Preoperative axillary ultrasound scan: its accuracy in assessing the axillary nodal status in carcinoma breast

The aim of this study is to report the accuracy of ultrasound scan in axillary node staging in breast carcinoma. Eighty-four patients with breast cancer attending a breast clinic were entered in this study and axillary ultrasound scan was performed using a 7.5 MHz probe. The sensitivity of ultrasound scan in detection of axillary nodal metastasis was 74% with a specificity of 89%, positive predictive value of 87%, negative predictive value of 84% and overall accuracy of 83%. The sensitivity was low (38%) when nodes were small or non-palpable. The Likelihood Ratio (LR) for the test positive was 6.37 and the LR for the test negative was 0.29. The combined assessment (Clinical Examination+Ultrasound scan+FNA) of axillary node status was very sensitive--88%, with a specificity of 100%, positive predictive value of 100%, negative predictive value of 88% and overall accuracy of 92%. Ultrasound scan of axilla is a valuable method of preoperatively assessing axillary nodal status, and may prove useful in managing patients with breast cancer.

Do they suffer more? Reflections on research comparing suicide survivors to other survivors

This article contrasts public perceptions of suicide survivors with conclusions based on comparative studies of suicide, fatal accident survivors, and other survivors. Although suicide is commonly thought to cause a particularly burden-some grief, quantitative studies have often failed to support this. We then offer some interpretations of these findings and suggest future pathways for research.

Hypopharyngeal perforation: an uncommon cause of pneumoperitoneum

Endotracheal intubation is common practice being performed both electively and as an emergency. Complications of this procedure are uncommon. A case is described of hypopharyngeal rupture after emergency intubation that presented with a pneumoperitoneum. The clinical signs, relevant investigations and management options are discussed for this injury and the need is emphasised for a high index of suspicion in order to make an early diagnosis.

Randomised trial of octreotide for long term management of cirrhosis after variceal haemorrhage

OBJECTIVE

To assess the efficacy of long term octreotide as adjuvant treatment to programmed endoscopic sclerotherapy after acute variceal haemorrhage in cirrhotic portal hypertension.

DESIGN

Randomised clinical trial.

SETTING

University hospital.

SUBJECTS

32 patients with cirrhotic portal hypertension.

INTERVENTIONS

Programmed injection sclerotherapy with subcutaneous octreotide 50 micrograms twice daily for 6 months, or programmed injection sclerotherapy alone.

MAIN OUTCOME MEASURES

Episodes of recurrent variceal bleeding and survival.

RESULTS

Significantly fewer patients receiving combined octreotide and sclerotherapy had episodes of recurrent variceal bleeding compared with patients given sclerotherapy alone (1/16 v 7/16; P = 0.037, Fisher's exact test), and their survival was significantly improved (P < 0.02, log rank test); this improvement was maintained for 12 months after the end of the study. Combined treatment also resulted in a sustained decrease in portal pressure (median decrease -6.0 mm Hg, interquartile range -10 to -4.75 mm Hg, P = 0.0002) compared with sclerotherapy alone (median increase 1.5 mm Hg, interquartile range 0.25 to 3.25 mm Hg), as well as a significant improvement in liver function as assessed by plasma concentrations of bilirubin, albumin, and alanine aminotransferase and by hepatocyte metabolism of aminopyrine labelled with carbon-14.

CONCLUSION

Long term octreotide may be a valuable adjuvant to endoscopic sclerotherapy for acute variceal haemorrhage in cirrhotic portal hypertension.

The peer relations of dropouts: a comparative study of at-risk and not at-risk youths

Little research has been devoted to exploring the relationship between high school disengagement and friendship network changes. In this study, the characteristics of friends, the environments of the friendship network and the nature of peer relations of students at-risk and not at-risk of dropping out of high school were compared. A questionnaire was given to 191 high school students (109 males, 82 females) from a middle class environment at the beginning and end of the school year. Results indicated that at-risk students had more dropout friends, more working friends, fewer school friends and fewer same-sex friends. Sex differences were discovered in several areas. Findings are discussed in relation to research and theories pertaining to dropouts and adolescent development.

Citrobacter freundii and fatal neutropenic enterocolitis following adjuvant chemotherapy for breast cancer

Neutropenic enterocolitis is increasingly being recognized as a life-threatening complication of chemotherapy, mainly for haematological and lymphoproliferative malignancies. It is under-recognized clinically, with the diagnosis often being made on post-mortem examination. Although active medical management is generally preferred, surgical intervention may be indicated. We report a case of fatal neutropenic enterocolitis, secondary to Citrobacter freundii, following adjuvant chemotherapy for breast cancer. We also review the literature, examining the aetiology, diagnosis and management of this often fatal entity.

Octreotide in the control of post-sclerotherapy bleeding from oesophageal varices, ulcers and oesophagitis

Bleeding from oesophageal varices, oesophageal ulcers or oesophagitis is occasionally massive and difficult to control. Octreotide, a synthetic analogue of somatostin lowers portal pressure and collateral blood flow including that through varices, increases lower oesophageal sphincter pressure, and inhibits the gastric secretion of acid as well as pepsin. Our current experience suggests it is effective in controlling acute variceal haemorrhage. Therefore we have examined the efficacy of octreotide in the control of post-sclerotherapy bleeding from oesophageal varices, oesophageal ulcers and oesophagitis. During the study period 77 patients experienced a significant gastrointestinal bleed (blood pressure < 100 mm Hg, pulse > 100 beats per min or the need to transfuse 2 or more units of blood to restore the hemoglobin level) following injection sclerotherapy of oesophageal varices. The source of bleeding was varices in 42 patients, oesophageal ulcers in 31 and oesophagitis in 4. All patients received a continuous intravenous infusion of octreotide (50 micrograms/h) for between 40-140h. If bleeding was not controlled in the first 12h after commencing octreotide hourly bolus doses (50 micrograms) for 24h were superimposed on the continuous infusion. Haemorrhage was successfully controlled by an infusion of octreotide in 38 of the 42 patients with bleeding from varices, in 30 of 31 patients with oesophageal ulceration, and all patients with oesophagitis. In the 1 patient with persistent bleeding from oesophageal ulceration and in 2 of the 4 with continued haemorrhage from varices, haemostasis was achieved by hourly boluses of 50 micrograms octreotide for 24h in addition to the continuous infusion. No major complications were associated with octreotide administration. The results of this study clearly indicate that octreotide is a safe and effective treatment for the control of severe haemorrhage after technically successful injection of sclerotherapy.

The management of persistent or recurrent variceal bleeding after injection sclerotherapy by somatostatin

Sixteen patients with persistent (n = 11) or recurrent (n = 5) variceal bleeding after injection sclerotherapy and balloon tamponade were treated with an intravenous infusion of somatostatin 250μg/ h. Somatostatin infusion successfully controlled the bleeding in 15 of the 16 patients but one rebled after 72 h of treatment. In one patient with poor liver function (Child’s C) bleeding was not controlled by somatostatin, further injection sclerotherapy or balloon tamponade of the oesophagus. The results of this study, although uncontrolled and with a small number of patients, suggest that somatostatin is a very effective treatment for the control of post-injection sclerotherapy variceal bleeding.

A prospective randomised controlled trial comparing the efficacy of somatostatin with injection sclerotherapy in the control of bleeding oesophageal varices

Since previous reports have suggested that somatostatin may be of value in the control of acute variceal haemorrhage, we compared its efficacy with that of injection sclerotherapy in a randomised controlled clinical trial. Eighty consecutive patients with endoscopically-proven severe variceal bleeding were randomised to injection sclerotherapy (n = 41) or somatostatin (n = 39) given as a continuous infusion of 250 micrograms/h for 5 days plus daily bolus administration of 250 micrograms. The efficacy of injection sclerotherapy and somatostatin infusion in controlling haemorrhage and preventing rebleeding (censored at 5 days), mortality (censored at 28 days) and complications was compared. The aetiology of the portal hypertension and transfusion requirements was similar between the two groups, but there were more patients with severe liver disease (Child's C) in the somatostatin group. There was no significant difference between the two treatments in the initial (p = 1.0) or overall control of bleeding (p = 0.58). Furthermore, somatostatin was as effective as injection sclerotherapy in controlling bleeding in patients with severe liver disease or in those actively bleeding at the time of their endoscopy. The relative risk of rebleeding whilst receiving somatostatin compared to injection sclerotherapy was 1.39 [95% Confidence Interval (CI) 3.73; 0.52], but this was reduced to 0.98 (95% CI 0.37; 2.67) when readjusted for Child's grading, the only prognostic factor shown to be of significance. Mortality was not significantly different between the two groups of patients (p = 0.31). The relative risk of dying whilst receiving somatostatin compared to injection sclerotherapy was 1.6 (95% CI 3.93; 0.66) but was reduced to 1.03 (95% CI 0.47; 2.47) when adjusted for Child's grading, the only significant prognostic factor. Complications in the somatostatin group were minor and less frequent than after injection sclerotherapy. The results of this study indicate that somatostatin is a safe treatment, which is as effective an endoscopic injection sclerotherapy for acute variceal bleeding.

Management of massive upper gastrointestinal haemorrhage from multiple sites of peptic ulceration with somatostatin and octreotide--a report of five cases

Surgical management of massive upper gastrointestinal bleeding after failed medical treatment may be hazardous because of diffuse bleeding from several sites, further complicated in some patients by intercurrent disease, age, or previous surgery. Experience with combined somatostatin and octreotide therapy in five such patients is described. All were treated initially with either intravenous somatostatin (250 micrograms/hour) or octreotide (Sandostatin) (50 micrograms/hour) for periods ranging from three to five days, after which they were given subcutaneous octreotide (50 or 100 micrograms three times daily). Bleeding was controlled by this regimen in all cases. The patients were all discharged from hospital on either ranitidine (n = 4) or omeprazole (n = 1). Repeat endoscopy at the end of the treatment period with somatostatin and octreotide (n = 1) or four weeks after discharge (n = 3) showed complete healing of the bleeding sites. Somatostatin and octreotide may be of value in controlling severe upper gastrointestinal bleeding in patients in whom surgery is hazardous because of bleeding from several peptic lesions further complicated in some by intercurrent disease or age.

The management of gastrointestinal haemorrhage by somatostatin after apparently successful endoscopic injection sclerotherapy for bleeding oesophageal varices

Twenty-two patients who experienced a severe haemorrhage from either oesophagitis (n = 8) or ulcers (n = 14) following injection sclerotherapy of their oesophageal varices were treated with intravenous administration of somatostatin (250 micrograms/h). Somatostatin was effective in controlling haemorrhage and preventing rebleeding in all eight patients bleeding from oesophagitis and in 12 of the 14 patients bleeding from oesophageal ulcers. In two patients with ulcers, haemorrhage persisted despite two periods of concominant balloon tamponade and somatostatin infusion and bleeding was eventually controlled by repeated hourly bolus injections of the hormone for 24 h superimposed on the continuous infusion. The results of this study suggest that somatostatin is an effective and safe treatment for the control of bleeding from either oesophagitis or ulcers following injection sclerotherapy of oesophageal varices.

Prospective study of the serosubmucosal (extramucosal) suture technique for gastrointestinal anastomosis

Seventy gastrointestinal anastomoses were constructed in 52 patients using a single layer of interrupted sutures placed in the serosubmucosal or extramucosal layer. Gastric anastomoses (n = 16) were performed by a partly open method, small bowel and colonic anastomoses (n = 44) by a closed method, and colorectal anastomoses (n = 10) by an open method. Wound infection occurred in two patients (3.8%) and three patients died (5.8%). Anastomotic leakage in four patients (7.7%) arose from three ileocolic anastomoses and one colorectal anastomosis. The third leak from an ileocolic anastomosis resulted in death and necessitated termination of the study on ethical grounds. There were two other postoperative deaths from cardiorespiratory causes (3.8%). The serosubmucosal or extramucosal technique is safe and effective (leak rate 1 of 26; 3.8%) when performed by the partly open or open method for gastric and colorectal anastomoses. However, when constructed by the closed method a relatively high leakage rate (3 of 44; 6.8%) occurs in anastomoses (ileocolic) generally associated with a low morbidity.

Preduodenal mechanisms in initiating gallbladder emptying in man

The existence of preduodenal phases of gallbladder emptying in normal volunteers was investigated by evaluating the effect of sham feeding a sandwich (chew and spit) (n = 15), the sight and smell of food followed by sham feeding a cooked meal (n = 15), and gastric distension (intragastric balloon tube) (n = 9) on gallbladder emptying and comparing these responses with those after ingestion of a standard meal (n = 14). A control group given no intestinal stimuli were studied to determine the frequency of spontaneous emptying during fasting (n = 18). 99mTc-EHIDA (2,6 diethylphenylcarbamoylmethyliminodiacetic acid) was used as the biliary tracer. The frequency of gallbladder emptying during fasting was 0.0045/min. Thus, in any 20 min period emptying occurred spontaneously in only about 1 in 11 volunteers. Significant emptying (greater than 5 per cent over 20 min) occurred in 8 out of 15 volunteers after sham feeding a sandwich (P less than 0.001 versus control), in 8 out of 15 volunteers after sham feeding a cooked meal (P = 1.0 versus sandwich sham feed, n.s.), in 6 out of 9 volunteers after gastric distension (P less than 0.001 versus control) and in 14 out of 14 volunteers after meal ingestion. The rate of emptying was significantly greater in the gastric distension and meal ingestion groups compared with other groups (P less than 0.05). However, the emptying rate after sham feeding was not significantly different from spontaneous gallbladder emptying (P greater than 0.05, n.s.). There was no significant difference in time to onset of emptying between the four stimulus groups (P greater than 0.05, n.s.). These results suggest that pre-duodenal stimuli can evoke gallbladder emptying in man, although the precise physiological significance of this phenomenon remains to be established.