The misogyny of iron deficiency.

Anaemia is common, particularly in women and the commonest underlying cause, iron deficiency, is often overlooked. Anaemia is associated with increased morbidity and mortality in patients undergoing anaesthesia; however, women are defined as being anaemic at a lower haemoglobin level than men. In this narrative review, we present the history of iron deficiency anaemia and how women's health has often been overlooked. Iron deficiency was first described as 'chlorosis' and a cause of 'hysteria' in women and initial treatment was by iron filings in cold wine. We present data of population screening demonstrating how common iron deficiency is, affecting 12-18% of apparently 'fit and healthy' women, with the most common cause being heavy menstrual bleeding; both conditions being often unrecognised. We describe a range of symptoms reported by women, that vary from fatigue to brain fog, hair loss and eating ice. We also describe experiments exploring the physical impact of iron deficiency, showing that reduced exercise performance is related to iron deficiency independent of haemoglobin concentration, as well as the impact of iron supplementation in women improving oxygen consumption and fitness. Overall, we demonstrate the need to single out women and investigate iron deficiency rather than accept the dogma of normality and differential treatment; this is to say, the need to change the current standard of care for women undergoing anaesthesia.

The effect of krill oil supplementation on skeletal muscle function and size in older adults: A randomised controlled trial.

BACKGROUND & AIMS: The aim of this study was to determine the effect of krill oil supplementation, on muscle function and size in healthy older adults. METHODS: Men and women, aged above 65 years, with a BMI less than 35kg/m2, who participated in less than 1h per week of structured self-reported exercise, were enrolled in the study (NCT04048096) between March 2018 and March 2020. Participants were randomised to either control or krill oil supplements (4g/day) for 6 months in this double blind randomised controlled trial. At baseline, 6 weeks and 6 months, knee extensor maximal torque was measured as the primary outcome of the study. Secondary outcomes measured were grip strength, vastus lateralis muscle thickness, short performance physical battery test, body fat, muscle mass, blood lipids, glucose, insulin, and C-Reactive Protein, neuromuscular (M-Wave, RMS and voluntary activation), and erythrocyte fatty acid composition. RESULTS: A total of 102 men and women were enrolled in the study. Ninety-four participants (krill group (26 women and 23 men) and placebo group (27 women and 18 men)) completed the study (mean (SD): age 71.2 (5.1) years and weight 71.8 (12.3) kg). Six months supplementation with krill oil resulted in, an increase in knee extensor maximal torque, grip strength and vastus lateralis muscle thickness, relative to control (p<0.05). The 6-month treatment effects were 9.3% (95%CI: 2.8, 15.8%), 10.9% (95%CI: 8.3, 13.6%) and 3.5% (95%CI: 2.1, 4.9%) respectively. Increases in erythrocyte fatty acid profile were seen with krill oil for EPA 214% (95%CI: 166, 262%), DHA 36% (95%CI: 24, 48%) and the omega-3 index 61% (95%CI: 49, 73%), relative to control (p < 0.05). Krill oil resulted in an increased, relative to control (p < 0.05), M-Wave of 17% (95%CI: 12.7, 38.1%) but there was no effect of krill oil on RMS, voluntary activation, or on any other secondary outcomes such as performance of the short performance physical battery test or quality of life. CONCLUSION: Krill oil supplementation for 6 months results in statistically and clinically significant increases in muscle function and size in healthy older adults. GOV IDENTIFIER: NCT04048096.

Resection of the liver for colorectal carcinoma metastases: a multi-institutional study of patterns of recurrence.

The Registry of Hepatic Metastases has collected data on consecutive patients from 24 institutions who have undergone hepatic resection for colorectal carcinoma metastases. Patterns of recurrence were examined in a subgroup of 607 patients who had undergone curative resection of isolated hepatic metastases. Forty-three percent of these patient have had recurrences in the liver and 31% have had recurrences in the lung (either alone or in combination with other organs). A multivariate analysis showed that patients with positive pathologic margins or bilobar metastases were at an increased risk of having a recurrence in the liver (68% and 64%, respectively). We conclude that: hepatic resection effectively controls hepatic tumor in a substantial number of patients, adjuvant therapy after hepatic resection should be directed at both the lung and liver to significantly increase survival, and patients with positive pathologic margins or bilobar metastases are at an increased risk for hepatic recurrence.

En bloc resection of primary melanoma with regional lymph node dissection.

En bloc resection of the primary melanoma with the regional lymph node drainage basin as a method of controlling disease within the area was used in 281 patients with stage I or II melanoma arising on the extremities (proximal to wrist or ankle) or on the trunk from 1954 through 1964. The en bloc operation was performed in 212 patients with a five-year cure of 73.5% (156 of 212). Seventy-six percent had histologically negative nodes. Only 2% developed regional recurrence. Sixty-nine patients had a discontinuous dissection. The five-year cure was comparable: 68% (47 of 69). The incidence of histologically negative nodes was similar (77%), but the regional recurrence rate was 14%. This difference is significant at P < .01. The incontinuity or en bloc procedure appears highly effective for its designed purpose.

Proximal extrahepatic bile duct tumors. Analysis of a series of 52 consecutive patients treated over a period of 13 years.

Fifty-two consecutive patients with proximal extrahepatic bile duct tumors were treated by one of us (J.G.F.) between 1974 and 1987 at Memorial Sloan-Kettering Cancer Center, New York, NY. Thirty-eight patients (73%) underwent palliative procedures aimed at relieving the biliary obstruction (group A) and 14 patients (27%) were operated on with curative intent (group B). The choice of the surgical procedure employed to relieve the biliary obstruction did not significantly influence the length of survival of patients in group A in whom the median survival was 13.5 months and the in-hospital mortality was 15.7%. Fifty percent of the patients in group B underwent major liver resections to macroscopically encompass the tumor. In this group, although 35% of the patients experienced major complications, no in-hospital mortalities were encountered and the median actuarial survival was 38 months. The projected and crude 5-year survival rates were 28% and 21%, respectively. Age, gender, extent of resection, microscopic status of margins of resection, and grade of the lesion did not affect the length of survival in patients in group B. Locoregional failure, either isolated or as a component of peritoneal failure, was detected in the 6 patients in whom the disease has recurred. Eighty-three percent of the patients in whom the disease has recurred were dead within 12 months of the diagnosis of recurrence. Two long-term survivors (14%) developed second primary tumors in the follow-up period.

Transplantation of embryonic ventral forebrain grafts to the neocortex of rats with bilateral lesions of nucleus basalis magnocellularis ameliorates a lesion-induced deficit in spatial memory.

Embryonic ventral forebrain grafts containing developing cholinergic cells were transplanted to the neocortex of rats with bilateral quisqualic acid lesions of the nucleus basalis magnocellularis. A lesion-induced deficit on performance of a spatial alternation test of memory was reduced by such transplants. When the same animals were treated with the acetylcholinesterase inhibitor physostigmine (0.05 mg/kg), however, performance on the behavioral task was not further promoted, and therefore, under these conditions, the cholinergic cortical transplants appear not to be subject to modulation by anticholinesterase drugs.

Women 35 years of age or younger have higher locoregional relapse rates after undergoing breast conservation therapy.

BACKGROUND: The use of breast conservation therapy (BCT) in young women with invasive breast cancer is controversial. To examine this important issue, rates of locoregional recurrence and overall survival after BCT were compared in two subsets of women--those < or = 35 years of age at time of surgery and their older counterparts. STUDY DESIGN: We examined records of 290 women with invasive breast cancer treated with BCT (local excision and axillary dissection) at Memorial Sloan-Kettering Cancer Center between 1984 and 1993. These included 87 patients < or = 35 years of age at time of surgery and 203 randomly selected patients > 35 years of age. Followup was obtained from physician charts or patient interviews, or both. Complete data on clinicopathologic factors, recurrence, and survival were available on 280 patients. RESULTS: Median followup from time of operation was 8.0 years for the entire group. Mean tumor size was 2.0 cm for women < or = 35 years and 1.8 cm for those > 35 (p = 0.07). Involved nodes were found in 48% of the young patients and 36% of the older patients (p = 0.08). Within our study group (n = 280), 274 patients received radiotherapy. Women < or = 35 years of age had significantly higher rates of locoregional recurrence and lower rates of overall survival than their older counterparts (p < 0.05). On multivariate analysis, these results were independent of tumor size and nodal status. A history of locoregional relapse, however, was not associated with a higher rate of death from disease in the entire cohort or in either age group. CONCLUSIONS: Patients < or = 35 years of age undergoing BCT for invasive breast cancer are at higher risk for locoregional recurrence and death from disease. The higher mortality rate, however, does not appear to be a direct result of locoregional relapse. Additional study is required to verify these findings. Currently, young age does not exclude patients from BCT in our practice. But, we include this data as part of the informed consent process.

Twenty-two year experience with periampullary carcinoma at Memorial Sloan-Kettering Cancer Center.

The resectability rate was high (84 per cent) for patients with periampullary cancer. The incidence of lymph node metastases was also high, being 50 per cent for those with small tumors (2 cm or less). The 5 year cure rate was 67 per cent for patients with negative nodes but 0 per cent for those with positive nodes.

Acoustic hemifields in the spatial release from masking of speech by noise.

The Hearing-in-Noise Test (HINT) is able to measure the benefit to speech intelligibility in noise conferred when the noise masker is displaced 90 degrees in eccentricity from a speech source located at zero degrees azimuth. Both psychoacoustic and neurophysiological data suggest that the perceptual benefit of the 90-degree azimuth separation would be greatest if the speech and noise were presented in different acoustic hemifields, and would be smallest if the two sources were in the same acoustic hemifield. The present study tested this hypothesis directly in ten normal-hearing adult listeners. Using the HINT stimuli, we confirmed the hypothesis. Release from masking scores averaged 8.61 dB for "between-hemifield" conditions, 6.05 dB for HINT conditions, and 1.27 dB for "within-hemifield" conditions, even though all stimulus configurations retained a 90-degree angular separation of speech and noise. These data indicate that absolute separation of speech and noise alone is insufficient to guarantee a significant release from masking, and they suggest that what matters is the location of the stimulus elements relative to the left and right spatial perceptual channels.

Technical curriculum models: are they appropriate for the nursing profession?

The technical view of curriculum epitomized by the Tylerian objectives-based model focuses on measurable, quantifiable outcomes. Partly because of the drive to legitimize nursing as a profession, nursing education has accepted the Tylerian approach to demonstrate acceptable levels of competence for nursing practice. This paper examines the appropriateness of the behavioural measurement of outcomes for nursing in the present decade, using the framework of Habermas' knowledge-constitutive interests. It is contended that nursing educational practices have not kept pace with changes in the ethos of nursing practice in the 1990s. Nursing education must shift its focus from the technical curriculum to encompass humanistic principles and critical reflection, compatible with currently accepted nursing values.

Parenting of at-risk infants in the face of uncertainty: home apnea monitoring of subsibs.

This article describes the experiences of a group of parents in New Zealand who lost infants to sudden infant death syndrome (SIDS) and who monitored their subsequent infants or subsibs (infants born after the death of an infant due to SIDS) at home for signs of apnea. Their caregiving experiences are explored within the framework of the substantive theory developed by Cohen (1993) that describes how another group of parents, those caring for children with chronic life-threatening illnesses, copes with living under conditions of sustained uncertainty. Attention is drawn to the similarities in both the grieving processes and coping strategies used by both groups of parents in these parallel situations.

Selective use of wide excision with elective lymph node dissection for malignant melanoma.

One hundred and eighty individuals with clinically negative regional lymph nodes are the basis of this study. One hundred and ten of these underwent an elective lymph node dissection. The incidence of histologically positive lymph nodes was 0 percent, 17 percent, and 42 percent for those with thin, intermediate thickness and deeply invasive lesions. Of these 25 patients with histologically positive lymph nodes, the metastases were micro in size (less than or equal to 2 mm) in 75 percent of the intermediate thickness group compared with 38 percent of the deeply invasive group. At the present time, the size of lymph node metastases appears to correlate with disease-free estimates: at 2 years, the disease-free estimates are 70 percent for those with micro metastases and 24 percent for those with macro metastases. Therapeutic success is influenced greatly by the number of circulating cancer cells challenging the host's defense mechanism. The large cell mass of clinically evident metastatic disease would appear to present most patients with an uncontrollable number.

Biostatistical basis of elective node dissection for malignant melanoma.

During the years 1954 through 1964, 259 individuals with primary malignant melanoma had an elective node dissection. Microscopic metastases were found in 15% of these patients. The presence of only a microscopic focus of involvement gave a 10-year cure rate of 67%; metastasis larger than a microscopic focus in a single node, 50%; and more than one node, 15%. One hundred forty-five individuals were treated by wide excision alone with 18% subsequently requiring a therapeutic lymphadenectomy with a ten-year cure of only 6%. A prospective study was then initiated which was concerned with efficacy of selection of patients for elective node dissection. Clark's level of invasion was determined for 258 patients treated since January 1972. The depth of invasion of the primary lesion was found to correlate directly with the absence of lymph node metastases, extent of nodal involvement, and rate of recurrence. It is concluded that the concept of elective node dissection is valid.

Contacts with a Canadian drug information and crisis centre, 1971-74.

This paper presents data on contacts with a Canadian drug information and crisis centre over a three year span (July, 1971 to June, 1974). The following trends emerged: (1) Although there was only a small change in the total number of contacts, there were substantial decreases in the number of "crisis" and "information" contacts and a substantial increase in the number of "counselling" contacts; (2) The number of "crisis" contacts involving each drug decreased over the time span, particularly those involving "psychedelic hallucinogens" other than L.S.D., solvents, cannabis and opiates. The number of alcohol-involved crisis contacts declined least and alcohol came to account for the second largest proportion of crisis contacts after L.S.D.; (3) There was little change in the age distribution of "crisis" contacts over the period; (4) Crisis contacts in the most recent period (1973-74) were more likely to be rated serious than in the earlier periods; (5) Crisis contacts were less likely to be sent to hospitals in the most recent period.

Selection of the optimum surgical treatment of stage I melanoma by depth of microinvasion: Use of the combined microstage technique (Clark-Breslow).

The methods of histologic staging of primary Stage I melanoma and the relation to lymph node metastases and survival after surgery was evaluated in 151 patients with extremity melanoma only. Microstaging by depth of invasion showed a better prognostic correlation than by histologic typing (into superficial spreading, or nodular melanoma). A correlation existed between depth of invasion (Clark's levels) and incidence of nodal metastases at elective node dissection. This incidence was 5% at Level II, 4% at Level III, 25% at Level IV and 75% at Level V. The measured depth of invasion added prognostic insight to each Clark's level; the minimal invasion at which nodal metastases occurred was 0.6 mm for Level II, 0.9 mm for Level III, 1.5 mm for Level IV and over 4 mm for Level V. The 5 year disease-free survival after surgery was 100% for Clark Level II, 88% for Level III, 66% for Level VI and 15% for Level V. There was a direct relation between the measured depth of invasion and survival and mortality from disease at 5 years. Mortality from disease at 5 years could be directly equated with 10 times microinvasion in mm. Microstaging by direct measurement gave a better prognostic correlation than was found using Clark's levels for more deeply invading melanoma. At this time there is suggestive evidence that patients with certain higher risk lesions may do significantly better with wide excision and elective node dissection than with wide excision alone. These high risk lesions include Clark Level III to V, lesions measuring 0.9 mm or greater and all nodular melanomas.