Impact of fine-needle aspiration cytology, ultrasonography and mammography on open biopsy rate in patients with benign breast disease

The management of breast disease has been influenced by breast imaging and fine-needle aspiration cytology (FNAC) for preoperative diagnosis. To investigate the impact of introducing an in-clinic FNAC service on patient management, the pathology records of patients presenting before and after introduction of the service were studied. Four management changes emerged. The number of patients investigated by histology and/or cytology increased (from 266 to 503), as did specimen numbers (392 to 728). The use of pathological services changed, with more cytology specimens (39 to 554), fewer needle-core biopsies (62 to three) and fewer excision biopsies (245 to 118). The number of patients admitted for surgery fell, especially those with a benign histological diagnosis (174 to 49). These figures demonstrate a change in the management of benign breast disease, from surgery with histopathological diagnosis to cytological diagnosis with surgery only if indicated clinically or from imaging.

Interactions of gelatinases with soluble and immobilized fetuin and asialofetuin

We have analyzed the interactions of human and mouse gelatinases with fetuin and asialofetuin. The data showed that recombinant human gelatinase A (MMP-2) and B (MMP-9) were both specifically bound to asialofetuin and fetuin immobilized to activated agarose (affigel) with subsequent cleavage of the enzymes to lower molecular weight forms, which were likewise bound to asialofetuin/fetuin. The binding of gelatinases to immobilized forms of asialofetuin and fetuins was abrogated in the presence of either soluble fetuin or asialofetuin. Endogenous mouse macrophage gelatinases (mol wt 92 and approximately 52 kDa) were also specifically bound to immobilized asialofetuin upon which the two forms of the gelatinases were reduced to a approximately 45-kDa fragment. The binding of the approximately 45-kDa fragment to asialofetuin was also abrogated in the presence of either soluble fetuin or asialofetuin. Whereas only the activated MMP-2 bound to immobilized asialofetuin had significant gelatinolytic activity, both the zymogen and the activated forms of MMP-9 hydrolyzed soluble [3H]gelatin to the same extent while still bound to asialofetuin. Our data suggest that cell surface bound fetuin/asialofetuin could perform two functions: they could (a) act as cell surface receptors or anchors for MMP-2 and MMP-9 and (b) bind and activate MMP-9 on the cell surface.

Teaching ethics in psychiatry: a one-day workshop for clinical students

In this paper we describe the objectives of teaching medical ethics to undergraduates and the teaching methods used. We describe a workshop used in the University of Liverpool Department of Psychiatry, designed to enhance ethical sensitivity in psychiatry. The workshop reviews significant historical and current errors in the ethical practice of psychiatry and doctors' defence mechanisms against accepting responsibility for deficiencies in ethical practice. The workshop explores the student doctors' own group ethos in response to ethical dilemmas, and demonstrates how the individual contributes to and is responsible for the group ethos through participation and also through nonparticipation. The student feedback about the workshop is reviewed. The Toronto Ethical Sensitivity Instrument was used to assess whether or not the workshop altered sensitivity. Compared to a control group the attenders' sensitivity was significantly increased (on Student's t-test p equals or is less than 0.002).

Preventing the nosocomial transmission of tuberculosis

OBJECTIVE

To study the efficacy of expanded tuberculosis infection control measures consisting primarily of administrative controls.

DESIGN

Descriptive case series.

SETTING

University-affiliated, inner-city hospital.

INTERVENTIONS

Introduction of expanded tuberculosis infection control measures (including an expanded respiratory isolation policy).

MEASUREMENTS

The number of tuberculosis exposure episodes and skin test conversion rates of health care workers were measured before and after implementation of expanded infection control measures. Tuberculosis exposure episodes (the number of patients who were not placed in respiratory isolation at admission but who subsequently had a diagnosis of acid-fast bacilli smear-positive pulmonary tuberculosis during that admission or within 2 weeks of discharge) were compared for two time periods: the 8 months before and the 28 months after implementation of infection control measures. Tuberculin skin test conversion rates among health care workers were evaluated during a 2.5-year period.

RESULTS

After expanded infection control measures were implemented, the number of tuberculosis exposure episodes decreased from 4.4 per month (35 episodes among 103 patient admissions for potentially infectious tuberculosis over 8 months) to 0.6 per month (18 episodes among 358 patient admissions for smear-positive pulmonary tuberculosis over 28 months) (odds ratio, 9.72; 95% CI, 4.99 to 19.25 [P < 0.001]). The cumulative number of days per month that potentially infectious patients with tuberculosis were not in isolation decreased from 35.4 to 3.3 (P < 0.001). A concomitant decrease in tuberculin skin test conversion rates in health care workers was seen; 6-month tuberculin skin test conversion rates decreased steadily from 3.3% (118 conversions in 3579 health care workers; 1/92 to 6/92), 1.7%, 1.4%, 0.6%, to 0.4% (23 conversions in 5153 workers [1/94 to 6/94]) (P < 0.001).

CONCLUSIONS

Infection control measures effectively prevented nosocomial transmission of tuberculosis to health care workers. Administrative controls appear to be the most important component of a tuberculosis infection control program and should be the first focus of such a program, especially at public hospitals, where resources are most likely to be limited.

MR of omental myelosynangiosis

PURPOSE

To describe MR findings in patients who have undergone omental transposition (omental myelosynangiosis) for spinal cord revascularization.

METHODS

Spin-echo MR images, without and with intravenous gadolinium, were obtained before and after surgery in three patients using a quadrature spine coil. Three-dimensional time-of-flight spinal MR angiography was also performed.

RESULTS

On routine MR, the transposed omentum is an irregular, lobulated fat-equivalent mass, containing serpiginous areas of flow void, which extends through the laminectomy site to lie directly adjacent to the cord surface. MR angiography demonstrated small omental vessels, some coursing to the omentum-cord interface; however, no definite extension into the cord was detected. In all patients, there was alteration in cord size and contour after transposition, but no change in cord signal. Clinical improvement was observed in one of the three patients. The signal characteristics of the transposed omentum changed, showing less homogeneity and a gradual loss of the signal over a period of 4 months.

CONCLUSIONS

MR delineates transposed omentum and associated postoperative changes in omental myelosynangiosis. MR angiography is useful as an adjunct to demonstrate the small vessels near the omentum-cord interface, but lacks sufficient resolution to demonstrate neoangiogenesis within the cord.

Seasonal activity and energetics of two species of varanid lizards in tropical Australia

The field metabolic rates (FMR) and rates of water flux were measured in two species of varanid lizards over five periods of the year in tropical Australia. The energetics of these species were further investigated by directly measuring activity (locomotion) and body temperatures of free-ranging animals by radiotelemetry, and by measuring standard metabolic rate (over a range of body temperatures) and activity metabolism in the laboratory. Seasonal differences in the activity and energetics were found in these goannas despite similar, high daytime temperatures throughout the year in tropical Australia. Periods of inactivity were associated with the dry times of the year, but the onset of this period of inactivity differed with respect to habitat even within the same species. Varanus gouldii, which inhabit woodlands only, were inactive during the dry and late dry seasons. V. panoptes that live in the woodland had a similar seasonal pattern of activity, but V. panoptes living near the floodplain of the South Alligator River had their highest levels of activity during the dry season when they walked long distances to forage at the receding edge of the floodplain. However, during the late dry season, after the floodplain had dried completely, they too became inactive. For V. gouldii, the rates of energy expenditure were 196 kJ kg^-1 day^-1 for active animals and 66 kJ kg^-1 day^-1 for inactive animals. The rates of water influx for these groups were respectively 50.7 and 19.5 ml kg^-1 day^-1. For V. panoptes, the rates of energy expenditure were 143 kJ kg^-1 day^-1 for active animals and 56 kJ kg^-1 day^-1 for inactive animals. The rates of water influx for these two groups were respectively 41.4 and 21.0 ml kg^-1 day^-1. We divided the daily energy expenditure into the proportion of energy that lizards used when "in burrows", "out of burrows but inactive", and "in locomotion" for the two species during the different seasons. The time spent in locomotion by V. panoptes during the dry season is extremely high for a reptile (mean of 3.5 h/day spent walking), and these results provide an ecological correlate to the high aerobic capacity found in laboratory measurements of some species of varanids.

Seasonal-Variation in Water Flux, Field Metabolic-Rate and Food-Consumption of Free-Ranging Koalas (Phascolarctos-Cinereus)

Mass-corrected field metabolic rates of free-ranging male koalas in central Queensland, Australia, varied between 0.329 MJ kg0.75 day-1 in summer and 0.382 MJ kg0.75 day-1 in winter. Field water influx measured 50.8 mL kg-0.8 day-1 in winter, increasing to 59.9 mL kg0.8 day-1 in summer for the same koalas, and was positively correlated with values for leaf moisture of food. Winter rates of water influx for koalas from Springsure were lower than those recorded for koalas from Victoria for the same period of the year. Mass-corrected feeding rates were lower in summer than winter; wet food intake was significantly lower than reported for similar sized female koalas from Victoria. The preferred browse was Eucalyptus crebra in winter and E. tereticornis in summer. Our study indicates that in central Queensland seasonal changes in diet selection by male koalas reflect increased energy requirements in winter and increased water requirements in summer.

Energy allocation for reproduction in a marsupial arboreal folivore, the common ringtail possum (Pseudocheirus peregrinus)

This study examines the annual energetics of a small folivorous marsupial, Pseudocheirus peregrinus. Particular attention was given to the energy and time allocated to reproduction by the females. Daily energy expenditure was measured directly using the doubly labelled water technique. Energy transferred to the young via the milk was estimated from information on milk composition and production. There was no significant seasonal variation in the energy expenditure or water influx of males or females. The mean daily energy expenditure of a 1-kg non-lactating adult ringtail possum was 615 kJ day^-1 or 2.2 times standard metabolic rate. Females showed significant changes in daily energy expenditure according to their reproductive status. Without the burden of lactation the total annual energy expenditure of an adult female was estimated as 212.4 MJ kg^-1 year^-1. The total annual energy expenditure of a female rearing two young was 247.5 MJ kg^-1 year^-1, with the late stage of lactation constituting the most energetically expensive period accounting for 30% of the total yearly energy expenditure during 24% of the time. Total metabolisable energy allocation during reproduction (22 MJ kg) was similar to estimates available for other herbivores, although, the peak metabolisable energy allocation during lactation (759 kJ day^-1) was lower than values available for other herbivores. The total energy requirement for reproduction (metabolisable energy plus potential energy exported to young via milk) suggests that the ringtail possum also has a relatively low overall energy investment in reproduction. It is suggested that the lactational strategy of the ringtail possum has been selected in order to spread the energy demands of reproduction over time due to constraints on the rate of energy intake imposed by a leaf diet and/or to prolong the mother-young bond. The strategies a female ringtail possum may employ to achieve energy balance when faced with the energy demands of reproduction are discussed.

Genetic ablation of IGFBP-2 suggests functional redundancy in the IGFBP family

Gene targeting allows mutations to be introduced selectively into any mouse locus of interest. This approach has already been used to demonstrate that insulin-like growth factor (IGF) peptides and receptors are required in vivo for normal prenatal growth. One of the IGFBP genes, IGFBP-2, has also been disrupted using gene targeting, and homozgyous null BP-2 mice are characterized by a decreased spleen size most apparent during early postnatal stages and increased adult circulating levels of several other IGFBPs. These alterations are considered less dramatic than the phenotypes initially predicted based on the fetal IGFBP-2 expression pattern, although several physiological paradigms can be envisioned that will provide additional tests for specific aspects of IGFBP function. Since all six IGFBP genes are expressed during prenatal rodent development, as well as in adult tissues, the IGFBP-2 null phenotype must also be compared with genetic ablations involving members of other gene families and in the context of the other IGFBP expression patterns in rodent embryonic, extraembryonic, and uterine tissues.

The impact of social cognitive variables on the initial level of depression and recovery

Thirty-seven patients who fulfilled DSM-III-R criteria for Major Depressive Disorder were recruited for a double-blind controlled trial of Desipramine and placebo for 6 weeks. Data about social cognitive variables, including social adversities, investment in roles and goals, general social support and crisis support were collected. Crisis support had a moderating effect on the initial level of depression: the more crisis support the subjects had, the less depressed they were on recruitment. Initial level of depression, the experience of adversity and drugs all contributed significantly to recovery defined as Hamilton Rating for Depression less than 10 at week 6. When recovery was defined as Hamilton score halved or more than halved between week 2 and week 6, subjects' level of ideal emotional support, and whether they had experienced adversity in their most invested domains, contributed significantly to recovery, independent of any drug effects or the initial level of depression. The higher their level of ideal emotional support, the less was the chance of these subjects recovering. The findings of this study pointed to the importance of controlling for psycho-social variables in studies of response to treatment.

The Children's Global Assessment Scale in clinical practice: an empirical evaluation

OBJECTIVE

The purpose of this study was to examine characteristics of the Children's Global Assessment Scale (CGAS) in the context of clinical practice.

METHOD

Ninety-five children admitted to a psychiatric inpatient unit were rated by their attending psychiatrist and by milieu staff on the CGAS. Measures of severity and type of symptomatology; social, behavioral, and school competence; intellectual level; social relatedness; and family stress were completed by parents and staff raters.

RESULTS

Results indicated that there was significant convergence in CGAS ratings by independent raters. CGAS ratings were unrelated to measures of symptomatology but were significantly related to indices of children's competence.

CONCLUSIONS

This pattern of results diverged from findings from highly controlled research settings and indicated that CGAS ratings obtained in clinical contexts may reflect evaluations of functional competence rather than severity of symptomatology.

Synthesis of steroidal D-ring fused pyrazolines: study of regiochemistry of addition

The addition of diphenylnitrilimine and C-o-chlorodiphenylnitrilimine to 3 beta-hydroxyandrost-5,16-diene (3b) produced a 1/1 ratio of regioisomeric, 1,3-diaryl-2-pyrazolines (6a, 7a and 6b, 7b), whereas the addition of N-o-chlorodiphenylnitrilimine gave a 5/1 ratio in favor of the [17 alpha, 16 alpha-d] regioisomer (7c). To further delineate the factors governing the regiochemistry of addition of diphenylnitrilimines to steroid 16-enes, additions were carried out on 16-acetyl-5 alpha-androst-16-ene (5b) and 1-acetylcyclopentene (10).

The relationship between serum p53 autoantibodies and characteristics of human breast cancer

Sera from 182 newly diagnosed breast cancer patients were assayed for antibodies to p53 using an enzyme-linked immunosorbent assay (ELISA) method, and antibodies were detected in 48 (26%) compared with 1 out of 76 (1.3%) normal control volunteers (P = 0.0001). In breast cancer patients, autoantibodies were found in all stages of disease progression: carcinoma in situ, primary invasive breast cancer and in metastatic disease. In the subset of patients in whom sequential sera were assessed over a 6 month period, changes in the p53 antibody titres were observed. The presence of antibodies to p53 correlated positively with high histological grade (P = 0.0012) and a history of second primary cancer (six positive out of eight cases). The incidence of autoantibodies was lower in those patients with a first-degree relative with breast cancer (P = 0.046). Out of 68 patients, there was a significant correlation between positive p53 autoantibody status and the detection of p53 protein in the tissue sections by immunocytochemistry (P = 0.002). In the seronegative patients, positive p53 tumour staining was strongly associated with a family history of breast cancer (P = 0.009). The p53 protein overexpressed in heritable breast cancers may therefore be less immunogenic. The presence of p53 autoantibodies provides important additional information to immunochemistry and may identify patients with aggressive histological types of breast cancer.

Comparative expression of fibroblast growth factor mRNAs in benign and malignant breast disease

The messenger RNAs for the angiogenic acidic and basic fibroblast growth factors are expressed at a significantly higher level in samples of human benign neoplastic and hyperplastic tissue than in samples from breast cancers. However, approximately one in four malignant breast cancer samples contain basic fibroblast growth factor mRNA at the same level as in the benign lesions when basic fibroblast growth factor mRNA levels are corrected with respect to levels of expression of glyceraldehyde-3-phosphate dehydrogenase mRNA. A similar proportion of human malignant breast cancer cell lines express a high level of basic fibroblast growth factor mRNA. The results suggest that some malignant breast cancers and their constitutive carcinoma cells express abundant levels of basic fibroblast growth factor mRNA. The resultant production of basic fibroblast growth factor by breast cancer cells within some tumours may contribute to their development.

Primary amyloidosis of the external auditory canal: case report

A case of primary amyloidosis of the external auditory canal is described. To the best of our knowledge this is the first case described in the literature.

Serum p53 auto-antibodies: incidence in familial breast cancer

Inactivation of the p53 gene, which codes for a tumour suppressor protein, is known to occur in the majority of human malignancies. An ELISA technique has been developed which has detected auto-antibodies to p53 in the serum of 25.6% of 176 women with breast cancer, considerably higher than previously reported with an immunoblotting technique. The incidence of auto-antibodies in those cases with a family history of breast cancer was 9.1%, compared to 29.4% in those with no family history (P = 0.029). In women without clinical breast cancer, 4 out of 36 (11.1%) of those with a positive family history were seropositive, compared to 1 out of 73 control women. Auto-antibodies were more frequently seen in the serum of breast cancer patients whose biopsies demonstrated overexpression of p53 protein. We conclude that auto-antibodies to p53 may have a role in the molecular characterisation of familial breast cancer.