Obesity in looked after children: is foster care protective from the dangers of obesity?

BACKGROUND: Obesity in all age groups of children has become an increasing concern in recent years. Children looked after by the Local Authority (LA) should be protected from health problems while being accommodated. These studies assess the effect on weight of looked after children (LAC) in the care of a Midlands County Council. They assess the frequency of obesity or overweight problems in looked after children following receipt into care and review changes in body mass index (BMI) while in the care of the LA. METHOD: The height and weight measurements of all 106 children who had statutory health assessments while in the care of the LA between 1 January 2004 and 30 December 2004 were used to calculate their BMI. The data were plotted onto standard Growth Foundation charts and the International Obesity Task Force Paediatric cut-offs were determined to distinguish overweight and obese children and young people. The date that the child had come into the care system and the number of moves of placement was obtained for each child from the social care. This was related to the total group and the overweight group of looked after children. RESULT: Looked after children are more likely to be overweight and obese compared with standard norms, and there are a number of children (35%) whose BMI increases once in care. OUTCOME: Looked after care did not protect a child from the national problem of increasing weight gain and obesity.

A randomized comparison of tamoxifen with surgical oophorectomy in premenopausal patients with advanced breast cancer.

We randomized 122 premenopausal women to receive tamoxifen or to undergo a surgical oophorectomy. Of 54 evaluable women treated with tamoxifen, 24% had an objective response, as compared with 21% of 53 women having an oophorectomy. The median duration of response for tamoxifen (20 months) was longer than that for surgical oophorectomy (7 months), but this did not achieve statistical significance (P = .056). Overall median survival was 15 months for 58 patients receiving tamoxifen and 25 months for 53 patients undergoing oophorectomy (P = .18). Toxicity was greater in those undergoing oophorectomy, though both treatments were well tolerated. In those premenopausal women for whom hormonal therapy is indicated, tamoxifen is a suitable alternative to surgical oophorectomy.

Surgical management of haemorrhaging renal angiomyolipoma in pregnancy.

INTRODUCTION: Renal angiomyolipoma (AML) is a benign mesenchymal tumour of the kidney with a tendency of aneurysm formation at risk of rupturing. Due to increased maternal circulation and hormonal influences, rupture risk is greater in pregnancy, often leading to a vascular emergency and premature delivery or termination. PRESENTATION OF CASE: A 24-weeks pregnant woman (45 years old, G6P1) presented with haematuria and flank pain. CT showed AML with acute haemorrhage. The patient became haemodynamically unstable and underwent urgent embolisation and follow-on total radical nephrectomy with the foetus being left in-utero. This involved a multidisciplinary team (urologist, vascular surgeon, interventional radiologist and obstetrician). The procedure was uncomplicated and the pregnancy went to term with a healthy girl delivered at 38 weeks. DISCUSSION: The incidence of AML is 0.13% in the general population. 21 reports of haemorrhaging AML in pregnancy have been published in the last 35 years. Mean gestational age was 29.6 weeks. Eight were treated conservatively to term, one underwent exploratory laparotomy with evacuation of haematoma only, five were embolised, and seven were managed with nephrectomy. Of the nephrectomy subgroup, one was preceded by vaginal delivery and five underwent concurrent caesarean section (one with pre-op embolisation). There were two associated foetal deaths. CONCLUSION: This case demonstrates that with a multidisciplinary approach, it is possible to successfully leave a foetus undelivered whilst performing a radical nephrectomy for a large bleeding AML in a woman carrying a late second trimester pregnancy.

Efficacy of early diagnosis and treatment in women with a family history of breast cancer. European Familial Breast Cancer Collaborative Group.

BACKGROUND: Surveillance programmes for women at increased genetic risk of breast cancer are being established worldwide but little is known of their efficacy in early detection of cancers and hence reduction in mortality. METHODS: Data were contributed from seven centres participating in the EU Demonstration Programme on Clinical Services for Familial Breast Cancer. All breast tumours (n = 161) detected prospectively, from the time of enrolment of women in a screening programme, were recorded. Analysis took account of age at diagnosis, whether tumours were screen-detected or not, their pathological stage and outcome by Kaplan-Meier survival plots. RESULTS: Mean age at diagnosis was 48.6 years. Overall, 75% of tumours were detected in the course of planned examinations. For women under age 50 at diagnosis, this figure was 68%. Eighteen percent were mammographically negative, (23% in patients under age 50). At first ("prevalence") round and at follow-up screening, 16% and 22% of tumours respectively were carcinoma in situ (CIS) while 27% and 22% respectively had evidence of nodal or distant spread (CaN+). Comparison of screen-detected and other tumours showed that the latter were more frequently mammogram-negative and CaN+. Overall five-year survival was 89% and five-year event-free survival 86%. Five-year event-free survival was 100% for CIS, 88% for invasive cancer without nodal or distant spread and 67% for CaN+. CONCLUSIONS: The majority of cancers arising in women at increased genetic risk of breast cancer can be detected by planned screening, even in those under age 50. Surveillance should include regular expert clinical examination and teaching of "breast awareness" as well as mammography. Attention to the logistics of screening programmes may improve still further the proportion of tumours that are screen-detected. The trend towards earlier pathological stage in tumours detected during follow-up rounds and the preliminary findings on survival analysis suggest that this approach will prove to be of long-term benefit for breast cancer families.

Proteinase-like peptidase activities and oestrogen receptor levels in breast cancer tissue.

The relationship between proteinase-like peptidase activities and oestrogen receptor levels and status in breast cancer tissue homogenates from 61 patients with breast cancer has been evaluated. With Spearman's rank-order correlation analysis, significant positive correlations were observed between receptor levels and the activities of cathepsin-(B + L)-like, cathepsin-H-like, trypsin-like, plasminogen-activator-like and elastase-like peptidases. In addition, the activities of all but the latter enzyme were significantly higher in patients with receptor-rich tumours than in receptor-poor tumours, and this may have implications for future treatment regimens for patients with oestrogen-receptor-rich tumours. The findings reported are consistent with the suggestion that in breast cancer there may be an association between steroid receptors and proteolytic enzymes such that the release of these enzymes may be under hormonal control.

Restriction enzyme analysis of cytomegalovirus DNA to study transmission of infection.

Restriction enzyme analysis of cytomegalovirus deoxyribonucleic acid (DNA) has been used to characterise virus isolates and has provided information on patterns of viral transmission. It was shown that virus isolated from a congenitally infected infant was unlikely to have originated from the 13 congenitally infected children with whom the mother, a nurse, had been in contact. Of nine mother and infant pairs, from whom cytomegalovirus was isolated, seven yielded strains that were indistinguishable for mother and child; one pair showed minor differences and one was clearly distinguishable. Virus isolates from seven children attending a day nursery were typed, and only siblings were excreting similar strains of cytomegalovirus. Further examples of the application of this technique to studies of cytomegalovirus in a family environment are given. It is concluded that characterisation of virus strains by restriction analysis of DNA is a valuable epidemiological tool.

Congenital cytomegalovirus infection: predisposing maternal factors.

In a prospective study of cytomegalovirus (CMV) infection in pregnancy 69 congenitally infected infants were identified. The age, race, marital status, social class, and parity of the mothers of congenital CMV infants were compared with those of the screened population of women with non-infected infants. These factors were all individually strongly associated with the prevalence of congenital CMV. However, once age, marital status, and race were accounted for, neither social class nor parity had any additional effect. The overall congenital CMV rate was 3 per 1000 livebirths, ranging from 25/1000 for single black women under 20 to 1.6/1000 in married or cohabitating white women over 25.

Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery.

Antibiotic prophylaxis has been used to good effect in the prevention of post-operative wound infections in patients undergoing gastrointestinal operations. We have assessed the use of a single dose of intravenous antibiotic (Augmentin 1.2 g), given with induction of anaesthesia as prophylaxis, against post-operative wound infection in women undergoing clean, elective breast surgery. Three hundred and thirty-four patients were recruited. Of the 164 receiving antibiotic prophylaxis 29 (17.7%) had wound infections compared with 32 (18.8%) in the placebo group (P=0.79). There were no significant differences in any other post-operative infective complications. Antibiotic prophylaxis is probably not required in clean, elective breast surgery.

Heterogeneity of chemosensitivity in human breast carcinoma: use of an adenosine triphosphate (ATP) chemiluminescence assay.

Cancer chemotherapy is currently given to patients with breast carcinoma on the basis of data from response rates in patients with advanced disease, or from the results of clinical trials of adjuvant therapy. However, individual tumours may vary in their response to particular cytotoxic drugs: optimal therapy for a population of patients may not be the correct treatment choice in individual cases. In this study we have used an ATP-based non-clonogenic chemosensitivity assay (TCA-100) to investigate the heterogeneity of chemosensitivity of human breast carcinoma to a number of cytotoxic drugs, both as single agents and in combination. Tissue was obtained from 33 patients. Most samples were excision biopsies, but sufficient tumour cells were obtained from three needle biopsies and three pleural effusions for assays to be performed. The results show wide variation in the response of individual breast tumours to single agents, but most tumours show sensitivity to the commonly used combination regimens. The TCA-100 assay may provide useful information to support the choice of regimen for breast cancer chemotherapy.

Is mammographic microcalcification of biological significance?

Mammographic microcalcification is a feature of a proportion of breast cancers. Its occurrence does not appear to be significantly associated with age or primary tumour size. Lymph node involvement by tumour is present in 50% of patients with mammographic microcalcification in relation to the primary tumour, but only 24% of patients without microcalcification. A significantly larger number of lymph nodes (61 of 241 nodes) are involved with tumour in patients with, in comparison to those without (59 of 476 nodes) microcalcification (P < 0.001, chi 2 test). These differences suggest a biologically significant role for the deposition of calcium in microcalcifications, which may relate to the process of tumour cell metastasis. This may be of importance in the assessment of patients with cancers which demonstrate microcalcification on mammography.

Inhibition of proteinase-like peptidase activities in serum and tissue from breast cancer patients.

The inhibitory profiles of several proteinase-like peptidases active on synthetic peptide (MCA) substrates, present in sera and 100,000g supernatants of malignant tissue from patients with breast cancer, have been studied using a series of known inhibitors including epoxysuccinyl peptides (E-64, Ep-475), Z-Phe-Phe-diazomethane, PMSF, iodoacetamide, 1-10-O-phenanthroline, leupeptin, aprotinin, elastatinal and alpha 2-macroglobulin. While in general the inhibition profiles confirmed reported substrate specificities some anomalies were observed. In particular, the serum activities on two cathepsin B substrates were unaffected by specific cysteine proteinase inhibitors and in breast tissue only 20-37% of activity towards these two substrates was apparently due to the presence of endopeptidases. However, the potent inhibition of other proteinase-like activities by the epoxysuccinyl peptides and leupeptin, or similar inhibitors, may be useful agents in the study of methods of combating tumour spread.

The usefulness of naftidrofuryl in severe peripheral ischaemia--a symptomatic assessment using linear analogue scales.

The effect of Naftidrofuryl (Nafronyl) on the symptoms of severe peripheral vascular disease has been studied in 40 hospital inpatients. Assessment of ischaemic symptoms and of symptoms which may occur with any type of chronic pain was made using a linear analogue system. Patients treated with naftidrofuryl showed a significant symptomatic improvement compared to patients treated without vasoactive drug therapy. These results show that this drug has a useful place in the treatment of severe ischaemic symptoms during assessment for vascular reconstruction and in those patients found to be unsuitable for limb-salvage operations.

Argyrophil carcinoma of the breast: a cytologic, histochemical, and ultrastructural study of a case.

Aspirate from an argyrophil carcinoma ("carcinoid") of the breast showed malignant dispersed epithelial cells. With Diff-Quik, the cytoplasm was seen to be abundant, with prominent eosinophilic granularity. The nuclei were fairly uniform, round or oval, and eccentric and had a finely stippled chromatin pattern. On histology, the tumor appeared typical for argyrophil carcinoma, and staining with Grimelius for argyrophilic granules was positive. Membrane-bound neurosecretory granules were seen on electron microscopy.

X-chromatin (Barr bodies) correlated with the DNA content of lobular neoplasia and invasive lobular carcinoma in the female breast.

Literature relating X-chromatin with the histologic grade in carcinoma of the breast is briefly reviewed. X-chromatin incidence has been determined in 14 cases of lobular neoplasia and 5 invasive lobular carcinomas of the breast and has been correlated with the DNA content in these sections examined by Feulgen microspectrophotometry. In 11 of the cases of lobular neoplasia, the DNA values fell within the diploid range and in the 3 remaining cases within the diploid to tetraploid range, while the 5 invasive lobular carconomas showed a DNA distribution between the diploid and tetraploid ranges. The X-chromatin counts of these cases were variable but did not correlate with the cytophotometrically observed degree of malignancy in lobular neoplasia. No statistically significant differences in X-chromatin count of lobular neoplasia and invasive lobular carcinoma could be seen.

Twelve tips for setting up an ambulatory care (outpatient) teaching centre.

The ambulatory care setting is becoming an increasingly important environment for clinical teaching. This reflects the changing focus of healthcare delivery with more procedures and patient treatment being delivered in this setting. Maximizing learning opportunities for students without compromising patient care has never provided a greater challenge. This paper shares 12 educational tips for developing an ambulatory care teaching centre where both students and patients benefit from a protected yet realistic clinical setting.

The modified B-mammoplasty incision: an alternative skin-conserving technique for mastectomy with immediate breast reconstruction.

A modification of the B-mammoplasty incision (originally described by Regnault for reduction mammoplasty) is presented for patients undergoing skin-conserving mastectomy and reconstruction. This approach has several advantages; not only does it facilitate good exposure for the oncological surgeon to carry out the mastectomy, but it can easily be extended into the axilla to allow nodal clearance and microvascular access. It creates a suitable pocket into which a flap can be tailored or implant/expander inserted, and further adjustment of the breast size or shape can be undertaken easily. Most importantly, the scar is confined to the infralateral aspect of the breast, leaving the aesthetically important upper and medial breast skin scar free.

A randomised controlled trial of medroxyprogesterone acetate in mastalgia.

A double-blind crossover study giving 20 mg/day of medroxyprogesterone acetate during the luteal phase was carried out in 26 women with cyclical mastalgia. Symptomatic response to this progestogen supplementation or placebo was assessed objectively by clinical examination and subjectively by linear analogue scales and breast pain charts. No significant relief of pain or tenderness was found on placebo or active treatment, irrespective of treatment order, and breast nodularity was similarly unaltered. No evidence of progesterone deficiency or prolactin abnormality was found. Side-effects were incurred in 11 patients (five on placebo, five on active treatment and one while on both) and were mostly vague premenstrual symptoms. We conclude that the therapeutic response of medroxyprogesterone acetate in cyclical mastalgia is no better than placebo and that progestogen supplementation can no longer be recommended for routine use in the management of breast pain.

The classroom competence and attitudes towards pedagogical principles of beginning teachers.

The relationship between preservice education students' (N = 135) attitudes towards general pedagogical principles and the quality of their classroom teaching was investigated. A weak negative relationship was obtained between students' attitudes and the assessment category 'relationships with children'. This suggests that fostering positive attitudes in preservice students towards general pedagogical principles, based on practices in themselves directly associated with enhancing pupil achievement, may result in lower quality teaching because of an adverse effect this has on pupil-teacher relationships.

A stage-theory model of cognitive development.

A model of the proportions of the population at various stages of cognitive development as a function of age is proposed. It is shown that a number of weaknesses in an earlier model proposed by Eckstein & Shemesh (1992a) are avoided. The new model accounts well for empirical data for the age range 13-18 years. The uses of such models in research are discussed.