Efficacy of bivalent fimbrial vaccines to control and eliminate intermediate forms of footrot in sheep

OBJECTIVE

The aim of this study was to determine the efficacy of serogroup-specific bivalent fimbrial vaccines in the control and elimination of relatively mild (intermediate) forms of footrot in sheep flocks in NSW, there being some evidence that such forms are difficult to control.

METHODS

Four flocks of sheep with history of footrot of intermediate virulence were selected based on clinical and bacteriological diagnoses. Dichelobacter nodosus serogroups included in bivalent vaccines at each farm were based on on-farm serogroup-prevalence data. Two doses of bivalent vaccine were administered with a 4-week interval between doses. Repeated post-vaccination inspections of all feet of between 100 and 119 animals per mob were conducted and foot swabs were collected for bacteriological testing. Blood samples were collected from 10 to 24 individually identified animals per flock at each inspection to check for agglutinating antibody responses.

RESULTS

In the majority of animals, antibody levels for serogroups included in each vaccine were above the level believed to be required for protective immunity. Footrot disappeared on farm 1 prior to vaccination, but did not reappear postvaccination. Footrot was controlled but not eliminated on farms 2, 3, and 4, where the prevalence and severity of the disease and number of serogroups present were reduced.

CONCLUSION

Serogroup-specific bivalent vaccines can be effective at controlling footrot caused by intermediate strains of D. nodosus.

Cancer and breast cancer awareness interventions in an intellectual disability context: A review of the literature

BACKGROUND

Women with an intellectual disability (ID) have a similar risk of developing breast cancer as women in the general population yet present with later stage breast cancers, which have poorer outcomes.

AIM

To identify whether there is a need to develop a breast cancer awareness intervention for women with an ID.

METHODS

Interventions aimed at increasing cancer awareness and breast cancer awareness for people with an ID were identified and critically appraised.

RESULTS

Five interventions to increase cancer awareness or breast cancer awareness in people with an ID were identified.

CONCLUSION

The review highlighted the paucity of theoretically underpinned breast cancer awareness interventions specifically aimed at women with an ID. Facilitating breast cancer awareness for women with an ID could potentially lead to earlier presentation of potential symptoms of breast cancer, earlier treatment, better prognosis and ultimately, improved survival. This article establishes that there is a need for an intervention underpinned by theory to increase breast cancer awareness in women with an ID.

Risk of colorectal cancer associated with BRCA1 and/or BRCA2 mutation carriers: systematic review and meta-analysis

BACKGROUND

Carriers of the BRCA1 and/or BRCA2 mutation incur a lifetime risk of up to 85 per cent for breast cancer, and between 20 and 40 per cent for ovarian cancer. Efforts to estimate the lifetime risk of developing colorectal cancer for BRCA mutation carriers have produced conflicting results. Consequently, there are no formal guidelines regarding the need for bowel screening for individuals with BRCA1 and/or BRCA2 mutations. This systematic review and meta-analysis determined the risk of colorectal cancer associated with BRCA carrier mutations.

METHODS

The primary outcome was incidence of colorectal cancer in BRCA mutation carriers. Secondary outcomes were the incidence in BRCA1 and BRCA2 carriers, Ashkenazi Jews, and age- and sex-matched cohorts.

RESULTS

Eleven studies were included in the review, with an overall population of 14 252 and 4831 colorectal cancers identified. Nine studies were included in the meta-analysis. There was no increase in colorectal cancer among patients carrying a BRCA mutation (odds ratio 1·03, 95 per cent c.i. 0·80 to 1·32; P = 0·82). After adjustment for Ashkenazi heritage, and age and sex estimates, there was no increased odds of developing colorectal cancer (with no heterogeneity, I²  = 0 per cent).

CONCLUSION

BRCA1 and/or BRCA2 mutation carriers are not at a higher risk of colorectal cancer.

Meta-analysis of the diagnostic accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph node metastasis

Background

Axillary lymph node status remains a significant prognostic indicator in breast cancer. Here, the diagnostic accuracy of ultrasound-guided fine-needle aspiration (US-FNA) and ultrasound-guided core needle biopsy (US-CNB) in axillary staging was compared.

Methods

A comprehensive search was undertaken of all published studies comparing the diagnostic accuracy of US-CNB and US-FNA of axillary lymph nodes in breast cancer. Studies were included if raw data were available on the diagnostic performance of both US-FNA and US-CNB, and compared with final histology results. Relevant data were extracted from each study for systematic review. Meta-analysis was performed using a random-effects model. The pooled sensitivity and specificity of US-FNA and US-CNB were obtained using a bivariable model. Summary receiver operating characteristic (ROC) graphs were created to confirm diagnostic accuracy.

Results

Data on a total of 1353 patients from six studies met the inclusion criteria and were included in the final analysis. US-CNB was superior to US-FNA in diagnosing axillary nodal metastases: sensitivity 88 (95 per cent c.i. 84 to 91) versus 74 (70 to 78) per cent respectively. Both US-CNB and US-FNA had a high specificity of 100 per cent. Reported complication rates were significantly higher for US-CNB compared with US-FNA (7·1 versus 1·3 per cent; P < 0·001). Conversely, the requirement for repeat diagnostic procedures was significantly greater for US-FNA (4·0 versus 0·5 per cent; P < 0·001).

Conclusion

US-CNB is a superior diagnostic technique to US-FNA for axillary staging in breast cancer.

A quantitative analysis of tumour characteristics in breast cancer patients with extranodal extension in non-sentinel nodes

BACKGROUND

The presence of extranodal extension (ENE) is well documented as a predictor of non-sentinel lymph node (NSLN) metastasis. The ACOSOG Z0011 trial (2011) concluded that patients who satisfy criteria including the absence of sentinel lymph node (SLN) ENE can forgo axillary clearance (AC). Currently there are no studies analysing the rate of ENE in NSLN metastasis in which the sentinel node was positive but had no ENE. Determining this incidence will help determine if current paradigms are resulting in residual ENE in NSLN metastasis by forgoing AC based on the Z0011 trial..

METHODS

This study determined incidence of ENE at NSLN metastasis in patients with a positive SLN biopsy without ENE in 162 symptomatic breast cancer patients who underwent AC between 2009 and 2014 at Cork University Hospital Breast Cancer Service, a teaching hospital of University College Cork.

RESULTS

Of 965 sentinel node biopsies performed 251 were identified as SLN positive, 162 (64.5%) underwent further AC. Of the 162 patients, 56.8% (92/162) were positive for ENE at SLN, of these 57.6% (53/92) had NSLN metastasis versus 17.1% (12/70) in the ENE-negative group (χ² test; P < 0.001). On adjusted analysis, ENE at the SLN was a significant predictor of NSLN metastasis (odds ratio [OR] 8.63; 95% confidence interval [CI] 3.26-22.86; P < 0.001). The incidence of NSLN-ENE in patients without SLN-ENE was 1/70 (1.4%) compared with 33.7% (31/92) in patients who had ENE at the SLN (χ² test; P < 0.001).

CONCLUSION

ENE at the SLN is an independent predictor of NSLN involvement; its absence significantly reduces the likelihood of ENE in NSLN metastasis..

Health literacy and the perception of risk in a breast cancer family history clinic

BACKGROUND

Informed consent is an essential component of medical practice, and especially so in procedural based specialties which entail varying degrees of risk. Breast cancer is one of the most common cancers in women, and as such is the focus of extensive research and significant media attention. Despite this, considerable misperception exists regarding the risk of developing breast cancer.

AIMS

This study aims to examine the accuracy of risk perception of women attending a breast cancer family history clinic, and to explore the relationship between risk perception accuracy and health literacy.

METHODS

A cross-sectional study of women attending a breast cancer family history clinic (n = 86) was carried out, consisting of a patient survey and a validated health literacy assessment. Patients' perception of personal and population breast cancer risk was compared to actual risk as calculated by a validated risk assessment tool.

RESULTS

Significant discordance between real and perceived risks was observed. The majority (83.7%) of women overestimated their personal lifetime risk of developing breast cancer, as well as that of other women of the same age (89.5%). Health literacy was considered potentially inadequate in 37.2% of patients; there was a correlation between low health literacy and increased risk perception inaccuracy across both personal ten-year (r_s = 0.224, p = 0.039) and general ten-year population estimations. (r_s = 0.267, p = 0.013).

CONCLUSION

Inaccuracy in risk perception is highly prevalent in women attending a breast cancer family history clinic. Health literacy inadequacy is significantly associated with this inaccuracy.

When pathological and radiological correlation is achieved, excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted

BACKGROUND

The diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up.

METHODS

A retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded.

RESULTS

2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41-70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.

PATI: Patient accessed tailored information: A pilot study to evaluate the effect on preoperative breast cancer patients of information delivered via a mobile application

OBJECTIVES

The information needs of cancer patients are highly variable. Literature suggests an improved ability to modulate personalised stress, increased patient involvement with decision making, greater satisfaction with treatment choices and reduced anxiety levels in cancer patients who have access to information. The aim of this project was to evaluate the effects of a mobile information application on anxiety levels of patients undergoing surgery for breast cancer.

MATERIALS AND METHODS

An application was developed for use with Apple iPad containing information on basic breast cancer biology, different treatments used and surgical techniques. Content and face validity studies were performed. A randomized control trial was designed, with a 1:2 allocation. Data collected include basic demographics and type of surgery. Questionnaires used included: the HADS, Mini-MAC, information technology familiarity and information satisfaction.

RESULTS

A total of 39 women participated. 13 women had access to an iPad containing additional information and 26 women acted as controls. The mean age was 54 and technology familiarity was similar among both groups. Anxiety and depression scores at seven days were significantly lower in control patients without access to the additional information provided by the mobile application (p = 0.022 and 0.029 respectively).

CONCLUSION

Anxiety and depression in breast cancer patients is both multifactorial and significant, with anxiety levels directly correlating with reduced quality of life. Intuitively, information should improve anxiety levels, however, we have demonstrated that surgical patients with less information reported significantly lower anxiety. We advise the thorough testing and auditing of information initiatives before deployment.

Validation and Assessment of a Technology Familiarity Score in Patients Attending a Symptomatic Breast Clinic

INTRODUCTION

New media technologies (computers, mobile phones and the internet) have the potential to transform the healthcare information needs of patients with breast disease (Ferlay et al. in Eur J Cancer 49:1374-1403, 2013). However, patients' current level of use and their willingness to accept new media for education and communication remain unknown.

METHODS

This was a single-centre clinic-based prospective cross-sectional study. A previously developed instrument was modified, validated and tested on patients attending a symptomatic breast clinic.

RESULTS

The instrument was evaluated on 200 symptomatic breast patients. The commonest outlets for education were staff (95 %), leaflets (69 %) and websites (59 %). Websites are more likely to be consulted by younger patients (<47 years), and patients who were working, students or homemakers (p < 0.05). Patients rated usefulness of information media in this order: (1) print, (2) phone, (3) website, (4) email, (5) text and (6) apps. Patients who were new to the clinic were more likely to find text messaging and emailing useful (n < 0.05). Younger patients (<47 years) are more likely to find text messages, apps, websites and email useful (p < 0.05). Urban patients are more likely to find websites and email useful (p < 0.05). Patients with higher education were more likely to favour apps, websites and email (p < 0.05). Smartphone owners were significantly more likely to rate text messaging, apps, websites and email as useful media (p < 0.05).

CONCLUSION

This study demonstrates that new media technology use among breast patients is expanding as expected along generational trends. As such its' further integration into healthcare systems can potentially ameliorate patient education and communication.

An International Multicenter Review of the Malignancy Rate of Excised Papillomatous Breast Lesions

BACKGROUND

Papillary lesions of the breast are a relatively rare, but heterogeneous group ranging from benign to atypical and malignant. Debate exists regarding the optimal management of these lesions. In the absence of more accurate risk-stratification models, traditional management guidelines recommend surgical excision, despite the majority of lesions proving benign. This study sought to determine the rate of malignancy in excised breast papillomas and to elucidate whether there exists a population in which surgical excision may be unnecessary.

METHODS

A multicenter international retrospective review of core biopsy diagnosed breast papillomas and papillary lesions was performed between 2009 and 2013, following institutional ethical approval. Patient demographics, histopathological, and radiological findings were recorded. All data was tabulated, and statistical analysis performed using Stata.

RESULTS

A total of 238 patients were included in the final analysis. The age profile of those with benign pathology was significantly younger than those with malignant pathology (p < 0.001). Atypia on core needle biopsy was significantly associated with a final pathological diagnosis of malignancy (OR = 2.73). The upgrade rate from benign core needle biopsy to malignancy on the final pathological sample was 14.4 %; however, only 3.7 % had invasive cancer.

CONCLUSIONS

This international dataset is one of the largest in the published literature relating to breast papillomas. The overall risk of malignancy is significantly associated with older age and the presence of atypia on core needle biopsy. It may be possible to stratify higher-risk patients according to age and core needle biopsy findings, thereby avoiding surgery on low-risk patients.

"Is general surgery still relevant to the subspecialised trainee?" A 10 year comparison of general versus specialty surgical practice

BACKGROUND

The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center.

METHODS

A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines.

RESULTS

11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62-2.58 bed days, p = 0.342) & emergency admissions (7.36-5.65, p = 0.026).

CONCLUSIONS

General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.

Surgical attire, practices and their perception in the prevention of surgical site infection

INTRODUCTION

Clean surgical scrubs, surgical gowns and headgear are worn by operative teams to decrease bacterial contamination and lower surgical site infection (SSI) rates.

METHODS

A detailed review was undertaken of peer-reviewed publications and other sources of material in the English language over the last 50 years included.

RESULTS

Surgical scrubs should be clean and made of tightly woven material. Studies investigating single-use gowns and drapes versus reusable gowns report conflicting evidence. Double gloving may reduce SSI rates in procedures where no antibiotic prophylaxis was administered. Bacterial contamination of the operative field has been shown to be decreased by the wearing of surgical headgear by the operating team.

CONCLUSIONS

Further consideration and better trials are required to determine the impact of different theatre clothing on SSI rates.

Development of an adhesive surgical ward round checklist: a technique to improve patient safety

Checklists have been shown to improve patient outcomes. Checklist use is seen in the pre-operative to post-operative phases of the patient pathway. An adhesive checklist was developed for ward rounds due to the positive impact it could have on improving patient safety. Over an eight day period data were collected from five consultant-led teams that were randomly selected from the surgical department and divided into sticker groups and control groups. Across the board percentage adherence to the Good Surgical Practice Guidelines (GSPG) was markedly higher in the sticker study group, 1186 (91%) in comparison with the control group 718 (55%). There was significant improvement of documentation across all areas measured. An adhesive checklist for ward round note taking is a simple and cost-effective way to improve documentation, communication, hand-over, and patient safety. Successfully implemented in a tertiary level centre in Dublin, Ireland it is easily transferable to other surgical departments globally.

Glucagon-like peptide-1 (GLP-1) and the regulation of human invariant natural killer T cells: lessons from obesity, diabetes and psoriasis

AIMS/HYPOTHESIS

The innate immune cells, invariant natural killer T cells (iNKT cells), are implicated in the pathogenesis of psoriasis, an inflammatory condition associated with obesity and other metabolic diseases, such as diabetes and dyslipidaemia. We observed an improvement in psoriasis severity in a patient within days of starting treatment with an incretin-mimetic, glucagon-like peptide-1 (GLP-1) receptor agonist. This was independent of change in glycaemic control. We proposed that this unexpected clinical outcome resulted from a direct effect of GLP-1 on iNKT cells.

METHODS

We measured circulating and psoriatic plaque iNKT cell numbers in two patients with type 2 diabetes and psoriasis before and after commencing GLP-1 analogue therapy. In addition, we investigated the in vitro effects of GLP-1 on iNKT cells and looked for a functional GLP-1 receptor on these cells.

RESULTS

The Psoriasis Area and Severity Index improved in both patients following 6 weeks of GLP-1 analogue therapy. This was associated with an alteration in iNKT cell number, with an increased number in the circulation and a decreased number in psoriatic plaques. The GLP-1 receptor was expressed on iNKT cells, and GLP-1 induced a dose-dependent inhibition of iNKT cell cytokine secretion, but not cytolytic degranulation in vitro.

CONCLUSIONS/INTERPRETATION

The clinical effect observed and the direct interaction between GLP-1 and the immune system raise the possibility of therapeutic applications for GLP-1 in inflammatory conditions such as psoriasis.

Preventing infection in general surgery: improvements through education of surgeons by surgeons

Surgical patients are at particular risk of healthcare-associated infection (HCAI) due to the presence of a surgical site leading to surgical site infection (SSI), and because of the need for intravascular access resulting in catheter-related bloodstream infection (CRBSI). A two-year initiative commenced with an initial audit of surgical practice; this was used to inform the development of a targeted educational initiative by surgeons specifically for surgical trainees. Parameters assessed during the initial audit and a further audit after the educational initiative were related to intra- and postoperative aspects of the prevention of SSIs, as well as care of peripheral venous catheters (PVCs) in surgical patients. The proportion of prophylactic antibiotics administered prior to incision across 360 operations increased from 30.0% to 59.1% (P<0.001). Surgical site dressings were observed in 234 patients, and a significant decrease was found in the percentage of dressings that were tampered with during the initial 48h after surgery (16.5% vs 6.2%, P=0.030). In total, 574 PVCs were assessed over the two-year period. Improvements were found in the proportion of unnecessary PVCs in situ (37.9% vs 24.4%, P<0.001), PVCs in situ for >72h (10.6% vs 3.1%, P<0.001) and PVCs covered with clean and intact dressings (87.3% vs 97.6%, P<0.001). Significant improvements in surgical practice were established for the prevention of SSI and CRBSI through a focused educational programme developed by and for surgeons. Potentially, other specific measures may also be warranted to achieve further improvements in infection prevention in surgical practice.

A descriptive study of consent documentation

The aim of this study was to observe the error rate in the consent process of a university hospital and to illicit the opinions of the consenting doctors on the process. A prospective observational review of theatre consent forms was performed along with an anonymous survey of non-consultant hospital doctors (NCHD's). No potential risks were documented in 95.3% of the 64 scrutinized consents and late alterations were required in 9%. Respondents to the NCHD survey estimated that they were unsure of the procedure or risks involved in an average of 29% of occasions. Interns admitted to being unsure of the details of the procedure in almost a third (32%) of cases, making them less well informed than their senior colleagues (p=0.024). This study highlights the difficulties encountered by consenting doctors, an issue which may lead to patient dissatisfaction, threaten the efficient running of a surgical unit and potentially expose its staff to avoidable litigation. It also recommends the use of multimedia adjuncts to facilitate both patient and doctor education in the consent process.

A study of the factors influencing school-going students considering medical careers

INTRODUCTION

Obtaining a place in an Irish medical school is extremely competitive, a situation mirrored in many other countries. We aimed to determine the factors influencing school students in deciding to study medicine in university. We further determined what level of interest exists in pursuing a surgical career after completion of medical school.

METHODS

The Royal College of Surgeons in Ireland hosts an annual "Introduction to Medicine" programme for senior school children. Attendees were surveyed using a Likert scale to examine the factors influencing the group in choosing to study medicine, and pursue surgery as their ultimate career choice.

RESULTS

A total of 128 completed the survey, giving a response rate of 100%. The opportunity to help others was most the most influential factors cited by students (97%). Males were significantly more likely to have an interest in a career in surgery rather than medicine (p = 0.003), and ranked "financial reward" (p = 0.036) as a more significant factors in influencing career choice than did females.

CONCLUSIONS

A clear understanding of these factors influencing our students in their career choices and a strategy of recruitment based on these is imperative in order to optimize recruitment of students most suited to working as doctors.

Assessing the functional performance of post-call hospital doctors using a Nintendo Wii

Sleep deprivation is an established part of the working life for Non-Consultant Hospital Doctors (NCHDs) in Ireland. Concern exists about the effect of extended NCHD work hours. We utilised a Nintendo Wii to evaluate motor function of NCHDs both prior to their on-call shift and the day afterwards. Data was exported to SPSS ver. 15 for statistical analysis with p < 0.05 considered significant. A total of 72 NCHDs were invited to participate in this study. There was a 62.5% (45) rate of follow-up. Overall 27 (60%) NCHDs were on medical call, with 18 (40%) on surgical call. There was no statistically significant difference between NCHDs pre-and post-call motor assessment scores. The majority of study participants (75.5%, n = 34) had four or more hours sleep. On-call duty allows for a greater than anticipated amount of sleep per on-call shift and therefore has a negligible effect on the motor skills of medical staff.

The role of topical antibiotics used as prophylaxis in surgical site infection prevention

Compared with systemic antibiotic therapy, the topical or local delivery of an antibiotic has many potential advantages. However, local antibiotics at the surgical site have received very limited approval in any of the surgical prophylaxis consensus guidelines that we are aware of. A review of the literature was carried out through searches of peer-reviewed publications in PubMed in the English language over a 30 year period between January 1980 and May 2010. Both retrospective and prospective studies were included, as well as meta-analyses. With regard to defining 'topical' or 'local' antibiotic application, the application of an antibiotic solution to the surgical site intraoperatively or immediately post-operatively was included. A number of surgical procedures have been shown to significantly benefit from perioperative topical prophylaxis, e.g. joint arthroplasty, cataract surgery and, possibly, breast augmentation. In obese patients undergoing abdominal surgery, topical surgical prophylaxis is also proven to be beneficial. The selective use of topical antibiotics as surgical prophylaxis is justified for specific procedures, such as joint arthroplasty, cataract surgery and, possibly, breast augmentation. In selective cases, such as obese patients undergoing abdominal surgery, topical surgical prophylaxis is also proven to be beneficial. Apart from these specific indications, the evidence for use of topical antibiotics in surgery is lacking in conclusive randomized controlled trials.

A comparison of performances of consultant surgeons, NCHDs and medical students in a modified HPAT examination

Following the implementation of the Fottrell report, entry to medical school in Ireland has undergone significant change. Medical school studentship is now awarded based on a combination of points obtained from the final examination of Irish secondary schools (the leaving certificate) combined with HPAT scores (Health Professions Admissions Test). The HPAT is designed to test a candidate's knowledge in several different fields including problem solving skills, logical and non verbal reasoning. A sample HPAT was administered to a test group composed of consultant surgeons, non consultant hospital doctors, and medical students. Statistical analysis was performed and no significant difference was found between the performances of the groups. This is surprising as it was expected that groups with greater experience at medical problem solving would have translated to higher scores. This exposes a flaw within the HPAT system and a potential weakness in the process of doctor selection.

Sentinel lymph node biopsy: Is it possible to reduce false negative rates by excluding patients with nodular melanoma?

OBJECTIVE

The aim of this study was to review the outcome of sentinel lymph node biopsy (SLNB) in patients with melanoma and to delineate whether patients with nodular melanoma are more likely to develop nodal recurrence despite negative SLNB.

METHODS

Consecutive patients with cutaneous melanoma undergoing SLNB were identified from a departmental database between 1997 and 2005. Factors including demographic data, site, histological subtype, depth and outcome were examined.

RESULTS

Of 131 patients, 103 were node negative and eligible for study. The median age was 53 (16-82) years with 46 patients being male (45%) and 57 female (55%). Primary melanoma sites included lower limb (49; 48%), upper limb (29; 28%), head (12; 11%), trunk (7; 7%) and back (6; 6%). The median Breslow thickness was 2mm. Superficial spreading accounted for 43% of melanoma with nodular accounting for 42%. Median follow-up was 40 (3-90) months. Of 20 relapses, seven recurred in the same nodal basin, three were satellite recurrences, one recurred with both satellite and nodal lesions simultaneously, and nine experienced haematogenous spread. Of the eight patients who developed recurrence in the same nodal basin, four were of nodular histological subtype (p=NS). All of the three patients with satellite lesions had nodular melanoma histologically (p=0.02). When nodal and satellite recurrences were combined, eight of 11 were histologically nodular (p=0.01).

CONCLUSIONS

This study indicates that lymphatic recurrence occurs more often in SLNB negative patients with nodular melanoma. Further evaluation of the inclusion criteria for sentinel node biopsy is warranted.

The influence of skin structure on permeability: an intersite and interspecies comparison with hydrophilic penetrants

For reasons that are unclear, skin from various body sites has different permeability properties. We have used hydrophilic penetrants (water, ethanol, mannitol, and paraquat) to study the in vitro permeability of skin from marmoset (eight body sites), man, and rat. Skin structure (stratum corneum thickness and number of cell layers; epidermal and dermal thickness; number and area of hair follicle openings per mm2) was compared with permeability. There was no apparent relationship between skin structure and permeability to the most rapid penetrants, water and ethanol. Follicle area opening was the structural feature that varied most between species and between body sites. Different marmoset body sites showed a threefold range in follicle area but this did not appear to influence the absorption rates of the test penetrants. However, among the species there was an 80-times range in follicle area, which correlated with the observed differences in rate of mannitol and paraquat absorption. Thus, permeability could be related to inter-species differences in skin structure, but only with the relatively slowly absorbed test penetrants, mannitol and paraquat.