Diagnostic accuracy of core biopsy for ductal carcinoma in situ and its implications for surgical practice.

BACKGROUND: Core biopsy is considered to be a highly accurate method of gaining a preoperative histological diagnosis of breast cancer. Ductal carcinoma in situ (DCIS) is often impalpable and is a more subtle form of breast cancer. AIM: To investigate the accuracy of core biopsy in the diagnosis of cancer in patients with DCIS. METHODS: All patients who had invasive cancer (n = 959) or DCIS (n = 92) that was confirmed by excision between 1999 and 2004 were identified. The diagnostic methods, histology of the core biopsy specimen and excision histology were reviewed in detail. RESULTS: Core biopsy was attempted in 88% (81/92) of patients with DCIS and in 91% (874/959) of those with invasive disease. Of those patients who underwent core biopsy, a diagnosis of carcinoma on the initial core was made in 65% (53/81) of patients with DCIS compared with 92% (800/874) of patients with invasive disease (p<0.0001). Smaller lesion size (p = 0.005) and lower grade (p = 0.03) were associated with increased risk for a negative or non-diagnostic core in patients with DCIS. The nature of the mammographic lesion or the method of biopsy did not affect the probability of an accurate core biopsy. Patients who had a preoperative diagnosis of DCIS by core biopsy had a reoperation rate of 36% compared with 65% of those that did not have a preoperative diagnosis (p = 0.007). CONCLUSION: Although core biopsies are highly accurate forms of obtaining a preoperative diagnosis in patients with invasive breast cancer, this is not the case in DCIS. As the number of surgical procedures can be reduced by core biopsy, it is still of considerable value in the management of DCIS.

Impact of the informed consent process on patients' understanding of varicose veins and their treatment.

AIM: It is particularly important that patients have reasonable understanding of the risks, benefits and nature of elective surgery. This study sought to analyse this level of understanding in patients undergoing varicose vein surgery METHODS: Eighty two patients completed a questionnaire in the vascular outpatient clinic and were asked to complete a telephone questionnaire following the clinic. RESULTS: Pain (n = 46) was the primary reason patients considered varicose vein surgery followed by appearance (n = 32). Most patients felt that varicose veins placed them at high risk of leg ulcers (n = 46) and DVT (n = 41). A high level of expectation that surgery would significantly affect pain and flares was recorded. While the outpatient visit did not materially change these misconceptions, an educational leaflet significantly enhanced the recall of complications (p = 0.028) in patients who remembered receiving a leaflet. CONCLUSION: Patients attending varicose vein clinics have an unrealistic expectation of the benefits of surgery and fail to understand the benign nature of their condition. The outpatient process has little effect on patient-held beliefs.

Surgical intervention in screen-detected patients versus symptomatic patients with breast cancer.

OBJECTIVES: The impact of population-based screening for breast cancer on the rate of breast-conserving surgery has not been established. We sought to evaluate whether surgical intervention in patients with screen-detected breast cancer differed from those with clinically detected tumours. SETTINGS: St Vincent's University Hospital and the BreastCheck Merrion Unit, part of the Irish National Breast Screening Programme, were the setting for the study. METHODS: A total of 902 patients referred for surgery to St Vincent's University Hospital over a four-year period (2000-2003) were studied. Patients with breast cancers detected during the prevalent round of screening (n=325) were compared with patients presenting with symptomatic disease (n=577). The operative procedure, nature of axillary surgery and histopathological findings were recorded in each case. RESULTS: There was an increase in breast-conserving therapy in the screened population compared with symptomatic cases (68% screened versus 53% symptomatic; p<0.0001), with a corresponding reduction in axillary clearance rates (65% screened versus 81% symptomatic; p<0.0001). Nodal positivity was similar following correction for size in all tumours >1 cm, regardless of method of detection. Sentinel node biopsy was successfully undertaken in 39% of tumours <2 cm (T1 tumours) [corrected] in the screening population. CONCLUSIONS: The screened population was statistically more likely to have breast-conserving therapy than the symptomatic group. Sentinel node biopsy has evolved into an acceptable alternative to axillary clearance in T1 cancers, particularly in screen-detected cases.

Factors that affect longevity of intravenous cannulas: a prospective study.

BACKGROUND: Few guidelines exist to guide medical personnel on the most successful means of achieving sustained intravenous cannulation. This study examines the impact of gauge and site of intravenous cannulas (IC) on the longevity of ICs in hospitalized patients. METHODS: A prospective study was conducted on 500 ICs inserted into patients of St Vincent's Private hospital from December 2005 to June 2006. Patients were followed until the IC had been removed or changed. Statistical analysis was performed using Cox proportional hazards. RESULTS: Of the 500 ICs inserted, 37% were 18 g, 46% were 20 g and 18% were 22 g. Gauge of IC was the most significant predictor of increased longevity of IC (P = 0.0002, RR = 1.17, 95% CI 1.08-1.27). The median survival of 18, 20 and 22 g were 57 h (95% CI 49-72), 43 h (95% CI 36-48.5) and 29 h (95% CI 24-40.5), respectively. The site of IC placement influenced the longevity of ICs (P = 0.005, RR= 0.7, 95% CI 0.55-0.9), as did male gender (P = 0.03, RR = 0.76, 95% CI 0.6-0.97). However in subgroup analysis, the most marked effect on IC longevity was evident in those patients with 18 g placed in the forearm/wrist (median 72 h) with less marked changes in other site/gauge combinations. In contrast, 22 g ICs placed in the hand had a median lifespan of 29 h. CONCLUSION: IC gauge and site of placement are important factors in determining IC longevity. 18 g ICs placed in the forearm/wrist can considerably increase the longevity of ICs and should be attempted in patients who require sustained cannulation.