Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey.

PURPOSE: Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS: An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS: The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS: There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.

Innovations for the future of breast surgery.

BACKGROUND: Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England. METHODS: Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery. RESULTS: Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla. CONCLUSION: Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

This article describes how future innovations in science and technology influence the management of breast cancer from a surgical perspective. This work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

Lecturer practitioners: a literature review.

Much of the existing literature on lecturer practitioners to date is comprised of the perspectives of individuals within the role and how they function in their specific setting. It is surprisingly difficult from this work, however, to define the role of lecturer practitioner. The authors were commissioned by a regional health authority to undertake a study of lecturer practitioners within that region. In the process of undertaking this study, a literature review was carried out. Whilst the authors found an abundance of literature surrounding the theory and practice gap, and the development of the lecturer practitioner role as one possible solution, they were not able to find a comprehensive review of the multifaceted aspects of the lecturer practitioner role. This paper is an attempt to provide such a review, and will address the following aspects: the need for lecturer practitioners; their origin within nursing and midwifery education; the development of the lecturer practitioner role; the debate surrounding academic and clinical credibility; and finally, the current situation for lecturer practitioners.

Recognition and assessment of teaching quality.

As colleges of nursing and midwifery move into higher education they will be shaped by the 'quality ethos' of their parent university, where in the past, excellence in teaching has in practice been less valued than other (e.g. research) activities. Application of the principles of standards, quality and competitiveness now underlie the quality assessment and quality audit procedures of the University Funding Councils. Colleges of nursing and midwifery have a culture that considers and values excellence in teaching. It is therefore essential that teachers of nursing and midwifery can clearly define their criteria for teaching quality, and more significantly, how this might be achieved, recognized and rewarded. This article discusses the nature of quality in education and suggests different models for consideration. The nature of teaching, teaching quality and competence is reviewed and analysed; with characteristics of good teaching given, in the context of higher education. The assessment of teaching is debated; and a range of criteria are suggested by which teaching activities might be evaluated and judged. By being clear and explicit about these issues nurse and midwifery teachers, as they move into higher education, can work with their higher education colleagues to shape the 'quality ethos' to one that values excellence in teaching on a par with that of research.

Prediction of fetal lung maturity by amniotic fluid fluorescence polarization, L:S ratio, and phosphatidyl glycerol.

The relation of amniotic fluid fluorescence polarization (FP) to fetal lung maturity was examined in 186 pregnancies terminating within 48 hours of the fluid collection. Among the 9 babies who developed hyaline membrane disease (HMD), 8 were associated with FP values of 0.340 or more, and 1 had an FP value of 0.329. In 95 of these patients, the lecithin:sphingomyelin (L:S) ratio and the presence or absence of phosphatidyl glycerol (PG) were also determined. All 9 infants with HMD had L:S ratios less than 2.00 and no PG detectable in the amniotic fluid. Using an FP value of 0.325 or less, an L:S ratio of 2.00 or more, and the presence of PG as criteria for lung maturity, FP, L:S ratio, and PG did not differ significantly in the number of false predictions of HMD. Each test detected some mature infants who would have been incorrectly classified by at least 1 of the other tests. The status of all infants born at 33 weeks' gestation or later who did not develop HMD would have been correctly predicted by FP, L:S ratio, or both. These 3 tests, therefore, are complementary and can be used in combination to reduce the number of false predictions of HMD.

Antihypertensive ureidopiperidines.

The synthesis of a series of 1-aralkyl-4-ureidopiperidines is reported. These compounds are related to the benzamidopiperidines exemplified by indoramin. Some of the ureidopiperidines are more potent antihypertensive agents than their benzamidopiperidine counterparts. Two examples, 1-(2-thenoyl)-3-[1-[2-(3-indolyl)ethyl]piperid-4-yl]urea and 1-(2-thenoyl)-3-[1-[4-(4-fluorophenyl)-4-oxobutyl]piperid-4-yl]urea (19 and 58), emerged as the most potent antihypertensive agents in this series.

Studies on the growth-inhibiting property of amniotic fluids from two United States population groups.

This study attempted to determine if lack of antimicrobial activity in amniotic fluid is the reason United States blacks have more amniotic fluid bacterial infection than whites. No significant interracial differences were found in a study of 111 fluids from whites and 56 fluids from blacks. It has been claimed that the phosphate:zinc ratio in amniotic fluid is an accurate predictor of antimicrobial activity. The present study found this often to be untrue. Amniotic fluids that lacked antimicrobial activity gained such activity when zinc was added, but the in vitro zinc levels required were usually higher than observed physiologic concentrations. Previous studies have claimed that antimicrobial activity first appears in the amniotic fluid in the third trimester of gestation. We found such activity in the majority of fluids by the end of the first trimester, with a Staphylococcus aureus indicator; in contrast, with Escherichia coli and Streptococcus agalactiae as test organisms, greater inhibition was observed after 35 weeks.

Neonatal sepsis due to group G streptococci.

Two cases of neonatal septicaemia due to group G streptococci (Streptococcus canis) are described. In one patient, infection coexisted with transient neonatal hyperthyroidism, while, in the other, concomitant group G streptococcal septicaemia and endometritis in the mother was seen. Group G streptococci are rare causes of infection, especially in the paediatric age group. Bacteria were identified by serological and biochemical methods. Both neonates responded well to penicillin therapy, but the maternal infection required combination therapy with penicillin G, gentamicin, and chloramphenicol. The literature on systemic group G streptococcal infection is briefly reviewed. With increasing use of serotyping in the identification of beta-haemolytic streptococci, non-group A organisms will probably be identified more frequently from neonatal and other infections.

Hypothesis: volatile anaesthetic agents enhance transplacental exchange between mother and fetus. A preliminary study of fetal scalp blood gas changes associated with enflurane anaesthesia.

A hypothesis that volatile anaesthetic agents, represented by enflurane, facilitate transplacental exchange was tested by simultaneous blood sampling of both mother and fetus. A trend towards improved fetal scalp blood gas status and maternal-to-fetal acid-base matching was observed with enflurane. Our results encourage further research into the feasibility of intra-uterine fetal resuscitation by anaesthetically induced promotion of intervillous perfusion.

Comparison of amniotic fluid optical density and foam stability test in predicting fetal lung maturity.

The ability of optical density measurements and the foam stability test to predict the L/S ratio of amniotic fluid (AF) was examined. Optical density measurements and the foam test predicted the L/S ratio with a similar degree of accuracy; neither was able to replace biochemical measurement of the L/S ratio because both gave false negative and false positive predictions. Optical density measurements and the foam test did not combine to increase the accuracy of prediction.

Effect of prophylactic outpatient administration of fenoterol on the time of onset of spontaneous labor and fetal growth rate in twin pregnancy.

A double-blind trial was conducted on outpatients with twin gestations to assess the effect of prophylactic administration of fenoterol on the fetal growth rate and the timing of the spontaneous onset of labor. No significant differences could be shown between the fenoterol-treated group of patients and the control group given a placebo. It is concluded that prophylactic administration of fenoterol does not have a significant effect upon the incidence of preterm labor or growth retardation in twin pregnancy.

Treatment of vaginal discharge with yoghurt.

A preliminary trial was conducted, using yoghurt to assess its potential for the management of vaginal discharge. The results were encouraging in non-specific vaginal discharge and warrant further investigation. The treatment was ineffective in reducing Trichomonas vaginalis infestation, and in this condition no further investigation is warranted.

Management of septic chemical abortion with renal failure. Use of a conservative regimen.

The concept that hysterectomy is of value in the management of septic abortion induced by instillation of soap or phenolic antiseptics into the uterus is challenged. Nineteen out of 20 such cases with renal failure were managed with intensive antibiotic therapy, peritoneal dialysis and an absolute minimun of surgical intervention. Seventeen patients recovered, with normal renal function. Of the 11 known to be subsequently exposed to conception seven have achieved normal pregnancies.

PIP: 20 cases of septic abortion were reviewed, all of which had suffered septic shock and renal failure attributed to intrauterine instillation of soap or phenolic antiseptic solutions, which were treated at Hammersmith Hospital from 1965-1972 to determine proper management of such patients. 19 were managed conservatively, from a surgical point of view, with 13 not even having the products of conception removed from the uterus. Intensive antibiotic treatment and peritoneal dialysis were the principles of management. 17 of the 19 recovered; all 17 retain normal renal function. Of these 17 survivors, 7 have had normal pregnancies, but only 11 of the 17 have been exposed to conception.

The amniotic fluid foam test and fat cell count in malnourished and well-nourished fetuses.

A malnourished fetus has a higher concentration of pulmonary surfactant in the amniotic fluid than its well-nourished contemporary. The clinical value of this observation is discussed. Malnourished fetuses have higher "fat cell" counts in their amniotic fluid than well-nourished contemporaries. Well-nourished fetuses, at the same gestational age have high fat cell counts when the surfactant concentration is high, and low fat cell counts when the surfactant concentration is low. The relationship between surfactant concentration and the fat cell count is discussed.

The quality of perinatal care received by patients in the Greater Harare area during 1973.

The perinatal deaths which occurred during 1973 in the Harare perinatal service were analysed in relation to their obstetric associations. Seventy-one per cent of all the deaths were associated with just five obstetric complications, namely asphyxia in laubour, preterm delivery, minor antepartum haemorrhage, unexplained intra-uterine death and disproportion. It is suggested that asphyxial deaths occurring labour will only be eliminated when continous cardiotocographic monitoring becomes standard practice for all patients. Until then, selected cardiotocography will remain as the main diagnostic aid. Its value will be improved by reviewing the principles of selection. The potential exists to eliminate preterm delivery by the use of beta-adrenergic stimulant drugs. It is suggested that the rational application of this potential would reduce perinatal mortality from preterm delivery. The unexplained intra-uterine deaths and those associated with a minor antepartum haemorrhage presented major problems of understanding and therefore management. These are discussed. Deaths associated with disproportion occurred in 0,10% of booked patients and 3,22% of unbooked patients. The management of the booked patient is satisfactory, and improvement in perinatal mortality will only be achieved by decreasing the number of unbooked patients.