Maternal chemical defenses predict offspring defenses in a dendrobatid poison frog

Within and among populations, alkaloid defenses of the strawberry poison frog (Oophaga pumilio) vary spatially, temporally, and with life history stage. Natural variation in defense has been implicated as a critical factor in determining the level of protection afforded against predators and pathogens. Oophaga pumilio tadpoles sequester alkaloids from nutritive eggs and are, thus, entirely dependent on their mothers for their defense. However, it remains unclear how tadpole alkaloid composition relates to that of its mother and how variation in maternally provisioned defenses might result in varying levels of protection against predators. Here, we demonstrate that natural variation in the alkaloid composition of a mother frog is reflected as variation in her tadpole's alkaloid composition. Tadpoles, like mother frogs, varied in their alkaloid composition but always contained the identical alkaloids found in their mother. Alkaloid quantity in tadpoles was highly correlated with alkaloid quantity in their mothers. Additionally, alkaloid quantity was the best predictor of tadpole palatability, wherein tadpoles with higher alkaloid quantities were less palatable. Mother frogs with greater quantities of alkaloids are, thus, providing better protection for their offspring by provisioning chemical defenses during one of the most vulnerable periods of life.

Evaluation of a computer-aided detection (CAD)-enhanced 2D synthetic mammogram: comparison with standard synthetic 2D mammograms and conventional 2D digital mammography

AIM

To evaluate the diagnostic performance of computer-aided detection (CAD)-enhanced synthetic mammograms in comparison with standard synthetic mammograms and full-field digital mammography (FFDM).

MATERIALS AND METHODS

A CAD-enhanced synthetic mammogram, a standard synthetic mammogram, and FFDM were available in 68 breast-screening cases recalled for soft-tissue abnormalities (masses, parenchymal deformities, and asymmetric densities). Two radiologists, blinded to image type and final assessment outcome, retrospectively read oblique and craniocaudal projections for each type of mammogram. The resulting 204 pairs of 2D images were presented in random order and scored on a five-point scale (1, normal to 5, malignant) without access to the Digital breast tomosynthesis (DBT) slices. Receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

There were 34 biopsy-proven malignancies and 34 normal/benign cases. Diagnostic accuracy was significantly improved for the CAD-enhanced synthetic mammogram compared to the standard synthetic mammogram (area under the ROC curve [AUC]=0.846 and AUC=0.683 respectively, p=0.004) and compared to the conventional 2D FFDM (AUC=0.724, p=0.027). The CAD-enhanced synthetic mammogram had the highest diagnostic accuracy for all soft-tissue abnormalities, and for malignant lesions sensitivity was not affected by tumour size. For all 68 cases, there was an average of 3.2 areas enhanced per image. For the 34 cancer cases, 97.4% of lesions were correctly enhanced, with 2.1 false areas enhanced per image.

CONCLUSIONS

CAD enhancement significantly improves performance of synthetic 2D mammograms and also exhibits improved diagnostic accuracy compared to conventional 2D FFDM.

CT staging for breast cancer patients with poor prognostic tumours

The aim of this study was to assess the value of computed tomography (CT) staging of the chest, abdomen and pelvis in patients with poor prognostic tumours and no symptoms of metastatic disease in those who have undergone primary surgical management for the treatment of breast cancer. Patients who had primary operable invasive breast cancer treated by surgery over a 2-year period were retrospectively identified. Pathological data from the surgical resection were used to calculate the Nottingham Prognostic Index. Patients with no symptoms of distant metastases who underwent CT staging of the chest, abdomen and pelvis as a result of being placed in the poor prognostic group were identified. The presence and sites of metastatic disease or any indeterminate finding were documented. Additional investigations generated as a result of the staging CT and the outcome were also recorded. Sixty-seven patients (80%) in the poor prognostic group underwent a staging CT. Forty-seven patients (70%) had no signs of metastatic disease on the staging CT. Two patients (3%) were diagnosed with metastatic disease, on the basis of the initial CT scan. Eighteen patients (27%) had an indeterminate finding requiring further investigation, generating 21 additional imaging tests - following this only one additional patient was diagnosed with metastatic disease. Seventeen patients with an initially indeterminate finding did not have metastatic disease, giving a false-positive rate of 25%. In total, three patients (4%) had a final diagnosis of metastatic disease. The routine use of CT staging in patients with no symptoms of distant metastases with primary operable breast cancer even when in a poor prognostic group is of limited value, with a low pick-up rate of metastatic disease and considerable risk of false-positive findings.

Does the insertion of a gel-based marker at stereotactic breast biopsy allow subsequent wire localizations to be carried out under ultrasound guidance?

AIM

To investigate whether the insertion of a gel-based marker at the time of stereotactic breast biopsy allows subsequent preoperative localization to be performed under ultrasound guidance.

MATERIALS AND METHODS

One hundred consecutive women who underwent either a 10 G stereotactic vacuum-assisted breast biopsy or 14 G stereotactic core biopsy with marker placement, followed by wire localization and surgical excision were identified. All had mammographic abnormalities not initially visible with ultrasound. The method of preoperative localization was recorded and its success judged with reference to the wire position on the post-procedure films relative to the mammographic abnormality and the marker. Histopathology data were reviewed to ensure the lesion had been adequately excised.

RESULTS

Eighty-three women (83%) had a successful ultrasound-guided wire localization. Successful ultrasound-guided localization was more likely after stereotactic vacuum biopsy (86%) compared to stereotactic core biopsy (68%), although this did not quite reach statistical significance (p=0.06).

CONCLUSION

The routine placement of a gel-based marker after stereotactic breast biopsy facilitates preoperative ultrasound-guided localization.

Managing soil nitrogen to restore annual grass-infested plant communities: effective strategy or incomplete framework?

Theoretical and empirical work has established a positive relationship between resource availability and habitat invasibility. For nonnative invasive annual grasses, similar to other invasive species, invader success has been tied most often to increased nitrogen (N) availability. These observations have led to the logical assumption that managing soils for low N availability will facilitate restoration of invasive plant-dominated systems. Although invasive annual grasses pose a serious threat to a number of perennial-dominated ecosystems worldwide, there has been no quantitative synthesis evaluating the degree to which soil N management may facilitate restoration efforts. We used meta-analysis to evaluate the degree to which soil N management impacts growth and competitive ability of annual and perennial grass seedlings. We then link our analysis to current theories of plant ecological strategies and community assembly to improve our ability to understand how soil N management may be used to restore annual grass-dominated communities. Across studies, annual grasses maintained higher growth rates and greater biomass and tiller production than perennials under low and high N availability. We found no evidence that lowering N availability fundamentally alters competitive interactions between annual and perennial grass seedlings. Competitive effects of annual neighbors on perennial targets were similar under low and high N availability. Moreover, in most cases perennials grown under competition in high-N soils produced more biomass than perennials grown under competition in low-N soils. While these findings counter current restoration and soil N management assumptions, these results are consistent with current plant ecological strategy and community assembly theory. Based on our results and these theories we argue that, in restoration scenarios in which the native plant community is being reassembled from seed, soil N management will have no direct positive effect on native plant establishment unless invasive plant propagule pools and priority effects are controlled the first growing season.

Does computer-aided detection have a role in the arbitration of discordant double-reading opinions in a breast-screening programme?

AIMS

To investigate whether a computer-aided detection (CAD) system could act as an arbitrator of discordant double-reading opinions, replacing the need for an independent third film reader.

METHODS

The mammograms of the 240 women that underwent arbitration by an independent third reader were identified from the 16,629 women attending our screening centre between July 2003 and April 2004. Mammograms of the arbitration cases were digitized and analysed by a CAD system. To assess the ability of CAD to act as the arbitrator, the site of the CAD prompts was retrospectively compared to the site of any abnormality noted by the original film readers. If a CAD prompt was placed on a region marked by one of the film readers then the decision of CAD as the arbitrator was that the women should be recalled for further assessment. If no mark was placed then the region was considered low risk and the decision was not to recall. The decision of CAD as the arbitrator was retrospectively compared with the original recall decision of the independent third reader.

RESULTS

There were 21 cancer cases in the group of women undergoing arbitration, diagnosed both at the original screening episode and subsequently. The independent third reader recalled 15/18 (83%) of the cancers that corresponded with the arbitrated lesion. CAD as the arbitrator would have recalled 16/18 (89%) of the cancers that corresponded to the arbitrated lesion. CAD acting as the arbitrator would have resulted in a significant increase in normal women being recalled to assessment in the arbitration group (P<0.001). The extra 50 recalls would have potentially increased the overall recall rate to assessment from 3.1 to 3.4%; a relative increase of 10%.

CONCLUSIONS

The main effect of CAD acting as an arbitrator of discordant double-reading opinions is to increase the recall rate, significantly above what is found when arbitration is performed by an independent third reader. Using CAD as an arbitrator may be an option to deal with discordant double-reading opinions when no other method of consensus or arbitration is available.

Can computerised tomography replace bone scintigraphy in detecting bone metastases from breast cancer? A prospective study

BACKGROUND

The aim of this study was to determine whether bone scans (BS) can be avoided if pelvis was included in CT thorax and abdomen to detect bony metastases from breast cancer.

MATERIALS AND METHODS

Results of 77 pairs of CT (thorax, abdomen, and pelvis) and BS in newly diagnosed patients with metastatic breast cancer (MBC) were compared prospectively for 12 months. Both scans were blindly assessed by experienced radiologists and discussed at multidisciplinary team meetings regarding the diagnosis of bone metastases.

RESULTS

CT detected metastatic bone lesions in 43 (98%) of 44 patients with bone metastases. The remaining patient had a solitary, asymptomatic bony metastasis in shaft of femur. BS was positive in all patients with bone metastases. There were 11 cases of false positive findings on BS.

CONCLUSION

Our findings suggest routine BS of patients presenting with MBC is not required if CT (thorax, abdomen, and pelvis) is performed.

Influence of temporal heterogeneity in nitrogen supply on competitive interactions in a desert shrub community

Soil nutrients in arid systems are supplied to plants in brief pulses following precipitation inputs. While these resource dynamics have been well documented, little is known about how this temporal heterogeneity influences competitive interactions. We examined the impacts of the temporal pattern of N supply on competitive intensity and ability in an N-limited desert shrub community. At our field site, the three codominant shrubs, Atriplex confertifolia, A. parryi, and Sarcobatus vermiculatus, differ in seasonal growth patterns, with A. confertifolia and S. vermiculatus achieving higher growth rates earlier in the growing season than A. parryi. We predicted that these timing differences in maximum growth rate may interact with temporal variation in N supply to alter competitive abilities over time. Seedlings of the two Atriplex species were planted either individually in field plots or as target plants surrounded by neighbor seedlings. After one year of establishment, the same amount of (15)N was applied to plots either as early spring pulses, mid spring pulses or continuously through the second growing season. Competitive effects were observed under continuous and pulsed N supply. Averaged across all target-neighbor treatments, competitive intensity was approximately 1.8-fold greater when N was pulsed compared to when N was supplied continuously, but overall, the outcome of competitive interactions was not influenced by N pulse timing. While the timing of resource supply did not differentially influence the competitive abilities of coexisting species in this system, the temporal pattern of resource supply did alter the intensity of competitive interactions among species. While additional studies in other systems are needed to evaluate the generality of these results, this study suggests that competitive intensity may not necessarily be a direct function of productivity or resource availability as traditionally assumed. Instead, the intensity of competitive interactions in resource-poor systems may depend upon the temporal pattern of resource supply.

Unusual benign breast lesions

The purpose of this article is to show examples of the radiological (mammography and/or ultrasound) and pathological appearances of unusual benign breast lesions. The conditions covered are granular cell tumours, fibromatosis, nodular fasciitis, myofibroblastomas, haemangiomas, neurofibromas, and leiomyomas. The article includes the first published description of the ultrasound appearance of a myofibroblastoma. Knowledge of these appearances may help confirm or refute radiological-pathological concordance of percutaneous biopsy results during multidisciplinary assessment of these lesions and aid patient management.

High apoplastic solute concentrations in leaves alter water relations of the halophytic shrub, Sarcobatus vermiculatus

Predawn plant water potential (Psi(w)) is used to estimate soil moisture available to plants because plants are expected to equilibrate with the root-zone Psi(w). Although this equilibrium assumption provides the basis for interpreting many physiological and ecological parameters, much work suggests predawn plant Psi(w) is often more negative than root-zone soil Psi(w). For many halophytes even when soils are well-watered and night-time shoot and root water loss eliminated, predawn disequilibrium (PDD) between leaf and soil Psi(w) can exceed 0.5 MPa. A model halophyte, Sarcobatus vermiculatus, was used to test the predictions that low predawn solute potential (Psi(s)) in the leaf apoplast is a major mechanism driving PDD and that low Psi(s) is due to high Na+ and K+ concentrations in the leaf apoplast. Measurements of leaf cell turgor (Psi(p)) and solute potential (Psi(s)) of plants grown under a range of soil salinities demonstrated that predawn symplast Psi(w) was 1.7 to 2.1 MPa more negative than predawn xylem Psi(w), indicating a significant negative apoplastic Psi(s). Measurements on isolated apoplastic fluid indicated that Na+ concentrations in the leaf apoplast ranged from 80 to 230 mM, depending on salinity, while apoplastic K+ remained around 50 mM. The water relations measurements suggest that without a low apoplastic Psi(s), predawn Psi(p) may reach pressures that could cause cell damage. It is proposed that low predawn apoplastic Psi(s) may be an efficient way to regulate Psi(p) in plants that accumulate high concentrations of osmotica or when plants are subject to fluctuating patterns of soil water availability.

The pathological and radiological features of screen-detected breast cancers diagnosed following arbitration of discordant double reading opinions

AIM

To compare the mammographic background pattern, the mammographic and the pathological features of screen-detected cancers diagnosed following arbitration of discordant double reading opinions with screen-detected cancers diagnosed following concordant double reading.

METHODS

Between April 2002 and December 2003, 249 patients were diagnosed with screen-detected malignancies following concordant double reading. In the same period 38 patients were diagnosed with screen-detected malignancies after their mammograms had undergone arbitration prior to recall. Mammograms of both groups of patients were reviewed retrospectively and the mammographic features documented. Histological data for both groups were also compared.

RESULTS

Cancers detected following arbitration were more likely to manifest as parenchymal distortions (44 versus 8%, p<0.001) and less likely to manifest as spiculate masses (19 versus 42%, p=0.014). Arbitration cancers were less likely to be detected in fatty breasts (4 versus 29%, p=0.01). Arbitration cancers were smaller (p=0.045). Lobular cancers were commoner in the arbitration group, although this was of borderline significance (19 versus 8%, p=0.057) There was no significant difference in patient age, tumour grade or lymph node stage between the two groups.

CONCLUSION

Cancers detected following arbitration are smaller and more likely to manifest as a parenchymal distortion compared with cancers detected by both readers. Arbitration cancers have broadly similar prognostic features to cancers detected by concordant double reading. It is estimated that approximately 11% more cancers are detected as a result of double reading with arbitration compared with single reading alone, after taking into consideration second reader bias.

Plant N capture from pulses: effects of pulse size, growth rate, and other soil resources

In arid ecosystems, the ability to rapidly capture nitrogen (N) from brief pulses is expected to influence plant growth, survival, and competitive ability. Theory and data suggest that N capture from pulses should depend on plant growth rate and availability of other limiting resources. Theory also predicts trade-offs in plant stress tolerance and ability to capture N from different size pulses. We injected K15NO3, to simulate small and large N pulses at three different times during the growing season into soil around the co-dominant Great Basin species Sarcobatus vermiculatus, Chrysothamnus nauseosus ssp. consimilis, and Distichlis spicata. Soils were amended with water and P in a partial factorial design. As predicted, all study species showed a comparable decline in N capture from large pulses through the season as growth rates slowed. Surprisingly, however, water and P availability differentially influenced the ability of these species to capture N from pulses. Distichlis N capture increased up to tenfold with water addition while Chrysothamnus N capture increased up to threefold with P addition. Sarcobatus N capture was not affected by water or P availability. Opposite to our prediction, Sarcobatus, the most stress tolerant species, captured less N from small pulses but more N from large pulses relative to the other species. These observations suggest that variation in N pulse timing and size can interact with variable soil water and P supply to determine how N is partitioned among co-existing Great Basin species.

The use of a short-acting benzodiazepine to reduce the risk of syncopal episodes during upright stereotactic breast biopsy

The use of sublingual lorazepam provides a safe and effective means of reducing the risk of syncopal episodes during upright stereotactic breast biopsy. Sublingual lorazepam, 2-4mg, was received by 19 women undergoing a total of 20 stereotactic procedures. Of 14 women who had previously fainted during upright stereotactic biopsy, 13 had a successful repeat biopsy following administration of sublingual lorazepam. All 4 women who received lorazepam for significant anxiety had successful biopsies. Stereotactic guided wire localization also was performed in 2 cases.

Patterns of metastatic breast carcinoma: influence of tumour histological grade

AIM

To assess if the pattern of metastatic spread of carcinoma of the breast varies according to tumour histological grade.

MATERIALS AND METHODS

The clinical details, histological features of the primary tumour, and imaging findings at presentation of patients with metastatic breast cancer have been recorded prospectively since 1997. The pattern of metastatic spread, age at metastasis, metastasis-free interval (MFI), and length of survival with metastases were analysed by tumour grade.

RESULTS

There was a significant association between histological high-grade tumours and high frequency of intra-pulmonary metastases (p=0.013); liver metastases (p=0.039); para-aortic lymphadenopathy (p=0.022) and metastatic presentation under 50 years of age (p=0.003). A significant correlation was also demonstrated between histological low-grade tumours and increased frequency of pleural disease (p=0.020); increased frequency of bone metastases (p=0.004); prolonged MFI (MFI>5 years; p<0.0001); and increased length of survival (p<0.0001).

CONCLUSION

There is a correlation between patterns of metastatic spread and tumour histological grade. This partly explains the negative prognostic value of high tumour grade, as metastases from grade 3 tumours more commonly occur at sites associated with a worse prognosis. This finding may also prove useful in interpreting imaging in patients who have a history of breast cancer and undergo subsequent imaging because of new symptoms.

Brain metastases from breast cancer: identification of a high-risk group

AIMS

Brain metastases from breast cancer are an uncommon initial presentation of metastatic breast cancer, but brain metastases commonly occur later in women's metastatic illness. The aims of this study were to document the type, frequency, and temporal occurrence of brain metastases from breast cancer as well as the survival of women with such metastases, and to attempt to identify a subgroup of women at high risk of brain metastases who may benefit from pre-emptive medical intervention.

MATERIALS AND METHODS

The radiological reports of all women presenting with metastases aged under 70 years who had subsequently died were examined. The type, frequency, temporal occurrence and survival with brain metastases were documented. Correlations were sought between the frequency of brain metastases and age at metastatic presentation, tumour grade, histological type and oestrogen receptor (ER) status.

RESULTS

Of 219 patients who had died with metastatic disease and who were under 70 years of age at metastatic presentation, 49 (22%) developed brain metastases. The development of brain metastases was related to young age (P = 0.0002), with 43% of women under 40 years developing brain metastases. Brain metastases were more common in women whose tumours were ER negative (38%) compared with women with ER-positive disease (14%) (P = 0.0003). By combining age and ER status, it is possible to identify a group of women (age under 50 years and ER negative) with a 53% risk of developing brain metastases. This group included many women who had chemotherapy for visceral metastases, and 68% had either stable disease or disease response at other sites at the time of brain metastases presentation.

CONCLUSION

It is possible to identify a subgroup of women with metastatic breast cancer at high risk of brain metastases who may benefit from pre-emptive medical intervention, such as screening or prophylactic treatment.

Metastatic Carcinoma of the Breast with Tubular Features: Differences Compared with Metastatic Ductal Carcinoma of No Specific Type

AIMS

To compare the metastatic pattern at presentation and the prognosis with metastases of 48 patients with carcinomas with tubular features (45 tubular mixed and three pure tubular) and 302 patients with tumours of ductal of no special type (DNST).

MATERIALS AND METHODS

We carried out a retrospective study from a prospectively maintained database of all patients who developed metastatic disease from carcinoma of the breast in Nottingham, U.K., since 1997. We recorded site of first presentation with metastatic disease, radiological features, histological features and characteristics of the primary tumour.

RESULTS

The group of patients with tubular features were older at metastatic presentation (63.9 years vs 59.6 years; P=0.012), had a longer disease-free interval (87 months vs 34 months: P<0.001) and a longer survival with metastases (P<0.002). This group were less likely to have liver metastases (23% vs 41%; P=0.028), in particular multiple liver metastases (50% vs 71%; P=0.015) than the patients with DNST. Other factors known to be associated with prolonged survival, such as low histological grade of the primary invasive tumour and positive oestrogen receptor (ER) status, were more common in the group of patients with tumours with tubular features (Grade 1: 33% vs 3%; Grade 2: 42% vs 25%; Grade 3: 25% vs 72%; P<0.001), (ER positivity 76% vs 52%; P=0.009). When patients with grade 2 tumours were compared, the age at metastatic presentation, disease-free interval and the presence of multiple liver metastases were still significantly different between the two groups.

CONCLUSION

Patients with metastatic breast carcinoma with tubular features have a longer survival with metastases than patients with metastatic DNST carcinoma. This improved survival can be explained by better well-recognised prognostic features, such as metastatic site pattern, histological grade, ER status and disease-free interval.

The current status of digital mammography

Digital imaging has shown rapid advances in recent years. Various different digital mammography systems are now available for clinical use. Digital mammography does have clear advantages over traditional screen film mammography, but this is yet to convincingly translate into improved cancer detection rates. This review aims to describe the different technologies, introduce concepts related to image quality and review the current evidence for the use of digital mammography systems in clinical practice. Advanced applications of digital mammography such as computer-aided detection (CAD) are also discussed.

Diagnosis of axillary nodal metastases by ultrasound-guided core biopsy in primary operable breast cancer

The purpose of this study was to examine the use of ultrasound (US)-guided core biopsy of axillary nodes in patients with operable breast cancer. The ipsilateral axillae of 187 patients with suspected primary operable breast cancer were scanned. Nodes were classified based on their shape and cortical morphology. Abnormal nodes underwent US-guided core biopsy/fine needle aspiration (FNA), and the results correlated with subsequent axillary surgery. The nodes were identified on US in 103 of 166 axillae of patients with confirmed invasive carcinoma. In total, 54 (52%) met the criteria for biopsy: 48 core biopsies (26 malignant, 20 benign node, two normal) and six FNA were performed. On subsequent definitive histological examination, 64 of 166 (39%) had axillary metastases. Of the 64 patients with involved nodes at surgery, preoperative US identified nodes in 46 patients (72%), of which 35 (55%) met the criteria for biopsy and 27 (42%) of these were diagnosed preoperatively by US-guided biopsy. In conclusion, US can identify abnormal nodes in patients presenting with primary operable breast cancer. In all, 65% of these nodes are malignant and this can often be confirmed with US-guided core biopsy.

Extensive summer water pulses do not necessarily lead to canopy growth of Great Basin and northern Mojave Desert shrubs

Plant species and functionally related species groups from arid and semi-arid habitats vary in their capacity to take up summer precipitation, acquire nitrogen quickly after summer precipitation, and subsequently respond with ecophysiological changes (e.g. water and nitrogen relations, gas exchange). For species that respond ecophysiologically, the use of summer precipitation is generally assumed to affect long-term plant growth and thus alter competitive interactions that structure plant communities and determine potential responses to climate change. We assessed ecophysiological and growth responses to large short-term irrigation pulses over one to three growing seasons for several widespread Great Basin and northern Mojave Desert shrub species: Chrysothamnus nauseosus, Sarcobatus vermiculatus, Atriplex confertifolia, and A. parryi. We compared control and watered plants in nine case studies that encompassed adults of all four species, juveniles for three of the species, and two sites for two of the species. In every comparison, plants used summer water pulses to improve plant water status or increase rates of functioning as indicated by other ecophysiological characters. Species and life history stage responses of ecophysiological parameters (leaf N, delta15N, delta13C, gas exchange, sap flow) were consistent with several previous short-term studies. However, use of summer water pulses did not affect canopy growth in eight out of nine comparisons, despite the range of species, growth stages, and site conditions. Summer water pulses affected canopy growth only for C. nauseosus adults. The general lack of growth effects for these species might be due to close proximity of groundwater at these sites, co-limitation by nutrients, or inability to respond due to phenological canalization. An understanding of the connections between short-term ecophysiological responses and growth, for different habitats and species, is critical for determining the significance of summer precipitation for desert community dynamics.

Bone metastases from breast carcinoma: histopathological - radiological correlations and prognostic features

The aim of this study was to identify factors that may be associated with the development of bone metastases in patients with metastatic breast carcinoma and to see if any of these factors had a bearing on subsequent survival. In total, 492 patients presented to the Nottingham City Hospital with metastatic breast carcinoma between July 1997 and December 2001. Of these, 267 patients had bone metastases at presentation with metastatic disease, 91 patients in this group had bone as their only site of metastatic disease. Sites of first presentation of metastatic disease were prospectively recorded, as were histological features of the primary tumour (tumour type, histological grade, lymph node stage, tumour size and oestrogen receptor (ER) status). The radiological features of the bone metastases, the metastasis-free interval and serological tumour marker levels at presentation with metastases were all recorded. There was a significant association between the development of bone metastases and lower grade tumours (P=0.019), ER-positive tumours (P<0.0001) and the lymph node stage of the primary tumour (P=0.047). A multivariate analysis found that metastasis-free interval, additional sites of metastatic disease other than bone, ER status and serological tumour marker levels all independently contributed to survival from time of presentation with bone metastases.

Prognostic factors for patients with hepatic metastases from breast cancer

Median survival from liver metastases secondary to breast cancer is only a few months, with very rare 5-year survival. This study reviewed 145 patients with liver metastases from breast cancer to determine factors that may influence survival. Data were analysed using Kaplan-Meier survival curves, univariate and multivariate analysis. Median survival was 4.23 months (range 0.16-51), with a 27.6% 1-year survival. Factors that significantly predicted a poor prognosis on univariate analysis included symptomatic liver disease, deranged liver function tests, the presence of ascites, histological grade 3 disease at primary presentation, advanced age, oestrogen receptor (ER) negative tumours, carcinoembryonic antigen of over 1000 ng ml(-1) and multiple vs single liver metastases. Response to treatment was also a significant predictor of survival with patients responding to chemo- or endocrine therapy surviving for a median of 13 and 13.9 months, respectively. Multivariate analysis of pretreatment variables identified a low albumin, advanced age and ER negativity as independent predictors of poor survival. The time interval between primary and metastatic disease, metastases at extrahepatic sites, histological subtype and nodal stage at primary presentation did not predict prognosis. Awareness of the prognostic implications of the above factors may assist in selecting the most appropriate treatment for these patients.British Journal of Cancer (2003) 89, 284-290. doi:10.1038/sj.bjc.6601038 www.bjcancer.com

Is the presence of mammographic comedo calcification really a prognostic factor for small screen-detected invasive breast cancers?

AIM

It has been suggested that the use of traditional prognostic factors such as histological grade and lymph node stage are not reliable predictors of outcome for small (<15 mm diameter) screen-detected breast cancers. It has also been suggested that the presence of mammographic comedo (casting) microcalcifications may be an important prognostic factor. We have determined prognostic factors for small screen-detected cancers in a univariate and multivariate fashion.

MATERIALS AND METHODS

Histological grade, lymph node stage, invasive tumour size and vascular invasion status was obtained on 161 consecutive patients with primary invasive breast cancer <15 mm diameter, detected by screening. The Nottingham Prognostic Index was calculated for each patient. The mammograms were assessed for the presence of microcalcifications, these being classified as either comedo or non-comedo. Survival data was also obtained.

RESULTS

Overall survival in this group of patients was excellent with only 12 patients (7.5%) dying from their breast cancer (mean follow-up 7.5 years). Univariate analysis showed a significant association between lymph stage and outcome (chi(2)=9.68, P=0.008). No significant association was demonstrated between the presence of comedo calcification and survival. Multivariate analysis confirmed lymph node stage as the only independent prognostic factor for these small screen-detected breast cancers (chi(2)=7.18, P=0.007). There were significant associations between the presence of comedo calcification on the screening mammogram and high histological grade and small tumour size.

CONCLUSION

Although the overall outcome for small screen-detected breast cancers (<15 mm diameter) is excellent, the presence of lymph node metastases is associated with a significant reduction in long-term survival. The presence of mammographic comedo calcification is not an independent prognostic factor, but is closely related to histological grade.

Developments in digital radiography: an equipment update

Digital X-ray imaging technology has advanced rapidly over the past few years. This review, particularly aimed at those involved in using and purchasing such technology, is an attempt to unravel some of the complexities of this potentially confusing subject. The main groups of X-ray imaging devices that are considered are digitisers of conventional radiographs, image-intensifier-based fluorography systems, photostimulable phosphor computed radiography, amorphous selenium-based technology for thorax imaging and flat-panel systems. As well as describing these different systems, we look at ways of objectively assessing their image quality. Concepts that are used and explained include spatial resolution, grey-scale bit resolution, signal-to-noise ratio and detective quantum efficiency. An understanding of these basic parameters is vital in making a scientific assessment of a system's performance. Image processing and techniques are also briefly discussed, particularly with reference to their potential effects on image quality. This review aims to provide a basic understanding of digital X-ray imaging technology and enables the reader to make an independent and educated assessment of the relative merits of each system.

Neurologic recovery and neurologic decline after spinal cord injury

Physicians caring for patients with spinal cord injury facilitate neurologic recovery by optimizing nutrition and general health, by coordinating active exercise and functional training to enhance the underlying synapse growth, reversal of muscle atrophy, and motor learning, and by controlling interfering spasticity. SCI physicians also must monitor for neurologic decline during initial rehabilitation and later in life, diagnose promptly and accurately such decline, and orchestrate the appropriate intervention.

Substance abuse and sexual activity in an overseas population of adolescent military dependents

To determine the incidence of high-risk behaviors, such as substance abuse and sexual activity, in an overseas population of adolescents, and how these rates compared to the general population in the United States, a survey of high school-aged military dependents residing overseas was undertaken. A questionnaire was designed and distributed to all 8th through 12th graders at the Department of Defense Dependent's School in Seoul, Korea. Use of tobacco products and a history of illicit drug use was similar to that of referant groups in the United States. Present use of illicit drugs was decreased. Use of alcohol was increased over that of similar age groups in America. The authors discuss these findings in light of the environmental differences in the overseas military community.

Oral administration of active vitamin D metabolites to low birthweight infants

The active vitamin D metabolites 1 alpha, 25-dihydroxycholecalciferol (Rocaltrol) and the analogue 1 alpha-hydroxycholecalciferol (One-Alpha) are adequately absorbed after oral administration in the preterm infant. The absorption pattern is similar to that seen in adults.

A model for dental workload measurement

The primary purpose of the study was to develop a model that would provide an efficient and standardized approach to workload reporting in a non-fee (HMO-like) dental care system. The model was also designed to predict the dental personnel resource requirements in the system as the overall dental needs of the population were already known. To accomplish this, a set of 246 task/procedures representing the broad scope of dental practice was developed. For each task/procedure, a Best Time-weighted Estimate (BTE) in terms of average expected man-minutes of work required for accomplishment was developed from over 35,000 actual time measurements on patient visits to 29 US Army dental clinics located throughout the United States. Because of the nature of the specific task/procedure data, it was necessary to use four different mathematical models to produce statistically optimal BTEs. It was concluded that, cumulatively the BTEs developed for each task/procedure evaluated could be used as a basis for both the development of a Dental Care Composite Unit workload measure and the determination of overall dental personnel resource requirements in a non-free dental care system.

Etiology of viral hepatitis in American soldiers

To define better which types of hepatitis are prevalent among American soldiers, the authors studied 413 separate episodes of acute viral hepatitis among 412 soldiers admitted to US Army hospitals during 1978-1979. Most soldiers (68.8%) had acute hepatitis B (estimated annual hospitalization rate: 5.41/1000 soldiers in West Germany, 2.51/1000 in South Korea, less than 1/1000 in the United States). Subtype ayw was predominant in Germany, whereas adr was predominant in South Korea. Hepatitis B was more often associated with contact history or parenteral use of drugs in West Germany than in South Korea (p less than 0.001). Non-A, non-B hepatitis accounted for 27% of cases in West Germany (2.16/1000), but only 3% in South Korea (0.11/1000); hepatitis A only 15% in South Korea (0.48/1000) and 1% in West Germany (0.08/1000). These findings indicate that hepatitis B is the most prevalent form of viral hepatitis among US soldiers worldwide but also suggest substantial differences in the epidemiology of this infection in South Korea and West Germany. Such data will be useful in developing hepatitis B immunization policy within the military.

The transmission and interpretation of emergency department radiographs

Twenty-five radiographic studies representative of the spectrum of trauma cases that might present to an emergency department were selected from actual cases presenting at Brooke Army Medical Center (BAMC) in San Antonio, Texas. The studies were then transmitted from a local television studio via satellite back to BAMC and three other Army hospitals. A panel of 29 physicians (11 radiologists, 7 emergency physicians, and 11 others from various specialty areas) viewed the images on commercial grade television sets and attempted to make a diagnosis. The diagnostic accuracy of the radiologists (86%) was significantly better than that of the other two groups (77% each). However, given the overall expense of a teleradiology network, this difference in accuracy - especially when translated into clinically significant errors - might not justify the establishment of such a network in terms of cost-effectiveness.

Serological markers for hepatitis types A and B among U.S. Arym soldiers, Germany

Viral hepatitis rates among U.S. Army soldiers in Europe have been found to be two to three times higher than corresponding rates for soldiers stationed in the U.S. Sera from 89 per cent of a representative Army unit with 865 members and a known hepatitis problem were tested for HBsAg, anti-HBs, anti-HBc, and anti-HA. The prevalence of HB markers was 20 per cent, and hepatitis A antibody was present in 25 per cent. A six-month follow-up, conducted on 260 individuals initially negative for all four tests, revealed that 11 of these were now HB seropositive, whereas none had seroconverted to anti-HA positive. The HB virus was the principal agent responsible for hepatitis in the unit surveyed.