The investigation and management of unilateral nipple discharge

INTRODUCTION

Between 16,000 and 48,000 women are estimated to present to UK breast clinics with nipple discharge each year. The incidence of malignancy in these women is 2.7-24.2%. Currently, there is no consensus on the best way to investigate and manage these women. The aim of this study was to assess the rate of malignancy in women presenting with unilateral nipple discharge, and to evaluate the role of examination, imaging and cytology in reliably predicting outcome.

METHODS

Breast units were asked to prospectively collect data on all new patients with unilateral nipple discharge. Data collected included discharge colour, whether it was uniductal or multiductal, examination and imaging findings, cytology results and outcome.

RESULTS

Complete datasets were submitted by 5 units on 228 patients. The incidence of malignancy was 4.4%. Clinical examination was valuable in detecting malignancy and multiductal discharge was not related to malignancy. The positive predictive value for detecting malignancy for an abnormality found on mammography was 53.5% and for ultrasonography, it was 65.2%. The role of cytology in detecting malignancy was inconclusive with positive predictive values of the presence of red blood cells and epithelial cells at 6.1% and 10.7% respectively.

CONCLUSIONS

A large number of women are investigated for nipple discharge (with huge resource implications) but there is little reliable evidence on the best way to investigate and manage these patients. A larger study is needed to evaluate the role of investigations in nipple discharge to produce guidelines on optimal management.

Extended Search for the Invisible Axion with the Axion Dark Matter Experiment

This Letter reports on a cavity haloscope search for dark matter axions in the Galactic halo in the mass range 2.81-3.31  μeV. This search utilizes the combination of a low-noise Josephson parametric amplifier and a large-cavity haloscope to achieve unprecedented sensitivity across this mass range. This search excludes the full range of axion-photon coupling values predicted in benchmark models of the invisible axion that solve the strong CP problem of quantum chromodynamics.

Valorisation of waste galvanizing dross: Emphasis on recovery of zinc with zero effluent strategy

Galvanizing dross-a waste product from steel industries but it can be a potential secondary resource for zinc through urban mining and recycling. In this concern, a novel and scalable recycling route with zero effluent strategy is developed for the recovery of zinc from galvanizing dross as high grade zinc salts along with value-added products through hydrometallurgical processing. In particular, as-such dross block was leached in 9% (v/v) sulphuric acid medium, wherein strong hydrogen gas effervescence results in alleviating the pulverization and stirring requirements; which are material and energy intensive. Leached zinc is purified and recovered as high purity ZnSO₄.(H₂O/7H₂O) and Zn₃(PO₄)₂.4H₂O through controlled crystallization and phosphate precipitation respectively; which find application in fertilizers and anti-corrosive paints. Temperature difference method was opted for the crystallization of zinc sulfate salts, wherein 70 °C and 30 °C were found to be stability range of crystallization of ZnSO₄.H₂O and ZnSO₄.7H₂O respectively. ZnSO₄-H₂O phase diagram is developed using Factsage calculations to corroborate crystallization study. Moreover, exhaustive thermodynamic analysis of Zn²⁺-PO₄^3--H₂O system at 303 K on precipitation of zinc phosphate using di-ammonium hydrogen phosphate (80-240 g/L) is conducted and the results reveal that with increasing pH (3-6), intermediate hydrogen phosphate species (H₃PO₄, H₂PO₄^- and H₂PO₄^2-) decompose to produce stable PO₄^3- ions leading to zinc phosphate precipitation. Impurity like Iron and supernatant solution left after crystallization are recovered as hydrated iron-calcium sulfate mixture and ammonium sulfate salt respectively. This explored route is economical and easily adaptable with zero effluents, therefore, transcends serious challenges in terms of energy requirement, scale-up and effluent generation.

Multifocal and multicentric breast cancer, is it time to think again?

Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.

Genetic influences on eight psychiatric disorders based on family data of 4 408 646 full and half-siblings, and genetic data of 333 748 cases and controls

BACKGROUND

Most studies underline the contribution of heritable factors for psychiatric disorders. However, heritability estimates depend on the population under study, diagnostic instruments, and study designs that each has its inherent assumptions, strengths, and biases. We aim to test the homogeneity in heritability estimates between two powerful, and state of the art study designs for eight psychiatric disorders.

METHODS

We assessed heritability based on data of Swedish siblings (N = 4 408 646 full and maternal half-siblings), and based on summary data of eight samples with measured genotypes (N = 125 533 cases and 208 215 controls). All data were based on standard diagnostic criteria. Eight psychiatric disorders were studied: (1) alcohol dependence (AD), (2) anorexia nervosa, (3) attention deficit/hyperactivity disorder (ADHD), (4) autism spectrum disorder, (5) bipolar disorder, (6) major depressive disorder, (7) obsessive-compulsive disorder (OCD), and (8) schizophrenia.

RESULTS

Heritability estimates from sibling data varied from 0.30 for Major Depression to 0.80 for ADHD. The estimates based on the measured genotypes were lower, ranging from 0.10 for AD to 0.28 for OCD, but were significant, and correlated positively (0.19) with national sibling-based estimates. When removing OCD from the data the correlation increased to 0.50.

CONCLUSIONS

Given the unique character of each study design, the convergent findings for these eight psychiatric conditions suggest that heritability estimates are robust across different methods. The findings also highlight large differences in genetic and environmental influences between psychiatric disorders, providing future directions for etiological psychiatric research.

High fructose-induced metabolic changes enhance inflammation in human dendritic cells

Dendritic cells (DCs) are critical antigen-presenting cells which are the initiators and regulators of the immune response. Numerous studies support the idea that dietary sugars influence DC functions. Increased consumption of fructose has been thought to be the leading cause of metabolic disorders. Although evidence supports their association with immune dysfunction, the specific mechanisms are not well understood. Fructose is one of the main dietary sugars in our diet. Therefore, here we compared the effect of fructose and glucose on the functions of human DCs. High levels of D-fructose compared to D-glucose led to activation of DCs in vitro by promoting interleukin (IL)-6 and IL-1β production. Moreover, fructose exposed DCs also induced interferon (IFN)-γ secretion from T cells. Proinflammatory response of DCs in high fructose environment was found to be independent of the major known metabolic regulators or glycolytic control. Instead, DC activation on acute exposure to fructose was via activation of receptor for advanced glycation end product (RAGE) in response to increased accumulation of advanced glycation end products (AGE). However, chronic exposure of DCs to high fructose environment induced a shift towards glycolysis compared to glucose cultured DCs. Further investigations revealed that the AGEs formed by fructose induced increased levels of inflammatory cytokines in DCs compared to AGEs from glucose. In summary, understanding the link between metabolic changes and fructose-induced DC activation compared to glucose has broad implications for immune dysfunction associated with metabolic disorders.

Graded Epidural Anaesthesia for Lower Segment Cesarean in a Parturient with Very Low Ejection Fraction

Dilated cardiomyopathy is characterized by left or biventricular dilatation with impaired ventricular contractility. It is associated with systolic dysfunction with decreased left ventricular ejection fraction and congestive progressive heart failure. Anaesthetic management of such condition is very challenging and requires highest level of expertise, strategy and precaution. We present such a case of dilated cardiomyopathy with a very low ejection fraction of 12% who underwent lower segment cesarean section under epidural anaesthesia with successful outcome.

Piezoelectrically Tuned Multimode Cavity Search for Axion Dark Matter

The μeV axion is a well-motivated extension to the standard model. The Axion Dark Matter eXperiment (ADMX) collaboration seeks to discover this particle by looking for the resonant conversion of dark-matter axions to microwave photons in a strong magnetic field. In this Letter, we report results from a pathfinder experiment, the ADMX "Sidecar," which is designed to pave the way for future, higher mass, searches. This testbed experiment lives inside of and operates in tandem with the main ADMX experiment. The Sidecar experiment excludes masses in three widely spaced frequency ranges (4202-4249, 5086-5799, and 7173-7203 MHz). In addition, Sidecar demonstrates the successful use of a piezoelectric actuator for cavity tuning. Finally, this publication is the first to report data measured using both the TM_{010} and TM_{020} modes.

A phase 1 trial of Vorinostat in combination with concurrent chemoradiation therapy in the treatment of advanced staged head and neck squamous cell carcinoma

Purpose Vorinostat is a potent HDAC inhibitor that sensitizes head and neck squamous cell carcinoma (HNSCC) to cytotoxic therapy while sparing normal epithelium. The primary objective of this Phase I study was to determine the maximally tolerated dose (MTD) and safety of Vorinostat in combination with standard chemoradiation therapy treatment in HNSCC. Patients and Methods Eligible patients had pathologically confirmed Stage III, IVa, IVb HNSCC, that was unresectable or borderline resectable involving the larynx, hypopharynx, nasopharynx, and oropharynx. Vorinostat was administered at the assigned dosage level (100-400 mg, three times weekly) in a standard 3 + 3 dose escalation design. Vorinostat therapy began 1 week prior to initiation of standard, concurrent chemoradiation therapy and continued during the entire course of therapy. Results Twenty six patients met eligibility criteria and completed the entire protocol. The primary tumor sites included tonsil (12), base of tongue (9), posterior pharyngeal wall (1), larynx (4) and hypopharynx (3). Of the 26 patients, 17 were HPV-positive and 9 were HPV-negative. The MTD of Vorinostat was 300 mg administered every other day. Anemia (n = 23/26) and leukopenia (n = 20/26) were the most commonly identified toxicities. The most common Grade3/4 events included leukopenia (n = 11) and lymphopenia (n = 17). No patient had Grade IV mucositis, dermatitis or xerostomia. The median follow time was 33.8 months (range 1.6-82.9 months). Twenty four of 26 (96.2%) patients had a complete response to therapy. Conclusion Vorinostat in combination with concurrent chemoradiation therapy is a safe and highly effective treatment regimen in HNSCC. There was a high rate of complete response to therapy with toxicity rates comparable, if not favorable to existing therapies. Further investigation in Phase II and III trials is strongly recommended.

Iatrogenic Genitourinary Fistula: Changing Trends

Aims: To study the frequency of iatrogenic cause amongst the surgery done for genitourinary fistula and to study the type and cause of iatrogenic genitourinary fistula. Methods: This is a 5 year retrospective study analyses 73 iatrogenic fistulas from 217 women undergoing surgery for genitourinary fistula repair from year 2013 to 2018 on going. The analysis considers frequency and characteristics of type of fistula. Results: Out of 217 genitourinary fistula 73(33.6%) were iatrogenic. Vaginal vault fistulas were 54.7% followed by ureteric fistula 32.8%, vesicovaginal fistula 10.9% and there were 2 iatrogenic RVF. The frequency of surgeries for iatrogenic fistula were found to be in increasing trend towards current years and 83.5% of the iatrogenic fistula were found with history of hysterectomy followed by emergency caesarean section 16.4%.  Conclusions: Women undergoing hysterectomy were under risk for iatrogenic fistula. Optimum work environment is important to reduce surgical error during procedures. Operating training should be emphasized on optimal surgical skills, decision making.

Cervical Cancer Screening with VIA in Eastern Nepal - 3 Years Analysis

Aims: To estimate the VIA positivity rate and to see the efficacy of the treatment with cryotherapy during follow up.Methods: A retrospective analysis of all VIA test from March 2012 to April 2015 were analyzed to estimate the VIA positivity rate of the screened population. Guideline for screening, treatment and follow up was as per the national guideline for cervical cancer screening and treatment 2010 of Nepal.Results: A total of 12,444 clients were screened, the VIA positivity rate was 5.9%, repeat VIA positivity rate at the end of one year during follow up was 1.2%, more than 98% had been screened for cervical cancer for the first time and the complication following cryotherapy was low.Conclusions: The VIA positivity rate of our population is comparable to the global magnitude. Screening for cervical cancer with VIA and treatment with cryotherapy is a feasible and acceptable form of screening in our setup. The recommendation would be scaling up of the facility up to grass root level that is linked to appropriate referral system.

Reduction in polyamine catabolism leads to spermine-mediated airway epithelial injury and induces asthma features

BACKGROUND

Airway epithelial injury is a crucial component of acute and severe asthma pathogenesis and a promising target for treatment of refractory asthma. However, the underlying mechanism of epithelial injury remains poorly explored. Although high levels of polyamines, mainly spermine, have been found in asthma and comorbidity, their role in airway epithelial injury and the cause of their altered levels in asthma have not been explored.

METHODS

We measured key polyamine metabolic enzymes in lung samples from normal and asthmatic subjects and in mice with OVA-induced allergic airway inflammation (AAI). Polyamine metabolism was modulated using pharmacologic/genetic modulators. Epithelial stress and apoptosis were measured by TSLP levels and TUNEL assay, respectively.

RESULTS

We found loss of the polyamine catabolic enzymes spermidine/spermine-N (1)-acetyltransferase-1 (SAT1) and spermine oxidase (SMOX) predominantly in bronchial epithelial cells (BECs) of human asthmatic lung samples and mice with AAI. In naïve mice, SAT1 or SMOX knockdown led to airway hyper-responsiveness, remodeling, and BEC apoptosis. Conversely, in mice with AAI, overexpression of either SAT1 or SMOX alleviated asthmatic features and reduced TSLP levels and BEC apoptosis. Similarly, while pharmacological induction of SAT1 and SMOX using the polyamine analogue bis(ethyl)norspermine (BENSPM) alleviated asthmatic features with reduced TSLP levels and BEC apoptosis, pharmacological inhibition of these enzymes using BERENIL or MDL72527, respectively, worsened them. Spermine accumulation in lungs correlated with BEC apoptosis, and spermine treatment caused apoptosis of human BEAS-2B cells in vitro.

CONCLUSIONS

Spermine induces BEC injury. Induction of polyamine catabolism may represent a novel therapeutic approach for asthma via reversing BEC stress.