[Pancreatic carcinoma?]. / Pankreaskarzinom?

We report the case of a 71 years old man suspected to suffer from pancreatic carcinoma because of a large mass in the pancreatic head. Intraoperatively, this suspicion could not be confirmed. An unspecific pancreatitis was found. Despite gastrojejunostomy and cholecystectomy with biliodigestive anastomosis and Y-Roux abdominal pain and a massive lost of weight persisted. In the course, the diagnosis of an autoimmune pancreatitis was maid and symptoms quickly improved after the introduction of corticosteroids. In the commentary of this paper the issue of autoimmune pancreatitis will be discussed.

The effects of levels-of-processing and organization on conceptual implicit memory in the category exemplar production test.

The distinction between item-specific and relational information (Hunt & Einstein, 1981) may be relevant to accounts of conceptual priming in the category exemplar production task. In three experiments, the implications of this hypothesis were tested by examining the effects of organization and levels-of-processing (LOP) on this implicit test. Consistent with the hypothesis, the effects of LOP were greater when study lists were organized by category than when they were presented randomly. Furthermore, when subjects claiming test awareness or intentional retrieval were excluded from the analysis, the LOP effect was reduced (and, in fact, eliminated) in the random list condition but remained robust in the categorized condition. Finally, the experimental design of the LOP manipulation (i.e., mixed-list within, blocked-list within, or between subjects) did not moderate the effects of LOP on this priming task.

The epidemiology of Paget's disease in Britain: is the prevalence decreasing?

To estimate changes in the age- and gender-specific prevalence of Paget's disease in Britain, we performed a radiographic survey of the disorder in 10 British centers, using sampling and radiographic methods identical to a study performed in 1974. In each center, a sample of abdominal radiographs of people aged 55 years and over was taken from stored films within the radiology department of the principal general hospital. The radiographs were identified by screening radiographic records over the period 1993-1995. Any abdominal radiograph in a subject aged 55 years and over which included the entire pelvis, sacrum, femoral heads, and all lumbar vertebrae was studied. The radiographs were evaluated by a trained observer and the consultant radiologist who participated in the original 1974 survey. Nine thousand eight hundred and twenty-eight radiographs (4625 men, 5203 women) were assessed in the 10 towns. The overall age/gender standardized prevalence rate was 2%, with a male/female ratio of 1.6. Prevalence increased steeply with age among men and women, rising to 6.9% of men and 5.8% of women aged 85 years and over. The prevalence of Paget's disease in the 10 towns in 1994 was only 40% of that observed during the 1974 study. The decline in prevalence was apparent in all 10 centers, but was most marked in those with high rates in the original study. This survey of Paget's disease in 10 British towns suggests a prevalence of 2.5% among men and 1.6% among women aged 55 years and over. Age-adjusted prevalence rates declined steeply between 1974 and 1994. These declines suggest an environmental contribution to the etiology of this disorder that requires further investigation.

[Esophageal surgery in the regional hospital]. / Osophaguschirurgie am Regionalspital.

In a small series of surgically treated patients with esophageal cancer (n = 22) modern trends are observed, namely--the frequent occurrence of adenocarcinoma (50% of cases) and of early stage (pT1) (36% of cases),--a low operative mortality (5%),--favorable oncological results for tumors not penetrating the esophageal wall (pT1, 2)(64% of patients at life without recurrence 2-7 1/2 years after surgery). For curative or palliative resection of distal tumors the abdomino-cervical (transhiatal) resection was favored (n = 17) with no instance of anastomotic insufficiency and with 2 cases only of locoregional recurrence. In a case of spontaneous esophageal perforation (Boerhaave) primary suture through an abdomino-transhiatal approach was successful. The interdisciplinary intensive care, necessary in surgery of the esophagus, may be of a high standard in the district hospital.

The clinical and radiological features of cholecystocolic fistulae.

The clinical and radiological features of seven patients presenting with cholecystocolic fistulae are reviewed. The majority of the patients were elderly (age range 43-85 years, mean 70.7 years) and there was a female preponderance (6:1). The condition usually has a benign clinical course. Diarrhoea was the most common presenting symptom and the typical clinical features of gallbladder disease were absent. Cholangitis occurred in only one patient. The time between onset of symptoms and diagnosis varied from 1 week to 2 years (mean 22 weeks). In only one patient was the diagnosis of biliary-intestinal fistula suspected on the basis of the plain abdominal radiograph (Case 5). A diagnosis of cholecystocolic fistula was established by barium enema (5 cases), endoscopic retrograde cholangiopancreatography (ERCP) (1 case) and diagnostic laparotomy (1 case). The only cause identified in this series was acute or chronic cholecystitis.

The impact of the first 3 years of breast cancer screening on the overall presentation of breast cancer.

We have assessed the effect of the first round of the Breast Cancer Screening Programme on the presentation of breast cancer in the Southampton Health District with respect to number of cases and pathological characteristics. A retrospective comparative survey of the presentation of breast cancer in the 3 years prior to breast cancer screening (1985-1988) with the presentation of breast cancer during the prevalent round of breast cancer screening (1988-1991) was performed. During the period of study 1536 cases of breast cancer presented. Six hundred and sixty presented in the years prior to screening and 864 during the first round of screening. All patients lived within the Southampton Health District. The study was designed to assess the changes in breast cancer presentation with regard to age, pathological characteristics, and treatment. Even allowing for the increases in the local population there was a significant increase in the number of cases of breast cancer diagnosed (chi 2 = 23.7, df = 1, P < 0.001). The majority of this increase was in the 50-64 age group. There was also a significant shift towards an earlier stage at diagnosis and a significant reduction in tumour size when all cases were included (mean 26 mm versus 34 mm P < 0.001). Screening also created the opportunity for less invasive treatment. Consequently there was a rise in the number of excisions by localization biopsy from 1% to 13% during the screening period. In conclusion, the National Breast Cancer Screening Programme (NBCSP) has had a significant impact on the presentation of breast cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

[The gamma nail--an ideal implant for treatment of unstable fractures in elderly patients]. / Der Gamma-Nagel--ein ideales Implantat zur Behandlung instabiler Frakturen bei alten Patienten.

Altogether we used the Gamma-Nail in 150 cases. We show here a series of 50 instable pertrochanteric femur fractures in very old patients which we treated with a Gamma-Nail. All cases started with full weight bearing at the 4th day after operation. A clinical and radiological control 12 weeks later shows good mobilisation of the hip in 70% of the cases. Shortening of the operated leg is rare in comparison of cases treated with a DHS. Two thirds of the patients returned after dismission of the hospital to the old social situation. The advantages in treating instable pertrochanteric femur fractures with the Gamma-Nail are immediate full weight bearing without risks of shortening of the operated leg and the closed reduction of the fracture.

[Stable interlocking intramedullary nailing of humeral fractures with the Seidel nail]. / Stabile Verriegelungsmarknagelung bei Humerusfrakturen mit dem Seidel-Nagel.

22 fractures of the humerus (15 traumatological, 7 pathological) were treated with the Seidel-Nail. The results after a follow-up between 4 and 20 months showed good mobility of the shoulder. As major complications two paresis of the radial nerve occurred. One disappeared spontaneously. The Seidel-Nail is a good implant for all kind of shaft fractures with an intact distal fragment of 5 cm and also for fractures of an intact humerus head.

Management of screen-detected breast cancer: audit of the first 100 cases in the Southampton and Salisbury breast screening programme.

With the natural history and optimal treatment of a high proportion of screen-detected breast cancers yet to be determined, treatment poses the management team with a number of therapeutic dilemmas. This study surveys the management policy and treatment of a consecutive series of 100 screen-detected cancers treated in a single breast unit. The problems encountered are discussed. There were 87 women with stage Tis or T1 tumours, including 26 women with in situ cancers, four with invasive cancers less than 5 mm in size, and seven with tubular cancers. Sixty-six women were managed with breast-conserving surgery and 36 women underwent localisation biopsy as the sole surgical treatment of the breast. With selection bias for high-grade and lateral tumours, only 2/13 cancers up to 10 mm in size were lymph node positive on axillary clearance. All lymph node positive women received adjuvant therapy. No adjuvant therapy was given in 43 cases, including those with in situ cancer. Thirty-six had extensive intraductal component (EIC). Patient and surgeon choice tends to be a major factor both in type of surgery and adjuvant therapy for screen-detected breast cancer. The optimal treatment for tumours detected by breast cancer screening is debatable and randomised trials on their management need to be expedited.

Breast size and prognosis in early breast cancer.

The influence of breast size on the prognosis of 196 patients with early breast cancer diagnosed in the period 1984-1985 was studied. Breast size was based on the volume from mammography. This method was validated against the volume of the mastectomy specimen determined by water displacement in 18 patients and found to be accurate (r = 0.93, P < 0.01). The median breast volume was 833.5 cm3 (interquartile range 522.8-1153.3 cm3). Breast size was significantly associated independently with age (Spearman's rank r = 0.24. P = 0.001), menstrual status (z = -4.81, P < 0.001), body weight (Spearman's rank r = 0.61, P < 0.001), T stage (z = -1.91, P = 0.05) but not N stage (z = -1.64, P = 0.10) or hormone receptor status (z = -0.80, P = 0.42). In an analysis of breast size and other known prognostic factors, based upon Cox's proportional hazards regression, N stage was the only significant factor for both breast cancer survival and disease-free survival. Even though women with larger tumours at presentation had larger breasts, breast size was not a significant prognostic factor in early breast cancer.

Ultrasonic attenuation in fibroadenoma of the breast.

Fifteen patients are described who attended out Breast Screening Programme, and were found to have sclerosed fibroadenomas, the imaging of which raised the possibility of carcinoma. In six of these a reflective zone between a mass lesion and distal acoustic shadowing might have been used to infer the benign diagnosis.

[The gamma-nail as a resilient alternative to the dynamic hip screw in unstable proximal femoral fractures in the elderly]. / Der Gamma-Nagel als belastungsstabile Alternative zur DHS bei der instabilen proximalen Femurfraktur des alten Menschen.

In a prospective randomised trial between September 1989 and June 1990 one hundred patients with per- and subtrochanteric fractures were consecutively treated by gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for gamma-nailing was longer than for DHS implantation and also the postoperative blood loss was higher in the gamma-nail group. We found no difference of intraoperative blood loss, of perioperative lethality and in duration of hospital care. 90% of gamma-nail patients and 80% of DHS patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Three patients in the DHS group with unstable fractures got cranial perforation of the cephalic screw mobilisation. Five patients of the gamma-nail group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the gamma-nail has proven to be more efficient than the DHS.

[The Gamma Nail in per- and intertrochanteric femoral fractures--alternative or supplement to the dynamic hip screw? A prospective randomized study of 100 patients with per- and intertrochanteric femoral fractures in the surgical clinic of the City Hospital of Triemli, Zurich, September 1989 - June 1990]. / Der Gamma-Nagel bei per- und intertrochantären Femurfrakturen--Alternative oder Ergänzung zur DHS? Eine prospektive randomisierte Studie anhand von 100 Patienten mit per- und intertrochantären Femurfrakturen an der Chirurgischen Klinik des Stadtspitals Triemli, Zürich, September 1989-Juni 1990.

In a prospective randomised trial between September 89 and June 90 one hundred patients with per- and subtrochanteric fractures were consecutively treated by Gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for Gamma-nailing was longer than for DHS-implantation and also the postoperative blood loss was higher in the Gamma-nail-group. We found no difference of intraoperative blood loss, of perioperative letality and in duration of hospital care. 90% of Gamma-nail-patients and 80% of DHS-patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Six patients (12%) with DHS had to be reoperated within 6 weeks. Three patients with unstable fractures got cranial perforation of the cephalic screw after mobilisation. The other three patients had soft tissue complications. Five patients (10%) of the Gamma-nail-group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the Gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the Gamma-nail has proven to be more efficient than the DHS.

Impact of an extensive in situ component on the presence of residual disease in screen detected breast cancer.

This study investigates the histopathological characteristics of a consecutive series of 100 screen detected breast cancers in relation to residual disease. Tumour type, size, grade, resection margins and extent of primary or associated in situ disease were all assessed by one pathologist. Thirty-seven women underwent further surgery (wider excision or mastectomy) and the resected specimen was examined for residual in situ or invasive cancer. In total, 36 cancers had an extensive in situ component, of which 69% were predominantly intraduct carcinoma of comedo type. Of the 37 women who underwent further resection, 21 (57%) women had residual cancer. Of those with initial disease at the resection margin, 16/25 (64%) had residual disease. Five of 12 (42%) with disease close to (within 2-3 mm) but not at the margin had residual disease. Of those with an extensive in situ component, 18/25 (72%) had residual disease, whereas only 2/12 (17%) women with none or some in situ disease had residual cancer. In screen detected breast cancer, residual cancer was present in 72% of women with an extensive in situ component at initial surgery. These women comprise a group in which conservation surgery may be inappropriate if completeness of excision is considered a prerequisite for breast conserving surgery.

Technique and results of localization biopsy in a breast screening programme.

The techniques of ultrasonographic and hookwire localization biopsy of impalpable breast lesions detected by a large breast screening unit during its first year of operation are described. Hookwire localization (HL) was performed using mammography. Ultrasonographic localization (UL) was used for lesions readily detectable by ultrasonography by marking the skin directly over the lesion and calculating its depth below the surface. UL is not appropriate when microcalcification is the sole mammographic abnormality. Localization was required for 150 of the 191 (78.5 per cent) screen-detected lesions. HL was used for 94 (62.7 per cent) and UL for 56 (37.3 per cent). Four lesions were missed by HL, none by UL; 35 per cent of lesions removed by HL and 39 per cent by UL were malignant, giving benign: malignant biopsy ratios of 1.8:1 and 1.5:1 respectively. Only 22 percent of the patients required overnight hospital stay. Localization biopsy plays a major role in the surgery for screen-detected lesions and, where applicable, UL is the technique of choice.

Ultrasound of the common bile duct in patients undergoing cholecystectomy.

One hundred patients undergoing cholecystectomy underwent ultrasonography of the biliary tree on the day prior to surgery. At operation a per-operative cholangiogram was performed unless stones were palpable in the duct. Pre-operative biliary ultrasonography accurately identified dilatation of the common bile duct (sensitivity 96%, specificity 95%) but was less accurate at detecting common duct stones (sensitivity 36%, specificity 98%). Thirty three percent of patients with dilated ducts on ultrasound did not have stones in the duct, while 20% of patients with common duct stones had normal sized ducts. We conclude that ultrasonography alone cannot reliably select patients who require exploration of the common bile duct, or select patients for operative cholangiography. Although pre-operative demonstration of common bile duct dilation is an absolute indication for operative cholangiography, by itself it does not indicate the need for exploration.

[Giant adenoma of Brunner's glands]. / Riesenadenom der Brunnerschen Drüsen.

Bleeding, obstruction and invagination are the common symptoms of large polyps in the duodenal bulb. We present 2 patients with a large ulcerated Brunner's gland adenoma. The clinical findings were acute bleeding and nonspecific upper gastrointestinal symptoms. The treatment was surgical due to a suspect histological finding in one case, a thick stalk in the other, and the fact that endoscopic polypectomy is a much higher risk procedure in the duodenum than in the colon.