A UK national survey of breast surgeons on primary endocrine therapy of early operable breast cancer

Introduction

A significant proportion of elderly breast cancer patients in the UK have no surgical treatment recorded and appear to be treated with primary endocrine therapy (PET) only. Despite this, PET remains one of the poorly studied areas in breast cancer therapy and very little is known about the practice of PET in the UK.

Methods

A questionnaire comprising 14 questions relevant to PET was sent to 489 breast surgeons who were members of the UK Association of Breast Surgery and returned questionnaires were analysed.

Results

Overall, 228 questionnaires (47%) were returned. The vast majority (93%) of surgeons who responded use PET in early operable breast cancer in elderly women unfit for surgery or owing to patient preference but 7% would recommend PET to fit elderly patients. Most (76%) use letrozole. The percentage of elderly patients treated with PET varied from <10% to 70% between surgeons. The majority (77%) of respondents had not formally audited the outcome of their PET patients and over 70% underestimated the expected survival of an 80-year-old woman.

Conclusions

Most UK breast surgeons use PET in elderly patients with surgically resectable breast cancer. While most use it in unfit, frail patients, a minority would treat even fit elderly women with PET. Most surgeons have not formally audited the outcome of their patients treated with PET and underestimate the expected survival of elderly patients, which might have an impact on their decision to offer PET rather than surgery.     

Electrospun inorganic and polymer composite nanofibers for biomedical applications

Engineered nanofibers are generally focused on filtration, solar cells, sensors, smart textile fabrication, tissue engineering, etc. Electrospun nanofibers have potential advantages in tissue engineering and regenerative medicine, because of the ease in the incorporation of drugs, growth factors, natural materials, and inorganic nanoparticles in to these nanofiber scaffolds. Electrospun nanofiber scaffolds composed of synthetic and natural polymers are being explored as scaffolds similar to natural extracellular matrix for tissue engineering. The requirement of the inorganic composites in the nanofiber scaffolds for favouring hard and soft tissue engineering applications is dealt in detail in the present review. Regarding drug delivery applications of the composite nanofibers, the review emphasizes on wound healing with silver nanoparticles incorporated nanofibers, bone tissue engineering, and cancer chemotherapy with titanium and platinum complexes loaded nanofibers. The review also describes gold nanoparticle loaded nanofibers for cancer diagnosis and cosmetic applications.     

Murine BAFF expression is up-regulated by estrogen and interferons: Implications for sex bias in the development of autoimmunity

Systemic lupus erythematosus (SLE) in patients and certain mouse models exhibits a strong sex bias. Additionally, in most patients, increased serum levels of type I interferon (IFN-α) are associated with severity of the disease. Because increased levels of B cell activating factor (BAFF) in SLE patients and mouse models are associated with the development of SLE, we investigated whether the female sex hormone estrogen (E2) and/or IFNs (IFN-α or γ) could regulate the expression of murine BAFF. We found that steady-state levels of BAFF mRNA and protein were measurably higher in immune cells (CD11b(+), CD11c(+), and CD19(+)) isolated from C57BL/6 females than the age-matched male mice. Treatment of immune cells with IFN or E2 significantly increased levels of BAFF mRNA and protein and a deficiency of estrogen receptor-α, IRF5, or STAT1 expression in splenic cells decreased expression of BAFF. Moreover, treatment of RAW264.7 macrophage cells with IFN-α, IFN-γ, or E2 induced expression of BAFF. Interestingly, increased expression of p202, an IFN and estrogen-inducible protein, in RAW264.7 cells significantly increased the expression levels of BAFF and also stimulated the activity of the BAFF-luc-reporter. Accordingly, the increased expression of the p202 protein in lupus-prone B6.Nba2-ABC than non lupus-prone C57BL/6 and B6.Nba2-C female mice was associated with increased expression levels of BAFF. Together, our observations demonstrated that estrogen and IFN-induced increased levels of the p202 protein in immune cells contribute to sex bias in part through up-regulation of BAFF expression.     

Standardized Aqueous Tribulus terristris (Nerunjil) Extract Attenuates Hyperalgesia in Experimentally Induced Diabetic Neuropathic Pain Model: Role of Oxidative Stress and Inflammatory Mediators

The present study aimed to evaluate standardized aqueous Tribulus terristris (nerunjil) extract on the pain threshold response in streptozotocin (STZ)‐induced diabetic neuropathic pain model in rats. After a single injection of STZ (40 mg/kg; i.p.), Wistar male rats were tested by the thermal and chemical‐induced pain models. Diabetic rats exhibited significant hyperalgesia, and these rats were left untreated for the first four weeks. Thereafter, treatment was initiated and continued up to week‐8. All the rats except the vehicle‐treated group received insulin 5 IU/kg/day to maintain plasma glucose levels. Treatment with nerunjil (100 and 300 mg/kg; p.o.) for 4 weeks significantly attenuated the nociception in behavioural models. Nerunjil also inhibited the tumour necrosis factor‐α and interleukin‐1 beta levels. The effect of nerunjil (300 mg/kg) is comparable to the standard drug Pregabalin (100 mg/kg). Nerunjil increased the superoxide dismutase, catalase, glutathione peroxidase, reduced glutathione, and decreased the lipid peroxide levels in dose‐dependent manner. Insulin alone‐treated rats failed to attenuate hyperalgesic response. In comparison to insulin alone‐treated rats, nerunjil exhibited significant increase in the pain threshold response. It could be concluded that in controlled diabetic states, nerunjil attenuated the neuropathic pain through modulation of oxidative stress and inflammatory cytokine release. Copyright © 2012 John Wiley & Sons, Ltd.     

Spontaneous rupture of the thoracic aorta.

Spontaneous rupture of the aorta without previous history of trauma, hypertension, or apparent aortic pathology is exceedingly rare. Delayed or nonoperative repair of this condition is usually lethal. Survival after spontaneous mid arch aortic rupture requires a high index of suspicion, rapid and appropriate diagnostic tests, and early operative repair. Clinical presentation, clues to diagnosis, and optimal management of this entity are discussed.     

Pyogenic hepatic abscess after pancreatic resection for chronic pancreatitis.

Seventeen patients underwent surgery for alcohol-induced chronic pancreatitis. Three patients later presented with pyogenic liver abscess. The time interval between surgery and presentation with hepatic abscess varied from 6 weeks to 3.5 years. All patients were diabetic, the presentation was insidious and all made an uneventful recovery, two with percutaneous drainage and one with antibiotics alone. The aetiology of this uncommon complication is discussed.     

A study of children and adolescents referred to a rapid diagnosis breast clinic.

AIM: Children and adolescents referred to a rapid diagnosis breast clinic were analysed to study the conditions these patients were referred with, their management, and the final outcome. METHODS: All new patients aged 18 or under seen in a breast clinic over a 39-month period to June 2004 were identified and their case notes were reviewed. RESULTS: Among 6930 new referrals, 88 (1.3 %) were aged 18 or under and 86 patients were included in the study (median age 16 yrs, range 8 - 18 yrs). Five patients were aged less than 12 and were referred with physiological breast buds. In girls aged 13 - 18 years, most were referred for an apparent palpable abnormality. Thirty percent had a family history of breast carcinoma and 35 % were on the oral contraceptive pill. Thirty-three patients (38 %) had a clinical examination only. Others, in addition to the clinical examination, had an ultrasound (US) (n = 24, 28 %), fine needle aspiration cytology (FNAC)/core biopsy (CB) (n = 5, 6 %) or both US and FNAC/CB (triple assessment) (n = 24, 28 %). No malignant disease was found. No diagnostic biopsies were performed. Only 5 patients had surgery, four for fibroadenoma and one for sebaceous cyst. CONCLUSIONS: Patients aged 18 years or under do not constitute a major workload problem for rapid diagnosis breast clinics. Malignant disease remains rare. A significant proportion of patients require only clinical examination and reassurance. The diagnosis can usually be made without open biopsies and less invasively using FNAC or CB.     

Collagenous gastritis: a case report, morphologic evaluation, and review.

Collagenous gastritis is rare; there are only four previous case reports. Histologic features seem to overlap with the other "collagenous enterocolitides"; however, pathologic criteria are not yet established for the diagnosis of collagenous gastritis. We describe an additional case of ostensible collagenous gastritis in a patient who initially presented with celiac sprue and subsequently developed colonic manifestations of mucosal ulcerative colitis. Endoscopic biopsies of the stomach revealed deposition of patchy, very thick bandlike subepithelial collagen in gastric antral mucosa, focal superficial epithelial degeneration, numerous intraepithelial lymphocytes, and a dense lamina propria lymphoplasmacytic infiltrate. Image analysis evaluation of gastric antral biopsies demonstrated a mean thickness of subepithelial collagen of 27.07 micron. Morphologic comparison was made with age-matched control groups of 10 patients who had normal gastric mucosal biopsies and 10 patients who had "chronic" gastritis, which revealed mean subepithelial collagen measures of 1.37 micron and 1.19 micron, respectively. We compared these morphologic findings with those of all previous case reports of collagenous gastritis and propose a pathologic definition based on the limited combined data. It seems that subepithelial collagen is dramatically thickened in reported cases of collagenous gastritis, with a cumulative mean measure of 36.9 micron. It is also apparent from this and previous reports that the thickened subepithelial collagen is accompanied by a chronic or chronic active gastritis and sometimes intraepithelial lymphocytes and surface epithelial damage. Recently described associations of lymphocytic gastritis, sprue, and lymphocytic colitis as well as collagenous and lymphocytic colitis suggest a common pathogenesis that empirically may include collagenous gastritis in the same disease spectrum. We propose that collagenous gastritis can be confidently identified by using analogous defined features of collagenous colitis: subepithelial collagen more than 10 micron in a patchy distribution, lamina propria lymphoplasmacytic infiltrates, intraepithelial lymphocytes, and surface epithelial damage. Collagenous gastritis also seems to have the same spectrum of associated clinical findings as collagenous colitis, including frequent coexistence of celiac sprue, watery diarrhea syndrome, and female predominance.     

‘This way please’: Apoptotic cells regulate phagocyte migration before and after engulfment

Apoptotic leukocyte clearance is a hallmark of the resolution of inflammation and is a central fate‐determining event for macrophages. The directional migration of motile phagocytes toward cellular corpses and the subsequent engulfment are tightly regulated, and the exciting molecular mechanisms for these complex steps are actively under investigation. In this issue Angsana et al. [Eur. J. Immunol. 2016. 46: 1592‐1599.] report that the chemokine receptor CXCR4 is upregulated on murine and human macrophages following the engulfment of apoptotic cells, or following exposure to the pro‐resolving nucleotide adenosine. This work, together with other recent findings, point toward a new mode of regulation of macrophages following the engulfment of apoptotic cells. In this commentary, we put these findings in relevant perspective and highlight its potential ramifications.     

Prospective Evaluation of Innovative Force Assessing Firmware in Simulation to Improve the Technical Competence of Surgical Trainees

Introduction

Suturing is an integral part of all surgeries. In minimal access surgery, the force exerted is based only on visual perception (tautness of the thread and degree of tissue deformation). An unbalanced suture force can cause tissue rupture or cut-through resulting in avoidable morbidity and mortality. There is a need to find ways of improving surgical dexterity and finesse without adversely affecting patient outcomes.

Aim

We aimed to calculate the knot-tying force in minimal access pancreatic surgery (MAPS) performed by experienced surgeons (ES) and use this information to develop a surgical suturing model to train the surgical trainees. We have developed a firmware for force sensor calibration and post-data analysis, using which we aimed to compare the differences in forces applied by a trainee as compared to ES.

Results

Our technology showed that, as compared to the ES, the trainee’s (TS) knot was unbalanced with significant differences in force applied per knot for each of the knots (P < 0.01). The shape of the Force curve for each suture was also different for the TS as compared to the ES. After using the training tool, the forces applied by the TS and the Force curve for the whole suture were similar to those of the ES.

Conclusion

Our firmware promises to be an excellent training tool for organ anastomosis. Considering the complexity and likely complications of MAPS, it is a sine qua non that the surgeon be highly experienced and skilled. Surgical simulation is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they can safely operate on humans.