Surgery in the elderly: is age a risk factor?

This prospective, observational one-year study analyzed 623 patients who were 60 years and older, out of a cohort of 2375 patients who were admitted consecutively to the general surgery wards of the University Hospital of the West Indies (UHWI). Even though only 9.7% of the Jamaican population are 60 years and older, this age group accounted for 26.2% of total admissions. Comparison of elderly and non-elderly patients showed no differences in gender, but less elderly patients were emergency admissions (52% vs 64%, p < 0.001), more underwent surgery (68% vs 60%, p < 0.001), their mean hospital stay was longer (11.5 vs 8.0 days, p < 0.001) and their mortality rate was higher (8.8% vs 1.9%, p < 0.001). Emergency admissions (52%) exceeded elective admissions in the elderly. Forty-four (80%) of the 55 deaths in the elderly group were admitted as emergencies compared to elective admissions (p < 0.001). There were 11 deaths among the 296 elective admissions (3.7%) but 44 deaths among the 327 emergency admissions (13.5%), a significant difference in mortality rates (p < 0.001). Overall, the death rate for males was higher. Cancer was the commonest admission diagnosis (21%) and that amongst mortalities. Steps to improve the opportunities for earlier admission and optimization of care of elderly surgical patients would not only benefit them but would be an important step towards a more efficient use of already scarce resources.

Integrin expression and survival in human breast cancer

BACKGROUND

Integrin cell adhesion molecules are fundamental to numerous cellular functions including anchorage, differentiation and proliferation. Reduced expression of certain alpha and beta integrin subunits in primary breast cancer cells has been correlated with increased invasion and metastasis. Conversely, over-expression of the alpha6 subunit has been linked to poorer survival. The objective of this study was to measure the survival of a cohort with breast carcinoma in relation to integrin expression and to evaluate their potential as prognostic indicators.

METHOD

Integrin expression on samples from 99 consecutive patients with breast cancer was assayed using monoclonal antibodies to the subunits alpha(1,2,3,6,V) and beta(1,3,4,5). This cohort has now been followed prospectively for almost five years allowing for early assessment of survival in relation to integrin expression.

RESULTS

Whilst analysis of the data confirmed the relation of survival to proven predictors of tumour grade, tumour size and vascular invasion, statistical significance was not demonstrated with regard to both lymph node status and all integrin subunits studied.

CONCLUSION

Previous research correlating certain integrin subunits with survival has not been confirmed in this study. Despite proven molecular importance in tumour cell adhesion, invasion and metastasis, integrin expression would appear not to translate clinically as independent indicators of prognosis, at least in the short-term.

Cancer of the colon and rectum in a Jamaican population: diagnostic implications of the changing frequency and subsite distribution

The aim of this study was to examine the clinical and pathological characteristics of colorectal cancer in Jamaica, to determine whether there was a change in the anatomic distribution and clinical presentation and to discuss the options for diagnosis and management. A comprehensive retrospective review of patients newly diagnosed with colorectal carcinoma was conducted at The University Hospital of the West Indies by reviewing both patient records and pathological data. These data were compared with previous reports of patients with colorectal cancer seen in Jamaica. One hundred and forty-seven patients were studied There were 85 females and 62 males with a female to male ratio of 1.37:1. The median age was 65.5 years (range 19 to 94 years). The predominant symptoms were abdominal pain in 91 patients, change in bowel habit in 77 patients and rectal bleeding in 74 patients. Sixty patients presented with weight loss and 28 with a rectal mass. The most common tumours were right-sided colonic cancers in 42 patients (28.5%) followed by sigmoid colon in 30 (20.4%) rectum in 34 (23.1%) and left and transverse colon accounting for 16 and 10 cases respectively. Most of the tumours were well or moderately differentiated adenocarcinomas. Only eight patients presented with Dukes' A disease, 50 with Dukes'B, 53 with Dukes'C disease and 34 with advanced disease. The findings showed that sigmoid and rectal tumours accounted for 43.5% of cancers. The colon/rectum ratio in this series was 3.3:1 indicating a significant proximal shift of colorectal cancers in this population in keeping with recent reports. The results of the current study suggest that the sub-site location of colorectal cancers seen is similar to that reported in high incidence countries such as the United States of America and parts of Europe but differs from the African continent which has a high proportion of rectal tumours. This right-sided preponderance also differs from previous studies in Jamaica, which report a higher incidence of rectal lesions The detection of early colorectal carcinoma will require screening at a stage when the disease is asymptomatic in order to improve the chance for cure. The data presented here imply that screening programmes should allow evaluation of the entire colon rather than the distal 25 cm.

Phyllodes tumour of the breast: a retrospective analysis of 30 cases

Phyllodes tumour (PT) is a rare neoplasm of the female breast that resembles fibroadenoma but occurs in an older age group. We retrospectively reviewed the medical records of 30 women who were treated for phyllodes tumour in our centre. Histological examination was performed by an experienced breast pathologist in all cases and tumours were classified as benign, border line malignant or malignant according to standard histological criteria. The mean age at diagnosis was 49 years (range: 19-80 years). Twenty-one (70%) of 30 tumours were benign and 9 (30%) were malignant (n=7) or borderline malignant (n=2). The mean tumour size was 46 mm (range: 20-100 mm). The final microscopic margins contained tumour in 13 (43%) of 30 cases and were free of tumour in 17 (57%) of 30 patients. After a median follow-up period of 6 years (range: 6 months-20 years), the tumour recurred locally in 5 (17%) patients. One patient had six local recurrences over an 18-year period. Local recurrences were more frequently observed in patients with malignant tumours compared with those with benign lesions (33% versus 10%). However, this association failed to reach statistical significance. There was no association between local recurrence, patient age, tumour size or positive microscopic margins. There was one death (3%) associated with a completely excised malignant tumour. The present study suggests that histological type and margins do not accurately predict the clinical course of PT and that there is a need to identify novel biological markers that more accurately predict the behaviour of this rare neoplasm.

Hot-water bottle induced thermal injury of the skin overlying Becker's mammary prosthesis

We report a case of a full thickness burn to the breast following the application of a hot-water bottle to the insensate skin overlying a mammary prosthesis.

Integrin beta1-mediated invasion of human breast cancer cells: an ex vivo assay for invasiveness

BACKGROUND

The integrin cell adhesion molecule (CAM) family is intimately involved in cell adhesion and invasion through tissue basement membranes (BM). As a consequence of the short survival of patient-derived human breast cancer cells, the invasion of such cells has not been previously reported. Our aims were to optimise culture conditions in order to establish a reliable invasion assay and to assess the effect on invasion of perturbations of the beta1 integrin receptors.

METHODS

Pure suspensions of viable carcinoma cells were isolated immunomagnetically from human breast cancer (HBC) samples and introduced onto a replicated glycoprotein BM within an invasion chamber. Degree of invasion was compared to both beta1 integrin expression and tumour grade. Additionally, the effect of beta1 receptor blockade with monoclonal antibody (mAb) was assessed.

RESULTS

Invasion was significantly greater in grade II than grade III tumour cells (p=0.0012). Anti-integrin beta1 monoclonal antibody inhibited cancer cell invasion by a mean of 83.96 +/- 4.80%.

CONCLUSIONS

The invasion assay confirmed the fundamental importance of beta1 integrin receptors to transmembrane invasion and reports this for the first time in cells isolated from primary breast cancer. It represents a potent research tool for investigation of the tumour biology of invasion at the integrin beta1-mediated cell-basement membrane interface. This assay has the potential clinical application of improved stratification of patients for adjuvant therapy on a more individual basis than currently available.

Abdominal ganglioneuromas in adults

Ganglioneuromas are rare tumours of the parasympathetic nervous system. Their definitive diagnosis is made on histological examination. When they arise from the adrenal medulla, their assessment and management are the same as those of other adrenal tumours. We here report 3 cases of ganglioneuromas highlighting important points regarding the radiological assessment, management, decision making and surgical approaches.

Giant mediastinal parathyroid adenoma with hypercalcemia

Parathyroid disease is uncommon, but when found it is always of interest to the physician. Most patients with parathyroid disease also have hypercalcemia. Benign adenomatous disease is the most frequent surgical parathyroid lesion seen. Most of these lesions occur in the neck and are usually <2 cm in diameter. We report the case of a 50-year-old patient with familial neurofibromatosis, a serum calcium of 19 mg/dl, nephrocalcinosis, and renal failure. Evaluation revealed a large (5.7 x 4.5 x 2.9-cm) mediastinal adenoma. At resection, the tumor weighed 39.5 g. Symptomatology rapidly improved postoperatively.

How significant is detection of ductal carcinoma in situ in a breast screening programme?

PURPOSE

To compare the histological grades of screen detected and non-screen detected ductal carcinoma in situ (DCIS) and to identify any differences that might support the contention that DCIS found by breast screening represents an over-diagnosis. The aim was also to establish whether any particular mammographic features of DCIS can be used to predict tumour grade reliably.

MATERIALS AND METHODS

Biopsy proven cases of DCIS (n=153) were reviewed with respect to grade and subdivided into high, intermediate and low grades using the Van Nuys classification. A more aggressive subset of DCIS (microinvasive and interval cancers) were similarly analysed. Mammograms were reviewed with regard to abnormal features and distribution, and the appearances correlated with grade.

RESULTS

Fifty-four percent (53/98) of screen detected and 62% (34/52) of non-screen detected DCIS were high grade. The rest were equally intermediate and low grade, with no statistical difference between the two groups. Eighty-four percent of the aggressive subset of tumours were high grade. Micro-calcification was present in 90% and in 10% there were soft tissue changes alone. Seventy-six percent of linear branching calcification was associated with high grade DCIS. Only 13% of high grade DCIS demonstrated punctate micro-calcification; however, 38% of cases of punctate micro-calfication were associated with high grade tumours and there was a great deal of overlap between the groups.

CONCLUSION

Most cases of DCIS in both screen and non-screen detected groups were high grade. Only one in five was low grade. Analysis of the aggressive subgroup underlines the significance of high grade DCIS. Mammographic patterns are not always reliable in the prediction of tumour grade. The detection of DCIS in screening programmes is important and should not be regarded as over-diagnosis.

The tissue distribution of the mRNA of ghrelin and subtypes of its receptor, GHS-R, in humans

Ghrelin is a novel growth hormone-releasing peptide, originally identified in the rat stomach as the endogenous ligand for the growth hormone secretagogue-receptor (GHS-R1a). Ghrelin is involved in the regulation of GH release, but it has recently been suggested that ghrelin may have other actions, including effects on appetite, carbohydrate metabolism, heart, kidney, pancreas, gonads, and cell proliferation. The distribution of ghrelin, its functional receptor (type 1a) and the unspliced, non-functional GHS-R type 1b mRNA expression was investigated in various human tissues using classical and real-time reverse transcription and polymerase chain reaction. GHS-R1a was predominantly expressed in the pituitary and at much lower levels in the thyroid gland, pancreas, spleen, myocardium and adrenal gland. In contrast, ghrelin was found in the stomach, other parts of the gut and, indeed, in all the tissues studied (adrenal gland, atrium, breast, buccal mucosa, esophagus, Fallopian tube, fat tissue, gall bladder, human lymphocytes, ileum, kidney, left colon, liver, lung, lymph node, muscle, muscle, myocardium, ovary, pancreas, pituitary, placenta, prostate, right colon, skin, spleen, testis, thyroid, and vein). GHS-R1b expression was also widespread in all tissues studied. The significance of the widespread tissue distribution of ghrelin remains to be determined. These data suggest that ghrelin might have widespread physiological effects via different, partly unidentified, subtypes of the GHS-R in endocrine and non-endocrine tissues.

Is radiotherapy needed after breast conservation for small invasive breast cancers?

AIMS

The purpose of this study was to determine the rate of local recurrence in patients with small invasive breast cancers (<1 cm) who had been treated with breast-conserving surgery either with (group 1) or without (group 2) adjuvant radiotherapy.

METHODS

This is a retrospective study of 110 patients with an invasive breast cancer less than 1 cm in size, treated in our centre by breast-conserving surgery. Parameters examined included age at and mode of presentation, histopathological features, adjuvant therapy, length of follow-up and outcome in terms of local recurrence rate and death.

RESULTS

In group 1 there were 59 women of median age 57 (38-80) years. The median tumour size was 9 (1-10) mm and median follow-up was 74 (15-110) months. There were no local recurrences. In group 2 the median age at presentation was 59 (48-81) years. The median tumour size was 7 (2-10) mm and median follow-up was 47 (14-93) months. There were three non-breast-cancer related deaths and three local recurrences (6%).

CONCLUSIONS

A local recurrence rate of 6% at almost 4 years median follow-up suggests that it may be possible to avoid adjuvant radiotherapy in a subgroup of largely screen-detected, node-negative patients with invasive tumours less than 1 cm, in whom adequate local excision is performed. Further follow-up is required to substantiate this.

Infiltrating fibromatosis of the breast: a potential pitfall

Mammary fibromatosis is a rare condition. It presents a big dilemma for the clinician, because it mimics breast cancer clinically, radiologically and sometimes cytologically. We report a case of fibromatosis of the breast and highlight the diagnostic difficulties and management.

The tissue distribution of the mRNA of ghrelin and subtypes of its receptor, GHS-R, in humans

Ghrelin is a novel growth hormone-releasing peptide, originally identified in the rat stomach as the endogenous ligand for the growth hormone secretagogue-receptor (GHS-R1a). Ghrelin is involved in the regulation of GH release, but it has recently been suggested that ghrelin may have other actions, including effects on appetite, carbohydrate metabolism, heart, kidney, pancreas, gonads, and cell proliferation. The distribution of ghrelin, its functional receptor (type 1a) and the unspliced, non-functional GHS-R type 1b mRNA expression was investigated in various human tissues using classical and real-time reverse transcription and polymerase chain reaction. GHS-R1a was predominantly expressed in the pituitary and at much lower levels in the thyroid gland, pancreas, spleen, myocardium and adrenal gland. In contrast, ghrelin was found in the stomach, other parts of the gut and, indeed, in all the tissues studied (adrenal gland, atrium, breast, buccal mucosa, esophagus, Fallopian tube, fat tissue, gall bladder, human lymphocytes, ileum, kidney, left colon, liver, lung, lymph node, muscle, muscle, myocardium, ovary, pancreas, pituitary, placenta, prostate, right colon, skin, spleen, testis, thyroid, and vein). GHS-R1b expression was also widespread in all tissues studied. The significance of the widespread tissue distribution of ghrelin remains to be determined. These data suggest that ghrelin might have widespread physiological effects via different, partly unidentified, subtypes of the GHS-R in endocrine and non-endocrine tissues.

Axillary node status in breast cancer patients prior to surgery by imaging with Tc-99m humanised anti-PEM monoclonal antibody, hHMFG1

In early breast cancer axillary nodes are usually impalpable and over 50% of such patients may have an axillary clearance when no nodes are involved. This work identifies axillary node status by imaging with a Tc-99m radiolabelled anti-Polymorphic Epithelial Mucin, humanised monoclonal antibody (human milk fat globule 1), prior to surgery in 30 patients. Change detection analysis of image data with probability mapping is undertaken. A specificity of 93% and positive predictive value of 92% (both 100% if a second cancer in the axilla with negative nodes is considered) were found. A strategy for combining negative imaging with the sentinel node procedure is presented.

The outcome of endometrial carcinoma surveillance by ultrasound scan in women at risk of hereditary nonpolyposis colorectal carcinoma and familial colorectal carcinoma

BACKGROUND

Endometrial carcinoma is the most common extracolonic malignancy associated with hereditary nonpolyposis colorectal carcinoma syndrome (HNPCC). The risk of endometrial carcinoma in HNPCC mutation carriers is approximately ten times that of the general population, and endometrial ultrasound surveillance to detect early cancer in asymptomatic individuals is recommended by the International Collaborative Group on HNPCC. There is little, if any, published data addressing the effectiveness of surveillance in HNPCC and familial colorectal carcinoma.

METHODS

The outcomes of endometrial carcinoma surveillance scans were collected from the St Mark's Hospital Imperial Cancer Research Fund Family Cancer Clinic in the UK and the Netherlands Foundation for the Detection of Hereditary Tumors. Two hundred ninety two women from HNPCC (171) or HNPCC-like (98) families between the ages of 25-65 years were offered pelvic ultrasound surveillance scans for a period of up to 13 years.

RESULTS

Results were available from 269 women. The study period included a total of 825.7 years of risk. Two cases of endometrial carcinoma were reported. Neither case was detected by surveillance scanning. Both cases presented at an early stage with symptoms and were subsequently cured.

CONCLUSIONS

Endometrial carcinoma surveillance in hereditary colorectal carcinoma may not offer obvious clinical benefits.

Concomitant off-pump myocardial revascularization and pheochromocytoma resection

Surgical management of patients with coexisting ischemic heart disease and pheochromocytoma remains challenging. We present one such case in which hybrid myocardial revascularization (angioplasty with stenting and off-pump coronary artery bypass grafting) and resection of pheochromocytoma were undertaken. Unusual features included simultaneous coronary artery surgery and tumor resection and, in particular, coronary artery surgery being performed without cardiopulmonary bypass.

Improved rat model for cerebral vasospasm studies

While the rat has been used extensively in subarachnoid hemorrhage (SAH)-cerebral vasospasm studies, concerns exist whether this animal represents a usable model because its time course and pattern of cerebral vasospasm following SAH is not comparable to that observed in man. At present, our knowledge of the rat model is based almost exclusively on studies using a 'single hemorrhage' method. Since there is a positive correlation between severity of cerebral vasospasm, and volume of subarachnoid blood, an obvious question is whether the rat will show modifications in vascular responses when insulted by a second SAH. Here, an SAH was produced in rats using a 'double hemorrhage' method. Following SAH, cerebral arteries showed pathological alterations, significant decreases in luminal perimeter, and increases in arterial wall thickness, over a 7-day post-SAH period. The above vascular features are considered to be indicative of cerebral vasospasm and their presence over a 7-day post-SAH period represents a significant time extension when compared to a single hemorrhage. These modified vascular responses made the double hemorrhaged rat a much-improved animal model.

Audit of a one-stop breast clinic--revisited

BACKGROUND

A one-stop diagnostic service has been available for women with symptomatic breast disease at St Bartholomew's Hospital for 5 years and was originally audited in May 1993. In re-auditing the one-stop service our aim was to see if our practice had improved following the original audit and to look at the impact which these changes in practice had made to the service offered to the patient.

METHODS

A prospective audit of 4 consecutive clinics was undertaken in November 1997. A total of 300 patients (59 new and 241 follow up) were seen in clinic in this time. The primary outcome measure concerned the completeness of triple assessment in the 40 patients who required one stop investigations, including mammography, ultrasonography and fine-needle aspiration cytology. In addition, mean time to initial consultation and level of awareness of the one-stop facility and its attendant time delay were measured.

RESULTS

Of the 300 clinic attendees 40 (38 new, 2 follow-up) had one-stop investigations. As a result of the one-stop service being in practice, 36 patients (90%) had a definitive management decision made at their first outpatient visit. Of these 2 were symptomatic cancers, forming 5% of the workload. A total of 86% of the workload was benign. Four patients (10%) had equivocal results. The mean waiting time from designated appointment until surgical consultation was 36.7 minutes and was disappointingly unchanged from that of the previous audit. However this does not take into account the significant reduction in staffing levels which has occurred between the two periods of assessment.

CONCLUSIONS

The initial audit identified a significant problem with time constraints, necessitating that a large number of patients with carcinomas return at a later date for further investigations. Booking only new patients at the beginning of clinic has provided a solution. Disappointingly, our figures do not show a significant improvement in mean waiting time compared with the previous audit, despite allowing GPs greater access of referral. Encouragingly, we have been able to maintain a similar standard of provision of care despite lower staffing levels and to implement the changes suggested by the original audit (thereby closing the audit loop).

Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurements

OBJECTIVE

To determine the accuracy of a technique using capnography to prevent inadvertent placement of small-bore feeding tubes and Salem sump tubes into the lungs.

SETTING

Twelve-bed medical intensive care unit (MICU) in a 557-bed teaching hospital.

PATIENTS

A total of 25 ventilated adult MICU patients were studied-5 in phase 1 and 20 in phase 2.

DESIGN

Phase 1 tested the ability of the end-tidal CO2 (ETCO2) monitor to detect flow (and thus accurately detect CO2) through small-bore feeding tubes. A small-bore feeding tube, with stylet in place, was placed 5 cm through the top of the tracheostomy tube ventilator adapter in five consecutive patients. The distal end of the feeding tube was attached to the ETCO2 monitor. The ETCO2 level and waveform were assessed and recorded. Because CO2 waveforms were successfully detected, a convenience sample of 20 adult MICU patients who were having feeding tubes placed (13 Salem sump tubes, 7 small-bore feeding tubes) was then studied. The technique consisted of attaching the ETCO2 monitor to the tubes and observing the ETCO2 waveform throughout placement.

RESULTS

The study hypothesis was supported. Of the seven small-bore feeding tubes tested, all were successfully placed on initial insertion. Placement was confirmed by absence of an ETCO2 waveform and by radiograph. Of the 13 Salem sump tubes, 9 were placed successfully on first attempt and confirmed by absence of CO2 and by air bolus and aspiration of stomach contents. ETCO2 waveforms were detected with insertion of four of the Salem sump tubes; the tubes were immediately withdrawn, and placement was reattempted until successful.

CONCLUSIONS

The technique described is a simple, cost-effective method of assuring accurate gastric tube placement in critically ill patients.

The gene fimbriata interacts non-cell autonomously with floral regulatory genes

In Antirrhinum majus, one proposed role of the gene fimbriata (fim) is as a mediator between the floral meristem identify gene floricaula (flo) and floral organ identity genes such as deficiens (def) and plena (ple). The mechanism of fim activity is probably unique as, while the other genes in the hierarchy are thought to be transcription factors, fim is thought to target proteins to a ubiquitin-mediated destruction pathway. Both flo and def have been shown to act non-cell autonomously. We tested the hypotheses that (i) fim acts in a non-cell autonomous manner; and (ii) non-cell autonomy of flo might be through activation and subsequent non-cell autonomous activity of fim. Plants bearing an unstable fim allele were monitored for revertant shoots. Analysis of fim RNA expression in plants derived from revertant shoots, and segregation of revertant phenotype in progeny from revertant plants, indicated that all were periclinal chimeras with wild-type fim expression only in subepidermal layers. Despite the absence of fim in the epidermal layer, expression of downstream genes was normal, suggesting non-cell autonomous activity of fim. Subsequently, we tested the hypothesis that fim is the mediator of flo non-cell autonomy by examining fim expression in flo periclinal chimeras. In these chimeras, fim is activated in cells where flo is not expressed, indicating that fim cannot be the sole mediator of flo non-cell autonomy.

Predictors of positive margins after local excision of ductal carcinoma in situ

BACKGROUND

This study aimed to examine the association between clinicopathologic parameters and positive margins in women with ductal carcinoma in situ (DCIS) treated by breast-conserving surgery (BCS).

METHODS

We retrospectively reviewed the clinical, radiologic, and pathologic data of 100 women who had undergone BCS for DCIS in our center.

RESULTS

Sixty-seven percent of patients presented via breast screening and 55% of all cases were diagnosed preoperatively on fine needle aspiration cytology ([FNAC] ie, C5). Overall, 45% of patients had clear margins after initial local excision. Positive margins showed a nonsignificant trend of association with distribution of microcalcifications (MCC), nonconsultant operating surgeon, inconclusive preoperative FNAC, presence of necrosis, and low specimen weight. There was a highly significant association between low grade DCIS (P = 0.003) and incomplete excision. There was no significant association with age, associated invasive focus, morphology of MCC, or with mode of presentation.

CONCLUSION

Positive margins after local excision of DCIS are significantly associated with low nuclear grade, and preoperative determination of nuclear grade by core biopsy may have surgical implications.

Does intraductal breast cancer spread in a segmental distribution? An analysis of residual tumour burden following segmental mastectomy using tumour bed biopsies

INTRODUCTION

Breast-conserving surgery for early breast cancer is now routinely used as an alternative to mastectomy. Despite post-operative radiotherapy, early local recurrence of tumour remains a concern. It has been reported that invasive and in-situ ductal carcinoma spread locally through the ductal tree in a segmental distribution, however, there is no consensus as to the best surgical method to maximize tumour clearance whilst leaving a good cosmetic result.

AIM

We aimed to measure the effectiveness of segmental mastectomy (excision of tumour plus associated segmental ductal tissue) in the clearance of different tumour types. Bed biopsy of the excision cavity was employed to assess the rate of incomplete excision or the multifocality of certain breast cancers.

METHODS

One hundred and one patients with breast cancers underwent segmental mastectomy and cavity bed biopsies. Specimens were assessed for tumour type and completeness of excision. An excision of the cancer was considered incomplete if the margins were involved or if any of the bed biopsies showed residual or multifocal tumour.

RESULTS

A total of 24 patients had incomplete tumour excision. Invasive ductal carcinoma was more likely to be completely excised by segmental mastectomy than invasive lobular carcinoma (P<0.05). Incomplete excision was associated with multifocality and the presence of extensive DCIS. The report of clear pathological margins was significantly more likely to be accurate, as measured by negative bed biopsies, in invasive ductal carcinoma when compared to invasive lobular carcinoma (P<0.05).

CONCLUSION

These results support the concept that ductal carcinomas spread locally in a segmental fashion. Patients with invasive ductal carcinomas are more likely to benefit from breast conserving surgery that is tailored to include the associated ductal tissue, in a segmental fashioned excision.

Choroidal metastasis-the initial presentation of breast carcinoma

We report a rare case of a breast carcinoma metastasis in the choroid presenting as the initial symptom of the primary disease.

Education provision for surgical senior house officers

The provision of formal education in surgical SHO training is a requirement for posts to be accredited by postgraduate deans. We carried out a questionnaire survey of surgical SHOs attending a Royal College of Surgeons of England study day to quantify the amount of time given to formal education and supervised operating. We found that 79% of SHOs at district general hospitals and 87.5% at teaching hospitals were provided with a formal education programme. Of these SHOs, 77% were able to attend the teaching on a regular basis. In an average week, 8% of SHOs received no supervised operating experience and 37% had no operations supervised by a consultant. These results suggest that many hospitals fall short of the accepted guidelines on basic surgical training. This issue must be addressed by the Royal Colleges.

The fall, recovery, orbit, and composition of the Tagish Lake meteorite: a new type of carbonaceous chondrite

The preatmospheric mass of the Tagish Lake meteoroid was about 200,000 kilograms. Its calculated orbit indicates affinity to the Apollo asteroids with a semimajor axis in the middle of the asteroid belt, consistent with a linkage to low-albedo C, D, and P type asteroids. The mineralogy, oxygen isotope, and bulk chemical composition of recovered samples of the Tagish Lake meteorite are intermediate between CM and CI meteorites. These data suggest that the Tagish Lake meteorite may be one of the most primitive solar system materials yet studied.

Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery

Antibiotic prophylaxis has been used to good effect in the prevention of post-operative wound infections in patients undergoing gastrointestinal operations. We have assessed the use of a single dose of intravenous antibiotic (Augmentin 1.2 g), given with induction of anaesthesia as prophylaxis, against post-operative wound infection in women undergoing clean, elective breast surgery. Three hundred and thirty-four patients were recruited. Of the 164 receiving antibiotic prophylaxis 29 (17.7%) had wound infections compared with 32 (18.8%) in the placebo group (P=0.79). There were no significant differences in any other post-operative infective complications. Antibiotic prophylaxis is probably not required in clean, elective breast surgery.

Is dissection of the internerve tissue during axillary lymphadenectomy for breast cancer necessary?

AIMS

The study evaluates the necessity of dissecting the tissue between the long thoracic and thoracodorsal nerves (internerve tissue) during axillary dissection in breast cancer surgery. By reviewing the lymph node yield and the metastatic rate in the internerve tissue, we examine whether the internerve tissue could be left in situ to minimize the risk of nerve injury.

METHODS

A prospective study was conducted on 30 consecutive women undergoing axillary lymphadenectomy for breast cancer. The internerve tissue remaining was excised separately after a routine axillary dissection and was examined by the same pathologist.

RESULTS

Twenty (67%) of 30 internerve specimens contained lymph nodes; the internerve nodes were positive for carcinoma in three cases (10%). In one case the lymph node in the internerve tissue was the only metastatic node in the axilla.

CONCLUSIONS

There is a significant incidence of lymph nodes (67%) and axillary node metastases (10%) in the tissue lying between the long thoracic and thoracodorsal nerves. Therefore excision of this internerve tissue is strongly recommended in order to optimize decision making regarding adjuvant treatment and oucome in women with operable breast cancer.

Integrin beta1 upregulation in MCF-7 breast cancer cells by angiotensin II

AIMS

Integrins are a major family of cell adhesion molecules whose function is perturbed in tumour invasion and metastasis. Angiotensin II (A II) is well-known in the systemic control of water and electrolyte homeostasis and haemodynamics, but recent evidence points to an additional local renin-angiotensin system (RAS) with possible long-term trophic effects including carcinogenesis.

METHODS

The effect of angiotensin II on MCF-7 human breast cancer cell line integrin expression was evaluated with immunocytochemistry (ICC) and immunoprecipitation (IP).

RESULTS

The experiments demonstrated a 1.40 +/- 0.14-fold increase in beta, integrin expression on MCF-7 cells following treatment with A II.

CONCLUSIONS

These findings report the first evidence of an association between integrins and the RAS in human breast cancer cells and suggest a novel research avenue for future anti-metastatic strategies, through the manipulation of cell adhesion mechanics, in the management of invasive human breast cancer.

The challenge of designing a database for auditing surgical in-patients

Surgical audit is imperative in modern practice, particularly in the developing world where resources are limited and efficient allocation important. The structure, process and outcome of surgical care can be determined for quality assurance or for research. Improved efficiency and reduction of morbidity and mortality are additional goals which may be accomplished. However, computerization, medical staff cooperation and the availability of dedicated staff are among the hurdles which may be encountered. We report the challenge of designing and establishing a database for auditing surgical inpatients in a developing country and the difficulties which were encountered.

The duration of human ocular Chlamydia trachomatis infection is age dependent

We studied the relationship between age and prevalence, duration and incidence of clinical and laboratory evidence of ocular Chlamydia trachomatis infection in a cohort of Gambian subjects examined bi-weekly for 6 months. The duration of disease and infection, estimated by stratified survival analysis, proportional hazards regression and Weibull modelling, was markedly age-dependent. The estimated median duration of disease was 13.2 weeks in 0-4-year-old subjects and 1.7 weeks in those age 15 and over. Adjustment for multiple infections, and for missing observations did not alter this trend. The cumulative incidence rate of disease was reduced threefold with age. More rapid disease resolution is the main source of reduction in prevalence of active trachoma and ocular C. trachomatis infection with age; disease incidence was reduced to a lesser extent. This age-dependent resolution may be effected by adaptive cellular immune mechanisms. Mechanisms responsible for natural immunity should receive appropriate emphasis in vaccine design.

Randomized double-blind study of the clinical duration and efficacy of Nesacaine-MPF 2% and 3% in peribulbar anesthesia

PURPOSE

To compare 2 commercially available concentrations of Nesacaine-MPF (2-chloroprocaine) to determine the time to onset of adequate motor blockade, the quality of surgical anesthesia, and the duration of motor blockade in the extraocular muscles after peribulbar anesthesia for cataract surgery.

SETTING

Tampa Eye and Specialty Surgery Center, Tampa, Florida, USA.

METHODS

This double-blind, randomized, single-center study comprised 40 patients scheduled to receive peribulbar anesthesia before cataract surgery. Patients were given 5 mL of Nesacaine-MPF 2% or 3% before surgery. Beginning at the end of the injection, assessments of ocular and eyelid movement were made every 2 minutes until adequate motor blockade was achieved or 25 minutes elapsed. Ocular assessments were made immediately after completion of surgery, 60 minutes after the end of the initial injection, and at 15 minute intervals thereafter until full recovery. Assessments of the quality of anesthesia achieved by the patient during surgery were made by the surgeon.

RESULTS

The 3% solution provided significantly faster onset of surgical anesthesia than the 2% solution (mean 3.9 minutes +/- 2.2 [SD] versus 6.0 +/- 3.6 minutes) (P = .02) but also required more time for recovery from anesthesia (98.9 +/- 18.7 minutes versus 84.8 +/- 20.6 minutes) (P = .02). All patients had adequate surgical anesthesia. Duration of ocular motor function was brief enough so that all patients could be sent home without an eye patch. Both concentrations were safe for use in this procedure.

CONCLUSION

Both Nesacaine-MPF 2% and 3% produced safe and effective peribulbar anesthesia in all patients; however, the 3% solution provided better duration of clinical anesthesia.