A multidisciplinary team approach minimises prophylactic mastectomy rates

BACKGROUND

Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making.

METHODS

We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded.

RESULTS

Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%).

DISCUSSION

MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Adenoid Cystic Carcinoma of Uterine Cervix

Primary adenoid cystic carcinoma of the cervix is a rare condition. It is a rare variant of adenocarcinoma and is mostly seen in postmenopausal women. Here we report a case of primary adenoid cystic carcinoma of uterine cervix. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 43-45 DOI: http://dx.doi.org/10.3126/njog.v8i1.8864

Hemifacial mass with extensive intralesional ossification and fat

The imaging appearance of neurofibromas is well described; however, macroscopic fat in a neurofibroma has been sparsely reported and intralesional ossification has only been documented twice in the literature. We describe a diffuse neurofibroma presenting as a hemifacial mass, atypical for the presence of extensive intralesional ossification and fat; the diagnosis was suggested on identification of other associated radiological features of neurofibromatosis.

Multiple intracranial tubercular abscesses in a child

2 Year old girl presented with fever and cough for 4 months. Neurological examination revealed right sided hemiplegia. Contrast enhanced computed tomography of brain showed multiple hypodense ring enhancing lesions. Pus on aspiration of intracranial abscess showed positive polymerase chain reaction for Mycobacterium tuberculosis. A possibility of tuberculosis though not commonly recognised may be considered in any child presenting with prolonged fever and multiple intracranial abscesses.

Anesthetic management for emergency cesarean section in a patient with severe valvular disease and preeclampsia

Wider selection of young patients for prosthetic valve replacement for valvular heart disease has resulted in an increase in number of women with heart disease reaching childbearing age. Such patients presenting in labor for emergency cesarean section require special consideration. We present a report of a parturient who presented at 36 weeks of gestation with severe aortic and mitral stenosis, pulmonary edema and severe preeclampsia. The goals of our anesthetic management included (1) careful airway management (2) maintaining stable hemodynamics (3) optimizing fluid status, and (4) preventing seizures. Issues related to management of patients with severe valvular disease, prosthetic valves and complications due to anticoagulant therapy during pregnancy are discussed.

Bilateral hematogenous Pseudomonas aeruginosa endophthalmitis after lung transplantation

Pseudomonas aeruginosa commonly colonizes the airways of patients with cystic fibrosis (CF). However, the occurrence of bacteremia with metastatic infection to the eye causing endogenous endophthalmitis is very rare. In the setting of lung transplantation, the significance of P. aeruginosa bacteremia in patients with CF whose airways are colonized before transplantation is unknown. We report a case of bilateral P. aeruginosa endogenous endophthalmitis in a patient with CF after lung transplant without documented bacteremia. The patient presented with acute eye symptoms in the presence of a left atrial thrombus and the disease followed a rapidly progressive course requiring aggressive medical-surgical treatment. Typically P. aeruginosa endophthalmitis has been associated with a poor visual prognosis. However, with combined medical-surgical management this patient retained useful vision in one eye without having retinal detachment or requiring enucleation. Endogenous endophthalmitis should be considered in the differential diagnosis of ocular complaints in patients with CF after lung transplant.

Oro-facial granulomatosis: a laryngeal presentation

We report the first case of oro-facial granulomatosis (OFG) presenting in pregnancy with laryngeal manifestations.

Negative ion fragmentations of deprotonated peptides: backbone cleavages directed through both Asp and Glu

The collision-induced spectra of [M - H](-) ions of a variety of natural and synthetic amphibian peptides containing Asp and/or Glu exhibit characteristic gamma backbone cleavage ions that identify the positions of these residues in the peptide. A theoretical study suggests that the Glu cleavage involves an S(N)i reaction of the carboxylate anion from the Glu alpha side chain to form a deprotonated cyclic lactone. The presence of either Asp or Glu or other residues that effect pronounced side-chain cleavages (e.g. Ser or Thr) results in the normal alpha and beta backbone cleavages being reduced in comparison to those cleavages which originate from side chains.

The search for charge-remote reactions of even-electron anions derived from 1,3-disubstituted adamantanes in the gas phase. Retro Diels-Alder and Norrish II processes

The collision induced decompositions of 3-substituted adamantane carboxylate anions have been studied with a view to uncovering charge-remote fragmentations of the 3-substituent. The 3-substituent is chosen so that it cannot approach the anion site, and so any fragmentations of that substituent should proceed independently of the charged centre, viz. charge-remote reactions. The following systems have been studied (i) the 3-cyclohexenyl system shows no charge-remote retro Diels-Alder fragmentation (DeltaH = +157 kJ mol(-1)), instead, charge-remote loss of the cyclohexenyl radical is noted, (ii) the 3-isobutyl ketone system shows no Norrish II cleavage (loss of C(3)H(6), DeltaH = +18 kJ mol(-1)), instead, the competitive losses of CO(2) from the charged carboxyl centre, together with charge-remote radical loss of the 3-substituent are observed, and (iii) the corresponding 3-isopropyl ester does show the "Norrish II" loss of C(3)H(6), together with competitive losses of CO(2) and the 3-substituent. It is concluded for cases (ii) and (iii), that an adamantane carboxylate anion system with a carbonyl group directly attached at the 3-position is not a suitable model system for studying charge-remote reactions.

Potential interstellar molecules. Formation of neutral C(6)CO from C(6)CO(-*) in the gas phase

Computations at the RCCSD(T)/aug-cc-pVDZ//B3LYP/6-31G* level of theory indicate that neutral C(6)CO is a stable species. The ground state of this neutral is the singlet cumulene oxide :C=C=C=C=C=C=C=O. The adiabatic electron affinity and dipole moment of singlet C(6)CO are 2.47 eV and 4.13 D, respectively, at this level of theory. The anion (C(6)CO)-* should be a possible precursor to this neutral. It has been formed by an unequivocal synthesis in the ion source of a mass spectrometer by the S(N)2(Si) reaction between (CH(3))(3)Si-C(triple bond)C-C(triple bond)C-C(triple bond)C-CO-CMe(3) and F(-) to form (-)C(triple bond)C-C(triple bond)C-C(triple bond)C-CO-Me(3) which loses Me(3)C* in the source to form C(6)CO(-)*. Charge stripping of this anion by vertical Franck-Condon oxidation forms C(6)CO, characterised by the neutralisation-reionisation spectrum (-NR(+)) of C(6)CO(-*), which is stable during the timeframe of this experiment (10(-6) s).

Traditional processing treatments as a promising approach To enhance the functional properties of rapeseed (Brassica campestris var. toria) and sesame seed (Sesamum indicum) meals

Different processing treatments were applied to rapeseed and sesame seed meals, and the functional properties of these products were assessed. All treatments except puffing for both meals and pressure cooking in sesame meal increased water absorption capacity (WAC). Fat absorption capacity (FAC) of rapeseed meals was enhanced significantly by all treatments. The full-fat meals of both sources showed maximum protein solubility when fermented and minimum protein solubility when pressure-cooked. Germinated and microwave-cooked meals enhanced foaming properties of rapeseed meals. Heat treatments, except microwave cooking, considerably reduced emulsifying properties of both meals. Fermentation and germination increased the specific viscosity of rapeseed meals, whereas processed sesame meals showed lower viscosity than dry sesame meals.

Interstellar molecules. Conversion Of C(3)O(-) to C(3)O in the gas phase

Neutral C(3)O has been prepared by collision induced neutralisation of the precursor radical anion formed by the reaction (-)C identical withC-CO-OEt --> C(3)O(-) + EtO(). The similar neutralisation reionisation ((-)NR(+)) and charge reversal (CR) spectra of C(3)O(-) indicate that the potential surfaces of C(3)O and C(3)O(+) show favourable vertical Franck-Condon overlap. This suggests that the bond connectivities of anion, neutral and cation C(3)O are the same. Copyright 1999 John Wiley & Sons, Ltd.

An evaluation of myelography with non-ionic water soluble contrast medium-iohexol

Iohexol myelography was performed in 25 cases of suspected spinal cord compression. Out of these, 24 cases gave optimally informative myelogram, while one case showed quasi-informative myelogram. Myelographic efficacy regarding the level of lesion was correct in all cases. On final evaluation 15 cases were diagnosed as extradural lesions, 9 cases as intradural extramedullary type and one case as diastematomyelia. Only single case which was diagnosed as intramedullary lesion on myelography was, in fact, an extradural lesion. There were only minor side-effects in the form of headache and paraesthesia in the lower limb. It was concluded that iohexol is a safe contrast medium with high efficacy and minimal side-effects for the total examination of spinal canal.

Comparative evaluation of computed tomography and cerebral angiography in the management of subarachnoid haemorrhage

Plain and contrast enhanced computed tomography (CT) scan of brain and cerebral angiography were done in 20 subjects of subarachnoid haemorrhage (SAH), diagnosed on the basis of clinical parameters and proved by cerebrospinal fluid (CSF) examination. Plain CT scan of brain confirmed the diagnosis of SAH in all the 20 (100%) cases, but was able to demonstrate the cause of SAH in 11(55%) cases only. Contrast CT scan provided additional information in 7 more cases. CT was also able to demonstrate the site and extent of bleeding, evidence of intraventricular bleeding and hydrocephalus. Cerebral angiography done in all the cases, confirmed the diagnosis in 14 (70%) cases diagnosed on CT and was able to give additional information in 4 more cases. It also showed excellent vascular details which were not possible with CT scan. It is concluded that enhanced CT scan should be done first in all the cases of SAH for preliminary scouting and angiography should be done where CT scan gives incomplete information or where surgical management is contemplated. Both the investigations were found to be complementary to each other.

Residues within the polycationic region of cGMP phosphodiesterase gamma subunit crucial for the interaction with transducin alpha subunit. Identification by endogenous ADP-ribosylation and site-directed mutagenesis

Interaction between the gamma subunit (Pgamma) of cGMP phosphodiesterase and the alpha subunit (Talpha) of transducin is a key step for the regulation of cGMP phosphodiesterase in retinal rod outer segments. Here we have utilized a combination of specific modification by an endogenous enzyme and site-directed mutagenesis of the Pgamma polycationic region to identify residues required for the interaction with Talpha. Pgamma, free or complexed with the alphabeta subunit (Palphabeta) of cGMP phosphodiesterase, was specifically radiolabeled by prewashed rod membranes in the presence of [adenylate-32P]NAD. Identification of ADP-ribose in the radiolabeled Pgamma and radiolabeling of arginine-replaced mutant forms of Pgamma indicate that both arginine 33 and arginine 36 are similarly ADP-ribosylated by endogenous ADP-ribosyltransferase, but only one arginine is modified at a time. Pgamma complexed with Talpha (both GTP- and GDP-bound forms) was not ADP-ribosylated; however, agmatine, which cannot interact with Talpha, was ADP-ribosylated in the presence of Talpha, suggesting that a Pgamma domain containing these arginines is masked by Talpha. A Pgamma mutant (R33,36K), as well as wild type Pgamma, inhibited both GTP hydrolysis of Talpha and GTP binding to Talpha. Moreover, GTP-bound Talpha activated Palphabeta that had been inhibited by R33,36K. However, another Pgamma mutant (R33,36L) could not inhibit these Talpha functions. In addition, GTP-bound Talpha could not activate Palphabeta inhibited by R33,36L. These results indicate that a Pgamma domain containing these arginines is required for its interaction with Talpha, but not with Palphabeta, and that positive charges in these arginines are crucial for the interaction.

Possible stimulation of retinal rod recovery to dark state by cGMP release from a cGMP phosphodiesterase noncatalytic site

Cyclic GMP phosphodiesterase, a key enzyme for phototransduction, contains alpha, beta (Palphabeta), and two gamma (Pgamma) subunits. In addition to catalytic sites, Palphabeta has two classes of noncatalytic cGMP binding sites with different affinities (Kd values <100 nM and >1 microM). Pgamma regulates Palphabeta as an inhibitor of cGMP hydrolysis and as a stimulator of cGMP binding to the high affinity noncatalytic sites. Pgamma release from Palphabeta by the GTP-bound alpha subunit of transducin (GTP.Talpha) interrupts these two functions. Here we describe a novel regulation of the Pgamma release by [cGMP] and its physiological implication. We isolated Pgamma mutants that exhibit abnormally one of these two functions, indicating the distinct domains in Pgamma are involved to express these functions. When [cGMP] was high ( approximately 5 microM), Pgamma responsible for the inhibition of cGMP hydrolysis was preferentially released, and cGMP hydrolysis activity of Palphabeta was increased about 10 times. When [cGMP] was low (less than approximately 0.5 microM), Pgamma responsible for the stimulation of cGMP binding to the high affinity sites was released. The Pgamma release resulted in the decrease of relative affinity of cGMP for the high affinity sites to at least (null)/1;10, followed by the rapid release of cGMP from one of the high affinity sites (apparent t1/2 = 3.8 s). cGMP ( approximately 5 microM) inhibited the extraction of Palphabeta from rod membranes by a Mg2+-free hypotonic buffer. The inhibition of Palphabeta extraction was not affected by Pgamma, suggesting that Palphabeta detects on the order of micromolar [cGMP] using low affinity noncatalytic sites on Palphabeta. Because [cGMP] is approximately 5 microM in darkness and lowered by photoexcitation and phosphodiesterase concentration is approximately 30 microM in rod photoreceptors, it is possible that cGMP phosphodiesterase functions to increase cytoplasamic [cGMP] after [cGMP] is reduced to the illuminated level.

A simple method for differentiating Leu and Ile in peptides. The negative-ion mass spectra of [M-H]- ions of phenylthiohydantoin Leu and Ile

Phenylthiohydantoin (PTH) amino acid derivatives are formed during sequential Edman degradation of peptides and proteins. Isomeric Leu and Ile (which differ only in respectively having iso-butyl and sec-butyl chains, and are often difficult to distinguish by conventional mass spectrometric techniques) may be readily identified by the characteristic decompositions of the [M-H]- ions of their PTH derivatives. The Leu spectrum shows major loss of propane, while that of the Ile derivative shows elimination of both methane and ethane. This method may be used routinely with 10 microgram quantities of peptide material.

Comparison of processing treatments on the composition and functional properties of rapeseed preparations (Brassica campestris L. var. toria)

Rapeseed preparations viz. rapeseed meal, concentrates and isolates were prepared using different processing treatments involving organic solvents, acids, alkali, steaming and boiling. Their anti-nutritional constituents and functional properties were studied in comparison to undefatted meal. Percent decrease in phytic acid and phenolic content was maximum in seeds boiled for 30 min and isolates, respectively. Isolate II prepared by sodium hexa-metaphosphate had minimum glucosinolates, maximum content of total proteins and much improved nitrogen solubility, emulsifying and foaming properties. Water absorption and fat absorption capacities were enhanced by boiling seeds prior to grinding and ammonia-methanol extraction, respectively. Viscosity decreased in all the treatments as compared to control.

Study of epigenetic variants in the Northern Indian crania

500 adult human skulls available in the Department of Anatomy, S. N. Medical College, Agra (India) were studied for the presence/absence of 32 epigenetic variants. The percentage of occurrence of these variants is compared with that of skulls of different countries. The factors affecting these variants are discussed in the light of available literature.

Reversal of skeletal resistance to parathyroid hormone in uremia by vitamin D metabolites: evidence for the requirement of 1,25(OH)2D3 and 24,25(OH)2D3

This study evaluates the role of vitamin D metabolites in the genesis of the skeletal resistance to the calcemic action of PTH in uremia. The changes in serum calcium after infusion of 2 U of PTE per kilogram per hour for 8 hr were evaluated in thyroparathyroidectomized dogs before and after 1 and 3 days of acute uremia produced by bilateral nephrectomy. The animals received vitamin D metabolites during the 3 days of uremia. Supplementation of 0.68 microgram/day 1,25(OH)2D3 and 24R,25(OH)2D3 restored the calcemic response to PTE to normal. This is in contrast to only partial correction of the response to PTE by 1,25(OH)2D3 alone. Administration of 1.36 microgram/day 24R,25(OH)2D3 did not improve the calcemic response to PTE. The results indicate that (1) both 1,25(OH)2D3 and 24R,25(OH)2D3 are necessary for the complete reversal of the impaired calcemic response to PTE, (2) this effect is not due to the increase in the amount of the dihydroxylated compounds of vitamin D, since equivalent amounts of these compounds in the form of 24R,25(OH)2D3 alone had no effect, and (3) the better effect of the combination of 1,25(OH)2D3 and 24R,25(OH)2D3 is most probably due to an interaction between these two metabolites of vitamin D permitting an intact calcemic action of PTH.