Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England

AIMS

English national guidelines recommend that breast reconstruction is made available to women with breast cancer undergoing mastectomy. We examined the use of immediate reconstruction (IR) across English Cancer Networks, who are responsible for the regional organisation of cancer services and ensuring equitable access to treatment.

METHODS

We analysed Hospital Episodes Statistics data for all women with breast cancer who underwent mastectomy in the English NHS between April 2006 and February 2009. IR rates were calculated for the 30 Networks. Multivariable logistic regression was used to adjust the rates for patient age, comorbidity, ethnicity and socioeconomic deprivation.

RESULTS

Of 44 837 mastectomy patients, 7375 (16.5%) underwent IR. The IR rate was highest in women under 50 years (32.7%) and lowest in women aged 70 years or over (1.5%), and was lower in women with more comorbidities. Unadjusted IR rates varied from 8.4% to 31.9% among the 30 Networks (p<0.001). Adjusting for their patient characteristics did not appreciably reduce Network-level variation, with adjusted IR rates still ranging from 8.0% to 29.4% (p<0.001). The risk-model also suggested that non-white women and those from more deprived areas were less likely to undergo immediate reconstruction.

CONCLUSIONS

There is substantial regional variation in immediate reconstruction use in England that is not explained by the characteristics of the local patient population. English Cancer Networks should act to reduce this variation. They should also examine why rates of reconstruction differ between particular patient groups.

Protein-energy malnutrition halts hemopoietic progenitor cells in the G0/G1 cell cycle stage, thereby altering cell production rates

Protein energy malnutrition (PEM) is a syndrome that often results in immunodeficiency coupled with pancytopenia. Hemopoietic tissue requires a high nutrient supply and the proliferation, differentiation and maturation of cells occur in a constant and balanced manner, sensitive to the demands of specific cell lineages and dependent on the stem cell population. In the present study, we evaluated the effect of PEM on some aspects of hemopoiesis, analyzing the cell cycle of bone marrow cells and the percentage of progenitor cells in the bone marrow. Two-month-old male Swiss mice (N = 7-9 per group) were submitted to PEM with a low-protein diet (4%) or were fed a control diet (20% protein) ad libitum. When the experimental group had lost about 20% of their original body weight after 14 days, we collected blood and bone marrow cells to determine the percentage of progenitor cells and the number of cells in each phase of the cell cycle. Animals of both groups were stimulated with 5-fluorouracil. Blood analysis, bone marrow cell composition and cell cycle evaluation was performed after 10 days. Malnourished animals presented anemia, reticulocytopenia and leukopenia. Their bone marrow was hypocellular and depleted of progenitor cells. Malnourished animals also presented more cells than normal in phases G0 and G1 of the cell cycle. Thus, we conclude that PEM leads to the depletion of progenitor hemopoietic populations and changes in cellular development. We suggest that these changes are some of the primary causes of pancytopenia in cases of PEM.

Stage-Specific Expressions of GLUT-1, GLUT-3 and GLUT-12 in Estrogen-Induced Breast Cancer

Increased glucose uptake and glycolysis are main metabolic characteristics of malignant cells. The glucose transporter-1 (GLUT-1), GLUT-3 and recently GLUT-12 have been shown in breast cancer cells in which estrogen play a critical role on its regulation and also associated with poor prognosis. However. the stage-specific GLUT regulation during the process of mammary carcinogenesis is unclear. In the present study we are aiming to study the GLUT expression pattern in an in vitro-in vivo model of estrogen induced carcinogenesis in which the human breast epithelial cell line MCF-10F is considered the normal counterpart E2 the transformed, C5 the invasive and T4 the tumorigenic stage. The gene expression of GLUTs was correlated with the ductulogenic pattern in a collagen matrix and the invasive properties using the Boyden chamber The RT-PCR data showed that the GLUT1 expression was downregulated in MCF10F after the treatment with 17β-estradiol (E2) and in the invasive cell type (C5), but not in the tumor cells (T4), which had no changes compared to MCF10F. C5 and T4 cells showed the highest rate of GLUT-3 expression. These cells were also found to be associated with loss of ductulogenesis, solid mass formation and higher invasion capacity. Whereas, GLUT-12 is downregulated in invasive and tumorigenic cells. We conclude that the estrogen-induced malignant transformation is associated with remarkably GLUT-3 expression, GLUT-1 re-expression at further stages, as well as GLUT-12 downregulation for transformed MCF-10F cells. (This work was supported by grant R21 ES015894from the NIEHS)

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5152.

Morphology of larval Gordius dimorphus (Nematomorpha: Gordiida)

Scanning electron microscopy was used to analyze superficial features of Gordius dimorphus Poinar, 1991, larvae that might serve as generic or specific diagnostic characters. Three adults of G. dimorphus (2 males and 1 female) were maintained under laboratory conditions until oviposition, which occurred within long strings commonly referred to as egg strings. Larvae have a cylindrical body, annulated and divided into 2 sections, plus an anterior preseptum and a posterior postseptum. Three concentric rings with 6 spines each surround the proboscis. The proboscis is retractile, dorsoventrally flattened, with 1 pair of forceps-like projections on its distal-most portion. On the surface of each projection, 3 pairs of aculeiforms spines are aligned and lean toward the proboscis opening. One large spine is present on the posterior portion of the postseptum. Papillae were not observed. Gordius dimorphus larvae are similar to previous light microscope descriptions. This is the first record of G. dimorphus in Brazil.

Proteocephalid cestode infection in alien fish, Cichla piquiti Kullander and Ferreira, 2006 (Osteichthyes: Cichlidae), from Volta Grande reservoir, Minas Gerais, Brazil

This work evaluates the variation of the parasitological indexes in 114 Cichla piquiti Kullander and Ferreira, 2006 (tucunaré) infected by two proteocephalid species (Cestoda) for the period of August 1999 to June 2001 in the Volta Grande reservoir, MG, Brazil. The relation between the parasitosis with rainfall and water quality (pH, electric conductivity, oxygen, chlorophyll, transparency and temperature) is discussed. Prevalence of Proteocephalus macrophallus (Diesing, 1850) and/or P. microscopicus (Woodland, 1935) was 83.3%, mean intensity 110.8 and mean abundance 100.7 during the period. A hundred percent prevalence was reported in August and December 1999, April and December 2000 and June 2001. The largest mean intensities of 122.7 (October 1999), 158.8 (December 1999), 96.4 (February 2000), 400.7 (April 2000), 215.6 (October 2000) and 136.4 (December 2000) were observed. Abiotic factors may favour the development of the species of the food chain that sustain the organisms in the diet of 'tucunaré', but in this case, there was no correlation (P > 0.05) between the values of prevalence, mean intensity and mean abundance with the rainfall and water quality. At the same time, these organisms may constitute the intermediate hosts of cestodes. The time-course between the fish species development and the parasitosis manifestation in the definitive host can explain the lack of correlation between the parasitological indexes and abiotic factors. The predation on small fishes and cannibalism described for 'tucunaré' might explain the high values of prevalence and intensity of infection. The results are also related to the exotic condition of the host in the reservoir.

Evidence for a change in the nuclear mass surface with the discovery of the most neutron-rich nuclei with 17<or=Z<or=25

The results of measurements of the production of neutron-rich nuclei by the fragmentation of a 76Ge beam are presented. The cross sections were measured for a large range of nuclei including 15 new isotopes that are the most neutron-rich nuclides of the elements chlorine to manganese (50Cl, 53Ar, ;{55,56}K, ;{57,58}Ca, ;{59,60,61}Sc, ;{62,63}Ti, ;{65,66}V, 68Cr, 70Mn). The enhanced cross sections of several new nuclei relative to a simple thermal evaporation framework, previously shown to describe similar production cross sections, indicates that nuclei in the region around 62Ti might be more stable than predicted by current mass models and could be an indication of a new island of inversion similar to that centered on 31Na.

p63 protein expression in high risk diffuse large B-cell lymphoma

BACKGROUND

p63 gene is a p53 homologue that encodes proteins with transactivation, DNA-binding and tetramerisation domains. The isoforms TAp63 and TAp73 transactivate p53 target genes and induce apoptosis, whereas the isoforms DeltaNp63 and DeltaNp73 lack transactivation and might have dominant-negative effects in p53 family members. p63 is expressed in germinal centre lymphocytes and can be related to the development of the lymphoma, but the prognostic significance of its expression in the survival of patients with diffuse large B-cell lymphoma (DLBCL) remains unclear.

AIMS

To determine whether quantitative immunohistochemical (IHC) analysis of p63 protein expression correlates with CD10 antigen, Bcl-6 antigen and IRF4 antigen expression and to determine whether p63 is a surrogate predictor of overall survival in high-intermediate and high risk DLBCL populations.

METHODS

CD10, Bcl-6 and IRF4 expression were retrospectively evaluated by IHC in 73 samples of high-intermediate and high risk DLBCL and were used to divide the lymphomas into subgroups of germinal centre B-cell-like (GCB) and activate B-cell-like (ABC) DLBCL. Similarly, p63 expression was evaluated by IHC and the results were compared with subgroups of DLBCL origin and with the survival rates for these patients.

RESULTS

p63 was expressed in more than 50% of malignant cells in 11 patients and did not show correlation with subgroups of GCB-like DLBCL or ABC-like DLBCL, but p63(+) patients had better disease-free survival (DFS) than those who were negative (p = 0.01).

CONCLUSIONS

p63(+) high-intermediate and high risk DLBCL patients have a better DFS than negative cases.

Acute Inpatients Units’ Old New Challenges: Compulsory Versus Voluntary Treatment

Background:

Besides preventive, maintenance and rehabilitative measures, it is very important that Psychiatry Services develop acute care interventions that include hospitalization treatments. Compulsory treatment is mandatory when patients have a severe mental illness that deprives them from their judgement abilities in such a way that they deny their illness, refuse necessary treatment, and may endanger themselves and/or others.

Aims:

To compare socio-demographic and clinical features of patients treated in compulsory and voluntary regimen. To make a reflection on the most suitable model for the acute inpatient services.

Methods:

Retrospective study of socio-demographic and clinical characteristics of patients admitted in an acute inpatients’ unit of a Psychiatric Hospital - Hospital de Magalhães Lemos - in 2006 and 2007. We compared data of compulsory (CA) and voluntary admissions (VA), and discuss their respective main problems.

Results:

Among the total 577 inpatients admitted, 13% were compulsory and 87% were voluntary. Schizophrenia was the most prevalent diagnosis in both groups (51% CA vs 26% VA). By discharge, prescription of depot antipsychotics was higher in CA, and treatment with antidepressants was higher in VA. In CA, 8 (11%) patients had discharge against medical advice (escape) vs 12 (2%) in VA.

Conclusion:

Results might suggest that the current facilities and/or procedures are not sufficient to offer the levels of protection needed to provide the best environment for patients’ recovery.

In the context of the recent efforts towards the reorganization of mental health services, specific measures should be considered, including acute inpatients units exclusively designed for CA.

Production and beta decay of rp-process nuclei 96Cd, 98In, and 100Sn

The beta-decay properties of the N=Z nuclei 96Cd, 98In, and 100Sn have been studied. These nuclei were produced at the National Superconducting Cyclotron Laboratory by fragmenting a 120 MeV/nucleon 112Sn primary beam on a Be target. The resulting radioactive beam was filtered in the A1900 and the newly commissioned Radio Frequency Fragment Separator to achieve a purity level suitable for decay studies. The observed production cross sections of these nuclei are lower than predicted by factors of 10-30. The half-life of 96Cd, which was the last experimentally unknown waiting point half-life of the astrophysical rp process, is 1.03_{-0.21};{+0.24} s. The implications of the experimental T_{1/2} value of 96Cd on the abundances predicted by rp process calculations and the origin of A=96 isobars such as 96Ru are explored.

The impact of a hybrid online and classroom-based course on palliative care competencies of family medicine residents

The University of Calgary offers a palliative care course that involves both classroom- and web-based learning for rural-based family medicine residents. This study assessed the impact of the course on palliative care-related competencies for two classes: 2004 and 2005. Instruments were developed to evaluate pre- versus post-course changes in knowledge (15-item quiz), attitudes (12-item survey), self-perceived comfort levels (19-item survey) and skills (3 long Objective Structured Clinical Examination stations (OSCEs), with accompanying standardised score sheets). In all, 16 and 20 residents participated in the 2004 and 2005 classes, respectively. Internal reliability values were acceptable to very good (Knowledge Quiz, Kuder-Richardson 20 = 0.5; Attitude Scale, alpha = 0.68-0.78; OSCE score sheets, alpha = 0.63-0.89; Self-Perceived Comfort Survey, alpha = 0.89-0.92). Inter-rater reliability values of the OSCE score sheets were alpha = 0.87 to 0.92. There was a significant improvement in the pre- versus post-course performances in OSCE 2 for 2004 and 2005 (P = 0.01; P = 0.01; d = 1.42 and 1.94, respectively). Despite statistically insignificant changes in the other OSCEs, acceptable to large effect sizes were noted (d = 0.4-1.34) for OSCE 1 in 2004 and OSCEs 3 in 2004 and 2005. Knowledge improved significantly pre-versus post-course in 2004 and 2005 (t = 4.44 and 8.99; d = 2.29 and 2.24, respectively). Significant improvements and large effect sizes were noted in the comfort scales, but a ceiling effect was noted in the communication subscale. This hybrid course resulted in significant improvements across four domains, knowledge, attitudes, self-perceived comfort scale, and skills, in 2 consecutive classes.

Prognostic impact of diffuse large B-cell lymphoma subgroups in patients undergoing autologous SCT

A total of 53 patients aged 18-60 years with high-intermediate or high-risk diffuse large B-cell lymphoma (DLBCL) were evaluated to analyze the impact of the cell of origin. Of 53 patients, 16 underwent autologous SCT (ASCT) in first remission and the rest received conventional chemotherapy. Immunohistochemistry was evaluated in 47 cases: 17 were of germinal center (GC) origin and 30 were of non-GC origin. There was no survival difference between the two groups. Overall survival (OS) and disease-free survival (DFS) at 3 years were 93 and 83%, respectively, for the 14 patients who underwent ASCT. Their DFS was significantly better than that of patients who achieved CR but did not undergo ASCT. We conclude that ASCT is safe and improves the DFS of high-intermediate and high-risk DLBCL, regardless of the cell of origin. This observation should be confirmed in a larger study.

Intruder configurations in the A=33 isobars: 33Mg and 33Al

The beta decay of 33Mg (N=21) presented in this Letter reveals intruder configurations in both the parent and the daughter nucleus. The lowest excited states in the N=20 daughter nucleus, 33Al, are found to have nearly 2p-2h intruder configuration, thus extending the "island of inversion" beyond Mg. The allowed direct beta-decay branch to the 5/2{+} ground state of the daughter nucleus 33Al implies positive parity for the ground state of the parent 33Mg, contrary to an earlier suggestion of negative parity from a g-factor measurement. An admixture of 1p-1h and 3p-3h configurations is proposed for the ground state of 33Mg to explain all of the experimental observables.

Palliative care education in Swiss undergraduate medical curricula: a case of too little, too early

Palliative medicine education is an important strategy in ensuring that the needs of terminally ill patients are met. A review was conducted in 2007 of the undergraduate curricula of all five of Switzerland's medical schools to identify their palliative care-related content and characteristics. The average number of mandatory hours of palliative care education is 10.2 h (median 8 h; range 0-27 h), significantly short of the 40 h recommended by the European Palliative Care Association's Education Expert Group. The median time allocated to designated palliative care blocks is 3 h (range 0-8 h). Most of the education occurs before the clinical years, and there are no mandatory clinical rotations. Three schools offer optional clinical rotations but these are poorly attended (<10% of students). Although a number of domains are covered, ethics-related content predominates; 21 of a total of 51 obligatory hours (41%). Communication related to palliative care is largely limited to 'breaking bad news'. In two of the schools, the teaching is done primarily by palliative care physicians and nurses (70% or more of the teaching). In the others, it is done mostly by educators in other clinical specialties and ethics (approximately 90% of the teaching). These findings show significant deficiencies.

The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution

In January 2006 the Centre Hospitalier Universitaire Vaudois (CHUV), a large university hospital in Lausanne, Switzerland, became the first hospital in Switzerland to allow assisted suicide (AS) in exceptional cases within its walls. However, euthanasia is illegal. This decision has posed several ethical and practical dilemmas for the hospital's palliative care consult service. To address these, the team embarked on a formal process of open dialogue amongst its members with the goal of identifying a collective response and position. This process involved meetings every 4 to 6 weeks over the course of 10 months. An iterative process unfolded. One of the principal dilemmas relates to finding a balance between the team's position against AS and the patient's autonomy and the institution's directive. Although all team members expressed opposition to AS, there were mixed opinions as to whether or not the team members should be present during the act if requested so by patients. Some thought this could be misinterpreted as complicity in the act and could send out mixed messages to the public and other health professionals about palliative care. Others felt that the team's commitment to nonabandonment obliged them to be present even if they did not provide the drug or give any advice or assistance. The implications of nonabandonment are explored, as are several other questions such as whether or not the teams are obliged to provide detailed information on AS when requested by patients.

A qualitative study of common functional problems experienced by people with complete ulnar nerve paralysis

OBJECTIVES

To identify the most common functional problems caused by ulnar nerve palsy. This study is the first phase in the process of developing a patient-centred hand function questionnaire specific for ulnar palsy.

DESIGN

Twenty-five participants with complete irreversible ulnar nerve palsy were asked to record the five main problems they had because of their hand deformity in the week before they came to hospital. They ranked these problems in order of priority. The participants had all been referred to LEPRA-HOINA Leprosy Reconstructive Surgery Hospital, Muniguda, Orissa, India for tendon transfer surgery.

RESULTS

Thirty-nine problems were experienced by the participants; 37 of these were functional problems. Five problems had a prevalence of > or =40%, these were holding soap (68%), eating (56%), buttoning (48%), holding a glass (44%) and lifting small objects (44%). Further analysis according to whether the left or right hand was affected was performed; 92% of participants with right ulnar nerve palsy had a problem eating compared to only 20% of those with left ulnar palsy. Eating was ranked as the most important problem by 28% of participants, holding a glass by 12% and holding soap by 8%.

CONCLUSIONS

Ulnar nerve palsy had an important impact on basic activities of daily living--eating, washing, and drinking. Not only are these activities themselves affected but the person with a hand deformity avoids social situations where it will be noticed. This study indicates that there is a need to identify and treat people who have ulnar nerve palsy in order that they can be integrated into society, become independent with activities of daily living and earn an income.

Use of ultrasound in 187 infants with suspected infantile hypertrophic pyloric stenosis

The diagnostic efficacy of ultrasound (US) in the diagnosis of infantile hypertrophic pyloric stenosis (IHPS) was evaluated, with particular attention paid to whether prematurity, age or weight correlate significantly to the sonographic measurements. The medical records of 187 infants with suspected IHPS were reviewed retrospectively. Eighty-seven had an US examination with details of the pylorus. Fifty-nine of these gave a positive diagnosis. The US criteria for a positive diagnosis were pyloric muscle thickness (PMT)>or=3 mm and pyloric muscle length (PML)>or=17 mm. The mean overall PMT was 4.14 mm and mean overall PML was 18.99 mm. Premature infants had a lower mean PML (17.8 mm) than the term infants (PML mean 19.3 mm); however, this was not significant (t-value 1.92, P=0.062). The sensitivity and specificity of PMT was 91 and 85%, respectively, and of PML 76 and 85%, respectively. The ability of US to diagnose IHPS using our criteria was significant (t-value, PMT 14.93 and PML 6.89; P<0.0001). There was no significant correlation between age, weight or prematurity and a sonographic diagnosis of IHPS (Pearson's coefficient<0.3). Therefore, the same US criteria should apply irrespective of prematurity, age or weight. Borderline PMT and PML measurements necessitate repeat US or alternative imaging.