Preoperative mammographic features predict clinicopathological risk factors for the development of local recurrence in breast cancer

This study attempts to correlate preoperative mammographic features with established clinicopathological risk factors for local recurrence with a view to selecting patients who might be unsuitable for breast-conserving surgery. A total of 357 patients underwent surgery for invasive breast cancer. All patients' preoperative mammograms were reviewed by a single radiologist (LW) blinded to clinicopathological features. The independent sample t-test and chi-squared tests were used to correlate preoperative mammographic features with established clinicopathological risk factors for the development of local recurrence. The presence of extensive in situ disease within the tumour was associated with both casting calcification and absence of a mammographic nidus (P=0.0001 and 0.002 respectively) but not with mammographic density. Furthermore casting calcification (P=0.003), absence of a mammographic nidus (P=0.027) and maximum nidus size (P=0.014) were all predictors of tumour bed positivity. This study has demonstrated that preoperative mammograms can be used to identify those patients at risk of occult disease and help select those patients that may be unsuitable for breast-conserving surgery.

Caring and cultural maintenance and transformation for secondary urban family caregivers of persons with stroke

An ethnographic study examined secondary urban family caregivers' caring and cultural maintenance and transformation as it influences their capacity to care for persons with stroke within African American family systems. Caring as experience was demonstrated by two domains: caring actions and caring family functions. Caring as meaning was centered in one domain: caring expressions. Cultural patterns were evidenced in the experience and meaning of caring and focused on cultural maintenance that the caregivers and their families developed to survive the caring situation. Culture transformation such as being open to more options could occur only if the caregivers' circumstances changed. For the most part, they were doing everything in their power to maintain their family system.

Adaptation by normal listeners to upward spectral shifts of speech: implications for cochlear implants

Multi-channel cochlear implants typically present spectral information to the wrong "place" in the auditory nerve array, because electrodes can only be inserted partway into the cochlea. Although such spectral shifts are known to cause large immediate decrements in performance in simulations, the extent to which listeners can adapt to such shifts has yet to be investigated. Here, the effects of a four-channel implant in normal listeners have been simulated, and performance tested with unshifted spectral information and with the equivalent of a 6.5-mm basalward shift on the basilar membrane (1.3-2.9 octaves, depending on frequency). As expected, the unshifted simulation led to relatively high levels of mean performance (e.g., 64% of words in sentences correctly identified) whereas the shifted simulation led to very poor results (e.g., 1% of words). However, after just nine 20-min sessions of connected discourse tracking with the shifted simulation, performance improved significantly for the identification of intervocalic consonants, medial vowels in monosyllables, and words in sentences (30% of words). Also, listeners were able to track connected discourse of shifted signals without lipreading at rates up to 40 words per minute. Although we do not know if complete adaptation to the shifted signals is possible, it is clear that short-term experiments seriously exaggerate the long-term consequences of such spectral shifts.

An outcomes study of an occupational medicine intervention program for the reduction of musculoskeletal disorders and cumulative trauma disorders in the workplace

Upper-extremity musculoskeletal pains or disorders (MSDs) account for a significant number of work-related illnesses in the US workforce. Although the concept of MSD prevention is appealing, little has been done to demonstrate the successful application and benefit of these programs. In 1995, an aircraft manufacturer established a unique risk-management program based on the individual risk assessment (CtdMAP) for new hires. The MSD intervention program was designed to prospectively evaluate each new employee for their individual risk of developing MSDs in the workplace. Before job placement, individuals at higher risk were assigned to a period of transitional work. Workers' compensation costs decreases per year were 16%, 3%, 24%, and 12%, while work hours increased by 56%. Employer-estimated savings in direct workers' compensation costs per year were $469,990, $678,337, $1,936,105, and $1,995,759.

Treatment of unicameral bone cyst with demineralized bone matrix

Eleven patients with active unicameral bone cysts were treated primarily with placement of demineralized bone matrix in the cyst by using a two-needle technique and a custom large-bore needle. Cyst healing was rated according to the Neer classification, and the average time of healing was 4.5 months. The demineralized bone matrix demonstrated an ability to obliterate the cyst in nine of 11 patients by using a single injection within 4-5 months, and at 2 years' follow-up, no cysts were deemed active or recurrent.

Management of patients with unstable angina in a general cardiology unit

AIMS

To review the clinical management of patients with unstable angina and to relate prospectively initial risk stratification, according to the Braunwald criteria, to subsequent cardiovascular events.

METHODS

From February to April 1996 we performed a three month prospective review of all patients with a diagnosis of unstable angina admitted to the coronary care unit at Auckland Hospital.

RESULTS

One hundred and four patients (61% male), with a mean age of 64 years, were classified as high (58%), intermediate (41%) or low risk (1%) for an adverse cardiac event. Twelve (12%) patients had a documented myocardial infarction, of whom 11 were in the high-risk group (p = 0.038). During hospitalisation there was one death. Twelve (12%) patients underwent inpatient exercise testing, five of whom proceeded to a coronary angiogram prior to hospital discharge. Twenty-two (21%) unstable patients underwent inpatient angiography without prior exercise testing. Twenty-one (20%) patients required revascularisation on the same admission: percutaneous coronary angioplasty (n = 14) or coronary artery bypass grafting (n = 7). Twelve of these 21 patients were in the high-risk group (p = 0.999, NS).

CONCLUSION

Patients admitted with unstable angina had low inpatient mortality but a 12% rate of subsequent myocardial infarction. Braunwald low-risk unstable angina patients were not admitted to the coronary care unit. Braunwald high-risk patients were more likely to develop a subsequent myocardial infarction. Stratification of patients into intermediate or high-risk groups did not relate to initial medical management or subsequent revascularisation. Thus, while this method of risk stratification may predict cardiovascular events, it may be of limited clinical use in the New Zealand environment.

Conceptual conflict: malaria control and intermecine warfare within a London postgraduate school

For more than twenty years after the end of World War II, uneasy relations existed between epidemiologists and protozoologists within the London School of Hygiene and Tropical Medicine, reflecting differences in their individual approaches to malariology and malaria control. The paper explores the particular problems created by the polarised views and lack of sympathy between George Macdonald and P.C.C. Garnham throughout the 1950s and 1960s.

The London and Liverpool Schools of Tropical Medicine 1898-1998

In June 1866, Patrick Manson (1844-1922), newly qualified in medicine at Aberdeen University, arrived in Formosa (Taiwan) to begin a career in the service of the Chinese Imperial Maritime customs. His five years there, and subsequently at Amoy on the Chinese mainland, set in train a sequence of events that has been called 'the birth of the science of tropical medicine'. For it was there that Manson began his solitary painstaking studies of the filarial larvae of elephantiasis, and of mosquitoes transmitting filarial infections. It was there that he first realised and acknowledged his own shortcomings in diagnosing and treating the 'tropical diseases' affecting his Chinese patients. These shortcomings were shared by many British colleagues, sent to outposts of the Empire, with no formal knowledge of diseases of hot climates, which did not then form part of the curriculum in British medical schools.

Immunogenic properties of synthetic fragments of Sm-D protein in normal and lupus mice

Antibodies against the Sm antigen are characteristic of systemic lupus erythematosus (SLE). They are found in 20-30% of SLE patients and it has been shown previously that up to 70% of SLE sera react with synthetic fragments 1-20 and 44-67 of the Sm-D polypeptide. To determine whether injections of these peptides might be pathogenic both were administered intraperitoneally into normal mouse strains BALB/c (H-2d), B10/brown (H-2k) and C57BL/6 (H-2b) and an autoimmune strain MRL/lpr (H-2k). IgG antibodies against peptide 1-20 were detected by ELISA in the sera of BALB/c and MRL/lpr mice but not in the sera of B10/brown and C57BL/6 mice. IgG antibodies against peptide 44-67 were found in the sera of BALB/c, B10/brown and MRL/lpr mice but not in the sera of C57BL/6 mice. Neither fragment induced a response against the whole Sm-D antigen as detected by Western blotting. Reactivity to synthetic fragments from other nuclear antigens was however detected in the sera of MRL/lpr mice, especially in those mice injected with Sm-D peptide 44-67 emulsified in Freund's adjuvant. Following immunization with Sm-D peptides, antibodies to ssDNA or dsDNA were not detected in the sera of BALB/c, B10/brown and C57BL/6 mice and in the MRL/lpr mice the naturally occurring production of these antibodies was not enhanced. No difference in IgG deposition in the renal glomeruli of the mice injected with the peptides compared with the control groups was observed. These results suggest that the humoral response to the Sm-D fragment is, at least partially, controlled by the MHC haplotype of the recipient mice, is related to dose and type of immunogen, and is also influenced by the presence of Freund's adjuvant. It is evident that although the sera of many SLE patients recognize either or both the 1-20 and 44-67 peptides, these peptides when injected into MRL/lpr mice are not directly pathogenic.

Sir Austin Bradford Hill: medical statistics and the quantitative approach to prevention of disease

Sir Austin Bradford Hill (1897-1991), son of a prominent medical physiologist, was destined for the study of medicine when World War I intervened. He chase to enlist as a pilot in the Royal Navy Air Service. Having contracted tuberculosis on his way to the Dardanelles, Hill was 'sent home to die'. In spite of the odds he recovered; but with no chance of working in physically taxing fields such as medicine or science. Advised and encouraged by Major Greenwood, he carved out for himself a career in medical statistics, first at the Medical Research Council and subsequently at the London School of Hygiene and Tropical Medicine, where his inspired teaching helped to shape the development of medical research in the second half of the twentieth century. He is particularly remembered for the way he made medical statistics an essential part of modern epidemiology, a new phase in an epidemiology concerned with chronic as well as with infectious diseases. At the same time, he introduced randomization where therapies-beginning with streptomycin in tuberculosis-could be evaluated in large-scale clinical trials. Perhaps his best known achievement is his design of the smoking and lung cancer trials, carried out with Richard Doll who later extended-and still extends-the trials which so convincingly have linked addiction to tobacco to patients' later problems with cancers and with coronary heart disease.

The lived experience of aloneness for older women currently being treated for depression

A phenomenological study was conducted to answer the following question: What is the lived experience of aloneness for older women currently being treated for depression? Eight women from Northern Ohio composed the purposively selected sample. Transcriptions of each 1-hr interview were reviewed by use of Colaizzi's (1978) method of data analysis. The analysis identified two major experiences of self for all participants: aloneness in depression and aloneness in recovery. Five paired, and somewhat dichotomous, themes defined the essence of aloneness: (a) vulnerability versus self-reliance, (b) fear versus hope, (c) helplessness versus resourcefulness, (d) loss of self-control versus self-determination, and (e) identity confusion versus self-reflection. All the participants expressed profound feelings of moving between the five paired themes as they gained clarity of insight into their experiences of depression and recovery. Results of this study make a valuable contribution by providing important insights into the lived experience of aloneness among older women currently being treated for depression, offer direction in the assessment and treatment of these women, and serve as an impetus for further research.

The S100 family protein MRP-14 (S100A9) has homology with the contact domain of high molecular weight kininogen

The heterodimeric molecule MRP-8/MRP-14 (S100A8/S100A9) is abundantly expressed in circulating monocytes and neutrophils. We report here an homology between the C-terminal 'tail' region of MRP-14 (S100A9) and sequences within the plasma protein, high molecular weight kininogen (HMWK) which are involved in binding to negatively charged surfaces such as kaolin. MRP-14 also binds to kaolin and is competitively inhibited by HMWK and by peptides corresponding to MRP-14 tail and the HMWK 'contact' regions. Furthermore both MRP-14 and the tail peptide inhibit the coagulation cascade in vitro giving functional relevance to the homology between MRP-14 and HMWK. At inflammatory sites, MRP-8/14 is localised to areas of close contact between myeloid cells and endothelium. The results of this study identify a potential binding region in MRP-14 and suggest that it could function by interfering with fibrin formation at sites of leukocyte transendothelial migration.

Graphical displays

This paper selectively reviews the field of scientific and medical graphics. Examples are provided using world health statistics and several new methods of presenting multivariate data are introduced.