Urban legend versus rural reality: patients' experience of attendance at accident and emergency departments in west Wales.

OBJECTIVES: To investigate why and how patients decide to attend accident and emergency (A&E) departments, and to assess their satisfaction with the experience, in a predominantly rural west Wales population. METHODS: This was a semi-structured follow up telephone interview of patients who walked in to A&E in one of four general hospitals in west Wales and were triaged as Manchester Triage score 4 or 5. Patients were recruited by nurses during the period July-November 2002. The study sample consisted of 176 male and 145 female patients, mean (SD) age 36.6 (20.0) years. The main outcome measure was a quantitative and qualitative description of the recalled experiences of A&E attenders, the circumstances of their attendance, and their satisfaction with the experience. RESULTS: Of the study sample, 78% attended with injury or illnesses of recent origin, and 50% with actual or presumed musculoskeletal injury, 73% of which were sustained within 10 miles of home. Travel to hospital was by private transport for 86%, average distance 7.4 miles. The majority (90%) were registered with a local GP, but 32% felt A&E was the obvious choice, and a further 44% considered their GP inaccessible to their needs. Patients' reasons for seeking health care at A&E were similar to those described in an English urban study. Waiting times were rarely excessive; 80% left within 2 hours, and patient satisfaction was generally high. Among the 87 patients (27%) who reported a less satisfactory experience, 48 (55%) of these complained of dismissive attitudes of doctors. CONCLUSIONS: Anecdotal accounts of abuse of A&E services and unreasonable patient expectations gain the status of "urban legends" within the medical profession. Among the predominantly settled rural population in west Wales, there is little evidence of unreasonable patient expectations, and most patients report high satisfaction levels. Patients' bad experiences most frequently arise from a dismissive attitude on the part of medical staff. These attitudes are often consequent on an A&E culture that views some patients' attendances as less appropriate than others.

Advanced gastrointestinal malignancy or benign inflammatory disease? An unusual presentation of sclerosing mesenteritis. Report of a case.

The presentation of change of bowel habit, weight loss, muscle wasting, ascites, and the surgical appearance of "omental cake" are almost pathognomonic of advanced gastrointestinal malignancy. In our case, these symptoms represented a unique presentation of the condition sclerosing mesenteritis. Despite its rarity, the clinician should be aware of this "sheep in wolf's clothing," the clinical importance of which lies in the condition's benign and self-limiting course and imparts to the patient a prognosis and treatment that could not be further removed from that of advanced malignancy. Investigations that may be helpful to the surgeon in distinguishing the condition from carcinomatosis and avoiding unnecessary laparotomy include preoperative colonoscopy, barium enema, cytology of any ascites, and intraoperative frozen section biopsy. Treatment of the condition is conservative unless it has caused extrinsic bowel obstruction.

Cutaneous malignant peripheral nerve sheath tumour (MPNST) of the hand: a review of current literature.

Malignant peripheral nerve sheath tumours (MPNST) are spindle cell sarcomas normally situated in the deep soft tissues. Cutaneous MPNST is an uncommon variant, usually occurring in the head and neck. When it arises in the upper limb this tumour may pose a considerable diagnostic and therapeutic problem. We present a case of cutaneous MPNST arising in the hand. Tumour extension was exclusively perineural along three major nerve trunks from an interdigital origin. Current knowledge of the clinical behaviour of cutaneous MPNST is reviewed.

Immunohistochemical analysis of p53 expression in anal squamous neoplasia.

AIMS: To determine the pattern of expression of the p53 tumour suppressor gene product in anal squamous neoplasia, and to determine if this could be used as a marker of disease progression. The association between p53 expression and human papillomavirus (HPV) 16 DNA status of the anal lesions was also investigated. METHODS: The presence and localisation of the p53 protein in formalin fixed, paraffin wax embedded specimens of anal squamous epithelium (normal and neoplastic) was examined using immunohistochemical staining with a panel of two monoclonal antibodies (DO-1, DO-7) and one polyclonal antibody (CM-1). Thirty nine normal anal epithelia, 14 anal intraepithelial neoplasia (AIN) grade 1, seven AIN 2, and 20 AIN 3 specimens were obtained from patients without demonstrable invasive disease; twelve AIN 3 specimens adjacent to invasive disease and 34 anal squamous cancers were also examined. Genomic DNA from all 126 specimens was extracted and analysed for HPV 16 DNA using the polymerase chain reaction (PCR). RESULTS: Nuclear p53 was strongly expressed in 67% (23/34) of invasive anal squamous tumours, 75% (9/12) of AIN 3 specimens adjacent to invasive disease, and in 60% (12/20) of AIN 3 specimens obtained from patients without demonstrable invasive disease. Two of the patients in the latter group with positively staining specimens subsequently developed invasive tumours which had staining characteristics similar to those of the AIN 3 specimens. p53 protein was expressed in very low concentrations in low grade AIN and not at all in normal anal squamous epithelium. In those specimens which stained positively for p53, HPV 16 DNA sequences were detected in 69.5% (16/23) of invasive disease, 77.7% (7/9) of AIN 3 adjacent to invasive disease, 75% (9/12) of AIN 3 obtained from patients without demonstrable invasive disease, 33.3% (2/6) of AIN 2, and in 40% (2/5) of AIN 1. There was no significant correlation between p53 immunostaining and HPV 16 DNA status (p < 0.05). CONCLUSIONS: Aberrant expression of the p53 gene product is probably involved in the pathogenesis of anal squamous neoplasia. Long term follow up studies of all patients with AIN are required to determine if this could be used as a marker of likely disease progression from high grade AIN to invasive disease. There does not seem to be an association between the presence or absence of HPV 16 DNA sequences and mutant p53 proteins in anal squamous neoplasia.

C-myc oncogene expression in anal squamous neoplasia.

AIMS: To determine the pattern of c-myc oncogene expression in anal squamous neoplasia and to determine if this could be used as a marker of disease progression. METHODS: The presence and localisation of the c-myc gene product p62 in archival specimens of anal squamous epithelium, normal and neoplastic, was examined using immunohistochemical staining with the monoclonal antibody Myc1-6E10. Ten normal and epithelia, 10 anal intraepithelial neoplasia (AIN) III, and 31 anal squamous cancers were examined. RESULTS: There was a noticeable difference between the staining characteristics of invasive tumours, normal anal epithelium, and AIN III. Intense, diffuse, mixed nuclear and cytoplasmic (n = 14) and exclusively nuclear (n = 8) staining in 22 of 31 (71%) of invasive anal tumours was observed. All positively staining tumours were well differentiated histologically, while the negatively staining nine of 31 (29%) were poorly differentiated (n = 7) and moderately well differentiated (n = 2). In six positively staining tumour sections adjacent areas of AIN III and non-dysplastic anal epithelium had staining characteristics similar to those of the invasive component. Staining in both normal anal epithelium (4/10) and AIN III specimens obtained from patients without a history of invasive disease (8/10) was less intense, focal in distribution, and exclusively nuclear. No difference in staining characteristics could be detected in these two groups. CONCLUSIONS: The results of this study suggest that c-myc oncogene expression is implicated in the pathogenesis of anal squamous neoplasia, and that immunohistochemical staining for c-myc protein may be helpful in identifying those AIN III lesions most likely to progress to invasive tumours.

Thorotrast granuloma: an unexpected diagnosis.

An example of a Thorotrast granuloma (thorotrastoma) occurred in the neck of a patient 44 years after a carotid angiogram in which Thorotrast was used as radiological contrast medium. The lesion had produced a "cold" abscess and the patient was undergoing treatment for retropharyngeal tuberculosis. Thorotrast leakage can produce unusual clinical symptoms and signs which are frequently misdiagnosed.

Cellular localisation of c-myc product in human colorectal epithelial neoplasia.

Aberrant expression of c-myc has been implicated in the development of colorectal carcinomas. We have used monoclonal antibodies 6E10 and 9E10, raised against mid-sequence and C-terminal peptides of the c-myc protein, to study the distribution of myc protein in normal and diseased bowel at the light microscope and ultrastructural levels. Normal mucosa showed staining only of some nuclei in the proliferative zones of crypts. In adenomas, staining varied from predominantly nuclear to pancellular to focal or pancytoplasmic. Moderately well differentiated areas of carcinomas gave strong focal cytoplasmic staining, while in poorly differentiated tumours staining was pancytoplasmic. Electron microscopy with these antibodies detected myc protein associated with dense chromatin and, where cytoplasmic staining occurred, with polyribosomes. Tumours showed a reduced staining of nuclear pores compared with normal tissue. Comparison of staining patterns with 6E10 and 9E10 in normal tissue, adenomas, and tumours suggests that tumour progression is associated with an accumulation of cytoplasmic c-myc protein, perhaps resulting from alterations to the C-terminus which reduce the efficiency of nuclear targeting of the protein and thus disrupt the regulation of the cell cycle.

Endocervical carcinoma and precursor lesions: c-myc expression and the demonstration of field changes.

The monoclonal antibody Myc 1-6E10 was used in an immunocytochemical technique to examine the expression of the c-myc oncogene in normal endocervices and those with glandular intraepithelial neoplasia and invasive malignancy. Eleven of 14 normal endocervical biopsy specimens did not express the gene, while three showed nuclear, or light basal cytoplasmic localisation of the gene product, or both. All but one of 14 cases of low and high grade glandular intraepithelial neoplasia, and all 17 cases of invasive adenocarcinoma, showed a pan-cellular pattern of immunostaining. Of considerable additional interest was the demonstration of field changes in morphologically normal glandular epithelium in those biopsy specimens with concurrent cervical glandular intraepithelial neoplasia or adenocarcinoma. This was manifest as increased concentrations of myc proteins compared with normal tissues. These results further support the role of the c-myc gene in oncogenesis, and in the light of field changes, suggest possible difficulties in the clinical management of this group of patients.

Nucleolar organiser regions in adenocarcinoma in situ and invasive adenocarcinoma of the cervix.

Silver binding nucleolar regions (AgNORs) were evaluated in normal endocervix, adenocarcinoma, and its potential precursor, adenocarcinoma in situ (AIS), in an attempt to increase an understanding of the natural history of cervical adenocarcinoma and to identify a marker for abnormal endocervical (atypical glandular) cells which could aid diagnosis and follow up of endocervical lesions. For every 50 cells the mean AgNOR counts were as follows: normal endocervical cells (n = 15) 79.8 (95% Cl 68-91); AIS (n = 20) 200.7 (95% Cl 182-219); and invasive adenocarcinoma (n = 30) 299 (271-328). There was no overlap between the groups of normal endocervical cells and invasive adenocarcinoma, but there was significant overlap between cases of invasive adenocarcinoma and carcinoma in situ. In six out of 17 cases with AIS, NOR count in adjacent morphologically normal glandular cells ("internal" controls) was increased when compared with the "external" (normal endocervical) control group. This suggests the presence of wider field changes not previously identified using routine histological methods. The findings suggest that AIS is a potential premalignant precursor of invasive adenocarcinoma, but that assessment of NORs is of no practical use in discriminating between the histological types of cervical carcinoma.

Mondor's disease associated with metastatic lung cancer in the breast.

We report what we believe is the first recorded case of Mondor's disease associated with metastatic lung cancer presenting in the breast. An association between Mondor's disease and primary breast cancer has been described previously. In patients with Mondor's disease and primary breast cancer has been described previously. In patients with Mondor's disease the possibility of underlying carcinoma, either primary or secondary, must be considered.

C-myc oncogene product P62c-myc in ovarian mucinous neoplasms: immunohistochemical study correlated with malignancy.

The monoclonal antibody Myc 1-6E10 was used to determine the cellular distribution of the c-myc oncogene product p62c-myc in 60 mucinous ovarian tumours. Three patterns of immunostaining were apparent: (i) nuclear staining alone; (ii) staining of the nucleus and basal cytoplasm; and (iii) staining of the entire cell. Of the 21 cases of mucinous cystadenoma, 11 showed nuclear staining alone, and a further case showed additional weak staining of the basal cytoplasm. Nuclear staining alone was not present in any of the 17 borderline mucinous tumours examined. Strong staining of the nucleus and basal cytoplasm was seen in 16 of these borderline cases, six of which also showed focal staining of the apical cytoplasm. All 22 cases of mucinous cystadenocarcinoma showed staining of the cell nucleus and entire cell cytoplasm. Focal staining of the apical cytoplasm in six of 17 borderline mucinous tumours produced a pattern of c-myc immunostaining similar to that of cystadenocarcinoma. Retrospective analysis of the clinical data showed that no significant differences between patients with borderline tumours of these two categories could be defined. Although immunostaining with Myc 1-6E10 can be used in the categorisation of mucinous ovarian tumours, it is concluded that standard histological criteria are more accurate indicators of tumour behaviour than is an assessment of c-myc expression.

The computed tomographic appearances of lymphangiectasia in the pelvis.

We describe the CT appearances of lymphangiectasia in the pelvis of a 21-year-old male who presented with fever, abdominal pain and swelling of the right thigh. Previous histological examination of a biopsy specimen from the patient's thigh had demonstrated lymphangiectasia.

Basal cell carcinoma of penis: case report.

Basal cell carcinoma of the penis is rare. A patient who presented with a penile and scrotal ulcer due to basal cell carcinoma is reported. Wide local excision and split skin grafting were performed to excise the lesion completely.