene programmes in the post-acute phase of rehabilitation care. A group of 20 TBI patients (10 experimental, 10 control) who were at least 1 month post-injury and had Rancho Los Amigos Scale scores of 6 or greater, were randomly selected for participation in the study. Oral hygiene status was assessed by a dental hygienist using a plaque index score developed by Silness and Loe. The experimental group received individualized oral hygiene instruction along with dental supplies for their personal use, including a dental mirror and red disclosing tablets. The control group received no such instructions or supplies. At 5-6 weeks following initial evaluation, 18 patients (nine from each group) were reassessed via the plaque index score. Comparisons between the control and experimental groups revealed significant differences on follow-up plaque scores with a lower mean score for the experimental group only on baseline and follow-up data yielding a significant decrease in plaque scores over time. These results suggest that dental hygiene interventions for patients following TBI can effectively promote dental plaque control.