The effect of introducing an in-theatre intra-operative specimen radiography (IOSR) system on the management of palpable breast cancer within a single unit.

INTRODUCTION: Intra-operative specimen radiography (IOSR) is used to screen specimens during breast-conserving surgery and attempt to identify incompletely excised lesions. Universal use of IOSR during surgery for impalpable breast cancer is advocated by current guidelines. This study evaluates the role of IOSR during breast-conserving surgery for palpable breast cancer. METHODS: Two cohorts of patients who underwent wide local excision for palpable breast cancer were identified. Retrospective analysis of histological margins, intra-operative cavity shaves, secondary re-excision rates and specimen weight was completed comparing performance prior to the introduction of IOSR (October 2003-April 2005) with that since its introduction (April 2006-October 2007). RESULTS: 224 Patients were included, 111 in the pre-IOSR cohort (PF) and 113 in the IOSR cohort (F). Patient demographics, tumour size and histology were comparable. No difference in margin involvement prior to intra-operative cavity shaving was noted, PF-26, F-31 (p=0.60). Intra-operative cavity shaves were carried out more frequently in the IOSR group, PF-9, F-32 (p=0.001). When compared with histological findings, IOSR identified margin compromise with sensitivity=58.1%, specificity=80.8%, positive-predictive value=56.25% and negative predictive value=81.9%. Re-operation rate was similar between the 2 groups, PF-26, F-31 (p=0.65). Significantly less tissue was excised following use of IOSR; PF-110g, F-70g (p=0.001). CONCLUSION: Introduction of IOSR significantly reduced specimen weights without increasing re-excision rates. As volume of breast tissue removed is the most significant determinant of cosmetic outcome following breast-conserving surgery, the use of IOSR should be advocated in the surgical management of palpable breast cancer.

The role of temporal artery biopsies in giant cell arteritis.

A knowledge of the disease process of giant cell arteritis and its diagnosis can help a surgeon to decide which patients will benefit from a biopsy being performed and identify where a biopsy would be of no value in their management. This article discusses the issues involved.

Improved experimental limit on the electric dipole moment of the neutron.

An experimental search for an electric dipole moment (EDM) of the neutron has been carried out at the Institut Laue-Langevin, Grenoble. Spurious signals from magnetic-field fluctuations were reduced to insignificance by the use of a cohabiting atomic-mercury magnetometer. Systematic uncertainties, including geometric-phase-induced false EDMs, have been carefully studied. The results may be interpreted as an upper limit on the neutron EDM of |d(n)|< 2.9 x 10(-26)e cm (90% C.L.).

Comparison of telomerase activity and GSTP1 promoter methylation in ejaculate as potential screening tests for prostate cancer.

New diagnostic tools are needed for the early detection of prostatic cancer. The molecular detection of prostate cancer cells in ejaculates was evaluated using complementary PCR-based methods. LNCaP cells, a cell line derived from prostatic carcinoma, were spiked into normal seminal ejaculates and the prostatic epithelial component of the specimens was isolated by immunomagnetic bead sorting, using a monoclonal antibody to prostate-specific membrane antigen (PSMA). Ejaculates from nine patients with a recent diagnosis of prostate cancer were processed in a similar fashion, using LNCaP-spiked aliquots as an internal positive control. Telomerase expression was evaluated by the telomeric repeat amplification protocol (TRAP) and glutathione S-transferase gene promoter (GSTP1) hypermethylation was evaluated by methylation-sensitive restriction endonuclease digestion and PCR amplification. Telomerase activity was detected in LNCaP cells recovered from normal seminal ejaculates but was not found in all nine samples from patients with prostate cancer. The sensitivity of GSTP1 analysis was similar to telomerase analysis for the detection of LNCaP cells from normal ejaculate samples but was positive in ejaculates from four out of nine patients with prostate cancer. GSTP1 DNA methylation status is more sensitive than telomerase analysis for the detection of malignant cells in seminal ejaculates from patients with prostate cancer.

Role of the renal collecting system in initial kidney stone formation.

BACKGROUND: The anatomic site where the initial kidney stone grows to a clinically significant size is unknown. METHODS AND MATERIALS: We studied human forniceal anatomy by microdissection and correlated the anatomic findings with the clinical presentation of kidney stones. In addition, we examined crystal attachment sites within the collecting system by direct infusion of calcium oxalate crystals into the renal pelvis of rabbits. RESULTS: Secondary urinary dead spaces were found in the fornices of compound papillae only, which were located at the poles of the kidneys. This feature correlated with a higher incidence of stones in these areas at the time of lithotripsy. Calcium oxalate crystals tended not to attach to either the renal papilla nor the pelvic sidewall unless these epithelia were previously injured with hydrochloric acid. CONCLUSION: The renal collecting system may serve as an anatomic site for crystal retention and growth but is unlikely to be the principal site for crystal attachment, unless prior cellular injury occurs.

Comparability of telephone and In-person structured clinical interview for DSM-III-R (SCID) diagnoses.

The SCID was administered twice, once by telephone and once in person (1 week later) to 41 college age men. For major depression (lifetime k =.64, current k =.66), results indicated good agreement. The lifetime occurrence estimate based on the telephone SCID diagnosis was lower than the in-person SCID estimate. Kappas for specific diagnoses were calculable for simple phobia (lifetime k =. 47, current k = .03) and social phobia (lifetime k =.29). Base rates were less than 10% for all individual diagnoses except lifetime major depression; therefore, the kappas may be unstable. For all diagnoses where there were any positive cases, percentages of negative agreement and specificity were high, whereas percentages of positive agreement and sensitivity were lower. Overall agreement was fair for specific lifetime diagnoses but poor for current diagnoses. These results suggest caution in assuming comparability of in-person and telephone SCID diagnoses. Circumstances under which a telephone SCID may be useful and ways to improve reliability are discussed.

Efficacy and cost-effectiveness of extracorporeal shock wave lithotripsy for solitary lower pole renal calculi.

PURPOSE: We determined the efficacy of extracorporeal shock wave lithotripsy monotherapy and compared its cost-effectiveness with percutaneous nephrolithotomy for the management of lower pole renal calculi. MATERIALS AND METHODS: The efficacy (stone-free rates at 3-months posttreatment) of shock wave lithotripsy with the modified Dornier HM3* machine was determined retrospectively in 114 patients with solitary lower pole renal calculi. Using cost data available from patient billing charges and efficacy data from the literature, the cost-effectiveness for percutaneous nephrolithotomy and shock wave lithotripsy as primary therapy was evaluated. To make this cost-effectiveness comparison, we developed a decision analysis model in which a patient in whom primary therapy failed was rendered stone-free with a secondary percutaneous nephrolithotomy procedure. RESULTS: The stone-free rates of solitary lower pole stones with a size range of less than 10, 11 to 20 and greater than 20 mm. were 76, 74 and 33%, respectively, with a single shock wave lithotripsy treatment. Based on average treatment costs for shock wave lithotripsy and percutaneous nephrolithotomy, the model results show that for stone sizes less than 2 cm. primary lithotripsy therapy followed by nephrolithotomy for failed cases is the least costly approach. For stone sizes greater than 2 cm. primary percutaneous nephrolithotomy may be more cost-effective. CONCLUSIONS: Whereas shock wave lithotripsy with the Dornier HM3 should be considered the initial treatment choice for most lower pole stones less than 2 cm., primary percutaneous nephrolithotomy should be considered for stones larger than 2 cm.

Venographic surveillance of tunneled venous access devices in adult oncology patients.

BACKGROUND: Tunneled venous access devices (VADs) are often essential in the care of patients with advanced malignancies, but they carry an uncertain risk of thrombosis. METHODS: To determine the incidence of venoocclusion related to silicone VADs in a population of adult oncology patients, we prospectively studied 50 individuals with upper extremity venograms approximately 6 weeks after their VADs had been implanted. Twenty-one of these patients were reevaluated with venograms approximately 12 weeks after catheterization. In addition, venograms were performed on a separate group of 24 patients who needed catheterization of axillary-subclavian veins that had been catheterized in the past. RESULTS: The 6-week venograms in the prospective study showed partial venous obstruction in 15 patients (30%), whereas three (6%) had developed symptomatic total venoocclusion by this time. The 12-week venograms showed two additional complete occlusions. Venograms of 30 previously catheterized veins showed complete venoocclusion in nine (30%), although only two had a history of thrombosis. CONCLUSIONS: Our observations indicate that VADs frequently cause partial venoocclusion within the first 6 weeks of catheterization and that permanent venous damage from VADs is common, even without a history of VAD-related thrombosis.