Regional nodal irradiation in the conservative treatment of breast cancer.

At this institution conservative treatment of breast cancer was begun in the 1960's. The following analysis represents our experience through 1984 with specific reference to the management of the regional lymph nodes. A total of 432 patients with clinical stage I and II breast cancer were treated between 1962 and 1984 with lumpectomy and radiation therapy.

Radiation therapy for ductal carcinoma in situ of the breast.

The optimal treatment for ductal carcinoma in situ (DCIS) of the breast is undefined. At three Connecticut hospitals 1) Yale-New Haven Hospital, New Haven; 2) Uncas-on-Thames Hospital, Norwich; 3) Norwalk Hospital, Norwalk, breast conservation therapy with lumpectomy followed by radiation therapy (RT) has been offered to women with DCIS as an alternative to mastectomy. From 1974 through 1987, 60 women with DCIS have been treated with RT.

Conservative surgery with radiation therapy in clinical stage I and II breast cancer. Results of a 20-year experience.

Conservative surgery and radiation therapy have been increasingly utilized at Yale-New Haven (Conn) Hospital since the 1960s. This analysis represents our experience from 1962 to 1982, with a total of 281 patients having a minimum assessable follow-up of five years and a median follow-up of 7.4 years.

Conservative surgery and radiation therapy in breast carcinoma: local recurrence and prognostic implications.

Conservative surgery with radiation therapy has been used with increasing frequency at Yale-New Haven Hospital since the late 1960's, resulting in a minimum evaluable follow-up time of 5 years on 278 patients treated prior to 1982. The radiation therapy technique generally encompassed treatment to the breast and regional lymph nodes of 4600 cGy with an electron beam boost to the tumor bed of 6400 cGy. Axillary dissection was performed in 19%, adjuvant chemotherapy in 7.

Results of radical radiation therapy in clinical stage I, technically operable non-small cell lung cancer.

From 1970 to 1983, 1,646 lung cancer patients were referred for treatment to the Hunter Radiation Therapy Center, Yale-New Haven Hospital. Forty-three patients had clinical Stage I non-small cell lung cancer felt to be surgically resectable but were treated with radical radiation therapy either for medical reasons (37 patients) or because the patient refused surgery (six patients). This group of clinical Stage I lung cancer patients is understaged by modern criteria since the majority of patients did not have thoracic CT scans and staging was based on fairly limited clinical and radiographic studies.

Malignant biliary obstruction: intracavitary treatment with a high-dose-rate remote afterloading device.

A new technique of intracavitary brachytherapy for malignant biliary obstruction is presented. The technique involves the use of a high-dose-rate remote afterloading device, which offers all the advantages of conventional brachytherapy with the added benefit that the dose can be delivered in a single treatment over a few minutes. The potential problems associated with conventional brachytherapy are thereby minimized.

Diastolic time during recovery from upright exercise in persons without heart disease.

To assess the relation between heart rate and diastolic time (cardiac cycle minus electromechanical systole) during the recovery period from upright exercise, 12 normal volunteers were studied immediately after and 2 and 5 minutes after exercise in the upright position. Although heart rate was significantly lower at 5 minutes compared with 2 minutes after exercise (106 vs 116 beats/min), there was significant shortening of diastolic time (from 251 to 230 ms) and total diastole per minute (from 28,634 to 24,220 ms/min). The explanation of this phenomenon appears to be disproportionate lengthening of diastolic time at 2 minutes after exercise, which must represent physiologic response due to increased left ventricular filling as well as continuing adrenergic effects, which would be diminished at 5 minutes.

Left ventricular performance during exercise: response of ear densitogram derivative.

The peak derivative of the ear densitogram (PD) has been shown to track left ventricular (LV) function during exercise. Measured as percent change in amplitude from resting control, PD in normal subjects slowly and consistently increased throughout exercise and to 2 minutes of recovery, followed by return to control level. In contrast, PD in patients with coronary artery disease rapidly increased only to 1 minute of exercise, with no significant subsequent increase.

Erythrityl tetranitrate compared with isosorbide dinitrate. Effects on systolic time intervals and nitrate modification of effects of food.

The pharmacologic effects of erythrityl tetranitrate (ETN) and isosorbide dinitrate (ISDN) were compared to placebo using systolic time intervals (STI) in a randomized, double-blind study in 15 fasted male volunteers. Sublingual doses of ETN 5 mg, ISDN 5 mg, and placebo were administered to each volunteer at weekly intervals, and measurements of heart rate and STI [pre-ejection period (PEP), left ventricular ejection time (LVET), and PEP/LVET ratio] were made serially for up to 6 hours after each dose. STI were determined using ear densitography.

Noninvasive tracking of peripheral resistance by ear densitography.

Owing to the interaction between the left ventricle and the arterial system, pulse contour during ejection is significantly affected by changes in peripheral resistance. Quantitative description of the pulse configuration as a function of peripheral resistance involves invasive investigation of complex frequency and impedance spectra. The ear densitogram noninvasively yields a pulse wave shown to closely track changes in the central arterial pulse; in this investigation, its decreasing systolic slope responded to changes in the peripheral resistance like those in the central pulse and in arterial models.

Tracking left ventricular performance noninvasively. Response of the peak ear pulse derivative during cardiac catheterization.

The peak derivative of the ear densitograph displacement pulse was monitored on 12 patients undergoing routine coronary angiography and left ventricular angiography. Simultaneous recording of cardiac output, heart rate, systolic time intervals, and ear densitogram were obtained throughout the progression from before angiographic injections to postcoronary angiography to after left ventricular angiography. The peak derivative of the ear densitogram (PD) consistently tracked mean systolic ejection rate, and changes in PD showed good correlation with changes in ejection rate (r=.

Effect of oral propranolol on left ventricular performance in patients with ischemic heart disease. Ear densitographic study during uninterrupted treadmill exercise.

The effect of oral propranolol on left ventricular performance during early upright exercise was evaluated by ear densitography in patients with arteriographic coronary artery disease (CAD). Measurements of systolic time intervals differentiated 10 unmedicated patients with CAD (group 1) and 15 patients with CAD taking propranolol (group 3). The patients in group 3 had less shortening of preejection period at 1 minute and 4 minutes of exercise than group 1 patients (p less than 0.

Bioavailability of organic nitrates: a comparison of methods for evaluating plethysmographic responses.

Erythrityl tetranitrate, a long-acting organic nitrate, was compared with isosorbide dinitrate in a double-blind, placebo-controlled complete crossover study in 15 healthy male volunteers. A digital plethysmogram and ear densitogram were used to assess the physiologic response to these two sublingual nitrates, with the intensity and duration of drug effect calculated by differences in diastolic amplitude intensity before and after drug administration. Both 5 mg sublingual erythrityl tetranitrate and 5 mg isosorbide dinitrate produced significant increases in diastolic amplitude intensity for up to 3 hours.

Rate of rise of the carotid pulse. An investigation of observer error in a common clinical measurement.

Bedside estimation of the rate of rise of the carotid pulse is a standard clinical observation whose reliability has not been determined. To ascertain interobserver agreement (primary objective) and compare the velocity of rise of the carotid displacement (not pressure) pulse (supplementary objective), three blinded observers evaluated, ranked and palpated the velocity of rise of carotid pulse as "unremarkable," "slow" or "rapid" in 20 consecutive patients. The relative rate of rise of the recorded carotid pulse was represented by the angle between baseline and the initial carotid peak at a standard paper speed of 100 mm/s.

Noninvasive assessment of left ventricular performance in patients with ischemic heart disease: ear densitographic study during uninterrupted treadmill exercise.

Among 738 consecutive patients with chest pain referred for exercise testing, only 17 men fulfilled strict criteria for this pilot study: (1) achievement of at least 90 percent of age-predicted maximal heart rate or electrocardiographic criteria for a positive test; (2) subsequent coronary angiography; (3) exclusion of prior heart disease; and (4) absence of medication. Measurements of systolic time intervals obtained with ear densitography during early exercise differentiated 10 patients with coronary artery disease (Group 1) from 17 men (7 patients plus 10 normal volunteers) with normal coronary arteries (Group 2). Despite nearly identical heart rate and blood pressure responses in both groups, men in Group 1 had a significantly greater reduction of preejection period (PEP) at 1 minute and 4 minutes as well as a greater decrease in PEP/LVET (left ventricular ejection time) ratio.

Elucidation of physiologic lengthening of left ventricular ejection time during early upright exercise.

To elucidate the relationship between heart rate (HR) and left ventricular ejection time (LVET) during early exercise, 30 patients with chest pain were studied at 1 (1') and 4 minutes (4'). Mean results for control leads to 1' exercise: HR 79 to 105 beats per minute, LVET 247 to 260 msec. Thus instead of shortening as predicted by the HR change at 1' of exercise, LVET rose significantly (p less than 0.

Responses of peak ear-pulse derivative to changing left ventricular function.

The ear densitograph displacement pulse derivative (dD/dtear) is the analog of the arterial pressure derivative (dP/dt) and behaves comparably under a variety of cardiocirculatory challenges. Technical reliability and uniform application of the transducer are advantages that make it ideal for intrasubject monitoring. With atrial fibrillation as a model of functional variability in eight subjects, peak dD/dtear (P) tracked echocardiographic stroke volume, ejection fraction, ejection rate, and velocity of circumferential fiber shortening quite closely with the exception of some values in three subjects, two of whom had mitral regurgitation and one paradoxic septal movement.

Cardiac responses to impulse exercise and recovery: systolic time intervals.

Exercise responses depend on work load and its pattern of delivery. Administering a very brief ("impulse") load aims to elicit significant responses through biologic sensitivity to rate - rather than degree - of change. Electrocardiograms, systolic time intervals (STI) and heart rate (HR) were recorded continuously in 10 normal subjects during and after brief (20-sec) bicycle exercise at 50, 100 and 150 W.

"Paradoxical" reduction in postexercise ejection time and increased transthoracic impedance.

Despite decreasing heart rate, left ventricular ejection time (LVET) transiently falls immediately following bicycle exercise. In seven normal, untrained subjects LVET decreases at 15 s postexercise corresponded (r = 0.78) with an increase in transthoracic electrical impedance (Z) consistent with decreased venous return to the thorax.

Noninvasive ambulatory monitoring of physiologic data: recording systolic time intervals.

Adding physiologic data to ambulatory electrocardiographic monitoring data yields information with great potential for diagnostic and therapeutic use. The ear densitogram's stability, demonstrated during exercise and under laboratory conditions, indicates its applicability to ambulatory monitoring as a source of systolic time intervals. Circuitry has been developed to feed the output of an ear densitogram pickup into one channel of a two-channel Holter monitor.

Cardiac response during uninterrupted treadmill exercise and recovery: measurement by systolic time intervals.

In 12 normal subjects, use of ear densitography permitted measurement of systolic time intervals (STI) during uninterrupted treadmill exercise to over 90 percent maximal heart rate on a modified Bruce protocol. Results for control (sitting leads to standing) leads to end-exercise at 18 minutes leads to 10 minutes' sitting recovery were--heart rate (HR): (77 leads to 861 leads to 171 leads to 98 beats per minute; preejection period (PEP): (106 leads to 111) leads to 49 leads to 110 msec; ejection time index (ETI) (351 leads to 330) leads to 380 leads to 366 msec; PEP/LVET (0.42 leads to 0.