Ten-year trend analysis of breast cancer, oncoplastic, and reconstructive breast surgery in a single institution (2010-2019), what has not changed?

PURPOSE: There has been a UK national directive to ensure that patients are offered reconstructive surgical options. We aimed to assess any change in oncoplastic practice over a 10-year period. METHODS: The surgical management of 7019 breast cancers was retrospectively assessed at Nightingale Breast Centre, Manchester University UK, from 2010 to 2019. The procedures were categorised into breast conservative surgery (BCS) and mastectomy ± immediate reconstruction. The data were analysed using inclusion and exclusion criteria. RESULTS: The overall rates of BCS and mastectomy were 60.1% and 39.9% respectively. No statistically significant change in the overall rates of BCS or mastectomy was observed over the last decade (p = 0.08). The rate of simple wide local excision (WLE) decreased from 98.7% to 89.3% (p < 0.001), whilst the rate of therapeutic mammoplasty (TM) increased from 1.3% to 8% (p < 0.01). The rate of chest wall perforator flaps (CWPF) changed from zero to account for 2.7% of all BCS by 2019. The overall rate of immediate breast reconstruction (IBR) did not significantly change over the study period, but it consistently remained above the national average of 27%. The rate of implant-based IBR increased from 61.3% to 76.5% (p = 0.012), whilst the rate of Latissimus Dorsi (LD) reconstruction decreased from 26.7% to 5.1% (p < 0.05). Additionally, the rate of nipple-sparing mastectomy significantly increased from 5.2% to 24%. CONCLUSION: No significant changes in the overall rates of BCS was observed, the rates of advanced breast conservation techniques, nipple-sparing mastectomy, and implant-based IBR all have increased, whilst the use of LD reconstruction decreased.

Assessment and outcomes of firefighter applicants with possible asthma.

BACKGROUND: Firefighter applicants (FFAs) with a history of asthma may be refused entry to the fire service because of potentially putting themselves and others at risk. AIMS: We undertook a service evaluation to identify respiratory and employment outcomes of FFAs with a history of asthma who had undergone additional respiratory assessment at our specialist occupational lung disease clinic during 2005-19. METHODS: We reviewed FFA medical records and categorized them as having either no current asthma or definite/probable asthma at the time of clinic assessment. 'No current asthma' was defined as negative non-specific bronchial hyper-responsiveness (BHR) to histamine/methacholine, and no symptoms or treatment within the 2 years before clinic. 'Definite/probable current asthma' was defined as either positive BHR, or negative BHR with symptoms and/or treatment within the previous 2 years. Around 1 year later, we contacted FFAs to enquire about their application outcome and current respiratory symptoms. RESULTS: Data were available on 116 applicants; of whom, 45% (n = 52) had definite/probable current asthma and were significantly more likely to be older, atopic to common aeroallergens, report atopic disease and have a lower forced expiratory volume in one second/forced vital capacity ratio compared with applicants with no current asthma. Only two individuals' applications were rejected due to asthma. At follow-up, just 2 (2%) of the 90 operational firefighters reported any recent trouble with asthma. CONCLUSIONS: A history of asthma alone is not sufficient to determine current asthma in FFAs. Even with a diagnosis of current asthma, FFAs are mostly successful in their application to join the fire service.

Follow-up survey of patients with occupational asthma.

BACKGROUND: Occupational asthma (OA) is often associated with a poor prognosis and the impact of a diagnosis on an individual's career and income can be significant. AIMS: We sought to understand the consequences of a diagnosis of OA to patients attending our clinic. METHODS: Using a postal questionnaire, we surveyed all patients attending our specialist occupational lung disease clinic 1 year after having received a diagnosis of OA due to a sensitizer (n = 125). We enquired about their current health and employment status and impact of their diagnosis on various aspects of their life. Additional information was collected by review of clinical records. RESULTS: We received responses from 71 (57%) patients; 77% were referred by an occupational health (OH) provider. The median duration of symptoms prior to referral was 18 months (interquartile range (IQR) 8-48). At 1 year, 79% respondents were no longer exposed to the causal agent. Whilst the unexposed patients reported an improvement in symptoms compared with those still exposed (82% versus 53%; P = 0.023), they had poorer outcomes in terms of career, income and how they felt treated by their employer; particularly those not currently employed. Almost all (>90%) of those still employed had been referred by an OH provider compared with 56% of those currently unemployed (P = 0.002)x. CONCLUSIONS: The negative impact of OA on people's careers, livelihood and quality of life should not be underestimated. However, with early detection and specialist care, the prognosis is often good and particularly so for those with access to occupational health.

Metabolic dysfunction following weight cycling in male mice.

BACKGROUND: Combatting overweight or obesity can lead to large fluctuations in an individual's body weight, often referred to as weight cycling or 'yo-yo' dieting. Current evidence regarding the potentially damaging effects of these changes is conflicting. METHODS: Here, we assess the metabolic effects of weight cycling in a murine model, comprising three dietary switches to normal or high-fat diets at 6 week intervals; male C57BL/6 mice were fed either a control (C) or high-fat (F) diet for 6 weeks (n=140/group). C and F groups were then either maintained on their initial diet (CC and FF, respectively) or switched to a high-fat (CF) or control (FC) diet (n=35/group). For the final 6 week interval, CC and CF groups were returned to the control diet (CCC and CFC groups), while FC and FF groups were placed on a high-fat diet (FCF and FFF) (n=28/group). RESULTS: For the majority of metabolic outcomes changes aligned with dietary switches; however, assessment of neuropeptides and receptors involved in appetite regulation and reward signalling pathways reveal variable patterns of expression. Furthermore, we demonstrate that multiple cycling events leads to a significant increase in internal fat deposition, even when compared with animals maintained on a high-fat diet (internal fat: FCF: 7.4±0.2 g vs FFF: 5.6±0.2 g; P<0.01). CONCLUSIONS: Increased internal adipose tissue is strongly linked to the development of metabolic syndrome associated conditions such as type 2 diabetes, cardiovascular disease and hypertension. Although further work will be required to elucidate the mechanisms underlying the neuronal control of energy homoeostasis, these studies provide a causative link between weight cycling and adverse health.

Orientation and stability of a bi-functional aromatic organic molecular adsorbate on silicon.

In this work we combine scanning tunneling microscopy, near-edge X-ray absorption fine structure spectroscopy, X-ray photoemission spectroscopy and density functional theory to resolve a long-standing confusion regarding the adsorption behaviour of benzonitrile on Si(001) at room temperature. We find that a trough-bridging structure is sufficient to explain adsorption at low coverages. At higher coverages when steric hindrance prevents the phenyl ring lying flat on the surface, the 2+2 cycloaddition structure dominates.

Reaction paths of phosphine dissociation on silicon (001).

Using density functional theory and guided by extensive scanning tunneling microscopy (STM) image data, we formulate a detailed mechanism for the dissociation of phosphine (PH3) molecules on the Si(001) surface at room temperature. We distinguish between a main sequence of dissociation that involves PH2+H, PH+2H, and P+3H as observable intermediates, and a secondary sequence that gives rise to PH+H, P+2H, and isolated phosphorus adatoms. The latter sequence arises because PH2 fragments are surprisingly mobile on Si(001) and can diffuse away from the third hydrogen atom that makes up the PH3 stoichiometry. Our calculated activation energies describe the competition between diffusion and dissociation pathways and hence provide a comprehensive model for the numerous adsorbate species observed in STM experiments.

Medical humanities: a closer look at learning.

The inclusion of medical humanities with medical curricula is a question that has been the focus of attention for many within the evolving field. This study addressed the question from a medical education perspective and aimed to investigate what students at Trinity College Dublin learned from participating in a short medical humanities student-selected module in their first year of an undergraduate medical programme. A total of 156 students provided a written reflection on a memorable event that occurred during their student-selected module. The reflections were analysed using the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) and through qualitative thematic analysis of the written reflections. Evidence of learning from the REFLECT quantitative analysis showed that 50% of students displayed higher levels of reflection when describing their experience. The reflection content analysis supported the heterogeneous nature of learning outcome for students, with evidence to support the idea that the module provided opportunities for students to explore their beliefs, ideas and feelings regarding a range of areas outside their current experience or world view, to consider the views of others that they may have not previously been aware of, to reflect on their current views, and to consider their future professional practice.

Ba termination of Ge(001) studied with STM.

We use controlled annealing to tune the interfacial properties of a sub-monolayer and monolayer coverages of Ba atoms deposited on Ge(001), enabling the generation of either of two fundamentally distinct interfacial phases, as revealed by scanning tunneling microscopy. Firstly we identify the two key structural phases associated with this adsorption system, namely on-top adsorption and surface alloy formation, by performing a deposition and annealing experiment at a coverage low enough (∼0.15 ML) that isolated Ba-related features can be individually resolved. Subsequently we investigate the monolayer coverage case, of interest for passivation schemes of future Ge based devices, for which we find that the thermal evaporation of Ba onto a Ge(001) surface at room temperature results in on-top adsorption. This separation (lack of intermixing) between Ba and Ge layers is retained through successive annealing steps to temperatures of 470, 570, 670 and 770 K although a gradual ordering of the Ba layer is observed at 570 K and above, accompanied by a decrease in Ba layer density. Annealing above 770 K produces the 2D surface alloy phase accompanied by strain relief through monolayer height trench formation. An annealing temperature of 1070 K sees a further change in surface morphology but retention of the 2D surface alloy characteristic. These results are discussed in view of their possible implications for future semiconductor integrated circuit technology.

Rat-specific IgG and IgG4 antibodies associated with inhibition of IgE-allergen complex binding in laboratory animal workers.

OBJECTIVES: The relationship between exposure to rodent allergens and laboratory animal allergy is complex; at highest allergen exposures there is an attenuation of sensitisation and symptoms which are associated with increased levels of rat-specific immunoglobulin (Ig)G and IgG4 antibodies. We set out to examine whether the increased levels of rat-specific IgG and IgG4 antibodies that we have previously observed at high allergen exposure in our cohort of laboratory animal workers play a functional role through blockage of the binding of IgE-allergen complex binding to CD23 receptors on B cells. METHODS: Cross-sectional survey of laboratory animal workers (n=776) in six UK pharmaceutical companies were surveyed. IgE-allergen complex binding to B cells was measured in 703 (97.9%) eligible employees; their exposure was categorised by either job group or number of rats handled daily. RESULTS: We observed a significant decrease in IgE-allergen complex binding to B cells with increasing quartiles of both rat-specific IgG and IgG4 antibodies (p<0.001). IgE-allergen complex binding to B cells was lower in workers with high allergen exposure, and significantly so (p=0.033) in the subgroup with highest exposures but no work-related chest symptoms. CONCLUSIONS: These findings demonstrate a functional role for rat-specific IgG/G4 antibodies in laboratory animal workers, similar to that observed in patients treated with high dose immunotherapy who become clinically tolerant, suggesting a potential explanation for the attenuation of risk at highest allergen exposures.

Respiratory protective equipment reduces occurrence of sensitization to laboratory animals.

BACKGROUND: Respiratory protective equipment (RPE) has been shown to reduce exposure to laboratory animal allergens, but there are no studies that have examined its effect on the development of sensitization. AIMS: To examine the effect of RPE on the risk of sensitization to laboratory animals. METHODS: Survey of UK laboratory animal workers conducted between 1999 and 2001. Information was recorded on the type of RPE used when first exposed to animals and at the time of the survey. Sensitization to rat urinary proteins was assessed using skin-prick tests and assays of specific serum IgE antibodies. RESULTS: There were 776 workers surveyed of whom 228 had been exposed for fewer than 5 years. Those more recently employed were more likely to have used RPE. In employees with <5 years of exposure the use of face masks at first employment was associated with a lower prevalence of sensitization, irrespective of the intensity of exposure to laboratory animals. This reduction was significant only in those who entered the animal house daily. CONCLUSIONS: The use of simple RPE at first exposure to laboratory animals may help to reduce the incidence of specific sensitization.

Infective skin conditions in an adult sea-going population.

Infective skin conditions represent a significant element of the caseload for sea-going and shore-side clinicians. They are common within the wider military setting due to the frequent requirement to live in close proximity to others in conditions which favour the spread of skin and soft tissue infections (SSTI). Within the UK civilian population, 24% of individuals see their family doctor for skin conditions each year, accounting for 13 million primary care consultations annually. Of these, almost 900,000 were referred to dermatologists in England in 2009-2010 and resulted in 2.74 million secondary care consultations. Several recent articles have highlighted the problem of Panton-Valentine Leukocidin Staphylococcus aureus (PVL-SA) infection and carriage in sailors on submarines, and soldiers deployed to Afghanistan. However, the majority of published articles relate to land-based military personnel. This article aims to provide an overview of the most common infective skin conditions presenting among Naval personnel (based on the authors' experience), illustrated by several case studies, together with an approach to their diagnosis and management.

Relationship between combat-related traumatic injury and ultrashort term heart rate variability in a UK military cohort: findings from the ADVANCE study.

INTRODUCTION: Combat-related traumatic injury (CRTI) has been linked to an increased cardiovascular disease (CVD) risk. The long-term impact of CRTI on heart rate variability (HRV)-a robust CVD risk marker-has not been explored. This study investigated the relationship between CRTI, the mechanism of injury and injury severity on HRV. METHODS: This was an analysis of baseline data from the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study. The sample consisted of UK servicemen with CRTI sustained during deployment (Afghanistan, 2003-2014) and an uninjured comparison group who were frequency matched to the injured group based on age, rank, deployment period and role in theatre. Root mean square of successive differences (RMSSD) was measured as a measure of ultrashort term HRV via <16 s continuous recording of the femoral arterial pulse waveform signal (Vicorder). Other measures included injury severity (New Injury Severity Scores (NISS)) and injury mechanism. RESULTS: Overall, 862 participants aged 33.9±5.4 years were included, of whom 428 (49.6%) were injured and 434 (50.3%) were uninjured. The mean time from injury/deployment to assessment was 7.91±2.05 years. The median (IQR) NISS for those injured was 12 (6-27) with blast being the predominant injury mechanism (76.8%). The median (IQR) RMSSD was significantly lower in the injured versus the uninjured (39.47 ms (27.77-59.77) vs 46.22 ms (31.14-67.84), p<0.001). Using multiple linear regression (adjusting for age, rank, ethnicity and time from injury), geometric mean ratio (GMR) was reported. CRTI was associated with a 13% lower RMSSD versus the uninjured group (GMR 0.87, 95% CI 0.80-0.94, p<0.001). A higher injury severity (NISS ≥25) (GMR 0.78, 95% CI 0.69-0.89, p<0.001) and blast injury (GMR 0.86, 95% CI 0.79-0.93, p<0.001) were also independently associated with lower RMSSD. CONCLUSION: These results suggest an inverse association between CRTI, higher severity and blast injury with HRV. Longitudinal studies and examination of potential mediating factors in this CRTI-HRV relationship are needed.

Improving the accuracy of self-assessment of practical clinical skills using video feedback--the importance of including benchmarks.

INTRODUCTION: Isolated video recording has not been demonstrated to improve self-assessment accuracy. This study examines if the inclusion of a defined standard benchmark performance in association with video feedback of a student's own performance improves the accuracy of student self-assessment of clinical skills. METHODS: Final year medical students were video recorded performing a standardised suturing task in a simulated environment. After the exercise, the students self-assessed their performance using global rating scales (GRSs). An identical self-assessment process was repeated following video review of their performance. Students were then shown a video-recorded 'benchmark performance', which was specifically developed for the study. This demonstrated the competency levels required to score full marks (30 points). A further self-assessment task was then completed. Students' scores were correlated against expert assessor scores. RESULTS: A total of 31 final year medical students participated. Student self-assessment scores before video feedback demonstrated moderate positive correlation with expert assessor scores (r = 0.48, p < 0.01) with no change after video feedback (r = 0.49, p < 0.01). After video feedback with benchmark performance demonstration, self-assessment scores demonstrated a very strong positive correlation with expert scores (r = 0.83, p < 0.0001). CONCLUSIONS: The demonstration of a video-recorded benchmark performance in combination with video feedback may significantly improve the accuracy of students' self-assessments.

Electronic effects of single H atoms on Ge(001) revisited.

The adsorption of isolated H atoms on the Ge(001) surface is studied using density functional theory (DFT) and scanning tunneling microscopy (STM). Two stable adsorption positions that are found in DFT correspond to H atom attachment to an up-or down-buckled Ge dimer atom, respectively. Surprisingly, in the case where H bonds to the down-buckled Ge atom, we find that there is a redistribution of a unit of charge which leaves the net charge of the doubly occupied dangling bond of the unreacted Ge atom intact. This configuration is found to be the more stable of the two structures. Comparison to filled- and empty-state STM images confirms that this lowest energy structure is observed at room temperature. These results represent a fundamentally different picture of the physics and chemistry of H adsorption to Ge(001) compared with previous work.

What influences postgraduate psychiatric trainees' attitudes to clinical audit?

INTRODUCTION: Clinical audit is an important component of safe and ethical practice but many clinicians cite barriers to engagement in audit. METHODOLOGY: A total of 81 basic specialist trainees in psychiatry were surveyed in terms of their basic demographic details and their knowledge, direct experience and attitudes in relation to clinical audit. RESULTS: Among the 49 (60.5%) who responded, 57.1% had received formal training in audit, but only 20.4% had received more than four hours of training in their whole career. The median positivity score was 30 out of a possible 54 (range 12-40), suggesting that participating trainees were barely more than 'undecided' overall when it comes to positive attitudes to clinical audit. Age, nationality and specific training did not predict attitudes to clinical audit. Gender, years of clinical experience and direct experience of clinical audit did not significantly predict attitudes to clinical audit, but these findings are at odds with some previous research. DISCUSSION: Much work is needed in improving postgraduate trainees' attitudes to clinical audit, given that clinical audit is essential for good medical practice. Ours is an initial study of this area of training limited by sample size and the narrowness of the group tested. Further study of other specialities, higher trainees and consultant trainers would further enhance our understanding.

Consultants in Scotland: survey of educational qualifications, experience and needs of Scottish consultants.

AIMS: To survey Scotland's NHS consultants regarding their teaching roles; educational qualifications/training; attitudes to educational qualifications; perceptions of health boards' attitudes to educational activities; usefulness of various educational courses and preferred delivery methods. METHODS: Postal questionnaire (n=3615). RESULTS: Sixty two percent response rate (n=2246). 98% had one or more roles in education/training. 54% spent more time in educational roles than job-plan allocations. 6% had educational qualifications. 30% rated educational qualifications valuable to their educational role; 21% to their career. 48% had not attended any educational training. 19% of respondents rated their health board as supportive of their educational activities. Respondents rated dealing with underperforming students (74%), dealing with challenging behaviour (63%), appraising students (63%), trainee assessment (61%) and feedback (58%) as the most useful topics. CONCLUSIONS: Scottish consultant involvement in educational activities is virtually universal but consultants perceive they need more time than allocated in job plans. Most consultants had no teaching qualifications. Nearly half had no formal training for educational activities. Educational qualifications were valued by a minority regarding both career development and educational activities. Increased access to staff development for teaching is required as NHS sources are not meeting the need for teacher training of consultant staff.

Electronic effects induced by single hydrogen atoms on the Ge(001) surface.

The properties of an isolated dangling bond formed by the chemisorption of a single hydrogen atom on a dimer of the Ge(001) surface are investigated by first-principles density functional theory (DFT) calculations, and scanning tunneling microscopy (STM) measurements. Two stable atomic configurations of the Ge-Ge-H hemihydride with respect to the neighboring bare Ge-Ge dimers are predicted by DFT. For both configurations, the unpaired electron of the HGe(001) system is found to be delocalized over the surface, rendering the isolated dangling bond of the hemihydride unoccupied. However, local surface charge accumulation, such as may occur during STM imaging, leads to the localization of two electrons onto the hemihydride dangling bond. The calculated surface densities of states for one of the charged Ge-Ge-H hemihydride configurations are found to be in good agreement with atomic-resolution STM measurements on n-type Ge(001). Comparison with a Si-Si-H hemihydride of the Si(001) surface shows similarities in structural properties, but substantial differences in electronic properties.

Cognitive bias in clinical medicine.

Cognitive bias is increasingly recognised as an important source of medical error, and is both ubiquitous across clinical practice yet incompletely understood. This increasing awareness of bias has resulted in a surge in clinical and psychological research in the area and development of various 'debiasing strategies'. This paper describes the potential origins of bias based on 'dual process thinking', discusses and illustrates a number of the important biases that occur in clinical practice, and considers potential strategies that might be used to mitigate their effect.

Profile of the oral health among ambulant older Greek and Italian migrants living in Melbourne.

BACKGROUND: Over the last 50 years an increasing number of migrants have settled in Australia. These immigrants now constitute a large proportion of the Australian population, and some research suggests that they may be at high-risk for oral diseases. METHODS: This paper presents data on the oral health status of a convenience sample of 721 ambulant Greek- (n = 367) and Italian-born (n = 354) adults aged 55 years or older. The volunteer participants were recruited through ethnic social clubs located in Melbourne, Australia. RESULTS: The sample was largely a dentate one (83.6 per cent); with a mean DMFS score of 67.5 (s.d. 37.4). Dentate participants had 13 per cent of their restorative care unmet, and 57.3 per cent needed oral hygiene instruction plus removal of stain and hard deposits on their teeth. Almost 8 per cent required complex periodontal therapy and 30 per cent of those fully edentulous were in need of full dentures. CONCLUSIONS: Comparing these findings with existing data on oral health of older adults in Australia, the participants in this study appear to have lower DMFS scores and a higher prevalence of gingivitis, but less need for complex periodontal treatment. Inequalities were apparent in the proportion of unmet restorative and prosthetics needs.