Evaluation of a computer program ('disect') to consolidate anatomy knowledge: a randomised-controlled trial.

BACKGROUND: The teaching of anatomy to medical undergraduates continues to develop. Medical imaging can accurately demonstrate anatomy. 'disect' is a computer program which manipulates and reconstructs real CT images in 3-D. AIM: To implement and assess a novel computer-based imaging resource. METHODS: Third-year undergraduate medical students at the University of East Anglia were randomised to different methods of delivering the program - either self-directed use or guided use with worksheets. Knowledge of gastro-intestinal anatomy was assessed using a 20-item test. Attitudes to using 'disect' were evaluated using Likert scales. RESULTS: Most students reported the program was easy to use and a valuable resource for learning anatomy. There was no difference in scores between guided use and self-directed use (10.7 marks versus 10.6 marks, p = 0.52). Students who undertook the anatomy special study module, which involved dissection of the digestive system, performed best (12.8 marks versus 9.9 marks, p = 0.005). CONCLUSION: Students can adequately use a computer program to see major anatomical structures derived from CT scans. Students reported that learning anatomy can be aided by the imaging-based resource. Learning anatomy is a multi-modal activity and packages like 'disect' can enhance learning by supplementing current teaching methods.

Is learning anatomy facilitated by computer-aided learning? A review of the literature.

BACKGROUND: There is ongoing debate concerning the best way to teach anatomy. Computer-assisted learning (CAL) is one option for teaching anatomy and these resources are increasingly available. AIMS: To assess the use of such resources in undergraduate medical student anatomy tuition. METHOD: Literature review. RESULTS: Eight quantitative studies were found and these tended to report favourably. Though these educational packages can show improvement in knowledge, the studies tended to cover small areas of anatomy or were assessed in short courses. There were also several assessments of learner's attitudes to CAL which tended to report favourably in terms of educational satisfaction and enjoyment. CONCLUSIONS: There is insufficient evidence to show that these resources have a true place for replacing traditional methods in teaching anatomy. Further research should be conducted to determine how to use these resources in conjunction with current teaching methods or how their use can be integrated into the current anatomy curriculum.

A Franco-British patients' and partners' satisfaction audit of breast reconstruction.

AIMS: To compare French and British patients' and partners' satisfaction with breast reconstruction after mastectomy and determine what factors affect it. METHODOLOGY: The study analysed validated questionnaires from 182 pairs (the woman and her partner), split equally between France and the UK. The patients underwent breast surgery at the Norfolk and Norwich University Hospital (NNUH) and at the Hôpital Saint-Louis in Paris, France. All main surgical procedures were considered. RESULTS: Participants were satisfied with the outcome but satisfaction levels differed between France and the UK, British patients reporting higher satisfaction (P=0.029) because of a closer match between their expectation and the outcome. There were also statistically significant differences in: There was no difference in satisfaction levels between patients and partners who accurately reported on patients' views and whose own views matched patients'. Satisfaction was correlated to the level of information, pain management, recovery time, technique used, cosmetic results, intervention timing, but not to the independent assessment of the outcome.

A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction.

METHOD: The cosmetic and psychological outcomes of patients who underwent reconstructive surgery, conservative surgery or simple mastectomy for breast cancer between 1995 and 2002 were compared. RESULTS: There was a significant correlation between good psychological adjustment and good cosmetic outcome scores (p=0.01-0.05). There was no difference in cosmetic outcome between different reconstruction methods. Reconstruction patients rated their cosmetic outcome better than conservative surgery patients, and conservative surgery patients better than mastectomy patients. There were no differences in psychological outcome between patient groups. CONCLUSION: Good perception of cosmetic outcome is associated with good psychological adjustment. There is no cosmetic advantage of one type of reconstruction over another. Reconstruction patients have a better body image compared with other treatment groups but there are no other psychological advantages of one type of treatment over another.

Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: an argument about timing.

OBJECTIVE: To conduct a systematic review to gather the available evidence on the optimum timing of the radiotherapy in relation to autologous breast reconstruction. MATERIAL AND METHODS: The data was extracted from scientific databases, and a manual follow-up of references. The studies were selected which included at least 20 patients with any method of autologous breast reconstruction who were treated with adjuvant radiotherapy either before or after their reconstruction, and had addressed the effects of radiotherapy on the cosmetic outcome in their results. The principal outcome was cosmetic appearance. Secondary outcomes were immediate and delayed complications. RESULTS: We could not find any randomised controlled trial on this topic. Ten studies were included, most were retrospective, heterogeneous in terms of control groups, radiation doses, follow-up duration, and outcome measurements. Two studies included no control groups, and four studies compared the outcomes of patients with radiotherapy either before (n=3) or after (n=1) autologous breast reconstruction. The overall incidence of complications was increased in patients with radiotherapy in three out of these four studies. Only four studies directly compared the outcomes of patients who received radiotherapy before with patients who received radiotherapy after autologous breast reconstruction and two out of these reported worse outcomes associated with post-reconstruction radiotherapy. CONCLUSIONS: Despite the paucity of the published data, the current evidence suggests that the radiation has a deleterious effect on autologous flap reconstruction. Until better methods of radiation delivery can be devised to minimise the long term radiation sequelae in the irradiated tissue, delayed reconstruction seems to be a safe option in most of the cases. However, the findings from these studies should be interpreted with great caution before generalising from their results.

Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria.

BACKGROUND: Several studies have suggested that breast cancer in black women is associated with aggressive features and poor survival. This study examines molecular markers along with clinical stage and pathological grade in breast cancer material from Jos, Nigeria. STUDY DESIGN: The histological diagnoses of 178 consecutive Nigerian patients with breast cancer were retrieved from their hospital records. A subset of 36 patients was staged and their tumours typed and graded. Immunohistochemical staining of sections from paraffin wax embedded tissues from these cases for the expression of oestrogen receptor (ER), progesterone receptor (PGR), Human ERBB2 (or HER2/neu), p53 and cyclin D1 (CCND1) was carried out using the avidin biotin complex (ABC) procedure. RESULTS: A majority of the cases were invasive ductal carcinoma (92.7%), high grade (grade 3, 70.6%) and of late clinical stage (stages III and IV, 58.3%). Only 25% and 27.8% of cases expressed ER and PGR respectively. The ERBB2 and CCND1 antigens were expressed in 25%, and 5.7% of cases respectively. The p53 protein was the most frequently expressed in this study (47.2% of cases). High grade tumours were significantly more likely to be ER and PGR negative (P = 0.006 and P = 0.002 respectively). CONLCLUSION: There is predominance of high grade, invasive ductal carcinomas which are likely to be ER and PGR negative but p53 positive. These features suggest a biologically aggressive form of breast cancer in Nigerian women with the possibility of poor response to both hormonal therapy and chemotherapy.

Information and support needs of women with primary relatives with breast cancer: development of the Information and Support Needs Questionnaire.

AIMS OF THE STUDY: The aim was to develop and pilot test a newly developed measure, The Information and Support Needs Questionnaire (ISNQ), for use with women with primary relatives with breast cancer. BACKGROUND/RATIONALE: Breast cancer is a major risk to the health of women in the United Kingdom (UK). Increasingly, research is documenting women's needs for information and support, particularly at the time of diagnosis. However, to date there is little understanding of the information and support needs of women who have a family history of breast cancer. Contributing to the dearth of understanding of female relatives' needs is the lack of valid and reliable instruments for use in descriptive and intervention research with this population. DESIGN/METHODS: The ISNQ and survey items documenting family history, sources of information and support for breast cancer risk, breast self-care practices, and other variables were pilot tested for the acceptability of the measures, appropriateness of the data collection methods, initial psychometric properties of the ISNQ, and time and financial costs of administration. Data were collected from 39 women living in the North-west of England who had primary relatives with breast cancer using mailed questionnaires and follow-up telephone interviews. FINDINGS: The items on the ISNQ were reported to be clear, acceptable to women and to yield relevant data. The psychometric properties of the new measure were satisfactory with a high reliability coefficient alpha. Descriptive findings indicate that women had moderate to high needs for information and support, but reported that these needs were not well met. CONCLUSIONS: The results of this pilot are guiding the development of a larger study in which the information and support needs of women with a family history of breast cancer are explored.

The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature.

AIM: Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome. METHODS: Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status. RESULTS: Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates. CONCLUSION: This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres.

Taking responsibility for cancer treatment.

One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n = 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n = 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n = 41) and a Surgeon Decision Group (n = 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Student assessment in undergraduate medical education in the United Kingdom, 1998.

This report describes the results of the project 'Assessment of Undergraduate Medical Education: Re-inventing the Wheel?' funded by the Nuffield Trust. The project was initiated in order to obtain information on current assessment practices in medical schools across the UK, to determine the extent of change as a consequence of the curricular reforms recommended by the General Medical Council (GMC) in 1993 and, if necessary, to stimulate debate about assessment and provide an impetus for change. The data obtained provide a detailed profile of the timing and nature of assessments used in medical schools and provide information for comparison with the survey of basic medical education in the British Isles carried out in 1977 and any subsequent studies. The study provides confirmatory and unexpected evidence. Schools are clearly revising their curricula consistent with recommendations made by the GMC. The main components of the study were as follows: a postal questionnaire sent to all UK medical schools, a national workshop, and four case studies of innovative assessment practices.

An evaluation of information cards as a means of improving communication between hospital and primary care for women with breast cancer.

This paper describes an intervention study aimed at improving communication between hospital services and the primary health care team. A series of information cards were developed by breast specialist secondary care professionals for members of the primary health care team. Women with breast cancer were involved in the communication pathway and were asked to take the information cards to their own general practitioner (GP) practice. It was envisaged that women would be more likely to utilize the primary health care team for information if they were aware that the primary health care team was in receipt of information specific to the treatment they had received. Women newly diagnosed with breast cancer were allocated to either an intervention (n=38) or non-intervention (n=38) group. Patient interviews were carried out around the time of diagnosis and at 4 months from diagnosis. Interviews were also carried out with 31 GPs to ascertain their views on the provision of information for women with breast cancer, and on the information cards if relevant. The study findings were interesting although not significant in terms of the direction anticipated. The cards did not impact on the utilization of the primary health care team and women in the intervention group were no more likely to utilize primary care sources of information than women in the non-intervention group. Factors such as the long-standing relationship women had with their GP, the perceived lack of specialist knowledge on the part of GPs and district nurses, and the women's perception that information seeking was not a tangible reason for primary care contact had an impact on information-seeking behaviour.

Current patterns of referral in breast disease.

The aim was to audit symptomatic referrals to this breast unit in 1998, in order to ascertain the main diagnosis in relation to age, and thereby identify the percentage and age of patients who were reassured and discharged without investigation. 3199 general practitioner referrals were seen in 1998. Of these, 8.7% (n=274) were diagnosed as cancer and 91.3% (n=2925) were given a non-malignant diagnosis. In those under 40 years, only 18 patients of the 1231 seen were diagnosed with cancer, and only one of these was younger than 30 years (29 years). Twenty-seven per cent (n=333) of women under 40 were diagnosed as normal, and of these 14% (n=174) had no investigation. We confirm the recommendations of the guidelines issued by the Department of Health, that in younger women without discrete lumps or family history, clinical examination and reassurance is adequate. This audit should therefore empower general practitioners, to confidently reassure the younger patient, without a discrete lump.

Impact of molecular biology on the clinical management of breast cancer.

The use of molecular markers is being explored in the prediction of risk of developing breast cancer, in the assessment of prognosis and in the identification of appropriate treatment. Rational selection of treatment for a patient requires an accurate assessment of the prognosis and prediction of the response to a given treatment. Neither of these is possible with current clinicopathological markers. As a result, the current management of breast cancer is empirical, based on the outcome of randomized clinical trials that examine average effects within populations. Clinicopathological factors can be used to separate patients into broad prognostic groups, and treatment decisions are made on this basis. With this approach up to 70% of patients receive adjuvant treatment that is either unnecessary or ineffective. Molecular biological markers have the potential to improve this situation. A wide range of markers have been shown to be predictors of prognosis, but added individually to current prognostic indicators they do not improve the functional accuracy of prognosis or response prediction. There is a need for a molecular prognostic index that combines the results of a number of markers and can be used in conjunction with a clinical index to produce a more useful prognosis. There is also a need for an index that will predict responses to specific treatments. The impact of molecular biology on clinical management is a revolution waiting to happen.

The relationship between breast asymmetry, breast size and the occurrence of breast cancer.

Breast cancer is the second most common cancer among women in the world and in developed countries it is the most common. The early identification of women at risk is therefore of great importance and any additional measures which may aid diagnosis, particularly in high risk groups, would be of benefit. Breast volume and breast asymmetry were calculated from mammograms of 250 women with breast cancer and compared with those of 250 age-matched controls. There was evidence that breast cancer patients had more breast asymmetry and larger breasts than age-matched healthy women. The former observation is the first evidence that high breast asymmetry may be a risk factor for breast cancer. Breast asymmetry is likely to be a predictor of, rather than the effect of breast cancer.

Is a histological section representative of whole tumour vascularity in breast cancer?

The assessment of a tumour's angiogenic potential, by measuring the microvessel density in histological sections, assumes that a 4-microm section is representative of whole tumour vascularity. This study has examined this assumption by comparing the vessel density found radiologically, after injecting specimens with contrast, with that found immunohistochemically. Twenty-one breast angiograms were performed following mastectomy for carcinoma and graded 1-3 for vessel density. Sections (4 microm) from these carcinomas were labelled for endothelial cells using anti-CD34, and the vessel counts were compared with the radiological grades. A significant correlation was found between the densities (P < 0.003, Kruskal-Wallis one-way ANOVA). We therefore conclude that the microvessel density measured in histological sections is representative of whole tumour vascularity.

Examining the technique of angiogenesis assessment in invasive breast cancer.

The intensity of angiogenesis as measured by the density of microvessels has been reported to be associated with a poor prognosis in invasive breast cancer in some, but not all, studies. The reasons for these discrepancies may be variations in the methodologies used. The monoclonal antibody used to identify the microvessels, the number of high-density areas or 'hotspots' counted and the type of value taken for statistical analysis (highest count or mean count) have varied between the different studies. We have assessed which of the three commonly used monoclonal antibodies provides the best visualization of microvessels in invasive breast cancer and have used methods that give reproducible data for the optimum number of 'hotspots' to count for each reagent. Thus, microvessels in formalin-fixed paraffin-embedded specimens from 174 primary breast cancers were immunohistochemically stained with monoclonal antibodies to FVIIIRAg, CD31 and CD34 and ten fields counted at 200 x magnification for each antibody. The highest count and the mean value of the highest of three, five and ten counts were used to examine the relationship between the density of microvessels and overall survival of patients with a median follow-up time of 7.1 years. Antibodies to CD31 and CD34 identified more vessels than antibodies to FVIIIRAg (median highest count per mm2: CD31 = 100, CD34 = 100, FVIIIRAg = 81). The monoclonal antibody to CD31, however, was the least reliable antibody, immunohistochemically staining only 87% of sections compared with 98% for the monoclonal to CD34 and 99% for the monoclonal to FVIIIRAg. There was a high degree of correlation between the number of vessels stained by the different antibodies, though there were some considerable differences in actual counts for serial sections of the same specimen stained by the different antibodies. Patients could be divided into two groups corresponding to those with high microvessel densities and those with low microvessel densities. Using Kaplan-Meier survival curves, there was a close association for all three antibodies between vessel density and survival whichever method of recording the highest vessel densities was used. Using log-rank tests and Cox's regression analysis, anti-CD34 gave the most significant results of the three antibodies, whereas a simple cut-off at the 75th percentile for the high and low groups produced the best association with patient survival. For anti-CD34 the highest microvessel density (P = 0.0014) and the mean value of the highest three microvessel densities (P = 0.004) showed a good correlation with patient death, whereas for anti-CD31 (P = 0.008) and anti-FVIIIRAg (P = 0.007) the highest count gave the best correlation using Cox's regression analysis.