Radial scar and carcinoma of the breast: microscopic findings in 32 cases

We retrospectively reviewed the microscopic findings in 32 histologically confirmed radial scars in 31 women diagnosed in our unit during 1994-1998. The median age at diagnosis was 53 years (range 47-63 years). Thirty-one (97%) of 32 lesions presented as screen detected mammographic abnormalities (28 stellate lesions, 2 microcalcifications and only 1 architectural distortion). One lesion presented as a palpable breast mass. Stereotactic or ultrasound-guided fine needle aspiration cytology (FNAC) was performed in 28 cases. Cytological analysis of FNAs revealed malignant cells (C5) in 8 (29%) cases, highly suspicious cells (C4) in 3 (11%) cases, atypical benign cells (C3) in 7 (25%) cases and benign epithelial cells (C2) in 10 (35%) cases. All non-palpable lesions were surgically excised following wire localization. Histological examination of the breast specimens (mean weight=16 g) demonstrated, in addition to a radial scar, 6 invasive carcinomas (2 infiltrating ductal, 2 tubular, 1 mixed ductal/lobular and 1 secretory carcinoma) and 4 ductal carcinoma in situ lesions (2 high grade, 1 high grade with micro-invasion and 1 low grade) arising in the radial scar. Of the remaining cases the radial scar was associated with atypical epithelial hyperplasia in 2 cases and regular epithelial hyperplasia in 17 cases (4 florid and 13 mild to moderate). In the 10 cases associated with malignancy, 9 had FNAC and was reported as malignant (C5) in 6 (67%) cases, highly suspicious (C4) in 2 (22%) cases and atypical (C3) in 1 (11%). False positive FNAC (C5) occurred in two patients, one of whom presented with pleomorphic microcalcifications suggestive of ductal carcinoma in situ. This patient was treated with a wire guided segmental mastectomy. All invasive tumours were less than 20 mm in size (T1) and of these 4 were grade I and 2 were grade II. Axillary dissection was performed in 4 patients none of whom had axillary node metastases. Our study demonstrates a significant incidence of malignancy associated with radial scars (31%) suggesting that radial scars may be premalignant lesions. This is supported by detecting various stages of mammary carcinogenesis (atypical epithelial hyperplasia, ductal carcinoma in situ, and early invasive malignancy) in these lesions. Fine needle aspiration cytology seems to be unreliable in the diagnosis of radial scar associated malignancy (67% sensitivity and 91% specificity). Stellate lesions, therefore, should be excised to obtain an histological diagnosis regardless of cytological findings. Further studies examining the biology of radial scars are required.

Control of organ asymmetry in flowers of Antirrhinum

Organ asymmetry is thought to have evolved many times independently in plants. In Antirrhinum, asymmetry of the flower and its component organs requires cyc and dich gene activity. We show that, like cyc, the dich gene encodes a product belonging to the TCP family of DNA-binding proteins that is first expressed in the dorsal domain of early floral meristems. However, whereas cyc continues to be expressed throughout dorsal regions, expression of dich eventually becomes restricted to the most dorsal half of each dorsal petal. This correlates with the effects of dich mutations and ectopic cyc expression on petal shape, providing an indication that plant organ asymmetry can reflect subdomains of gene activity. Taken together, the results indicate that plant organ asymmetry can arise through a series of steps during which early asymmetry in the developing meristem is progressively built upon.

Treatment of low rectal carcinoma by transanal electrocoagulation

This study reports the first 13 cases of biopsy-proven low rectal carcinoma treated by transanal electrocoagulation using a locally manufactured instrument. At the University Hospital of the West Indies, over a 16-year period, 9 patients were treated for cure, six of whom have no clinical evidence of recurrence for one to 12 years. Four cases who were offered this procedure for palliation defaulted after a single treatment. Transanal electrocoagulation provides an additional option for treating patients with small, mobile low rectal cancers, following careful screening for evidence of nodal or distant spread. The procedure can also be used in the local control of disease in patients with distant spread or in whom a major operation is not feasible.

The significance of new densities and microcalcification in the second round of breast screening

AIM

To assess the nature of new densities and microcalcifications in the second round of breast screening.

MATERIALS AND METHODS

A total of 34 634 women were screened at our unit in the second round of the United Kingdom National Health Service Breast Screening Programme. Of those attending for the second time, 302 were recalled for further work-up of 311 new lesions. The lesions were divided into masses, microcalcifications, asymmetric densities and architectural distortions. Masses were classified according to margin and density, and microcalcifications according to morphology and distribution.

RESULTS

Among women attending for the second time, the cancer detection rate was 0.45% (89 cancers). One hundred and eighty-eight new masses were identified: 53 well-defined (two malignant), 67 partially defined (six malignant), 54 ill-defined (18 malignant), and 14 spiculate (14 malignant). Well-defined masses were usually cysts, especially in women on hormone replacement therapy. Of 97 new microcalcifications, 71 were pleomorphic (28 malignant), 12 linear (one malignant), and 14 punctate (none malignant). Twenty-five new asymmetric densities were identified (five malignant). One of two architectural distortions was malignant. Malignancy was found in 21% of new masses, 30% of new microcalcification and 20% of asymmetric densities.

CONCLUSION

Carcinoma was found in 24% of all new mammographic abnormalities appearing in a 3-year screening period. Spiculate and ill-defined masses, clustered pleomorphic microcalcification, and new asymmetric densities should be regarded with particular suspicion. The use of fine needle aspiration cytology in combination with imaging assessment may help to reduce the number of benign excisional biopsies for new mammographic lesions.

Granulosa-theca cell tumour of the ovaries. A late metastasizing tumour

Granulosa-theca cell tumours are ovarian neoplasms of low malignancy with hormone secreting potential, accounting for 2-3% of all ovarian cancers. They have an uncertain clinical course and a potential for late recurrence after surgical removal. Clinical features of a patient presenting with pulmonary metastases 21 years after removal of the primary tumour are described, along with a review of the management options.

An audit of patient acceptance of one-stop diagnosis for symptomatic breast disease

AIMS

The impetus for optimizing outpatient provision of breast-care services has come both from the patient and management in order to reduce anxiety and make full use of scarce resources. The one-stop diagnostic clinic for the investigation of symptomatic breast lesions is a relatively recent concept with well-known service benefits. However, acceptance to the patient has not been previously investigated.

RESULTS

The results of this prospective audit demonstrate a high level of patient satisfaction with the multi-disciplinary, one-stop breast clinic.

Transcription of the prorenin gene in normal and diseased breast

The angiotensin II type 1 (AT1) receptor is present in a wide variety of human and animal tissues, and is particularly abundant in epithelial cells. Because of this, and because it is known that tissue renin angiotensin systems (RASs) exist that have specific local functions, we investigated the expression and localisation of components of the RAS in normal and diseased breast tissue. Using a monoclonal antibody to the AT1 receptor, immunocytochemistry confirmed that the AT1 receptor was characteristically distributed in ductal epithelial cells in both normal and malignant tissue, and in most, although not all, cells in invasive tumours. Transcription of prorenin mRNA was studied by in situ hybridisation, using a DIG-ddUTP tail-labelled probe specific for the human prorenin gene. In normal tissue, and in cases of ductal carcinoma in situ, prorenin mRNA was distributed in myoepithelial cells and in a band of connective tissue cells completely surrounding the AT1-containing ductal epithelial cells. This prorenin transcribing tissue was disrupted and attenuated in invasive tumours, and in some of these, prorenin mRNA transcription could not be detected at all. Functions ascribed to the tissue RASs include regulation of mitosis and tissue modelling, as well as fluid and electrolyte transport. The results presented here strongly suggest the possibility that a tissue RAS may also be present in the breast, closely coupled to the provision of angiotensin II to the AT1 receptors in ductal epithelial cells. This mechanism is disrupted in cancer.

The Antirrhinum ERG gene encodes a protein related to bacterial small GTPases and is required for embryonic viability

Small GTPases have diverse roles in animals and yeast, including signal transduction, regulation of secretion, organisation of the cytoskeleton, and control of cell division. Similar GTPases have also been found in bacteria, such as the Escherichia coli GTPase ERA, which is involved in regulating metabolism and cell division [1,2]. Many small GTPases have been cloned from plants but their functional analysis has largely been limited to complementation of mutations in corresponding yeast genes, and antisense experiments which have implicated these proteins in processes such as root nodulation [3,4]. No mutations in plant GTPases have been reported, and thus their true importance in plant growth and development is unknown. Here we report the isolation of a gene from Antirrhinum majus encoding a protein from an entirely novel class of eukaryotic GTPases showing strongest similarity to the prokaryotic protein ERA. We have named this gene ERG (for ERA-related GTPase). The ERG gene is expressed in dividing or metabolically active cells. We generated a deletion allele of ERG by site-selected transposon mutagenesis and have shown that seeds containing embryos and endosperm homozygous for this deletion arrest soon after fertilisation. We conclude that ERG has a crucial role in plant growth and development, possibly by influencing mitochondrial division.

Control of floral homeotic gene expression and organ morphogenesis in Antirrhinum

The development of reproductive organs in Antirrhinum depends on the expression of an organ identity gene, plena, in the central domain of the floral meristem. To investigate the mechanism by which plena is regulated, we have characterised three mutants in which the pattern of plena expression is altered. In polypetala mutants, expression of plena is greatly reduced, resulting in a proliferation of petals in place of reproductive organs. In addition, polypetala mutants exhibit an altered pattern of floral organ initiation, quite unlike that seen in loss-of-function plena mutants. This suggests that polypetala normally has two roles in flower development: regulation of plena and control of organ primordia formation. In fistulata mutants, plena is ectopically expressed in the distal domain of petal primordia, resulting in the production of anther-like tissue in place of petal lobes. Flowers of fistulata mutants also show a reduced rate of petal lobe growth, even in a plena mutant background. This implies that fistulata normally has two roles in the distal domain of petal primordia: inhibition of plena expression and promotion of lobe growth. A weak allele of the floral meristem identity gene, floricaula, greatly enhances the effect of fistulata on plena expression, showing that floricaula also plays a role in repression of plena in outer whorls. Taken together, these results show that genes involved in plena regulation have additional roles in the formation of organs, perhaps reflecting underlying mechanisms for coupling homeotic gene expression to morphogenesis.

Orbital psuedotumour with intracranial extension. A case report

Inflammatory pseudotumour of the orbit is an unusual condition of unknown aetiology which rarely extends beyond the orbit. To our knowledge 19 cases with intracranial extension have been reported, none of which involved the pituitary fossa or sphenoid sinus. Most required cytotoxic agents, surgery or radiotherapy in addition to corticosteroids. We present a case of orbital pseudotumour with extension into the pituitary fossa, sphenoid sinus and cavernous sinuses with vascular compression. Marked clinical improvement occurred on steroid therapy alone.

A common mechanism controls the life cycle and architecture of plants

The overall aerial architecture of flowering plants depends on a group of meristematic cells in the shoot apex. We demonstrate that the Arabidopsis TERMINAL FLOWER 1 gene has a unified effect on the rate of progression of the shoot apex through different developmental phases. In transgenic Arabidopsis plants which ectopically express TERMINAL FLOWER 1, both the vegetative and reproductive phases are greatly extended. As a consequence, these plants exhibit dramatic changes in their overall morphology, producing an enlarged vegetative rosette of leaves, followed by a highly branched inflorescence which eventually forms normal flowers. Activity of the floral meristem identity genes LEAFY and APETALA 1 is not directly inhibited by TERMINAL FLOWER 1, but their upregulation is markedly delayed compared to wild-type controls. These phenotypic and molecular effects complement those observed in the tfl1 mutant, where all phases are shortened. The results suggest that TERMINAL FLOWER 1 participates in a common mechanism underlying major shoot apical phase transitions, rather than there being unrelated mechanisms which regulate each specific transition during the life cycle.

Hypertrophic cardiomyopathy in pregnancy. The use of two-dimensional and Doppler echocardiography during labor and delivery: a case report

Hypertrophic cardiomyopathy (HCM) in pregnancy can result in a high incidence of maternal complications. Although echocardiography is frequently performed in pregnant women with HCM in order to confirm their hemodynamic classification, this modality has not been applied during labor and delivery in these patients. This case report documents the application of two-dimensional and Doppler echocardiography during labor and delivery in a 35-year-old woman with HCM.

A common mechanism controls the life cycle and architecture of plants

The overall aerial architecture of flowering plants depends on a group of meristematic cells in the shoot apex. We demonstrate that the Arabidopsis TERMINAL FLOWER 1 gene has a unified effect on the rate of progression of the shoot apex through different developmental phases. In transgenic Arabidopsis plants which ectopically express TERMINAL FLOWER 1, both the vegetative and reproductive phases are greatly extended. As a consequence, these plants exhibit dramatic changes in their overall morphology, producing an enlarged vegetative rosette of leaves, followed by a highly branched inflorescence which eventually forms normal flowers. Activity of the floral meristem identity genes LEAFY and APETALA 1 is not directly inhibited by TERMINAL FLOWER 1, but their upregulation is markedly delayed compared to wild-type controls. These phenotypic and molecular effects complement those observed in the tfl1 mutant, where all phases are shortened. The results suggest that TERMINAL FLOWER 1 participates in a common mechanism underlying major shoot apical phase transitions, rather than there being unrelated mechanisms which regulate each specific transition during the life cycle.

An audit of outcome including patient satisfaction with immediate breast reconstruction performed by breast surgeons

Reconstruction of the female breast is becoming ever more frequently requested by patients after mastectomy for cancer. One of the least complex techniques is that of local tissue expansion with a permanent prosthesis. We present our experience and the clinical outcomes of the first 100 patients to have undergone surgery in the 4 years since the introduction of this method of breast reconstruction in our unit. A retrospective study was performed with a detailed questionnaire being sent to each patient for subjective assessment of satisfaction. Data were also collected on the rates of clinical infection of the prosthesis and the need for further surgery, including capsulotomy, nipple reconstruction and contralateral procedures. With 84% expressing their satisfaction at the final result, immediate breast reconstruction is both feasible and highly acceptable to the majority of patients.

The significance of involved tumour bed biopsy following wide local excision of breast cancer

AIM

Following wide local excision of breast cancer approximately 25% of patients have residual disease in the tumour bed. The aim of this study was to determine whether positive bed biopsy correlated with either local recurrence or overall survival.

METHOD

Following wide excision bed biopsies were taken at four separate sites from the tumour bed. Histopathological assessment of the bed biopsies was made and compared to features within the primary tumour. Patients were followed-up over a median period of 6.17 years and local recurrence and survival data documented.

RESULTS

Two hundred and sixty-eight patients were included in the study and 63 had positive bed biopsies. In all, 85 patients had a recurrence of breast cancer and 69 died. Kaplan-Meier plots showed no evidence of a difference in survival between bed biopsy positive and negative patients. Bed biopsy positive patients were at greater risk of local recurrence.

CONCLUSIONS

These findings suggest that positive bed biopsy is associated with an increase in local recurrence rates but has no effect on overall survival following wide excision of breast cancer.

Mucoepidermoid carcinoma of the breast: a case report and review of the literature

Muco-epidermoid carcinoma is a rare primary of the breast with previous reports of only 15 cases. As the following case report demonstrates, it can be very difficult to diagnose on aspiration cytology and a negative result should be interpreted with caution.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

99mTc-labelled SM3 in the preoperative evaluation of axillary lymph nodes and primary breast cancer with change detection statistical processing as an aid to tumour detection

The extent of primary surgery for breast cancer could be tailored to the patient if previous information on the presence or absence of lymph node involvement could be reliably determined. Prospective radioimmunoscintigraphy in 29 patients with primary breast cancer that was found on screening has been undertaken with 555 MBq (15 mCi) 99mTc SM3, an Imperial Cancer Research Fund (ICRF) murine monoclonal antibody, 0.5 mg with images at 10 min and 22 h, and analysis using a change detection algorithm. Sites of significant change between the early and later images were displayed as a map of probabilities. Image-positive and -negative axillary lymph nodes were compared by histology in the 28 evaluable patients. The correct identification of the presence or absence of node involvement, even if impalpable, has been shown in 24 out of 28 patients (29 lymph node groups). Sensitivity was 90% (nine out of ten), specificity 84% (16 out of 19) and accuracy 86%. These results encourage further assessment of this technique.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND

Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation.

OBJECTIVE

To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation.

METHODS

A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used.

RESULTS

Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group.

CONCLUSION

Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

Are frequent inner cannula changes necessary?: A pilot study

OBJECTIVE

To determine the incidence of obstruction and colonization in adult patients in the surgical and medical intensive care units who received inner cannula changes daily versus those who did not.

DESIGN

Quasi-experimental prospective study using a convenience sample of patients randomly assigned to one of two methods.

SETTING

Mid-Atlantic university-affiliated tertiary care center.

PATIENTS

Sixty patients within 24 hours of receiving a surgical tracheostomy.

OUTCOME MEASURES

Obstruction and bacterial colonization of inner cannula.

INTERVENTIONS

All inner cannulas were checked daily for obstruction and cultured on postoperative days 1 and 3.

RESULTS

No statistically significant difference was noted in colonization (p = 0.13) between protocols, and no obstructions were noted in either.

CONCLUSION

The study suggests that the routine practice in critical care units of changing tracheostomy inner cannulas may be unnecessary. Although the results of this study are limited, and may not be generalized to other populations, it demonstrates that practice standards related to the care of tracheostomy inner cannula need to be challenged.

Dual role for fimbriata in regulating floral homeotic genes and cell division in Antirrhinum

The fimbriata (fim) gene of Antirrhinum affects both the identity and arrangement of organs within the flower, and encodes a protein with an F-box motif. We show that FIM associates with a family of proteins, termed FAPs (FIM-associated proteins), that are closely related to human and yeast Skp1 proteins. These proteins form complexes with F-box-containing partners to promote protein degradation and cell cycle progression. The fap genes are expressed in inflorescence and floral meristems in a pattern that incorporates the domain of fim expression, supporting an in vivo role for a FIM-FAP complex. Analysis of a series of novel fim alleles shows that fim plays a key role in the activation of organ identity genes. In addition, fim acts in the regions between floral organs to specify the correct positioning and maintenance of morphological boundaries. Taking these results together, we propose that FIM-FAP complexes affect both gene expression and cell division, perhaps by promoting selective degradation of regulatory proteins. This may provide a mechanism by which morphological boundaries can be aligned with domains of gene expression during floral development.

Inflorescence commitment and architecture in Arabidopsis

Flowering plants exhibit one of two types of inflorescence architecture: indeterminate, in which the inflorescence grows indefinitely, or determinate, in which a terminal flower is produced. The indeterminate condition is thought to have evolved from the determinate many times, independently. In two mutants in distantly related species, terminal flower 1 in Arabidopsis and centroradialis in Antirrhinum, inflorescences that are normally indeterminate are converted to a determinate architecture. The Antirrhinum gene CENTRORADIALIS (CEN) and the Arabidopsis gene TERMINAL FLOWER 1 (TFL1) were shown to be homologous, which suggests that a common mechanism underlies indeterminacy in these plants. However, unlike CEN, TFL1 is also expressed during the vegetative phase, where it delays the commitment to inflorescence development and thus affects the timing of the formation of the inflorescence meristem as well as its identity.

Inflorescence commitment and architecture in Arabidopsis

Flowering plants exhibit one of two types of inflorescence architecture: indeterminate, in which the inflorescence grows indefinitely, or determinate, in which a terminal flower is produced. The indeterminate condition is thought to have evolved from the determinate many times, independently. In two mutants in distantly related species, terminal flower 1 in Arabidopsis and centroradialis in Antirrhinum, inflorescences that are normally indeterminate are converted to a determinate architecture. The Antirrhinum gene CENTRORADIALIS (CEN) and the Arabidopsis gene TERMINAL FLOWER 1 (TFL1) were shown to be homologous, which suggests that a common mechanism underlies indeterminacy in these plants. However, unlike CEN, TFL1 is also expressed during the vegetative phase, where it delays the commitment to inflorescence development and thus affects the timing of the formation of the inflorescence meristem as well as its identity.

Altered cell-matrix contact: a prerequisite for breast cancer metastasis?

The integrins are receptors that regulate interaction between epithelial cells and the extracellular matrix. Previous studies have shown that a reduction in the expression of the alpha2beta1, alpha3beta1, alpha6beta1, alpha(v)beta1 and alpha(v)beta5 integrins in primary breast cancer is associated with positive nodal status. In order to assess the functional significance of altered integrin expression, primary breast cancer cells were derived from individual patients with known tumour characteristics using immunomagnetic separation. Purified human fibronectin, vitronectin, laminin and type IV collagen were used to represent the principal extracellular matrix proteins in an in vitro adhesion assay. Primary breast cancer cells from lymph node-positive patients were significantly less adhesive to each of the matrix proteins studied (P<0.001, Mann-Whitney U-test). Matrix adhesion of primary breast cancer cells from node-negative patients was inhibited by appropriate integrin monoclonal antibodies (P<0.001, paired Wilcoxon test). Adhesion to fibronectin, vitronectin and laminin, but not type IV collagen, was influenced by the inhibitor arginine-glycine-aspartate, suggesting that breast cancer cell recognition of collagen IV is mediated through alternative epitopes. Weak matrix adhesion correlated with loss of integrin expression in tissue sections from corresponding patients assessed using immunohistochemistry. This study demonstrates a link between altered integrin expression and function in primary breast cancers predisposed to metastasize.

Origin of floral asymmetry in Antirrhinum

Dorsoventral asymmetry in flowers is thought to have evolved many times from a radially symmetrical ancestral condition. The first gene controlling floral asymmetry, cycloidea in Antirrhinum, has been isolated. The cycloidea gene is expressed at a very early stage in dorsal regions of floral meristems, where it affects growth rate and primordium initiation. Expression continues through to later stages in dorsal primordia to affect the asymmetry, size and cell types of petals and stamens.

Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery. A comparison with halothane

BACKGROUND

Sevoflurane is an inhalational anesthetic with characteristics suited for use in children. To determine whether the induction, recovery, and safety characteristics of sevoflurane differ from those of halothane, the following open-labeled, multicenter, randomized, controlled, phase III study in children undergoing ambulatory surgery was designed.

METHODS

Three hundred seventy-five children, ASA physical status 1 or 2, were randomly assigned in a 2:1 ratio to receive either sevoflurance or halothane, both in 60% N2O and 40% O2. Anesthesia was induced using a mask with an Ayre's t piece or Bain circuit in four of the centers and a mask with a circle circuit in the fifth center. Maximum inspired concentrations during induction of anesthesia were 7% sevoflurane and 4.3% halothane. Anesthesia was maintained by spontaneous ventilation, without tracheal intubation. End-tidal concentrations of both inhalational anesthetics were adjusted to 1.0 MAC for at least 10 min before the end of surgery. Induction and recovery characteristics and all side effects were recorded. The plasma concentration of inorganic fluoride was measured at induction of and 1 h after anesthesia.

RESULTS

During induction of anesthesia, the time to loss of the eyelash reflex with sevoflurane was 0.3 min faster than with halothane (P < 0.001). The incidence of airway reflex responses was similar, albeit infrequent with both anesthetics. The total MAC.h exposure to sevoflurane was 11% less than the exposure to halothane (P < 0.013), although the end-tidal MAC multiple during the final 10 min of anesthesia was similar for both groups. Early recovery as evidenced by the time to response to commands after sevoflurane was 33% more rapid than it was after halothane (P < 0.001), although the time to discharge from hospital was similar for both anesthetics. The mean ( +/- SD) plasma concentration of inorganic fluoride 1 h after discontinuation of sevoflurane was 10.3 +/- 3.5 microM. The overall incidence of adverse events attributable to sevoflurane was similar to that of halothane, although the incidence of agitation attributable to sevoflurane was almost threefold greater than that attributable to halothane (P < 0.004).

CONCLUSIONS

Sevoflurane compared favorably with halothane. Early recovery after sevoflurane was predictably more rapid than after halothane, although this was not reflected in a more rapid discharge from the hospital. The incidence of adverse events was similar for both anesthetics. Clinically, the induction, recovery, and safety characteristics of sevoflurane and halothane are similar. Sevoflurane is a suitable alternative to halothane for use in children undergoing minor ambulatory surgery.

Integrin expression in breast cancer cytology: a novel predictor of axillary metastasis

The integrins are heterodimeric transmembrane receptors of varying alpha and beta subunits that modulate cell adhesion to each other and to the extracellular matrix. Loss of integrin expression on primary breast cancer frozen sections measured by immunohistochemistry may be related to the presence of axillary metastasis. The clinical application of this finding would be increased if integrin expression could also be shown to be reliably measured on breast cancer cells obtained by fine needle aspiration cytology. Axillary operations may be planned as a single stage procedure from outpatients, and neoadjuvant therapy protocols may be developed without surgery to the axilla. Expression of the alpha 1, alpha 2, alpha 3, alpha 6, alpha v, beta 1, beta 3 and beta 5 integrin subunits were measured by immunohistochemistry and immunocytochemistry in 58 patients. Integrin measurement by both these methods were found to be closely associated using the kappa-test. Loss of expression of the alpha 1, alpha 2, alpha 3, alpha 6, alpha v, beta 1 and beta 5 integrin subunits measured by cytology and histology were each related to positive nodal status (chi(2) test). Measuring integrin expression on cytology is of clinical value and may prove to have prognostic significance.

Pathways for inflorescence and floral induction in Antirrhinum

The presentation of flowers on a modified stem, the inflorescence, requires the integration of several aspects of meristem behaviour. In Antirrhinum, the inflorescence can be distinguished by its flowers, hairy stem, modified leaves, short internodes and spiral phyllotaxy. We show, by a combination of physiological, genetical and morphological analysis, that the various aspects of the inflorescence are controlled by three pathways. The first pathway, depends on expression of the floricaula gene, and is rapidly and discretely induced by exposure to long daylength. Activation of this pathway occurs in very young axillary meristems, resulting in a floral identity. In addition, the length of subtending leaves and hairiness of the stem are partially modified. The second pathway affects leaf size, internode length, and stem hairiness, but does not confer floral meristem identity. This pathway is induced by long daylength, but not as rapidly or discretely as the floricaula-dependent pathway. The third pathway controls the switch in phyllotaxy from decussate to spiral and is activated independently of daylength. The coordination of these three programmes ensures that apical and axillary meristem behaviour is integrated.

Origin of allelic diversity in antirrhinum S locus RNases

In many plant species, self-incompatibility (SI) is genetically controlled by a single multiallelic S locus. Previous analysis of S alleles in the Solanaceae, in which S locus ribonucleases (S RNases) are responsible for stylar expression of SI, has demonstrated that allelic diversity predated speciation within this family. To understand how allelic diversity has evolved, we investigated the molecular basis of gametophytic SI in Antirrhinum, a member of the Scrophulariaceae, which is closely related to the Solanaceae. We have characterized three Antirrhinum cDNAs encoding polypeptides homologous to S RNases and shown that they are encoded by genes at the S locus. RNA in situ hybridization revealed that the Antirrhinum S RNase are primarily expressed in the stylar transmitting tissue. This expression is consistent with their proposed role in arresting the growth of self-pollen tubes. S alleles from the Scrophulariaceae form a separate group from those of the Solanaceae, indicating that new S alleles have been generated since these families separated (approximately 40 million years). We propose that the recruitment of an ancestral RNase gene into SI occurred during an early stage of angiosperm evolution and that, since that time, new alleles subsequently have arisen at a low rate.

The prevalence of seat belt use in Jamaica. An observational study

An observational cross-sectional survey showed that 21.1% of private motor vehicle drivers and 13.5% of front seat passengers voluntarily wore seat belts in Kingston, Jamaica, where there is no law requiring this. Rear passenger utilisation was not examined. Compared to males, females were significantly more likely to wear seat belts when driving but not as front seat passengers. Of all motor vehicles examined, 10.1% were not equipped with seat belts. The oldest group of vehicles were mostly not fitted with seat belts. Drivers of older vehicles were significantly less likely to use seat belts even when the vehicles were equipped with belts. Implementation of legislation can reduce mortality, morbidity and costs from road traffic accidents which are relatively frequent in Jamaica. Male drivers, drivers of older vehicles and all passengers may require specific targeting in an educational and enforcement campaign should legislation, which is highly desirable, be implemented.

Control of inflorescence architecture in Antirrhinum

Flowering plants exhibit two types of inflorescence architecture: determinate and indeterminate. The centroradialis mutation causes the normally indeterminate inflorescence of Antirrhinum to terminate in a flower. We show that centroradialis is expressed in the inflorescence apex a few days after floral induction, and interacts with the floral-meristem-identity gene floricaula to regulate flower position and morphology. The protein CEN is similar to animal proteins that associate with lipids and GTP-binding proteins. We propose a model for how different inflorescence structures may arise through the action and evolution of centroradialis.

Molecular probes for sweeteners: immunorecognition of superpotent guanidinium compounds

Monoclonal antibodies (MAb) were made to two different superpotent guanidino sweet tasting ligands, N-(p-cyanophenyl)-N'-(diphenylmethyl)-guanidineacetic acid and N-(p-cyanophenyl)-N'-(cyclooctyl)-guanidineacetic acid. In the present study we examined the binding specificity of three MAb clones (denoted as NC10.7, NC10.13, and NC37.3). The isotypes of these MAb were determined to be IgG1 kappa for NC10.7 and NC37.3, while NC10.13 was IgG2b, kappa. The dissociation constants for the MAb were 19 nM (NC10.7), 28 nM (NC10.13), and 16 nM (NC37.3). The binding specificity of each MAb was characterized by a competitive inhibition radioimmunoassay using related sweetener analogues. Antibodies to this family of sweet tasting compounds may be useful probes for the study of sweet taste chemistry and identification of novel sweet taste ligands.

Growth enhancement of implanted human colorectal cancer cells by the addition of fibroblasts in vivo

The effect of fibroblasts on the growth of HT29 human colorectal cancer cells was used to study stromal modulation of tumour growth dynamics. Fibroblasts were isolated from rat livers, 1, 2.5 and 4 days after two-thirds partial hepatectomy and from normal livers. Cells harvested 2.5 and 4 days after hepatectomy ('fast' fibroblasts) had a significantly faster growth rate in vitro than those harvested on day 1 or those from normal livers (P < 0.02). The fibroblasts were inoculated with HT29 colorectal cancer cells into nude mice. Controls received cancer cells with or without a fibroblast cell line (C3H10T 1/2). At 3 weeks both tumour take and growth (size) were significantly greater in the group inoculated with cancer cells and 'fast' fibroblasts than in the other groups (tumour take 100 versus 42-75 per cent, P < 0.03; median tumour size 3.5 versus 0.3-0.4 g, P < 0.02). In conclusion, tumour growth is enhanced by fibroblasts, especially by those derived from actively regenerating liver. It is suggested that the stimulation is not only mechanical but may also involve a humoral mechanism.

Control of flower development and phyllotaxy by meristem identity genes in antirrhinum

The flower meristem identity genes floricaula (flo) and squamosa (squa) promote a change in phyllotaxy from spiral to whorled in Antirrhinum. To determine how this might be achieved, we have performed a combination of morphological, genetic, and expression analyses. Comparison of the phenotypes and RNA expression patterns of single and double mutants with the wild type showed that flo and squa act together to promote flower development but that flo is epistatic to squa with respect to early effects on phyllotaxy. We propose that a common process underlies the phyllotaxy of wildtype, flo, and squa meristem development but that the relative timing of primordium initiation or growth is altered. This process depends on two separable events: setting aside zones for potential primordium initiation and partitioning these zones into discrete primordia. Failure of the second event can lead to the formation of continuous double spirals, which are occasionally seen in flo mutants.

Cell lineage patterns and homeotic gene activity during Antirrhinum flower development

BACKGROUND

Homeotic genes controlling the identity of flower organs have been characterized in several plant species. To determine whether cells expressing these genes are specified to follow particular developmental fates, we have studied the pattern of cell lineages in developing flowers of Antirrhinum. Each flower has four whorls of organs, and progenitor cells of these can be marked at particular stages of development using a temperature-sensitive transposon. This allows the cell lineages in the flower to be followed, as well as giving information about rates of cell division.

RESULTS

We show here that, prior to the emergence of organ primordia, cells in the floral meristem have not been allocated organ identities. After this time, lineage restrictions arise between whorls, correlating with the onset of expression of genes that control organ identity. A further lineage restriction appears slightly later on, between the dorsal and ventral surfaces of the petal. Our results further suggest that the rates of cell division fluctuate during key stages of meristern development, perhaps as a consequence of meristem-identity gene expression.

CONCLUSIONS

The patterns of lineage restriction and organ-identity gene expression in early floral meristems are consistent with some cells being allocated specific identities at about this stage of development. Plant cells cannot move relative to each other, so lineage restrictions in plants may reflect particular orientations and/or rates of growth at boundary regions.

Primary aortoenteric fistula

One hundred and thirty-eight patients with abdominal aortic aneurysms were treated by aneurysmorrhaphy over an eleven-year period. Six patients, all male and aged 60-74 years, were found to have developed primary aortoenteric fistulae. Four patients presented with bleeding into the gastrointestinal tract in association with a tender abdominal swelling. In the other two cases, the aneurysm was discovered at emergency laparotomy for gastrointestinal haemorrhage. The presence of the fistula was confirmed at operation in five patients and at autopsy in one. Two patients died, one from a massive gastrointestinal haemorrhage prior to surgery, the other from sepsis complicated by Adult Respiratory Distress Syndrome and renal failure following operation.

In vitro regulation of human breast cancer cell adhesion and invasion via integrin receptors to the extracellular matrix

The extracellular matrix consists of the interstitium and the basement membrane. Cellular interaction with fibronectin, laminin and collagen provides a possible mechanism by which cancer cells adhere, invade and metastasize. The integrins are a major family of adhesion molecules that recognize epitopes on the extracellular matrix as ligands. These include the alpha 2 beta 1, alpha 3 beta 1, alpha v beta 1 and alpha v beta 5 integrins, most of which were found to be expressed on MCF-7, T47D, MDA-MB-231, ZR75-1 and Hs578T breast cancer cell lines. Each cell line adhered to the matrix proteins in a dose-dependent manner and was inhibited by monoclonal antibodies against relevant integrins. Only Hs578T was significantly invasive through fibronectin but both Hs578T and MDA-MB-231 invaded through laminin and type IV collagen in an in vitro assay. The invasive potential of these cell lines could be inhibited by integrin antibodies added to cells before incubation, but the addition of antibodies after cells were allowed to adhere to the matrix failed to inhibit invasion. Inhibition of cellular adhesion to the matrix reduced the invasive potential of breast cancer cell lines. As integrin antibodies inhibit cell invasion in vitro, the integrins may be of potential value as antitumour therapeutic agents.

Modulation of very late activation-2 laminin receptor function in breast cancer metastasis

BACKGROUND

Very late activation-2 (VLA-2) is an integrin receptor for laminin that consists of an alpha 2- and a beta 1-subunit. In human breast cancer, down-regulation of VLA-2 expression is related to positive nodal status. The functional significance of altered integrin expression in individual patients has never been investigated. To test the hypothesis that less adhesive primary breast cancer cells were predisposed to metastasize, variation in VLA-2 modulation of cell attachment to laminin with nodal status was studied.

METHODS

Integrin expression was measured by means of immunohistochemistry on cryostat sections. Primary breast cancer cells were isolated by enzymatic disaggregation and immunomagnetic separation. Cell adhesion to laminin was evaluated in an in vitro assay, and the effect of monoclonal antibodies against the component subunits of VLA-2 was assessed.

RESULTS

Adhesion of primary breast cancer cells from women with positive nodes to laminin was significantly reduced compared with women with negative nodes (p < 0.001, Wilcoxon signed rank test). VLA-2 antibodies inhibited primary breast cancer cell attachment of women with negative nodes but not women with positive nodes. Strong adhesion to laminin was related to node-negative status (chi-squared, 16.33; p < 0.001) and to positive integrin expression (chi-squared, 31.54; p < 0.001).

CONCLUSIONS

VLA-2-mediated adhesion of primary breast cancer cells to laminin differs with nodal status. Measurement of VLA-2 expression may thus be of clinical value as a prognostic indicator in the assessment of breast cancer.

Perioperative pain management

The clinical anesthesia, general surgery, and gynecology literature addressing the pathophysiology and management strategies for perioperative pain were reviewed. There are few prospective, randomized studies from which to draw meaningful conclusions. Nevertheless, a theoretical construct has been developed which may help the gynecologic surgeon optimizing pain management. The era of managed care and shorter hospital stays has focused physicians and, in particular, surgeons on elements of patient care that can be addressed and improved. Reducing or eliminating postoperative pain without excessive sedation promotes rapid mobilization and return to self-care. Strategies for pain management can be adopted that reduce postoperative ileus and other adverse reactions to analgesics.

Clinical audit of a specialist symptomatic breast clinic

The efficient delivery of health care requires vigilant quality assurance. We describe the audit of our symptomatic breast clinic, which includes the option of a one-stop diagnostic service. A total of 134 new and 386 follow-up patients attended over four consecutive clinics. The majority of new referrals (68%) were seen by a consultant surgeon. Urgent referrals were seen significantly sooner than routine referrals (P < 0.001, chi 2-test), and the mean wait from designated appointment to seeing the surgeon was 37.6 (range-68 to 171) min. One-stop investigations were offered to 50 patients; of these, 36 women (72%) had a total wait of less than 2 h. For those not investigated at the same clinic, the mean time until investigations was 6.1 (range 0-36) days and mean recall was 2.7 (range 1-8) weeks. Patients undergoing definitive surgery for cancer (n = 5) were operated on average 14.2 (range 7-27) days after the decision was made in outpatients, while the mean waiting time for non-cancer operations was 49.7 (range 15-98) days. Objective audit on outpatient services is possible and can lead to improvement of services.