Breast cancer risk perception among women who have undergone prophylactic bilateral mastectomy

BACKGROUND: Prophylactic bilateral mastectomy is a preventive option for women who are at high risk of developing breast cancer. We compared the perceptions of breast cancer risk among women who had previously undergone prophylactic bilateral mastectomy with objective estimates of their breast cancer risk. METHODS: We asked 75 women in the Canadian province of Ontario who had undergone prophylactic bilateral mastectomy between 1991 and 2000 to provide a complete family history of the cancers that had occurred by the time of their surgery and to indicate their BRCA1 and BRCA2 gene mutation status. This information was used to generate estimates of each woman's risk for breast cancer by using the Gail model, the Claus model, and the BRCAPRO model. Sixty of the women also provided their own estimates of their lifetime risks of developing breast cancer before and after they had prophylactic mastectomy. Risk estimates were compared using Wilcoxon's signed-rank test and Pearson's product-moment correlation analysis. All statistical tests were two-sided. RESULTS: The women estimated that their lifetime risk of developing breast cancer before surgery was, on average, 76% (range = 20%-100%) and after surgery was 11.4% (range = 0%-60%). The mean estimated absolute risk reduction the women attributed to prophylactic mastectomy was 64.8%. The average computer-generated risk estimates were 59% for the 14 women who reported that they carried a BRCA1 or BRCA2 gene mutation and 17% for the other women (of whom 43 had a strong family history of breast cancer and 18 had a limited family history). Breast cancer risk was statistically significantly overestimated by all women except for the known BRCA1 and BRCA2 gene mutation carriers. CONCLUSION: Women who undergo prophylactic bilateral mastectomy have an exaggerated perception of their breast cancer risk before surgery. Formal genetic counseling and genetic testing may result in more accurate risk perceptions to guide women in choosing other preventive options.     

A short history of biological warfare

Biological weapons have been used in war from the start of recorded history. This article reviews the history of the subject, including the outbreak of the Black Death and the use of smallpox against American Indians. The new science of microbiology was misused from soon after its start and, despite the 1925 Geneva Protocol, the Japanese experimented extensively on prisoners in China. The Allies carried out extensive research during the Second World War, notably the United Kingdom into anthrax on Gruinard Island and the United States into a variety of agents. Despite the 1972 Biological Weapons Convention (BWC), a major programme continued in the former Soviet Union (leading to an accidental outbreak of anthrax). Most recently Iraq was revealed as having an extensive programme, with weaponization of large amounts of various agents, and several terrorists groups have attempted to use biological agents as weapons. Modern developments in biotechnology could lead to even more serious developments, and effective preventive measures, including strengthening of the BWC, are imperative.     

Nuclear cardiology in the UK: activity and practice 1997

A questionnaire was sent to 251 nuclear medicine centres asking for details of nuclear medicine activity, and nuclear cardiology activity and practice in 1997. One hundred and seventy-one (68%) centres replied. Nuclear medicine activity was estimated at 11.8 studies/1,000 population/year, and 9.5% of these studies were within cardiology (1.12 studies/1,000/year). Myocardial perfusion imaging (MPI) studies accounted for 77% and radionuclide ventriculography (RNV) for 22% of all nuclear cardiology. On a national basis this represents activity levels of 0.86 and 0.25 studies/1,000/year for MPI and RNV, respectively. Of the 171 responding centres, 102 (60%) performed MPI studies and 81 (79%) of these reported that activity was increasing. However, MPI activity was unevenly distributed between hospitals. Two centres accounted for 13% of total MPI; others had far lower activity rates, and 51/102 (50%) centres performed less than 200 MPI studies/year. Comparison with previous surveys showed that nuclear medicine activity had almost doubled since 1990 (it was 6.0 studies/1,000 population in 1990, 9.3 studies/1,000 in 1994 and 11.8 studies/1,000 in 1997). Over the same period, nuclear cardiology activity had also risen, the greatest increase being seen for the last 3 years (it was 0.7 studies/1,000 population in 1990, 0.82 studies/1,000 in 1994 and 1.12 studies/1,000 in 1997). Despite these encouraging figures, MPI activity for 1997 remained well below that recommended by the British Cardiac Society in 1994 (2.6 studies/1,000/year) as adequate to serve the needs of patients with cardiac disease in the UK; it was also below the European average activity for the same year (2.2 studies/1,000/year). The anticipated increased workload for nuclear cardiology is encouraging despite the wide and varied practice of nuclear cardiology around the UK. The nuclear medicine community now needs to address the issues that will prevent it keeping up with demand, such as restricted camera time, excessive waiting lists and outdated equipment, but also to standardise acquisition and reporting techniques so that all studies, wherever performed, will be of a uniformly high standard.     

Elbow fistulas using autogeneous vein: patency rates and results of revision

Background: The provision and maintenance of vascular access remains a major cost to end stage renal failure programmes. There are few reports regarding the surgical revision of the failing native elbow arteriovenous fistula (AVF). Patients and methods: A retrospective case note review was performed on all patients identified from the hospital vascular access database as having undergone construction of an autogeneous vein elbow AVF. Over a seven year period 282 autogeneous vein AVFs were fashioned in 232 patients using the brachial artery as the in-flow conduit. Of these 208 were brachiocephalic fistulas, or a variant thereof, and 74 were fashioned using the transposed autologous basilic vein (136 male: 96 female; median age 60 years, range 14–94 years). Results: Of 282 elbow fistulas 197 were successfully used for dialysis (70%). Cumulative primary patency of elbow fistulas using autogeneous vein in this series was 68%, 54%, and 44% at one, two, and three years respectively. A further 34 revision procedures were performed on 28 fistulas to maintain fistula function, and cumulative secondary patency after surgical revision was 75%, 60%, and 46% at one, two, and three years. Overall 21 out of 34 procedures (62%) successfully restored fistula function and cumulative primary patency of the revised fistulas was 56% at one year. Eighteen AVFs (brachiocephalic, n=12; autologous basilar vein, n=6) required revision for access dysfunction secondary to a short stenoses within 4 cm of the arteriovenous anastomoses. Of these 18 AVFs eight were revised by excision of the stenosed segment and either primary anastomoses of the two cut ends of arterialised vein or reanastomoses of the proximal venous limb proximally on the brachial artery. In another nine fistulas the excised segment was replaced with a short interposition graft (polytetrafluoroethylene, n=7; native basilic vein, n=1; bovine carotid artery, n=1). One fistula with postanastomotic stenoses and a more proximal needle site stenoses was revised using two vein patches. Overall 100% were patent at 24 hours, 13 provided successful dialysis (72%), and cumulative primary patency was 67% and 50% at six months and one year respectively. Conclusions: Successful surgical revision of failing native elbow fistulas can restore patency and improve cumulative secondary patency with potential benefits in terms of patient morbidity and mortality. These results compare favourably to published patency rates after fistula salvage using interventional radiological techniques.     

Postnatal regulation of oxygen delivery: hematologic parameters of postnatal dogs.

Hematologic parameters influencing tissue oxygen delivery in dogs during the first 4 mo of life have been investigated. The rapid growth and increase in body temperature during this period imply an increased metabolic rate and increased tissue oxygen demand. Hemoglobin concentration and hematocrit decrease during the 1st mo following birth. The total red cell mass does not decrease during this period. The observed hemodilution can be attributed to an increasing plasma volume in the growing animal. The blood oxygen affinity decreases during this same period, resulting in a more effective tissue oxygen delivery. Erythropoiesis, as estimated from the percent circulating reticulocytes, decreases following birth and does not increase until 1 mo of postnatal life. The increase of erythropoietic activity during the 2nd mo of postnatal life coincides with an increase in red cell mass, hematocrit, and hemoglobin concentration.     

Detecting curable disease following hepatectomy for colorectal metastases

INTRODUCTION: Although resection may be curative for patients with hepatic colorectal metastases, recurrence occurs in the majority. Recurrence is occasionally amenable to repeated resection. The aim of the present study was to evaluate which modalities, at what intervals, detected potentially curable resection. METHODS: The records of patients undergoing hepatectomy for colorectal metastases over 10 years in one centre were retrospectively reviewed to determine when and how recurrence was diagnosed. Specific attention was paid to the detection of potentially curable disease. RESULTS: Of 41 recurrences, 22 occurred in the first year postoperatively, 21 of which were suitable for palliative treatment only. Ten of 19 recurrences occurring after 1 year underwent potentially curative intervention, 10 were diagnosed by computed tomography (CT). Carcinoembryonic antigen did not diagnose any curable recurrence. CONCLUSIONS: A follow-up protocol is proposed, based on annual CT.     

How much liver resection is too much?

BACKGROUND: Hepatic failure occurring after liver resection carries a poor prognosis and is a complication dreaded by surgeons. Inadequate reserve in the remaining parenchyma leads to a steady decrease in liver function, inability to regenerate, and progression to liver failure. For this reason, many methods to quantify functional hepatic reserve have been developed. METHODS: This article reviews the main methods used in the assessment of hepatic reserve in patients undergoing hepatectomy and their use in operative decision making. RESULTS: A range of methods to categorically quantify the functional reserve of the liver have been developed, ranging from scoring systems (such as the Child-Pugh classification) to tests assessing complex hepatic metabolic pathways to radiological methods to assess functional reserve. However, no one method has or is ever likely to emerge as a single measure with which to dictate safe limits of resectability. CONCLUSIONS: In the future, the role of residual liver function assessment may be of most benefit in the routine stratification of risk, thus enabling both patient consent to be obtained and surgical procedure to be performed, with full information and facts regarding operative risks. However, there is no one single test that remains conclusively superior.