Initial experience in setting up a medical student first responder scheme in South Central England.

Prehospital emergency medicine (PHEM) is a recently recognised subspecialty of emergency medicine, and anaesthetics, intensive care and acute medicine, in the UK, and yet it receives little to no mention in many undergraduate medical curricula. However, there is growing interest in PHEM among medical students and junior doctors. Several programmes are in existence across the UK that serve to provide teaching and exposure of prehospital care to medical students and junior doctors. However, relatively few students are able to gain significant first-hand experience of treating patients in the prehospital phase. In this short report, we discuss our experience of launching the student first responder (SFR) scheme across three counties in the Thames Valley. Medical students are trained by the regional ambulance service and respond to life-threatening medical emergencies in an ambulance response vehicle. The scheme is likely to benefit the ambulance service by providing a wider pool of trained volunteer first responders able to attend to emergency calls, to benefit patients by providing a quick response at their time of need, and to benefit medical students by providing first-hand experience of medical emergencies in the community. In its first 15 months of operation, SFRs were dispatched to 343 incidents. This scheme can serve as a training model for other ambulance services and medical schools across the UK.

Intraoperative assessment of sentinel node using imprint cytology.

BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary sampling as the axillary staging procedure of choice in patients with breast cancer. Accurate intraoperative evaluation of the SLN would allow axillary lymph node clearance to be performed during the initial operation when the SLN is positive for metastatic disease. The aim of the present study was to assess the accuracy of intraoperative imprint cytology (IC) of the SLN in two different institutions in the United Kingdom. METHODS: All breast cancer patients who underwent a SLN biopsy using a standard protocol in two hospital breast units were included. The SLN was sent fresh to the pathology laboratory, where it was immediately processed and examined by a cytopathologist using IC. The intraoperative IC results were compared with the final histopathological results. No therapeutic decisions were made based on the results of IC in this study. RESULTS: A total of 166 patients were included, with 47 positive and 119 negative cases on final histology. Of the 47 patients who were positive on final histology, there were 29 positive and 18 negative cases on IC (sensitivity = 61.7%). All 119 patients who were negative on final histology were negative on IC (specificity, 100%). The negative and positive predictive value of the final histology was 86.9% and 100%, respectively. The accuracy of IC was 89.2%. CONCLUSIONS: The results from these two breast units are comparable with findings reported in the published literature, confirming that IC can be used to assess SLN biopsy intraoperatively. No unnecessary axillary node clearance would have been carried out based on the results of IC.

Extended-release epidural morphine vs continuous peripheral nerve block for management of postoperative pain after orthopedic knee surgery: a retrospective study.

The purpose of this study was to compare the efficacy and safety of extended-release epidural morphine (EREM) and perineural infusion (PNI) to control pain after total knee arthroplasty. A convenience sample of 200 patients was obtained using a retrospective chart review of patients who underwent a total knee arthroplasty. Institutional review board approval was obtained, and 100 charts of patients who received EREM and 100 patient charts for PNI were reviewed. The main end points were pain scores up to 48 hours postoperatively, and the ancillary end points were supplemental opioid requirements and adverse effects. Data were analyzed using the Pearson chi2 where appropriate or the Fisher exact test, and all continuous variables were examined using a Wilcoxon rank test. The results of the study showed no significant differences between the 2 groups for the levels of pain preoperatively, immediately postoperatively, and at 48 hours postoperatively. However, at both 12 hours and 24 hours postoperatively, the PNI group had a significantly higher pain score than the EREM group. The EREM group had better pain scores; however, one must look at a number of different variables when deciding if EREM is the correct choice for postoperative pain management.

Simultaneous evaluation of maspin and CXCR4 in patients with breast cancer.

AIM: To study simultaneously the actions of maspin and CXCR4, which share several similar pathways in cancer, including apoptosis and angiogenesis. METHODS: Our material consisted of 151 invasive breast carcinomas arranged in a tissue microarray setting. Maspin and CXCR4 expression was evaluated by immunohistochemistry. Microvessel density was assessed by CD34 immunodetection and apoptosis by the Tdt-mediated dUTP nick end labelling assay. RESULTS: Maspin expression was related to CXCR4 expression, apoptosis, patient age and the Nottingham prognostic index. The expression of both maspin and CXCR4 progressively increased in high-grade tumours. In patients with lymph node negative breast cancer, maspin overexpression was associated with increased risk of death. High CXCR4 expression was associated with prolonged survival of patients with high maspin expression. CONCLUSIONS: Our results show that maspin overexpression could prove to be a potentially useful marker, especially for the clinically important group of patients with lymph node negative breast cancer. The expression of CXCR4 is of less significance in our study, but may be informative for specific patient subsets or in a longer time frame.

Reactivity with A monoclonal antibody to Epstein-Barr virus (EBV) nuclear antigen 1 defines a subset of aggressive breast cancers in the absence of the EBV genome.

Previous studies have suggested that common breast cancers are associated with EBV. We used a highly sensitive quantitative real-time PCR method to screen whole tumor sections of breast cancers for the presence of the EBV genome. EBV DNA was detected in 19 of 92 (21%) tumors, but viral load was very low in positive samples (mean = 1.1 copy EBV/1000 cells, maximum = 7.1 copies EBV/1000 cells). Importantly, quantitative real-time PCR failed to detect the EBV genome in microdissected tumor cells from any case. Using a monoclonal antibody (2B4-1) reactive against the EBV nuclear antigen-1, we noted strong staining of tumor nuclei in a proportion of those breast cancers that had tested negative for the presence of the EBV genome. Because nuclear staining with the 2B4-1 antibody was previously observed more frequently in poor prognosis breast cancers, we examined a larger series of breast cancers with complete clinical follow-up. Strong punctate staining of tumor cell nuclei was observed in 47 of 153 (31%) breast cancers; 2B4-1-positive tumors were significantly more likely to be ER-negative (P < 0.0001), to be of higher grade (P = 0.001) and larger (P = 0.03), to involve more regional lymph nodes (P = 0.01), and to have higher Nottingham Prognostic Index scores (P = 0.0003). Conclusions are: (a) EBV can be regularly detected in whole sections of breast cancers but viral copy number is very low; (b) in these cases, tumor cells do not harbor virus; and (c) reactivity with the monoclonal antibody 2B4-1 is detectable in the absence of the EBV genome and is strongly associated with ER-negative breast tumors and with prognostically unfavorable disease. Additional studies should be directed to the identification of this protein and to elucidation of its role in breast cancer.

Attitudes of U.K. breast and plastic surgeons to lipomodelling in breast surgery.

UNLABELLED: Lipomodelling is increasingly popular in breast surgery. The aims of this study were to elucidate the prevalence and practice of lipomodelling by surgeons in the UK and explore their attitudes and reservations to the technique. METHODOLOGY: A study specific questionnaire was circulated to Breast and Plastic Surgeons with an interest in breast reconstruction. RESULTS: 228 surgeons responded. Lipomodelling in breast surgery was performed by 48/70 (69%) plastic surgeons and 17/158 (11%) breast surgeons (p < 0.0001). Most attitudes were positive with over 60% surgeons agreeing that the benefits of lipomodelling outweighed the risks. Critics cited the lack of prospective, long term follow up data (16%) in addition to oncological (4%), radiological (8%) and efficacy (4%) concerns. CONCLUSIONS: Lipomodelling is performed by the majority of plastic surgeons who responded. Despite oncological, radiological and efficacy concerns, the majority of surgeons feel that the benefits of lipomodelling in the breast outweigh the risks.

Evaluation of imidacloprid-treated traps as an attract and kill system for filth flies during contingency operations.

Two field trials were conducted to evaluate if filth fly trap efficacy was increased by augmentation with an insecticide application to the trap's exterior. Four Fly Terminator Pro traps (Farnam Companies, Inc, Phoenix, AZ) baited with Terminator Fly Attractant (in water) were suspended on polyvinyl chloride pipe framing at a municipal waste transfer site in Clay County, Florida. The outer surfaces of 2 traps were treated with Maxforce Fly Spot Bait (Bayer Environmental Science, Research Triangle Park, NC) (10% imidacloprid) to compare kill rates between treated and untreated traps. Kill consisted of total flies collected from inside traps and from mesh nets suspended beneath all traps, both treated and untreated. Each of 2 treated and untreated traps was rotated through 4 trap sites every 24 hrs. In order to evaluate operational utility and conservation of supplies during remote contingency operations, fly attractant remained in traps for the duration of the first trial but was changed daily during the second trial (following manufacturer's recommendations). In addition, ½ strength Terminator Fly Attractant was used during the first trial and traps were set at full strength during the second trial. Flies collected within the traps and in mesh netting were counted and identified. Three species, Musca domestica (L.), Chrysomya megacephala (F.), and Lucilia cuprina (Wiedemann), comprised the majority of samples in both trials. The net samples recovered more flies when the outer surface was treated with imidacloprid, however, treated traps collected fewer flies inside the trap than did untreated traps for both trials. No significant statistical advantage was found in treating Fly Terminator Pro trap exteriors with Maxforce Fly Spot Bait. However, reducing manufacturer's recommended strength of Terminator Fly Attractant showed similar results to traps set at full strength. Treating the outer surfaces may improve kill of fly species that do not enter the trap. Terminator Fly Attractant was also found to be more effective if traps were not changed daily and left to hold dead flies for longer periods.

Immediate breast reconstruction after mastectomy: what are the long-term prospects?

INTRODUCTION: Immediate breast reconstruction after mastectomy has known psychological and financial advantages but it is difficult to compare the outcome of various methods of reconstruction. Re-operation rates are an objective measure of surgical intervention required to attain and maintain acceptable cosmesis. PATIENTS AND METHODS: A series of 95 patients (110 immediate reconstructions) was analysed for number of re-operations required within 5 years of initial surgery, magnitude of procedures, 'survival' of the reconstruction and effect of radiotherapy. RESULTS: Although more intervention was seen in patients with implant-based reconstruction and the time-course over which autologous and implant-based reconstructions fail is different these did not reach statistical significance. Radiotherapy has a significant effect on failure of implant-based reconstruction. CONCLUSIONS: Long-term, large studies of immediate reconstruction are required to assess adequately the impact of type of reconstruction on re-operation rates. The National Mastectomy and Breast Reconstruction Audit is ideally placed to provide answers to remaining questions about longevity of immediate breast reconstruction and the effect that late failure has on patient satisfaction.

Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial.

BACKGROUND: Sentinel lymph node biopsy in women with operable breast cancer is routinely used in some countries for staging the axilla despite limited data from randomized trials on morbidity and mortality outcomes. We conducted a multicenter randomized trial to compare quality-of-life outcomes between patients with clinically node-negative invasive breast cancer who received sentinel lymph node biopsy and patients who received standard axillary treatment. METHODS: The primary outcome measures were arm and shoulder morbidity and quality of life. From November 1999 to October 2003, 1031 patients were randomly assigned to undergo sentinel lymph node biopsy (n = 515) or standard axillary surgery (n = 516). Patients with sentinel lymph node metastases proceeded to delayed axillary clearance or received axillary radiotherapy (depending on the protocol at the treating institution). Intention-to-treat analyses of data at 1, 3, 6, and 12 months after surgery are presented. All statistical tests were two-sided. RESULTS: The relative risks of any lymphedema and sensory loss for the sentinel lymph node biopsy group compared with the standard axillary treatment group at 12 months were 0.37 (95% confidence interval [CI] = 0.23 to 0.60; absolute rates: 5% versus 13%) and 0.37 (95% CI = 0.27 to 0.50; absolute rates: 11% versus 31%), respectively. Drain usage, length of hospital stay, and time to resumption of normal day-to-day activities after surgery were statistically significantly lower in the sentinel lymph node biopsy group (all P < .001), and axillary operative time was reduced (P = .055). Overall patient-recorded quality of life and arm functioning scores were statistically significantly better in the sentinel lymph node biopsy group throughout (all P < or = .003). These benefits were seen with no increase in anxiety levels in the sentinel lymph node biopsy group (P > .05). CONCLUSION: Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.