A randomised comparison of the effects of oral versus transdermal 17beta-oestradiol, each combined with sequential oral norethisterone acetate, on serum lipoprotein levels

OBJECTIVE

To investigate the effects of oral versus transdermal 17beta-oestradiol, given in both cases with sequential addition of oral norethisterone acetate, on serum lipid and lipoprotein levels in postmenopausal women.

DESIGN

Open, randomised, parallel groups study.

SETTING

University Clinical Research Group.

POPULATION

Sixty-four postmenopausal women with climacteric complaints who were otherwise healthy were screened. Of these, 58 fulfilled the entry criteria.

METHODS

Fifty-eight postmenopausal women were randomised to receive either oral 17beta-oestradiol/oestriol (Trisequens) or transdermal 17beta-oestradiol (Estrapak) together with cyclical addition of norethisterone acetate for 48 weeks.

MAIN OUTCOME MEASURES

Serum levels of total cholesterol, triglycerides, high density lipoproteins (HDL), low density lipoproteins (LDL), very low density lipoproteins (VLDL), apolipoproteins, and lipoprotein(a) at baseline, and after 46 weeks (oestrogen-alone phase), and 48 weeks (oestrogen-progestogen phase) of treatment.

RESULTS

Oral oestradiol therapy did not affect serum total cholesterol levels during the oestrogen-alone phase, but during the combined phase there was a 5% fall (P < 0.05) due to a 7% decrease in LDL cholesterol levels (P < 0.01). Oral therapy also increased serum triglyceride levels by 9.4% during the oestrogen-alone phase (P < 0.05). During the combined phase of transdermal therapy, there was a 19% fall in serum triglyceride levels (P < 0.05) and a 6% fall in HDL levels (P < 0.05). Oral oestradiol reduced lipoprotein(a) levels by 31% during the oestrogen-alone phase and by 37% with norethisterone acetate addition (P < 0.05). Transdermal therapy had no significant effect on lipoprotein(a).

CONCLUSIONS

Other than a minor fall in HDL3 in women receiving transdermal 17beta-oestradiol, coadministration of oral progestogen in general improved, rather than worsened, this serum lipoprotein profile.

Permeability characteristics of human oocytes in the presence of the cryoprotectant dimethylsulphoxide

Equilibration of oocytes with cryoprotectants is a prerequisite of low temperature storage. However, cryoprotectant exposure may induce damage via osmotic stress. Knowledge of cell membrane permeability characteristics and their temperature dependence would facilitate the design of cryopreservation protocols in which osmotic stress is minimized and the incidence of intracellular freezing is reduced. To obtain such data, the volume change of donated human oocytes following exposure to cryoprotectant was measured at a variety of temperatures. After removal of cumulus cells, each oocyte was placed in a 5 microl droplet of phosphate-buffered medium. The oocyte was held in position by suction generated using a fine pipette and perfused with 1 ml 1.5 mol/l dimethylsulphoxide (DMSO) at 30, 24 or 10 degrees C. The volume of the oocyte before, during and after perfusion was recorded by videomicroscopy. Oocyte volume was calculated from radius measurements and the Kedem-Katchalsky (K-K) passive coupled transport coefficients, namely L(p) (hydraulic permeability), P(DMSO) (permeability to DMSO) and sigma (reflection coefficient) were derived. The resulting coefficients were L(p) = 1. 65 +/- 0.15, 0.70 +/- 0.06 and 0.28 +/- 0.04 microm/min.atm; P(DMSO) = 0.79 +/- 0.10, 0.25 +/- 0.04 and 0.06 +/- 0.01 microm/s and sigma = 0.97 +/- 0.01, 0.94 +/- 0.03 and 0.96 +/- 0.01 at 30, 24 and 10 degrees C respectively. The activation energy for L(p) was 14.70 and for P(DMSO) was 20.82 kcal/mol. The permeability parameters of human oocytes are higher than those of murine oocytes, suggesting that they require a shorter period of exposure to DMSO with concomitantly reduced toxic effects.

Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs

OBJECTIVE

Many patients fail to attend cardiac rehabilitation. Attempts to identify sociodemographic or clinical predictors of non-attendance have not been very successful; therfore, this study aimed to determine whether the illness beliefs held during hospitalisation by patients who had suffered acute myocardial infarction or who had undergone coronary artery bypass graft surgery could predict cardiac rehabilitation attendance.

SUBJECTS AND METHODS

152 patients were prospectively studied of whom 41% had attended cardiac rehabilitation at six months.

RESULTS

In addition to being older, less aware of their cholesterol values, and less likely to be employed, non-attenders were less likely to believe their condition was controllable and that their lifestyle may have contributed to their illness.

CONCLUSION

It should now be determined whether interventions aimed at optimising certain perceptions could promote cardiac rehabilitation uptake among those patients who could benefit the most.

A family IIb xylan-binding domain has a similar secondary structure to a homologous family IIa cellulose-binding domain but different ligand specificity

BACKGROUND

Many enzymes that digest polysaccharides contain separate polysaccharide-binding domains. Structures have been previously determined for a number of cellulose-binding domains (CBDs) from cellulases.

RESULTS

The family IIb xylan-binding domain 1 (XBD1) from Cellulomonas fimi xylanase D is shown to bind xylan but not cellulose. Its structure is similar to that of the homologous family IIa CBD from C. fimi Cex, consisting of two four-stranded beta sheets that form a twisted 'beta sandwich'. The xylan-binding site is a groove made from two tryptophan residues that stack against the faces of the sugar rings, plus several hydrogen-bonding polar residues.

CONCLUSIONS

The biggest difference between the family IIa and IIb domains is that in the former the solvent-exposed tryptophan sidechains are coplanar, whereas in the latter they are perpendicular, forming a twisted binding site. The binding sites are therefore complementary to the secondary structures of the ligands cellulose and xylan. XBD1 and CexCBD represent a striking example of two proteins that have high sequence similarity but a different function.

Predictors of mortality in adult patients with blunt injuries in New York State: a comparison of the Trauma and Injury Severity Score (TRISS) and the International Classification of Disease, Ninth Revision-based Injury Severity Score (ICISS)

BACKGROUND

The purpose of this study was to determine the statistical model that best predicted mortality from blunt trauma using a contemporary population-based database.

METHODS

1994-1995 New York State Trauma Registry data for patients with blunt injuries were used to predict mortality using three statistical models: (1) the original Trauma and Injury Severity Score (TRISS) model based on Major Trauma Outcome Study data, (2) a new TRISS model whose coefficients were derived using New York data, and (3) the International Classification of Disease, Ninth Revision-based Injury Severity Score (ICISS) with predicted survival values obtained from the Agency for Health Care Policy and Research's Health Care Utilization Project. The models were compared with respect to discrimination (using the C statistic) and calibration (using the Hosmer-Lemeshow [H-L] statistic). In addition, the models were tested to see how well they predicted outcomes for each of the three mechanisms of blunt injury.

RESULTS

The ICISS model had a significantly higher C statistic (0.878) and a better H-L statistic (29.38) for predicting mortality for all adult patients with blunt injuries. The original TRISS model had very poor calibration (H-L = 687.38). None of the three models predicted mortality accurately for victims of motor vehicle crashes or victims of low falls. When separate models were developed for all motor vehicle crashes, low falls, and other blunt injuries, the ICISS and New York TRISS models both fit well, although the calibration was marginal in most cases. The ICISS model had a statistically significantly higher C statistic for other blunt injuries and for motor vehicle crashes. The New York TRISS model had better calibration for low falls.

CONCLUSIONS

The ICISS has promise as an alternative to TRISS, but many more comparative studies need to be undertaken using updated TRISS coefficients. Models should also be developed for mechanisms of injury, not just for blunt and penetrating injuries.

Long-term follow-up following bone marrow transplantation for Hunter disease

Bone marrow transplantation (BMT) was performed in 10 patients with Hunter disease (mucopolysaccharidosis type II, iduronate-2-sulphatase deficiency). The donor was an HLA-identical sibling in 2 cases, an HLA-nonidentical relative in 6 cases, a volunteer unrelated donor in 1 case, and details were not available in 1 case. Only three patients have survived for more than 7 years post BMT; however, this high mortality probably resulted from poor donor selection. In two, there has been a steady progression of physical disability and mental handicap. One patient has maintained normal intellectual development, with only mild physical disability. It is possible that BMT may be useful in selected patients with MPS II.

Cryopreservation of bovine ovarian tissue: structural normality of follicles after thawing and culture in vitro

The recovery of viable follicles from cryopreserved ovarian tissue would be of benefit in many areas of assisted reproduction. Structural integrity needs to be maintained following cryopreservation of ovarian tissue in order to retrieve healthy follicles which can then be cultured in vitro to produce viable oocytes. We have assessed the effect of in vitro culture of bovine tissue for 0, 1, 4, 24, or 48 h after exposure to, or cryopreservation in, dimethylsulphoxide. Immediately after freezing, normality of primary and preantral follicles within the tissue was significantly lower than for tissue exposed to the cryoprotectant without freezing or for control tissue. After 4 h in culture, cryopreserved tissue appeared to have recovered from damage caused by freezing, although the percentage of tissue with normal morphology declined after 24 and 48 h of culture. There was no significant difference between percentage normality in control tissue and tissue exposed to the cryoprotectant without freezing for any of the culture times studied. These data indicate that it is possible to freeze/thaw bovine ovarian tissue while retaining a reasonable yield of morphologically intact follicles and that a short period of post-thaw culture may enhance follicle recovery.

Ligand binding by antibody IgE Lb4: assessment of binding site preferences using microcalorimetry, docking, and free energy simulations

Antibody IgE Lb4 interacts favorably with a large number of different compounds. To improve the current understanding of the structural basis of this vast cross-reactivity, the binding of three dinitrophenyl (DNP) amino acids (DNP-alanine, DNP-glycine, and DNP-serine) is investigated in detail by means of docking and molecular dynamics free energy simulations. Experimental binding energies obtained by isothermal titration microcalorimetry are used to judge the results of the computational studies. For all three ligands, the docking procedure proposes two plausible subsites within the binding region formed by the antibody CDR loops. By subsequent molecular dynamics simulations and calculations of relative free energies of binding, one of these subsites, a tyrosine-surrounded pocket, is revealed as the preferred point of complexation. For this subsite, results consistent with experimental observations are obtained; DNP-glycine is found to bind better than DNP-serine, and this, in turn, is found to bind better than DNP-alanine. The suggested binding mode makes it possible to explain both the moderate binding affinity and the differences in binding energy among the three ligands.

Independently melting modules and highly structured intermodular junctions within complement receptor type 1

A segment of complement receptor type 1 (CR1) corresponding to modules 15-17 was overexpressed as a functionally active recombinant protein with N-glycosylation sites ablated by mutagenesis (referred to as CR1 approximately 15-17(-)). A protein consisting of modules 15 and 16 and another corresponding to module 16 were also overexpressed. Comparison of heteronuclear nuclear magnetic resonance (NMR) spectra for the single, double, and triple module fragments indicated that module 16 makes more extensive contacts with module 15 than with module 17. A combination of NMR, differential scanning calorimetry, circular dichroism, and tryptophan-derived fluorescence indicated a complex unfolding pathway for CR1 approximately 15-17(-). As temperature or denaturant concentration was increased, the 16-17 junction appeared to melt first, followed by the 15-16 junction, and module 17 itself; finally, modules 15 and 16 became denatured. Modules 15 and 16 adopted an intermediate state prior to total denaturation. These results are compared with a previously published study [Clark, N. S., Dodd, I, Mossakowska, D. E., Smith, R. A. G., and Gore, M. G. (1996) Protein Eng. 9, 877-884] on a fragment consisting of the N-terminal three CR1 modules which appeared to melt as a single unit.

Sequence-divergent units of the ABA-1 polyprotein array of the nematode Ascaris suum have similar fatty-acid- and retinol-binding properties but different binding-site environments

Polyproteins comprise long polypeptides that are post-translationally cleaved into proteins of different function, or tandemly repetitive polypeptides which are processed into multiple versions of proteins which are presumed to have the same function. In the latter case the individual units of the polyprotein can differ substantially in sequence. Identity of function between the different units therefore cannot be assumed. Here we have examined the ABA-1 polyprotein allergen of the parasitic nematode Ascaris suum and found it to contain units which show a 50% difference in amino acid sequence. The parasite therefore produces at least two radically different forms of the allergen encoded within the polyprotein array. In fluorescence-based ligand-binding assays, recombinant polypeptides representing the two forms (designated ABA-1A1 and ABA-1B1) showed similar binding affinities for a range of fluorescent active-site probes [retinol, dansylundecanoic acid, dansyl-DL-alpha-amino-octanoic acid, cis-parinaric acid (cPnA)] and for the non-specific hydrophobic surface probe 8-anilinonaphthalene-1-sulphonic acid. However, the molecular environments in the active sites are markedly different, as indicated by disparate fluorescence emission peaks and intensities of bound probes. CD showed that the proteins have similar secondary structures but differ in susceptibility to chemical denaturation/unfolding by guanidinium chloride. Both retain a single conserved tryptophan residue in a characteristic non-polar environment, as revealed by extreme fluorescence blue shift. Thus the gross differences in sequence of the two proteins are not reflected in their ligand-binding specificities but in their binding-site environments.

Prolactin response to the severity of surgical insult

Prolactin levels are elevated significantly during the recovery process from surgical insult, implying a role for prolactin in the neuroendocrine immune network. This study examined the importance of severity of surgical insult to the prolactin response. Two groups of surgical patients were chosen consecutively and studied prospectively. Seven patients scheduled for "clean" elective surgery, i.e., herniorrhaphy and laparoscopic cholecystectomy, were compared with seven patients scheduled for prolonged abdominal exploration. Blood was drawn for prolactin and cortisol at 8:00 AM on the day of surgery and on postoperative days one, three, and five. Using a two-tailed test, preoperative prolactin levels and levels on postoperative days three and five were significantly different in the prolonged surgery group (.012 and .002, respectively). There were no statistically significant differences in preoperative and postoperative prolactin levels in the clean surgery group. Cortisol levels were not significantly elevated in either group. These results indicate that the prolactin response to surgery is related to the severity of the surgical insult.

Effect of a microwave coagulator on implanted liver neoplasms in rats

An experimental study was conducted to determine the applicability of a microwave (MW) source for coagulation and dissection of metastatic tumour and liver parenchyma. Twenty PVG rats were studied after implantation of MC28 tumour cells into the liver. Eleven days later they underwent sham laparotomy (control) MW coagulation of the tumour deposit, local resection of the tumour deposit with 2 mm clearance or resection of the tumour with MW coagulation of the resection zone. The control animals all died with blood-stained ascites and heavy tumour burden in the liver. After MW coagulation, tumours disappeared in all but one rat. Local resection also led to tumour clearance in 4 of 5 rats. MW coagulation of the resection zone allowed rapid bloodless resection, and no tumour recurrence was observed after 40-89 days. We conclude that MW coagulation is a potentially useful tool for ablation of hepatic metastasis and as an adjunct to hepatic resection.

The intravenous model of murine tuberculosis is less pathogenic than the aerogenic model owing to a more rapid induction of systemic immunity

The detection of mRNA in the murine model of tuberculosis for key cytokines involved in protective immunity in the lung tissues revealed a much faster emergence of the interferon (IFN)-gamma response in the intravenous route than in the aerosol route of inoculation. This slower response in the lungs was associated with a stronger inflammatory response, resulting in large granulomatous structures and eventual tissue damage.

Priorities for research in Emergency Medical Services for Children: results of a consensus conference. EMSC Research Agenda Consensus Committee, National EMSC Resource Alliance

STUDY OBJECTIVE

The study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC).

METHODS

A consensus group was convened using the Rand'-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC.

Site-directed mutagenesis of proline 204 in the 'hinge' region of yeast phosphoglycerate kinase

Site-specific mutants have been produced in order to investigate the role of proline 204 in the 'hinge' region of yeast phosphoglycerate kinase (PGK). This totally conserved proline has been shown to be the only cis-proline in the high resolution crystal structures of yeast, B. stearothermophilus, T. brucei and T. maritima PGK, and may therefore have a role in the independent folding of the two domains or in the 'hinge' bending of the molecule during catalysis. The residue was replaced by a histidine (Pro204His) and a phenylalanine (Pro204Phe), and the resulting proteins characterised by differential scanning calorimetry (DSC), circular dichroism (CD), tryptophan fluorescence emission and kinetic analysis. Although the secondary and tertiary structure of the Pro204His protein is generally similar to that of the wild-type enzyme as assessed by CD, the enzyme is less stable to heat and guanidinium chloride denaturation than the wild-type. In the denaturation experiments two transitions were observed for both the wild-type and the Pro204His mutant, as have been previously reported for yeast PGK [Missiakas, D., Betton, J.M., Minard, P. & Yon, J.M. (1990) Biochemistry 29, 8683-8689]. The first transition is accompanied by an increase in fluorescence intensity leading to a hyperfluorescent state, followed by the second, corresponding to a decrease in fluorescence intensity. However, for the Pro204His mutant, the first transition proceeded at lower concentrations of guanidinium chloride and the second transition proceeded to the same extent as for the wild-type protein, suggesting that sequence-distant interactions are more rapidly disrupted in this mutant enzyme than in the wild-type enzyme, while sequence-local interactions are disrupted in a similar way. The Michaelis constants (K(m)) for both 3-phospho-D-glycerate and ATP are increased only by three or fourfold, which confirms that, as expected, the substrate binding sites are largely unaffected by the mutation. However, the turnover and efficiency of the Pro204His mutant is severely impaired, indicating that the mechanism of 'hinge' bending is hindered. The Pro204Phe enzyme was shown to be significantly less well folded than the wild-type and Pro204His enzymes, with considerable loss of both secondary and tertiary structure. It is proposed that the proline residue at 204 in the 'hinge' region of PGK plays a role in the stability and catalytic mechanism of the enzyme.

Novel classes of fatty acid and retinol binding protein from nematodes

Parasitic nematodes have recently been found to produce proteins which represent two new classes of fatty acid and retinoid binding protein. The first is the nematode polyprotein allergens/antigens (NPAs) which, as their name suggests, are synthesised as large polyproteins which are subsequently cleaved at regularly spaced sites to form multiple copies of a fatty acid binding protein of approximately 14.5 kDa. Binding studies using molecular environment-sensitive fluorescent ligands have shown that the binding site is highly unusual, producing blue-shifting in fluorescence to an unprecedented degree, suggesting a remarkably non-polar environment and isolation from solvent water. Computer-based structural predictions and biophysical observations have identified the NPAs as highly helical proteins which might form a four helix bundle, so constitute a new class of lipid binding protein from animals. The second class, like the NPAs, binds both fatty acids and retinol, but with a higher affinity for the latter. These are also highly helical but are structurally distinct from the NPAs. The biological function of these new classes of protein are discussed in the context of both the metabolic requirements of the parasites and the possible role of the proteins in control of the immune and inflammatory environment of the tissue sites parasitised.

Priorities for research in emergency medical services for children: results of a consensus conference

STUDY OBJECTIVE

To arrive at a consensus on the priorities for future research in emergency medical services for children.

METHODS

A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3.

RESULTS

The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services.

Crystallization and preliminary X-ray crystallographic analysis of a vancomycin-N-acetyl-D-Ala-D-Ala complex

A vancomycin-N-acetyl-D-Ala-D-Ala complex has been crystallized by the sitting-drop vapour-diffusion method using imidazole maleic buffer at pH 7.6. The novel crystals obtained belong to the space group P6322 with unit-cell parameters a = b = 73.43 (1), c = 277.17 (4) A, gamma = 120 degrees. The crystal density was determined as 1. 106 g cm-3 which gives a supercell of 24 molecules (12 dimers) per asymmetric unit for an acceptable Matthews number and an estimated solvent content of 42%. Data were collected at room temperature to 2. 8 A.

Priorities for research in emergency medical services for children: results of a consensus conference

OBJECTIVE

To arrive at a consensus on the priorities for future research in emergency medical services for children.

METHODS

A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge (2), change behavior (3), improve health (4), decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting research agenda for such services.

Predictors of local recurrence following excision alone for ductal carcinoma in situ

BACKGROUND

The treatment of ductal carcinoma in situ (DCIS) remains controversial, particularly in regard to the selection of patients who may be appropriately treated with wide excision alone. To help identify such patients, the authors assessed prognostic factors for local recurrence in patients with DCIS treated with excision alone.

METHODS

The study population consisted of 59 patients diagnosed with DCIS between 1985 and 1990. All had been treated with excision alone, had their histologic slides available for re-review by a study pathologist, and had negative margins of excision on review. The median age at diagnosis was 54 years, and the median follow-up time was 95.5 months. Ninety-six percent presented with mammographic findings only; all patients had a reexcision. The size of the DCIS was assessed by the total number of low-power fields (LPF) in which DCIS was present (median LPF = 5).

RESULTS

Ten patients experienced a local recurrence (LR) at 5-132 months (median, 37 months) after excision. The actuarial 5-year LR rate was 10%. Four of the recurrences were invasive carcinomas, and 6 were DCIS. No patients have developed metastatic disease or have died of disease. Lesion size >5 LPF was the only significant prognostic factor for local recurrence on univariate analysis (3% vs. 17% for < or = 5 vs. > or = 5 LPF, P = 0.02) and in proportional hazards models. Although patients with nuclear Grade 3 lesions had a higher LR rate than those with nuclear Grade 1 and 2 lesions (18% vs. 6% and 5%, respectively) and patients with close margins (< or = 1 mm) had a higher LR rate than patients with negative margins (>1 mm) (25% vs. 8%), these differences did not reach statistical significance. Among the 19 cases with margins negative by more than 1 mm, lesion size < or = 5 LPF, and nuclear Grade 1 or 2, there were no LRs; by contrast, the remaining 40 patients had a 5-year actuarial LR rate of 15% (P = 0.08).

CONCLUSIONS

Lesion size was the only statistically significant prognostic factor for local recurrence in this series of patients with DCIS treated with excision alone. Other factors, such as margin status and nuclear grade, may also be useful in the identification of patients with DCIS who can be managed with excision alone. However, the most reliable and reproducible method of assessing these factors and the best way to combine them have not been determined.