Women's views about breast cancer prevention at mammography screening units and well women's clinics.

Background: Women attending mammography screening units (msus) and well women's clinics (wwcs) represent a motivated cohort likely to engage in interventions aimed at primary breast cancer (bca) prevention. Methods: We used a feasibility questionnaire distributed to women (40-49 or 50-74 years of age) attending msus and wwcs in Halifax, Nova Scotia, to examine■ women's views about bca primary prevention and sources of health care information,■ prevalence of lifestyle-related bca risk factors, and■ predictors of prior mammography encounters within provincial screening guidelines.Variables examined included personal profiling, comorbidities, prior mammography uptake, lifestyle behaviours, socioeconomic status, health information sources, and willingness to discuss or implement lifestyle modifications, or endocrine therapy, or both. A logistic regression analysis examined associations with prior mammography encounters. Results: Of the 244 responses obtained during 1.5 months from women aged 40-49 years (n = 75) and 50-74 years (n = 169), 56% and 75% respectively sought or would prefer to receive health information from within, as opposed to outside, health care. Lifestyle-related bca risk factors were prevalent, and most women were willing to discuss or implement lifestyle modifications (93%) or endocrine therapy (67%). Of the two age groups, 49% and 93% respectively had previously undergone mammography within guidelines. Increasing age and marital status (single, separated, or divorced vs. married or partnered) were independent predictors of prior mammography encounters within guidelines for women 40-49 years of age; no independent predictors were observed in the older age group. Conclusions: Women attending msus and wwcs seem to largely adhere to mammography guidelines and appear motivated to engage in bca primary prevention strategies, including lifestyle modifications and endocrine therapy. Women's views as observed in this study provide a rationale for the potential incorporation of bca risk assessment within the "mammogram point of care" to engage motivated women in bca primary prevention strategies.

Indium-111 chloride scintigraphy in adult osteomyelitis.

Osteomyelitis is a common clinical problem that may be difficult to diagnose. We compared the performance of indium-111-labeled white cells ([111In]WBC) to 111In chloride ([111In]Cl) in two groups of adult patients suspected to have osteomyelitis or septic arthritis. Using [111In] WBC, 52 scans were performed on 51 patients. Nineteen patients had osteomyelitis. The sensitivity was 84% and specificity 82%. Using [111In]Cl, 48 scans were performed on 47 patients. Twelve had osteomyelitis. Sensitivity was 91%, and specificity was 89%. In each group, one false-negative study occurred in vertebral osteomyelitis. Three false-negative studies using [111In]WBC were due to failure to distinguish between combined bone and soft-tissue infection and soft-tissue infection alone. False-positive studies in both groups were due to overlying soft-tissue infection or inflammatory arthritis. Chi-squared test showed no significant difference in performance between the two agents. Indium-111 chloride is easier to prepare and use than [111In]WBC, which requires a time-consuming labeling process.

Assessment of painful late effects of lumbar spinal fusion with SPECT.

UNLABELLED: The authors reviewed planar, SPECT and other contemporaneous radiologic images of the spine and the medical records of 33 patients with back pain after lumbar fusion surgery in order to determine the value of SPECT in the assessment of painful late effects of spinal fusion surgery. METHODS: Twenty-one patients had lateral fusion, nine patients had posterior fusion only and three patients had anterior and posterior fusions. There were 24 patients who had surgery more than 4 yr ago (late group, mean 11.8 yr) and 9 patients who had surgery less than 4 yr ago (early group, mean 17.8 mo). RESULTS: The most common SPECT abnormality in patients in the late group were lesions in the vertebral bodies and apophyseal joints in the free motion segments adjacent to the fused segments (62.5% of patients). Such lesions occurred in 46% of patients after lateral fusion, in 87.5% of patients after posterior fusion and in 67% of patients after posterior and anterior fusions. No SPECT abnormalities were detected in the fused segments in patients in the late group with solid lateral fusion but were detected in three patients with solid posterior fusion. These results correlate with biomechanical studies that have shown posterior fusion to produce the largest amount and lateral fusion to produce the least amount of stress in the free segments adjacent to the fusion. Lateral fusion was found to have a more stabilizing effect than posterior fusion. CONCLUSION: In addition to the already established value of SPECT in detecting painful pseudoarthrosis, our results indicate that SPECT is of value in the assessment of painful late effects of fusion.

Pharmacokinetics, biodistribution and tumor localization of two anti-human B-cell chronic lymphocytic leukemia monoclonal antibodies and their F(ab)'2 fragments in a xenograft model.

We investigated the pharmacokinetics, biodistribution and tumor localization of intravenously injected Dal B01 and Dal B02, two monoclonal antibodies (MoAbs) directed against tumor associated antigens on human chronic lymphocytic leukemia (CLL) B cells, and their F(ab)'2 fragments in nude mice bearing xenografts of the human B cell CLL line D10-1. More of the percentages of the injected dose (% ID) of these two MoAbs and their F(ab)'2 fragments specifically localized in the tumor xenografts than in normal tissues. Compared to intact MoAbs, their F(ab)'2 fragments had lower % ID in tumors and were cleared from circulation faster. Well-defined tumor images were obtained at 24 and 48 h after administration of [131I]Dal B02 F(ab)'2 fragment and at 96-192 h after administration of [131I]Dal B02. A comparison between intravenous and intraperitoneal routes of administration of [131I]Dal B02 did not reveal any difference in the localization of % ID in tumor or normal tissues.

Monoclonal-antibodies to human breast-cancer associated antigens.

Eleven murine monoclonal antibodies (MABs) were produced using human mammary cancer (HMC) cell lines as immunogens: None reacted with normal breast tissue, but each had a distinctive pattern of reactivity with HMC and benign proliferative lesions. Two MABs bound to overlapping epitopes of an M(r) 47,000 cell-surface antigen and were endocytosed: nine bound to secretable intracytoplasmic antigens(s). Four of the MABs immunoprecipitate antigens that upon reduction yielded an M(r) 73,000 moiety. None reacted with components of milk. All antigens were sensitive to trypsin, three to periodate oxidation but none to neuraminidase. One cell-surface-localizing MAB investigated, selectively localized in HMC xenografts.

Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism.

BACKGROUND: The Geneva and Wells pre-test probability scores are intended to replace empirical assessment of patients with suspected pulmonary embolism (PE). The effect of clinical experience on the inter-rater variability of these scores, and on empirical judgement, is unknown. AIM: To determine whether medical staff appointment grade affects the inter-rater variability of these pre-test probability scores, or empirical assessment, in patients with suspected PE. DESIGN: Questionnaire survey. METHODS: Doctors were grouped by grade (mean number of years since graduation+/-SEM): house officers 0.7+/-0.2, registrars 6.3+/-0.6, consultants 25+/-4 and applied pre-test probability scores to actual case scenarios. RESULTS: The Geneva score was the most consistent method of determining pre-test probability and was unaffected by clinical experience (Geneva kappa=0.73, Wells kappa=0.38, empirical kappa=0.23, p<0.001 ). With empirical judgement, inter-rater variability was inversely proportional to clinical experience (house officers kappa=0.37, registrars kappa=0.24, consultants kappa= 0.16, p<0.05). DISCUSSION: The Geneva score was the least variable method and can be applied by junior or senior doctors. Using empirical judgement, junior doctors were more likely to agree on the pre-test probability of PE than were their more senior colleagues. This may imply that as physicians gain experience, they recognize that the diagnosis of PE can be difficult to assess and are reluctant to exclude it on clinical grounds.

Noninvasive testing in women presenting with chest pain: evidence for diagnostic uncertainty.

OBJECTIVE: To gain insight into the diagnostic utility of exercise stress testing in women. DESIGN: Observational prospective cohort study. SETTING: The Victoria General Hospital, Halifax, Nova Scotia. PARTICIPANTS: Consecutive women with chest pain referred by cardiologists or internists for exercise stress testing between May 30, 1992 and November 30, 1992 and followed prospectively to February 28, 1993. INTERVENTION: The proportion of patients subsequently referred for thallium scintigraphy and/or coronary angiography and their clinical profiles were determined. MAIN RESULTS: Of 183 patients studied, stress testing was positive in 48 (26.2%), negative in 48 (26.2%) and nondiagnostic in 87 (47.5%). Women with negative results were more likely to have had normal baseline electrocardiograms (ECGs) (P = 0.002) and least likely to have undergone prior angiography (P = 0.0003). Subsequent thallium scintigraphy and/or coronary angiography was undertaken in 33.3%, 18.8% and 27.6% with positive, negative and nondiagnostic index stress tests, respectively. None of chest pain, cardiac risk factors, previous cardiac investigations or baseline ECG discriminated 33 patients with negative or nondiagnostic stress results who had additional tests from 102 who did not. CONCLUSION: Exercise stress testing poorly screens women with chest pain for coronary artery disease (diagnostic in only 52.5%). Further study was undertaken in 27.6% with nondiagnostic tests and, surprisingly, in 18.8% with negative results. Why certain women with nondiagnostic, and so many with negative, stress tests were referred for further investigation was unclear. These results suggest diagnostic uncertainty when females presenting with chest pain are assessed.

Abnormal Tc-99m MAA accumulation.

Image findings are described in two patients who received radiochemically impure Tc-99m MAA radiopharmaceutical preparations. The cases are completely separate and show clinically the presence of hydrolyzed-reduced technetium (TcO2) in a radiopharmaceutical product.

Renal accumulation of technetium-99m sulfur colloid.

A case of renal uptake in a routine technetium-99m sulfur colloid liver/spleen study is reported. The possible causes of uptake by the kidneys in view of the patient's previous history are discussed.

Remnants of normal tissue in polycystic disease of the liver. A cause for difficulty in the interpretation of indium-111 white blood cell study.

On In-111 WBC images, diffuse homogeneous uptake of the radiopharmaceutical should be present throughout the liver. The authors present a case of a febrile patient with polycystic liver disease in whom the normal diffuse uptake was not seen. Instead, the images demonstrated focal areas of uptake, which suggested infection. Tc-99m SC liver spleen scintigraphy demonstrated the In-111 WBC foci to correspond to areas of residual normal parenchyma. The patient underwent laparotomy and liver transplantation and no abscesses were found. Pathologic examination of the liver revealed multiple uninfected cysts and residual normal parenchyma in the caudate lobe, corresponding to the findings on scintigraphy.

The complementary role of hepatobiliary scintigraphy and abdominal sonography in a patient with a hepatic cyst and suspected acute cholecystitis.

A 51-year-old woman was admitted with suspected acute cholecystitis. A large hepatic cyst was found incidentally by abdominal sonography, which displaced an "abnormal" gallbladder. Hepatobiliary scintigraphy visualized the gallbladder and excluded acute cholecystitis, but required the anatomic information from sonography to verify the abnormal location of the gallbladder. Additionally, scintigraphy showed the cyst not to communicate with the biliary tract. Pathologic findings revealed mild chronic cholecystitis and a simple mesothelial hepatic cyst. This case illustrates the complementary role of hepatobiliary scintigraphy and abdominal sonography in patients with distorted hepatobiliary anatomy and suspected acute cholecystitis.

180 degrees SPECT of the spine in patients with low back pain. Comparison with 360 degrees acquisition.

Single-photon emission computed tomography has been proven to detect more abnormalities than planar bone scintigraphy in patients with low back pain (LBP). Both 180 degrees and 360 degrees acquisitions were performed in 24 patients with LBP to determine whether the shorter 180 degrees posterior SPECT is as accurate for abnormality detection as 360 degrees acquisition. The vertebral bodies and posterior elements of 193 vertebrae were scored on a five-point score (1 = normal, 5 = abnormal), independently by three experienced physicians, on three separate reconstructed image sets: standard, filtered, back projection 360 degrees acquisition, distance-weighted 360 degrees acquisition, and standard, filtered, back projection 180 degrees acquisition. With one exception, no statistically significant difference in score was found between 180 degrees and 360 degrees images. For one observer, the mean score of the posterior elements was higher on 180 degrees compared to 360 degrees standard images. These results indicate that 180 degrees acquisition SPECT may be used for abnormality detection in patients with LBP.

The loss of early pregnancy.

It is often assumed that early loss of pregnancy is not followed by emotional distress. When such distress does occur, it often goes undetected. Early loss of pregnancy is frequently followed by typical grief such as that occurring after any bereavement. Most recent studies have shown that although social termination of pregnancy in the first trimester has few adverse psychological sequelae for most women, there are vulnerable women who do experience significant emotional distress afterwards. Risk factors for poor psychological outcome include poor social support, past psychiatric history and ambivalence about the termination. The procedures used for second trimester terminations of pregnancy are likely to be a particular source of distress. Psychiatric disorder may also follow if termination is refused. Careful assessment of all women before social termination will identify vulnerable women who may benefit from counselling and support afterwards. After spontaneous abortion or miscarriage, many women experience significant emotional distress, which persists for several months. Guilt and anger are common. Some women are particularly vulnerable to developing psychiatric disorder after spontaneous abortion, for example women with a past psychiatric history, poor social support, previous spontaneous abortion and personality traits such as neuroticism. Many women would benefit from follow-up and support afterwards; extra support and reassurance are often needed during the next pregnancy. Termination for fetal abnormality is more likely to induce grief than relief for many women; these pregnancies are usually wanted, second trimester terminations are distressing, and there is often guilt at destroying a life and/or opting out of rearing a handicapped child. Recent research has demonstrated substantial levels of psychiatric morbidity after termination for fetal abnormality, particularly in those with a past psychiatric history, those with poor social support, and those who feel they have opted out of bearing a handicapped child. Women receive little support of follow-up after such terminations, yet many would benefit from it. Such women are in particular need of reassurance and support during a subsequent pregnancy.