Performance of a clinical prediction score for thrombotic thrombocytopenic purpura in an independent cohort.

BACKGROUND AND OBJECTIVES: Idiopathic thrombotic thrombocytopenic purpura (TTP) is a rare, clinically diagnosed disorder characterized by widespread intravascular platelet thrombosis. The pathophysiology involves acquired deficiency of ADAMTS13 (A disintegrin and metalloprotease with thrombospondin type 1 repeats), the enzyme responsible for cleavage of high molecular weight vonWillebrand factor multimers. Disease mortality is high, although prompt treatment with plasma exchange is generally effective. A readily available and highly reliable method of identifying ADAMTS13-deficient patients for appropriate plasma exchange is therefore of interest. MATERIALS AND METHODS: Our initial study involved the assessment of multiple clinical and laboratory variables in patients with clinically suspected TTP for whom ADAMTS13 assay was performed. Five variables were found to be of significant predictive power. This enabled the development of a point-based scoring system to efficiently determine the likelihood of TTP and response to plasma exchange in a given patient. This current study involved a separate validation cohort of patients with clinically suspected TTP who underwent ADAMTS13 testing within two large healthcare systems in Utah between 2009 and 2011. The previously derived score was applied to this cohort and its performance was analysed. Additionally, the original and validation cohorts were combined to revisit the predictive power of individual variables and the five-variable prediction score. RESULTS: A total of 84 (11 paediatric cases excluded) patients comprised the validation population. The percentage of TTP diagnoses in this group (10%) was identical to that in the initial cohort. Using an ADAMTS13 activity of <10% of normal, our original score correctly predicted or excluded severe ADAMTS13 deficiency in all patients in the second cohort when data for all variables was available. Individual variables retained predictive power and the performance of a three-variable parsimonious model, as well as the ultimate diagnoses for patients in the second cohort are described. CONCLUSION: This work confirms the predictive power of a simple point-based score to exclude TTP as evidenced by severe ADAMTS13 deficiency in appropriately selected patients. It may enable clinicians to rapidly begin plasma exchange or to pursue an alternative cause of thrombotic microangiopathy.

What Can We Learn from Parents of Caries-Free and Caries-Active Hispanic Children?

OBJECTIVE: This study evaluated strength-based motivators within Hispanic families that support the creation of health in their children. A mixed-methods approach was used to understand differences in Hispanic parental factors between caries-free (CF) and caries-active (CA) children. METHODS: A cross-sectional survey was conducted with 200 parent-child triads (primary child: between 0 and 6 y; reference child: between 0 and 10 y) recruited from health centers in the Denver Metro area. All the participating children received an oral examination, and the triads were grouped as CF or CA based on the caries status of the primary child. Qualitative data were collected through in-depth individual interviews with the parents. The analysis only involved the primary child. Bivariable analysis were conducted between parent factors (independent variables) and presence or absence of caries (outcome variable). The variables with P < 0.20 in the bivariable analysis were subjected to 2 multivariable logistic regression models. The children in the CF group had mean (SD) age of 2.8 (1.28) y compared to the CA group at 4.0 (1.55) y (P < 0.001). Bivariable analysis demonstrated that parents in the CF group reported higher oral hygiene behavior scores (P = 0.047), perceived fewer barriers (P = 0.009) to accessing preventive dental care, and considered their children more susceptible to cavities (P = 0.001) compared to parents in the CA group. Multivariable model (adjusting for socioeconomic characteristics) demonstrated that parents of CF children perceived high susceptibility to caries for their children (P = 0.040). Multivariable model (adjusting for acculturation) demonstrated an association of parental oral hygiene behavior (P = 0.040) and parent-perceived susceptibility to caries (P = 0.010) with CF child status. Qualitative interviews revealed that parents in the CF group were concerned about their children's higher susceptibility to caries and tried to establish good oral hygiene routines for their children. CONCLUSION: The results of this study demonstrated that parental behaviors and health beliefs could be significant determinants of caries status in Hispanic children. KNOWLEDGE TRANSFER STATEMENT: Results of this study indicate that parental oral health beliefs and behaviors are significant determinants of caries status in children of Hispanic population. Parental beliefs could motivate them to take action or establish behavior that prevents dental caries in their children. Health care providers and caries prevention efforts can incorporate this information to tailor oral health promotional messaging and approaches to improve the oral health of Hispanic children.

Image-guided breast biopsy: state-of-the-art.

Percutaneous image-guided breast biopsy is widely practised to evaluate predominantly non-palpable breast lesions. There has been steady development in percutaneous biopsy techniques. Fine-needle aspiration cytology was the original method of sampling, followed in the early 1990s by large core needle biopsy. The accuracy of both has been improved by ultrasound and stereotactic guidance. Larger bore vacuum-assisted biopsy devices became available in the late 1990s and are now commonplace in most breast units. We review the different types of breast biopsy devices currently available together with various localization techniques used, focusing on their advantages, limitations and current controversial clinical management issues.

Maternal Factors Associated with Early Childhood Caries in Urban Latino Children.

The objective of this investigation was to describe maternal psychosocial, behavioral, and acculturation factors associated with early childhood caries in a sample of urban Latino mother-child dyads. A cross-sectional survey was conducted with 100 mothers whose children (under the age of 6 y) were patients at the Dental Center at Children's Hospital Colorado in Aurora, Colorado. All children participating in the study received an oral examination to measure decayed, missing, filled, surfaces (dmfs). Participating mothers were given the option to sign the consent form and complete the survey in English or Spanish, according to their preferred language. The survey used demographic, behavioral, knowledge, and several psychosocial variables. Bivariate analysis was conducted with dmfs as a dependent variable. The associations between independent variables and dmfs were modeled using negative binomial regression. Mean ± SD dmfs for the entire sample was about 11 ± 16.85. The mothers who spoke Spanish had children with significantly (P = 0.046) higher dmfs scores (15.2) compared to mothers who spoke English (7.56). Preference of Spanish language was significantly associated with self-efficacy (P = 0.0043), oral health knowledge (P = 0.0024), and 3 subscales of the health belief model: perceived severity (P = 0.057), perceived barriers (P = 0.0002), and perceived susceptibility (P = 0.008). Both in the univariate and the multivariate models, oral health behavior and preferential use of Spanish remained significantly associated with higher dmfs scores. Results of this study demonstrate that maternal oral health behaviors and preferred language are significant factors associated with early childhood caries in urban Latino children. Knowledge Transfer Statement: Results of this study indicate that maternal oral health behaviors and the level of acculturation are significantly associated with caries in urban Latino children. Caries prevention efforts in this population could use this information to tailor oral health messaging according to the level of acculturation in mothers.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in American Indian Children.

INTRODUCTION: In a randomized controlled trial, the effectiveness of motivational interviewing (MI) combined with enhanced community services (MI + ECS) was compared with ECS alone for reducing dental caries in American Indian children on the Pine Ridge Reservation. The intervention was developed and delivered with extensive tribal collaboration. METHODS: A total 579 mother-newborn dyads were enrolled and randomized to the MI + ECS and ECS groups. They were followed for 36 mo. Four MI sessions were provided, the first shortly after childbirth and then 6, 12, and 18 mo later. Both groups were exposed to ECS, which included public service announcements through billboards and tribal radio, as well as broad distribution of brochures on behavioral risk factors for early childhood caries (ECC), toothbrushes, and toothpaste. MI impact was measured as decayed, missing, and filled tooth surfaces (dmfs). Secondary outcomes included decayed surfaces, caries prevalence, and maternal oral health knowledge and behaviors. Modified intention-to-treat analyses were conducted. Eighty-eight percent of mothers completed at least 3 of 4 MI sessions offered. RESULTS: After 3 y, dmfs was not significantly different for the 2 groups (MI + ECS = 10, ECS = 10.38, P = 0.68). In both groups, prevalence of caries experience was 7% to 9% after 1 y, 35% to 36% at 2 y, and 55% to 56% at 3 y. Mean knowledge scores increased by 5.0, 5.3, and 5.9 percentage points at years 1, 2, and 3 in the MI + ECS group and by 1.9, 3.3, and 5.0 percentage points in the ECS group (P = 0.03), respectively. Mean maternal oral health behavior scores were not statistically significantly different between the treatment arms. CONCLUSION: In summary, the MI intervention appeared to improve maternal knowledge but had no effect on oral health behaviors or on the progression of ECC (ClinicalTrials.gov NCT01116726). KNOWLEDGE TRANSFER STATEMENT: The findings of this study suggest that motivational interviewing focusing on parental behaviors may not be as effective as previously hoped for slowing the development of childhood caries in some high-risk groups. Furthermore, social factors may be even more salient determinants of oral health than what we previously supposed, perhaps interfering with the capacity to benefit from behavioral strategies that have been useful elsewhere. The improvement of children's oral health in high-risk populations characterized by poverty and multiple related life stresses may require more holistic approaches that address these formidable barriers.

The myristylation signal of p60v-src functionally complements the N-terminal fps-specific region of P130gag-fps.

The P130gag-fps protein-tyrosine kinase of Fujinami sarcoma virus contains an N-terminal fps-specific domain (Nfps) that is important for oncogenicity. The N-terminal 14 amino acids of p60v-src, which direct myristylation and membrane association, can replace the gag-Nfps sequences of P130gag-fps (residues 1 to 635), producing a highly transforming src-fps polypeptide. Conversely, gag-Nfps can restore modest transforming activity to a nonmyristylated v-src polypeptide. These results emphasize the modular construction of protein-tyrosine kinases and indicate that Nfps, possibly in conjunction with gag, functions in the subcellular localization of P130gag-fps.

Germline E-cadherin mutations in hereditary diffuse gastric cancer: assessment of 42 new families and review of genetic screening criteria.

BACKGROUND: Mutations in the E-cadherin (CDH1) gene are a well documented cause of hereditary diffuse gastric cancer (HDGC). Development of evidence based guidelines for CDH1 screening for HDGC have been complicated by its rarity, variable penetrance, and lack of founder mutations. METHODS: Forty three new gastric cancer (GC) families were ascertained from multiple sources. In 42 of these families at least one gastric cancer was pathologically confirmed to be a diffuse gastric cancer (DGC); the other family had intestinal type gastric cancers. Screening of the entire coding region of the CDH1 gene and all intron/exon boundaries was performed by bi-directional sequencing. RESULTS: Novel mutations were found in 13 of the 42 DGC families (31% overall). Twelve of these mutations occur among the 25 families with multiple cases of gastric cancer and with pathologic confirmation of diffuse gastric cancer phenotype in at least one individual under the age of 50 years. The mutations found include small insertions and deletions, splice site mutations, and three non-conservative amino acid substitutions (A298T, W409R, and R732Q). All three missense mutations conferred loss of E-cadherin function in in vitro assays. Multiple cases of breast cancers including pathologically confirmed lobular breast cancers were observed both in mutation positive and negative families. CONCLUSION: Germline truncating CDH1 mutations are found in 48% of families with multiple cases of gastric cancer and at least one documented case of DGC in an individual under 50 years of age. We recommend that these criteria be used for selecting families for CDH1 mutational analysis.

Dissecting aortic aneurysm associated with a midsystolic click.

A midsystolic click occurred in a patient with a type 1 dissecting aneurysm. The mechanism of production of the systolic click may be related to rapid deceleration of blood against the intimal flap. Combined phonocardiography and echocardiography (using a new second right intercostal space approach) proved to be helpful in differentiating this sound from an aortic and pulmonary ejection click. In addition, other causes of midsystolic clicks, such as mitral and tricuspid valve prolapse, were excluded.

On the road to metallic nanoparticles by rational design: bridging the gap between atomic-level theoretical modeling and reality by total scattering experiments.

The extent to which current theoretical modeling alone can reveal real-world metallic nanoparticles (NPs) at the atomic level was scrutinized and demonstrated to be insufficient and how it can be improved by using a pragmatic approach involving straightforward experiments is shown. In particular, 4 to 6 nm in size silica supported Au(100-x)Pd(x) (x = 30, 46 and 58) explored for catalytic applications is characterized structurally by total scattering experiments including high-energy synchrotron X-ray diffraction (XRD) coupled to atomic pair distribution function (PDF) analysis. Atomic-level models for the NPs are built by molecular dynamics simulations based on the archetypal for current theoretical modeling Sutton-Chen (SC) method. Models are matched against independent experimental data and are demonstrated to be inaccurate unless their theoretical foundation, i.e. the SC method, is supplemented with basic yet crucial information on the length and strength of metal-to-metal bonds and, when necessary, structural disorder in the actual NPs studied. An atomic PDF-based approach for accessing such information and implementing it in theoretical modeling is put forward. For completeness, the approach is concisely demonstrated on 15 nm in size water-dispersed Au particles explored for bio-medical applications and 16 nm in size hexane-dispersed Fe48Pd52 particles explored for magnetic applications as well. It is argued that when "tuned up" against experiments relevant to metals and alloys confined to nanoscale dimensions, such as total scattering coupled to atomic PDF analysis, rather than by mere intuition and/or against data for the respective solids, atomic-level theoretical modeling can provide a sound understanding of the synthesis-structure-property relationships in real-world metallic NPs. Ultimately this can help advance nanoscience and technology a step closer to producing metallic NPs by rational design.

The role of ultrasound in breast cancer screening. A consensus statement by the European Group for Breast Cancer Screening.

The members of the European Group for Breast Cancer Screening have considered the use of ultrasound in breast diagnosis and breast cancer screening. After wide consultation and a detailed literature review, the consensus of the Group on the role of ultrasound is as follows: current evidence indicates that ultrasound of the breast is an important adjunct to mammography and clinical examination in the further assessment of both palpable and impalpable breast abnormalities. However, the use of ultrasound in population screening of asymptomatic women is associated with unacceptably high rates of both false positive and false negative outcomes. At present there is little evidence to support the use of ultrasound in population breast cancer screening at any age.

Woman feels breast lump--surgeon cannot: the role of ultrasound in arbitration.

The role of ultrasound scanning (USS) in patients complaining of a breast lump where the clinical examination (CE) is normal is not clearly defined. To determine this in greater detail, all patients complaining of a breast lump underwent CE. Where no lump could be found, but was still reported by the patient, an USS was performed. All lesions underwent biopsy and/or aspiration, as well as mammography in suspicious cases or those over 40 years of age. This cohort represented 5% of all referrals in the study period. Four hundred and twenty women were prospectively studied in this way. Median follow up is 3.4 years (range 2.5-4.2 years). Twenty two had solid lumps (of which 3 were cancers) and 48 had cysts. Nineteen patients re-presented with symptoms in the same breast (median time = 12 months (range 4.5-20 months), all of which were imaged on USS: 15 cysts and 4 further cancers (3 in the same quadrant as the original lump, one contralateral) were identified. Women with symptomatic breast lumps and a normal CE can be considered a reliable indication that cancer is very unlikely to be present (negative predictive value = 0.98). Ultrasound may be a suitable complimentary investigation, which will relieve symptoms in those with cysts and can detect small clinically--and sometimes mammographically--occult breast cancers.

Screening women aged less than 50 years with a family history of breast cancer.

Family history is an important breast cancer risk factor and is a common reason for referral to specialist breast clinics for consideration of breast screening. The aims of this study were to determine cancer detection rates and prognostic features of breast cancers identified in women aged less than 50 years at increased risk of breast cancer who attend a Family History Breast Screening Clinic (FHC). Between January 1988 and December 1995, 1371 asymptomatic women aged less than 50 years underwent annual clinical breast examination and biennial mammography due to a family history of breast cancer. A total of 29 cancers (23 invasive and 6 in situ) were detected or presented as interval cancer during a mean follow-up of 22 months (range 0-96 months). This gave a relative risk for invasive breast cancer in this high-risk group of 5 when compared with an age-matched female population in the U.K. The cancer screening detection rates were similar to those of women aged 50 years or over undergoing population screening in the NHS Breast Screening Programme (NHSBSP)--FHC prevalent screen 8 per 1000 screening visits versus NHSBSP 6.5 per 1000, FHC incident screen 3.3 per 1000 screening visits versus NHSBSP 3.8 per 1000. A higher proportion of in situ cancers were detected in the FHC screened group compared with cancers identified in symptomatic patients from an age-matched risk group (21% versus 4%). No differences were demonstrated for invasive tumour size, grade or lymph node stage between symptomatic and screened women. The early results of this study suggests that young women at risk of breast cancer due to a family history may benefit from regular breast screening due to the early detection of in situ lesions.

A statistical model and computer program to estimate association constants for the binding of fluorescent-labelled monoclonal antibodies to cell surface antigens and to interpret shifts in flow cytometry data resulting from alterations in gene expression.

Flow cytometry is used to obtain estimates for the distribution of fluorescent ligands bound to cell surface receptors throughout a cell sample. The equipment used provides light scattering parameters and also cell staining data in the form of dot plots and histograms of fluorescence intensities and the frequency of occurrence of particular fluorescence intensities. It is then assumed that fluorescence intensity is proportional to the number of labelled ligands bound to surface receptors. In this paper we present an outline of a statistical theory to account for the stretching and translation of such flow cytometry profiles which occur either as a result of alterations in gene expression, or from changing the sub-saturating concentration of fluorescent-labelled monoclonal antibodies or lectins used to stain the cells. We describe how the theory has been incorporated into two programs CSAFIT (cell surface antigen fit) and MAKCSA (make data to test CSAFIT). The program CSAFIT can be used to estimate two parameters, alpha and beta, by constrained non-linear regression analysis of the flow cytometry profiles. If the shift results from changes in the concentration of a staining agent then the estimates alpha and beta calculated by CSAFIT are functions of the ligand concentration, the ligand type and the cell line characteristics. They quantify the stretch and translation events that are encountered in flow cytometry. So when the parameter estimates alpha and beta are then further analysed as functions of ligand concentration, estimates for the average association constant K for the binding-site/ligand interaction can be obtained. This paper describes details of the development of programs CSAFIT and MAKCSA. We also discuss the distribution of parameter estimates calculated by CSAFIT and the overall performance of CSAFIT as assessed by simulation studies using data generated by MAKCSA.

A new method for the simultaneous assay of rosette-forming and antibody-secreting cells, utilising immune adhesion reactions in monolayer.

Mixtures of sheep erythrocytes and immune spleen cells from mice were incubated in shallow slide chambers coated with erythrocyte ghosts or anti-mouse Ig, with poly L-lysine as a coupling agent. Antigen-binding cells and erythrocytes surrounding antibody-releasing lymphocytes became bound to the reactive surfaces by immunocytoagglutination and could be readily observed on inversion of the chambers. The sensitivity of the method compares with those currently in use for quantification of antibody-releasing cells, and resolution of rosettes is markedly superior to that obtainable in other assay systems. The advantages and limitations of the method are discussed.

Two dimensional echocardiographic diagnosis of aortic dissection.

The usefulness of two dimensional echocardiography in establishing the diagnosis of aortic dissection was evaluated. Forty-two patients were referred for study; 15 had a dissection and 27 did not. Two dimensional echocardiography detected the intimal flap in 12 of 15 patients with a dissection, the three false negative studies were in patients with a localized dissection. There was one false positive study in the 27 patients who did not have a dissection.

Real-time two-dimensional echocardiography in differentiating vascular from nonvascular mediastinal lesions.

We evaluated the ability of two-dimensional echocardiography to differentiate vascular from nonvascular causes of radiologic mediastinal masses or widening. In 22 patients with a radiologic mass, two-dimensional echo detected a mass in 11 patients, an aortic aneurysm in four patients, left ventricular pseudoaneurysm in four patients, and marked pulmonary artery dilatation in three patients. In 36 patients with mediastinal widening, two-dimensional echocardiography detected an aneurysm in 28 and a mass in four patients; it was normal in four patients. Two-dimensional echocardiography can differentiate vascular from nonvascular radiologic mediastinal abnormalities.

Radioisotope for occult lesion localisation (ROLL) of the breast does not require extra radiation protection procedures.

AIM OF STUDY: Dosimetry data from patients and hospital personnel involved in the use of radioisotope for occult lesion localisation (ROLL) of the breast were collected to determine the need for extra radiation protection procedures. METHODS: Sixty-three patients have been enrolled to date into a randomised trial evaluating ROLL. Two megabecquerels of (99m)Tc- MAA in a syringe was mixed with X-ray contrast medium; this was injected directly into the lesion under image guidance. A gamma-detecting probe (Neo-Probe) was used to locate the area of radioactivity. Radiation doses to all staff groups were estimated using time and motion studies and dose rate measurements at a range of distances during each stage of ROLL. RESULTS: The finger dose [FD](+/-95% CI) was considered to be the critical variable for surgeons and radiologists. Surgeon FD=9.3+/-3.3 microSv, Radiologist FD=0.5+/-0.13 microSv. Whole body doses [WBD](+/-95% CI) were estimated for other staff groups. Nurse WBD=0.4+/-0.4 microSv, porter WBD: nil, contamination and waste: nil. CONCLUSIONS: In the case of a surgeon performing 100 procedures per annum, a FD dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv. Annual WBD to assisting staff may reach 0.04 mSv, compared to an annual limit of 6 mSv. These low doses and the lack of contamination of radioactive waste indicate that no additional radiation protection measures are required.

Thrombolytic therapy of synthetic graft occlusions before vascular reconstructive procedures.

The objective of this study was to evaluate the impact of thrombolysis of synthetic grafts before urgent vascular reconstruction. In 29 patients, 41 thrombosed synthetic grafts that underwent intraarterial thrombolysis were studied. The cases were divided into three groups: group I--complete thrombolysis followed by reconstruction; group II--complete thrombolysis alone; and group III--incomplete lysis requiring reconstruction or sympathectomy. Follow-up ranged from 1 to 556 days (mean: 149 days). Kaplan-Meier analysis was used to determine patency and limb salvage rates. One-year patency and limb salvage rates were 53% and 95%, 34% and 67%, and 38% and 48%, respectively, for groups I, II, and III. Eighteen complications occurred in 16 of the 41 (39%) episodes. One patient died of intracranial hemorrhage. The best results were achieved when complete lysis was followed by appropriate reconstruction. Patency was equally poor in complete thrombolysis alone and reconstructions required by incomplete thrombolysis. Limb salvage was better after complete thrombolysis, regardless of the appropriate reconstruction.

Thrombolysis theraphy in patients with femoropopliteal synthetic graft occulsions.

BACKGROUND: The aim of this study was to evaluate the efficiency of thrombolysis in the presence of an occluded femoropopliteal synthetic graft. PATIENTS AND METHODS: Over a 3-year period, 46 occluded femoropopliteral grafts were treated with urokinase and reconstruction. The cases were divided into three groups: group 1 (n=25), complete thrombolysis followed by reconstruction or angioplasty or both; group 2 (n=5), complete thrombolysis alone; and group 3 (n=16), failure of thrombolysis requiring reconstruction or leading to amputation. Patients were completely observed after treatment for more than 1 year. RESULTS: There are no fatal complications among patients with thrombolytic therapy. In group 1, the 3-year patency rates were 12% and the 3-year limb salvage rates were 77%. In group 2, the 3-year patency rates and the limb salvage rates were 20% and 80%, respectively. The group 3 patency rates and the limb salvage were 8% and 40%, respectively. The best results were achieved in patients who had thrombolysis followed by reconstruction (group 1) and in those who had thrombolysis alone (group 2). limb salvage was poor in patients with failure of lytic therapy regardless of the reconstruction (P<0.01). CONCLUSION: The use of intra-arterial urokinase followed by secondary vascular reconstructive procedures was studied. The patient with synthetic graft occlusion still has a reasonably favorable prognosis for long-term limb salvage when thrombolysis is successful.

Detecting which invasive cancers at mammographic screening saves lives?

OBJECTIVES: Assessment of the features of primary operable breast carcinomas arising in women known to subsequently develop metastatic disease, to show for which invasive breast cancers earlier detection by mammographic screening is potentially beneficial. These data were applied to a separate series of screen detected cancers. METHODS: Features associated with the development of metastatic disease after a previous operable breast cancer were ascertained from examination of histological sections of the initial primary carcinoma and in particular the incidence of nodal positivity and definite vascular invasion. Trends in the frequency of nodal involvement and vascular invasion according to histological grade, invasive size, and tumour type were then examined in a further group of 573 screen detected invasive cancers to predict the likelihood of development of systemic disease in these women. RESULTS: Of 173 women who developed metastatic disease after a previous operable breast cancer, 79 (72%) had nodal metastases and 62 (59%) had definite vascular invasion. A high proportion (84%) had either lymph node metastases or vascular invasion or both. The absence of vascular invasion and nodal involvement in invasive breast cancer indicated a low risk of subsequent development of metastatic disease. In the screen detected group, grade 1 invasive cancers <20 mm in size and grade 2 and 3 cancers <10 mm in size had low rates of nodal involvement and vascular invasion. There was a gradual trend to small size, lymph node negativity, and less vascular invasion when comparing screen detected ductal carcinoma of no special type, tubular mixed carcinoma, and tubular carcinoma. Cancers with a lobular component tended to be larger and more often lymph node positive than ductal and no specific type carcinomas. CONCLUSIONS: These data suggest that identification of grade 1 cancers less than 20 mm in size and grade 2 and 3 cancers less than 10 mm in size at screening is likely to be beneficial, with a lower likelihood of developing metastatic disease from these lesions. The detection of tubular mixed carcinomas and ductal carcinomas of no specific type also appears beneficial. However the detection of tumours with lobular features at breast screening does not seem to significantly benefit the patient.