Targeting medical students to promote women in surgery.

The under-representation of women in surgical subspecialities is a well-aired topic. Most efforts to redress the surgical gender balance have, to date, been directed at opportunities for women in surgical training. We report on a one-day symposium organized by the Royal College of Surgeons of Edinburgh to promote interest in taking up a surgical career, aimed at senior women medical students and newly qualified doctors. Although 130 of the attendees who were surveyed did not change their opinion about the four most off-putting aspects of a surgical career, the symposium succeeded in increasing the appeal of a surgical career in 50%, apparently by the intensive exposure to a large and varied sample of female surgical role models.

Studies in surgical trauma: oxidative stress in ischaemia-reperfusion of rat liver.

1. Hypovolaemic shock associated with surgical trauma has been studied in a rat liver ischaemia-reperfusion model by determination of oxidative stress, lipid peroxidation and tissue infiltration of polymorphonuclear leucocytes. 2. Liver ischaemia alone resulted in slight liver oedema and polymorphonuclear leucocyte infiltration, a slight increase in thiobarbituric acid-reacting substances (an index of lipid peroxidation) and decreases in liver reduced glutathione and total radical-trapping antioxidant parameter, indices of oxidative stress. Ischaemia plus 30 min of reperfusion further increased liver oedema, polymorphonuclear leucocyte infiltration and thiobarbituric-acid reacting substances, and further decreased liver reduced glutathione and total radical-trapping antioxidant parameter. 3. After 60 and 90 min of reperfusion, oedema (40% increase), polymorphonuclear leucocyte infiltration (40-fold increase) and thiobarbituric-acid reacting substances (20-fold increase) were maximal, and liver reduced glutathione (75-95% decrease) and total radical-trapping antioxidant parameter (85-90% decrease) were at a minimum. 4. All parameters were exacerbated by 24 h starvation. Liver reduced glutathione closely paralleled total radical-trapping antioxidant parameter, and ischaemia alone depleted both by 30% in fed rats and 50% in fasted rats. 5. Oxidative stress and lipid peroxidation were associated more with the period of reperfusion and polymorphonuclear leucocyte infiltration. Polymorphonuclear leucocyte infiltration into lung also occurred after 90 min of liver reperfusion. 6. Possible mechanisms of hepatic ischaemia-reperfusion-induced oxidative stress are discussed.

6-sulphatoxymelatonin production in breast cancer patients.

The daily pattern of the major urinary metabolite of melatonin, 6-sulphatoxymelatonin (aMT6s), was determined in women prior to having a breast biopsy. Women with malignant tumors appeared to have significantly lower 24 h concentrations of aMT6s with a decrease in the amplitude of the rhythm compared to women with benign tumors. The amount of urinary aMT6s was dependent upon the age of the subject but was not affected by either menopausal status or body mass index. However, when the women with malignant tumors were compared with a large group of normal women of the same age their aMT6s levels were not outside the normal range. The results show that a large control group and very accurate age matching are essential when investigating melatonin production in different groups of subjects.

Management of screen detected ductal carcinoma in situ of the female breast.

Thirty eight ductal carcinomas in situ of the female breast detected during the first 7 years of screening by the Guildford Breast Screening Unit have been treated by one surgeon. Twenty-eight cases were treated conservatively and ten by mastectomy. In the group treated conservatively there have been five local recurrences: four as ductal carcinoma in situ and one as node negative microinvasive carcinoma. There were no clinical or pathological features that predicted local recurrence, which was detected only by follow-up mammography. Based on these early results, an initially conservative approach to screen detected ductal carcinoma in situ is advocated.

Plasma lipids and prolactin in patients with breast cancer.

In a comparative study of pre- and postmenopausal women with benign and malignant breast disease, a number of differences were observed in circulating plasma prolactin and lipid concentrations. Plasma lipids, phospholipids, triglycerides, cholesterol and free fatty acids were all higher in blood obtained from breast cancer patients prior to surgery. HDL-Cholesterol levels were significantly lower in these patients. These differences remained when the patient groups were sub-divided according to menopausal status. Plasma prolactin concentrations were also found to be higher in cancer compared with non-cancer patients, this effect being more marked in premenopausal than in postmenopausal patients. Premenopausal patients with invasive or poorly differentiated disease had significantly higher prolactin levels than those with non-invasive disease. No correlations were found between plasma prolactin and any of the lipid fractions.

Femoral hernia causing pneumoperitoneum.

Richter's hernia, in which only a portion of the circumference of the intestine lies within the sac, is a common complication of femoral hernia. This case report is of 39 year old female who presented with a pneumoperitoneum and was found at laparotomy to have a right femoral Richter's hernia containing a knuckle of perforated small bowel. This is a previously unreported presentation of femoral hernia.

Invasive breast cancer--the tip of an iceberg.

Use of large (6 in. X 4 in.) paraffin sections in the routine examination of specimens from patients with operable breast cancer has revealed multiple quadrant involvement by carcinoma in 20% of 186 consecutive cases. Eighty-nine per cent of patients had invasive carcinomas, which were associated with carcinoma in situ (CIS) in 71%. CIS was frequently extensive, and in 47% was remote from the principal invasive lesion. Fourteen patients had multifocal invasive disease with 34 separate primary tumours. The involvement of 32% of sampled axillary nodes by tumour, combined with this significant incidence of multiple quadrant disease, brings into question the rationale of local surgery in most cases even of early breast cancer. Mastectomy with node sampling permits full assessment of the extent of disease, which is essential for the logical selection of patients for adjuvant therapy. The potential role for limited surgery in non-invasive and very small invasive tumours in combination with radiotherapy remains under evaluation.

The Guildford breast screening project.

Of the 24 069 women aged 45-64 registered with a Practitioner in the South West Surrey Health District 69% attended for breast cancer screening by clinical examination and mammography, with the resultant cancer detection rate of 5.5/1000 women screened and a cancer: benign biopsy rate of 1:1.77. These cancers represent 94% of cancers diagnosed in screened women and 84% of all cancers diagnosed in the total population of this age within one year of the screening invitation. Seventy-three percent of the cancers detected by screening and 66% of all cancers diagnosed in the total population within a year of the screening invitation were 2 cm (or less) in maximum diameter.

Features of mammorgraphically negative breast tumours.

Mammography is a highly sensitive and specific technique in the diagnosis of breast cancer, but some tumours show no radiological features of malignancy. A total of 9.3 per cent of 323 consecutive patients with operable breast cancer had negative mammographic reports, and the clinical radiological and pathological findings in these cases are compared with those in the mammographically diagnosed group. Misinterpretation of carcinoma as a benign lesion and diagnostic difficulties in the dense dysplastic breast were found to be the main causes of error.

Vessel dimensions in premature altheromatous disease of aortic bifurcation.

The area ratio of the abdominal aortic bifurcation is defined as the ratio of the sum of the cross-sectional areas of the common iliac arteries to the cross-sectional area of the aorta. Abnormality of the area ratio is associated with initiation of atheroma of the lower aorta. Hypoplasia of the abdominal aorta predisposes to early occlusion as the atheromatous process advances.In five out of six women with thrombosis at the aortic bifurcation the area ratio was low. Hypoplasia of the abdominal aorta was present in two of these patients. All six patients were successfully treated by aortoiliac disobliteration and reconstruction.