Thromboxane biosynthesis in cancer patients and its inhibition by aspirin: a sub-study of the Add-Aspirin trial.

BACKGROUND: Pre-clinical models demonstrate that platelet activation is involved in the spread of malignancy. Ongoing clinical trials are assessing whether aspirin, which inhibits platelet activation, can prevent or delay metastases. METHODS: Urinary 11-dehydro-thromboxane B2 (U-TXM), a biomarker of in vivo platelet activation, was measured after radical cancer therapy and correlated with patient demographics, tumour type, recent treatment, and aspirin use (100 mg, 300 mg or placebo daily) using multivariable linear regression models with log-transformed values. RESULTS: In total, 716 patients (breast 260, colorectal 192, gastro-oesophageal 53, prostate 211) median age 61 years, 50% male were studied. Baseline median U-TXM were breast 782; colorectal 1060; gastro-oesophageal 1675 and prostate 826 pg/mg creatinine; higher than healthy individuals (~500 pg/mg creatinine). Higher levels were associated with raised body mass index, inflammatory markers, and in the colorectal and gastro-oesophageal participants compared to breast participants (P < 0.001) independent of other baseline characteristics. Aspirin 100 mg daily decreased U-TXM similarly across all tumour types (median reductions: 77-82%). Aspirin 300 mg daily provided no additional suppression of U-TXM compared with 100 mg. CONCLUSIONS: Persistently increased thromboxane biosynthesis was detected after radical cancer therapy, particularly in colorectal and gastro-oesophageal patients. Thromboxane biosynthesis should be explored further as a biomarker of active malignancy and may identify patients likely to benefit from aspirin.

The role of sentinel lymph node biopsy in planning adjuvant therapy for elderly women with low-risk breast cancer.

Sentinel lymph node biopsy (SLNB) guides adjuvant therapy in breast cancer. There is controversy regarding its use in elderly women with low-risk breast cancer. This study aimed to determine whether a positive SLNB in this group affected the decision to offer adjuvant therapy compared with younger patients. This retrospective review included 492 patients, 89 of whom had a positive SLNB. Elderly, node-positive women were significantly less likely to receive chemotherapy than their younger counterparts (P < .0001), suggesting the use of SLNB in the elderly could be rationalized.

A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool.

BACKGROUND AND AIMS: Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS: Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION: The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.

Death within 48 h--adverse events after general surgical procedures.

BACKGROUND: Comorbidity and emergency intervention are established risk factors for post-operative mortality. This study sought to identify adverse events associated with death within 48 h of general surgical procedures. METHODS: All general surgical patients who died within 48 h of operative intervention from 2002-2006 in Scotland underwent retrospective peer review using established Scottish Audit of Surgical Mortality (SASM) methodologies (www.SASM.org). RESULTS: During the 5 years, 1299 patients died within 48 h of surgery, 1134 (87.3%) admitted as an emergency, with a mean age of 71 years; 898 patients (69.1%) were ASA grade 3, 4 or 5; 727 (56.0%) patients had cardiovascular, 398 (30.6%) respiratory and 191 (14.7%) renal comorbidity. Over time exploratory laparotomy (443, 34.1%) was carried out less often (p = 0.004) prior to death due to cardiovascular disease (435, 33.5%), mesenteric ischaemia (264, 20.3%) or multi-organ failure (255, 19.6%). The decision to operate by consultant surgeons rose significantly (p < 0.001). Adverse events were identified in 721 of the 1299 cases; concerns about inappropriate operations (p = 0.018) and poor pre-operative assessment (p = 0.012) decreased significantly. CONCLUSIONS: Patients dying within 48 h of surgery are usually elderly, emergency admissions with significant comorbidities who die of cardiovascular events. Timely, appropriate surgery and high quality peri-operative care delivered by consultant staff may prevent early post-operative mortality.

Mortality associated with the treatment of gallstone disease: a 10-year contemporary national experience.

BACKGROUND: Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland. METHODS: Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease. RESULTS: Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36). DISCUSSION: Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.

Breast Core Biopsy Information and Consent: Do we Prepare or do we Scare?

Informed consent has important ethical considerations for invasive procedures. Anecdotal evidence suggests an informed consent policy could heighten anxiety. We evaluated whether detailed information about breast biopsy prior to appointment negatively impacted patient experiences. Phase 1 surveyed patients receiving a standard appointment letter who underwent core biopsy (group A). Phase 2 surveyed two groups receiving standard letter plus biopsy leaflets: those who underwent core biopsy (group B) and those who did not (group C). The analysis included descriptive statistics and qualitative thematic analysis. Hundred percent of group A felt they were given enough information prior to biopsy and 72% felt it would not be helpful having information to read in the clinic beforehand. Hundred percent of group B and 94.1% of group C found it helpful to receive information with their letter. Common themes were good service, verbal explanation, and appreciation of written information. Despite concerns that too much information would heighten anxiety, this has not resulted in negative clinic experiences. Most patients found detailed information included with their appointment letter helpful, regardless of whether they had a biopsy or not.

Magnetic resonance imaging for invasive lobular carcinoma: is it worth it?

BACKGROUND: Invasive lobular cancer (ILC) of the breast can provide diagnostic and therapeutic challenges due to its often mammographically occult and multifocal nature. UK guidelines recommend magnetic resonance imaging (MRI) when considering breast conserving surgery (BCS) in women with a diagnosis of ILC. A small number of studies have shown that due to its low specificity, MRI can lead to additional invasive investigations whilst rarely identifying additional tumour foci that affect management. We carried out a retrospective study of patients diagnosed with ILC to assess the impact of MRI on management and to evaluate if breast density on mammography could indicate likelihood of additional disease being found on MRI. METHODS: A retrospective analysis of the electronic patient records for all cases of ILC diagnosed between January 2013 and December 2016 was carried out. RESULTS: A total of 110 cases of ILC were identified of which 69 women were considered for BCS and 58 (84.1%) women underwent MRI. A further abnormality was seen in 22 (37.9%) patients of whom 13 (59.1%) had a further core biopsy with 4 cases being positive for malignancy. Overall MRI changed the surgical plan from BCS to mastectomy in 7 (10.1%). Breast density did not predict the presence of additional findings on MRI. CONCLUSIONS: MRI assessment of ILC rarely affects the management when BCS is considered. Having radiologically denser breasts did not correlate with increased reoperation rate. Larger prospective studies may provide further guidance on MRI specificity and breast density.

Physical activity referral to cardiac rehabilitation, leisure centre or telephone-delivered consultations in post-surgical people with breast cancer: a mixed methods process evaluation.

BACKGROUND: Physical activity (PA) programmes effective under 'research' conditions may not be effective under 'real-world' conditions. A potential solution is to refer patients to existing PA community-based PA services. METHODS: A process evaluation of referral of post-surgical patients with early-stage breast cancer to cardiac rehabilitation exercise classes, leisure centre with 3-month free leisure centre membership or telephone-delivered PA consultations for 12 weeks. Quantitative data were collected about PA programme uptake and reach, patient engagement with the PA programme, delivery and fidelity and PA dose. Qualitative data were collected about patient experiences of taking part in the PA programmes. Audio-recorded qualitative interviews of participants about the programmes were analysed thematically. Quantitative data were reported descriptively using means and SD. RESULTS: In Phase I, 30% (n = 20) of eligible patients (n = 20) consented, 85% (n = 17) chose referral to leisure centre, and 15% (n = 3) chose cardiac rehabilitation. In Phase II, 32% (n = 12) consented, 25% (n = 3) chose leisure centre and 75% (n = 9) chose telephone-delivered PA consultations. Walking at light intensity for about an hour was the most common PA. All Phase I participants received an induction by a cardiac rehabilitation physiotherapist or PA specialist from the leisure centre but only 50% of Phase II participants received an induction by a PA specialist from the leisure centre. Four themes were identified from qualitative interviews about programme choice: concerns about physical appearance, travel distance, willingness to socialise and flexibility in relation to doing PA. Four themes were identified about facilitators and barriers for engaging in PA: feeling better, feeling ill, weight management, family and friends. CONCLUSIONS: The current community-based PA intervention is not yet suitable for a definitive effectiveness randomised controlled trial. Further work is needed to optimise PR programme reach, PA dose and intervention fidelity. TRIAL REGISTRATION: ISRCTN11183372.

Factors associated with patients in the Scottish Highlands who chose mastectomy when suitable for breast conservation.

BACKGROUND: Despite being suitable for breast conservation surgery (BCS) a proportion of women choose mastectomy. This study aimed to assess the pre-operative pathological and geographic factors associated with choosing mastectomy rather than BCS in a single centre that serves a large geographical area encompassing urban, rural and remote island populations. METHODS: A retrospective analysis of all patients suitable for BCS between January 2011 and December 2013 was undertaken. Pre-operative pathological features were compared using the Pearson chi squared test as was distance to the treatment centre from the patient's home. A questionnaire was sent to all those who chose mastectomy to identify the factors that influenced their decision. RESULTS: A total of 446 patients suitable for BCS were identified of which 46 (11%) chose to undergo mastectomy. Patients choosing mastectomy were more likely to present symptomatically (P=0.009), have tumours larger than 20 mm at diagnostic imaging (P=0.001) and have positive axillary staging (P=0.004). Patients choosing mastectomy were more likely to live remotely (P=0.051). Those patients who chose mastectomy felt this gave a better long-term outcome (18 patients, 44%) and peace of mind (14 patients, 34%). CONCLUSIONS: Adverse pre-operative pathological features were associated with patients choosing mastectomy rather than BCS. There was a trend for patients who chose mastectomy to live remotely from the treatment centre. Patients choosing mastectomy most commonly cited a better long-term outcome and peace of mind as the reason behind their decision. Understanding what influences a patient's surgical choice will allow clinicians and patients to engage in a fully informed pre-operative decision making process.

Screening mammography uptake within Australia and Scotland in rural and urban populations.

OBJECTIVE: To test the hypothesis that rural populations had lower uptake of screening mammography than urban populations in the Scottish and Australian setting. METHOD: Scottish data are based upon information from the Scottish Breast Screening Programme Information System describing uptake among women residing within the NHS Highland Health Board area who were invited to attend for screening during the 2008 to 2010 round (N = 27,416). Australian data were drawn from the 2010 survey of the 1946-51 cohort of the Australian Longitudinal Study on Women's Health (N = 9890 women). RESULTS: Contrary to our hypothesis, results indicated that women living in rural areas were not less likely to attend for screening mammography compared to women living in urban areas in both Scotland (OR for rural = 1.17, 95% CI = 1.06-1.29) and Australia (OR for rural = 1.15, 95% CI = 1.01-1.31). CONCLUSIONS: The absence of rural-urban differences in attendance at screening mammography demonstrates that rurality is not necessarily an insurmountable barrier to screening mammography.

Pilonidal abscess in the breast: a case report.

Pilonidal sinus is a common entity, most often occurring in the natal cleft. Pilonidal sinus with abscess formation has also been described in hairdressers in the interdigital space. We report a case of pilonidal abscess of the breast in a hairdresser, a rarely reported site, which requires awareness on the clinician's part of this occupational risk, for appropriate management and post-surgery advice on prevention. It is particularly important to impart such information to the reporting pathologist who is key to making this histological diagnosis.

Volvulus of the sigmoid colon treated by percutaneous endoscopic colostomy.

Volvulus of the sigmoid colon is a condition that, in the Western world, predominately affects the elderly. In fit patients sigmoid colectomy, after a period of decompression, is the treatment of choice. However, this carries a high mortality in elderly high-risk patients. Percutaneous endoscopic colostomy (PEC) has been reported as a treatment for those who are considered high risk for surgery. We report the successful use of PEC in an 87-year-old lady, for the treatment of recurrent sigmoid volvulus, without complication. This procedure has also been used effectively for colonic pseudo-obstruction, constipation, and obstructed defecation. There are various complications associated with PEC, the most serious of which is tube migration and fecal peritonitis. Our experience supports the use of PEC to treat sigmoid volvulus in those too frail for colonic resection.

Microcoil embolisation of mycotic cystic artery pseudoaneurysm: a viable option in high-risk patients.

Mycotic cystic artery pseudoaneurysm is a rare complication of cholecystitis, of which the main treatment has been cholecystectomy plus ligation of the cystic artery. We highlight our experience with successful coil embolisation of this condition without the need for surgical intervention. This is followed by a comprehensive review of the literature regarding management of this unusual condition.