Morphine-induced pruritus after spinal anaesthesia.
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Analgesics, Opioid↗
Biomedical subjects
M Galea
Publications and source records attributed to M Galea.
Uptime as a measure of recovery in children postappendectomy.
PURPOSE: The aim of this study was to objectively measure recovery time after open and laparoscopic appendectomy using an activity monitor (PAL 1). METHODS: The PAL 1 records the amount of time that the subject is upright (uptime). Children wore the PAL 1 for 10 days continuously, beginning within the first 48 hours postoperatively. RESULTS: Uptime data were collected for 5 or more days for 42 children (open, n = 16; laparoscopic, n = 26). All children had low levels of uptime in the initial postoperative period. There was weak evidence of a quicker recovery rate for children in the laparoscopic group (P =.09). The difference in mean uptime between groups was of statistical significance by day 7 postoperatively with children in the laparoscopic group having a higher mean uptime than those in the open group (difference of 0.7 hours; 95% confidence intervals 0.0 to 1.4 hours in a 24-hour period). CONCLUSIONS: The results of this study show that recovery postappendectomy can be quantified by the measurement of uptime and that children undergoing a laparoscopic procedure may recover marginally more quickly than those undergoing an open procedure.
Adolescent↗
Uptime normative values in children aged 8 to 15 years.
The 'Uptimer' is a custom-made lightweight battery-operated remote activity monitor that records the amount of time an individual spends in the upright position, which is also known as 'uptime'. The aims of this study were to determine levels of uptime over 24 hours and the relation between uptime and a child's age, sex, height, weight, and body mass index (BMI). Uptime was recorded in 529 normally developing children (318 females, 211 males), aged between 8 and 15 years. All children wore an Uptimer continuously for a 24-hour period that included a typical school day. Mean uptime for children in this study was 5.4 hours (SD 1.3; range 1.5 to 10.3 hours), over a 24-hour period. Uptime followed approximately a normal distribution in this population and did not have a linear relation to age, height, weight, nor BMI. Results of this study may be used as a normative database for the evaluation of uptime in children with physical disabilities.
Adolescent↗
Variability in the measurement of uptime in children: a preliminary study.
OBJECTIVE: To examine variability in 'uptime' (the amount of time spent in the upright position). DESIGN: An observational study. SETTING: The community (i.e., homes and schools in the Melbourne metropolitan area). SUBJECTS: Normal children between 8 and 15 years of age (18 girls and 8 boys). EQUIPMENT: An 'uptimer', a lightweight, battery-operated remote monitor, was used to record uptime. PROCEDURE: Each child in the study wore the uptimer continuously over a 24-hour period, which included a typical day at school, on four separate occasions, one week apart. RESULTS: The variability in repeated measures of uptime in the same child (standard deviation 0.8 hours in 24 hours) was lower than the variability between the children (standard deviation 1.1 hours in 24 hours). We estimate that a single uptime measurement has reliability given by an ICC of 0.65 (95% confidence interval 0.49-0.82), which is calculated by dividing the between-child variability by the total variability (within-child and between-child variability). There were no systematic differences in mean uptime between occasions of measurement. CONCLUSION: As an estimate of the time that a child spends in the upright position, a single 24-hour period of measurement of uptime may vary considerably from one occasion to the next. However, this within-child variability is less than the variability between children. In large-scale field studies a one-off measurement of uptime may be acceptable, but in small rehabilitation studies uptime should be measured on at least three occasions.
Adolescent↗
New distance learning courses from the Raven Department of Education.
The Raven Department of Education is marking the new century by developing two new distance learning courses, both of which will include computer-based learning using the College web site. STEP 2000 will be offered to basic surgical trainees from August 2000 and replaces the MRCS-STEP course for those preparing to take the MRCS examination. The second course is the department's first distance learning offer for higher surgical trainees. Designed for HSTs in general surgery in years 1-3, it provides an introduction to the surgery of breast disease. In the two articles below, the sessional tutors leading these developments outline the main features of the two courses and explain the educational principles behind them.
Education, Distance↗
Epidural ropivacaine for the initiation of labor epidural analgesia: a dose finding study.
UNLABELLED: The purpose of our study was to determine the lowest concentration of ropivacaine that offers pain relief for the initiation of labor epidural analgesia. Women in active labor were enrolled in this prospective, randomized, double-blinded study to receive either ropivacaine 0.20% (Group I), ropivacaine 0.15% (Group II), or ropivacaine 0.10% (Group III). After placement of the epidural catheter, 13 mL of the study medication was administered. Fifteen minutes later, the adequacy of analgesia was assessed. If the woman reported that her degree of analgesia was not adequate, an additional 5 mL of the study medication was given, the degree of pain relief was reassessed 15 min later, and the study was concluded. A sequential study design was used to assess the success rates. We found that 26 of 28 (93%) women in Group I had adequate analgesia, compared with only 18 of 28 (64%) in Group II (P = 0.014) and 4 of 12 (33%) in Group III (P = 0.003). We conclude that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%. IMPLICATIONS: The lowest effective concentration of ropivacaine for the initiation of labor epidural analgesia has not been determined. We found that ropivacaine 0.20% offers adequate analgesia significantly more often than either ropivacaine 0.15% or ropivacaine 0.10%. If one selects ropivacaine as the sole local anesthetic for the initiation of labor epidural analgesia, the minimal concentration should be 0.20%.
Adult↗
EphA4 (Sek1) receptor tyrosine kinase is required for the development of the corticospinal tract.
Members of the Eph family of tyrosine kinase receptors have been implicated in the regulation of developmental processes and, in particular, axon guidance in the developing nervous system. The function of the EphA4 (Sek1) receptor was explored through creation of a null mutant mouse. Mice with a null mutation in the EphA4 gene are viable and fertile but have a gross motor dysfunction, which is evidenced by a loss of coordination of limb movement and a resultant hopping, kangaroo-like gait. Consistent with the observed phenotype, anatomical studies and anterograde tracing experiments reveal major disruptions of the corticospinal tract within the medulla and spinal cord in the null mutant animals. These results demonstrate a critical role for EphA4 in establishing the corticospinal projection.
Animals↗
Maximum voluntary weight-bearing by the affected and unaffected legs in standing following stroke.
OBJECTIVE: To compare stroke patients to control subjects for ability to transfer body weight onto the affected and unaffected leg in standing; to investigate intra-session reliability. DESIGN: Comparative clinical study conducted within a single session. BACKGROUND: There is a paucity of quantitative data about maximum voluntary weight-bearing in patients during rehabilitation following stroke. METHODS: A Kistler force platform was used to quantify maximum amount of body weight transferred to a single limb in the lateral and forward directions during weight-shifting. Twelve control subjects matched by gender and age (median 64 years) were compared to 12 inpatient stroke patients after a median of 37 days post-onset. RESULTS: The median score for control subjects was approximately 95% of body weight to each leg in both directions. In contrast, stroke patients transferred less body weight (P<0.01) to the affected leg (65.5% lateral; 54.9% forward) and also to the unaffected leg (85.0% lateral; 80.1% forward). For the stroke patients, transfer of body weight was more challenging in the forward direction than the lateral direction on the affected leg (P<0.05). Relative to individual differences in the stroke group, error due to the repeated measurement process was low. CONCLUSION: The testing procedure was found to discriminate between stroke patients and control patients and had high retest reliability within a single session.
Journal Article↗
An evaluation of the cell cycle-associated monoclonal antibody Ki-S1 as a prognostic factor in primary invasive adenocarcinoma of the breast.
Immunohistochemical staining with the novel monoclonal antibody Ki-S1, believed to recognize a cell cycle-associated antigen, was investigated in 110 cases of invasive carcinoma of the breast. Immunoreactivity indices were compared with disease-free interval (DFI), overall survival, and a series of other prognostic indicators. Significant positive correlations were found between the percentage of strongly positive immunoreactive nuclei and tumour size, histological grade and type, vascular invasion, and mitotic count. A significant negative correlation was found with age. No significant correlation was found with either DFI or overall survival. Although a correlation with mitotic count does imply that the Ki-S1 antigen is cell cycle-associated to some extent, Ki-S1 does not appear to be a useful prognostic factor in human breast carcinoma.
Adenocarcinoma↗
Metallothionein expression in human breast cancer.
Metallothioneins are ubiquitous low molecular weight proteins characterised by high cysteine content and affinity for binding heavy metals. Abnormal metallothionein function and expression have been implicated in various disease states, including neoplasia. The aim of this study was to investigate metallothionein expression in human breast carcinoma. Sections of routinely fixed and processed blocks of tumour from 100 consecutive cases of primary operable breast carcinoma were stained for metallothionein using a recently developed monoclonal antibody and a standard immunohistochemical technique. Expression was scored on the basis of microscopical assessment of percentage of tumour cells staining. One patient was lost to follow-up and excluded from the study. A significant association (P < 0.0001) was observed between metallothionein expression and tumour type, with low levels being observed in tumours of good prognostic type. There was also a significant association with local recurrence (P < 0.02) and a significant difference (P < 0.02) in both survival and disease-free interval between tumours showing low and high levels of expression, the latter indicating a poor prognosis. No relationship was observed with patient age, tumour size, lymph node stage, histological grade, vascular invasion, menopausal status or oestrogen receptor status. The assessment of metallothionein expression in human breast cancer appears to provide prognostic information and may have important implications for understanding its development.
Breast Neoplasms↗
Mammographic features of invasive lobular and invasive ductal carcinoma of the breast: a comparative analysis.
The mammographic appearances of 86 invasive lobular carcinomas were compared with those of 86 invasive ductal carcinomas of no special type matched for age, size and stage. There was no significant difference in the frequency of a mammographic abnormality consistent with malignancy between the lobular carcinoma (90%) and ductal carcinoma (96%) groups. A spiculate mass was the commonest feature in both groups (69% and 63%, respectively). There were no differences in the imaging features of masses in the two groups. In the lobular carcinoma group any mammographic abnormality was more likely to be seen on only one view and calcifications were less frequently observed. Multiple lesions were more frequent in the ductal carcinoma group. However, although these differences appeared to reach statistical significance, as they were only apparent in a study with a large number of comparisons, it is unlikely that these differences are practically significant. Analysis of the lobular invasive group failed to demonstrate any significant differences in the imaging features of the classical and mixed sub-types, a spiculate mass being the most common single abnormality in both. No mammographic differences of practical use to distinguish invasive lobular from invasive ductal carcinoma of no special type were demonstrated.
Adult↗
Pathological-radiological correlations in benign lesions excised during a breast screening programme.
Benign biopsies are an inevitable part of any screening programme. They add significantly to the psychological and financial 'cost' of screening and so should be kept to a minimum. To identify possible means of reducing these false positive results we have reviewed the mammographic features of 108 benign lesions removed during prevalent round screening and correlations were sought with the pathological findings. The commonest mammographic abnormalities leading to benign biopsy were non-comedo type suspicious calcification (29%), poorly defined mass (21%), architectural distortion (19%) and a well defined mass (18%). The histological correlates were: non-comedo type suspicious calcification (fibrocystic change 60%, sclerosing adenosis 35%, and radial scar/CSL 13%), poorly defined masses (fibrocystic change 37%, fibroadenomas 37%, and sclerosing adenosis 25%) and architectural distortion (radial scar/CSL 61% and fibrocystic change 26%). Methods of reducing screening provoked benign biopsies are discussed.
Breast↗
Pathological prognostic factors in breast cancer. III. Vascular invasion: relationship with recurrence and survival in a large study with long-term follow-up.
The invasion of vascular spaces (lymphatic and/or blood vessel) by tumour, as assessed on routine haematoxylin and eosin sections, was investigated in a consecutive series of 1704 women with primary operable invasive breast carcinoma. Strict morphological criteria were used. Patients were under 70 years of age and received definitive surgery with no adjuvant systemic therapies. Information from regular follow-up (range 3-17 years) was recorded on to a computer database. Definite vascular invasion was seen in 22.8% of cases and concurrence between pathologists was high. In univariate analyses, vascular invasion was strongly associated with lymph node stage (P < 0.0001), tumour size (P < 0.0001), histological grade (P < 0.0001) and type of tumour (P < 0.0001). In multivariate analyses vascular invasion was of independent prognostic significance for both survival and for local recurrence of tumour; patients with tumours showing no vascular invasion had a significant survival advantage and a reduced risk of local recurrence. No association with oestrogen receptor status or menopause status was seen. The results confirm that histological assessment of vascular invasion provides independent prognostic information in primary operable breast carcinoma which may be helpful in making clinical decisions.
Aged↗
Ideas in pathology. Ductal carcinoma in situ of the breast: a proposal for a new simplified histological classification association between cellular proliferation and c-erbB-2 protein expression.
UNLABELLED: The diagnosis of ductal carcinoma in situ of the breast (DCIS) has become common with the advent of breast screening programs. METHODS: Proliferation indices (S-phase fraction) were studied in 76 cases of pure DCIS. Tumors were classified according to conventional criteria and also according to a novel simplified classification based on cellular necrosis and morphology. This new classification defines three distinct tumor groups: pure comedo in 19 (25.0%) cases, DCIS with necrosis (non-pure comedo) in 21 (27.6%) patients, and DCIS without necrosis in 36 (47.4%) of cases, the latter group comprising largely classical cribriform or micropapillary architectural subtypes. RESULTS: Flow cytometric DNA analysis showed a significantly higher S-phase fraction in comedo DCIS than in the subgroup of DCIS tumors without necrosis (P < 0.01 [anova]). A preliminary analysis of disease recurrence and disease-free survival in a large series of 391 cases of pure DCIS showed that of 181 cases of pure comedo DCIS there were 19 local recurrences at the 7-year stage (82% 7-year disease-free survival), with 5 local recurrences in 51 cases of DCIS with necrosis (non-pure comedo) (85% 7-year disease-free survival) and only 6 local recurrences in the 159 cases of the DCIS-without-necrosis subgroup (94% 7-year disease-free survival). The chi 2 value for the frequency of disease recurrence of all cases of DCIS with necrosis (i.e., combining the groups of comedo DCIS and DCIS with necrosis (non-pure comedo)) as compared to DCIS without histological evidence of necrosis was 5705 (df = 2; P = 0.0001), and the chi 2 for disease-free survival of types of DCIS with necrosis as compared to cases without necrosis was 178 (df = 2; P = 0.0001). This analysis indicates that the histological presence of necrosis appears to be a relatively powerful predictor of increased disease recurrence and poorer disease-free survival after treatment for DCIS. CONCLUSIONS: Necrosis in DCIS in the absence of pure classical comedo morphology is a feature of more biologically aggressive in situ breast cancer with an intermediate proliferative fraction as compared with the high proliferative fraction of pure comedo DCIS and the low proliferative fraction of DCIS without necrosis. There was no significant difference in DNA ploidy (diploid or aneuploid) between the subgroups as assessed by chi 2 analysis. Further larger studies are required to establish if DCIS with necrosis (non-pure comedo) also shows a greater tendency to local recurrence after breast conservation treatment than do subtypes of DCIS without necrosis. DCIS with necrosis (non-pure comedo) should be adopted as a distinct histological subgroup of DCIS in future clinical studies of in situ mammary carcinoma.
Biomarkers, Tumor↗
Oestrogen receptor expression in ductal carcinoma in situ of the breast: relationship to flow cytometric analysis of DNA and expression of the c-erbB-2 oncoprotein.
The expression of oestrogen receptor protein (ER) was examined in 151 cases of symptomatic or screening detected pure ductal carcinoma in situ (DCIS) of the breast by immunocytochemical assay (ERICA), in formalin-fixed paraffin-embedded tissue, with the monoclonal antibody H 222 (Abbott). Forty-eight tumours (31.8%) of cases were ER positive. Twenty-seven (17.9%) of cases showed high level ER expression and 21 (13.9%) of cases showed low level ER immunoreactivity. Significant associations of positive tumour ER immunoreactivity and non-comedo architecture chi 2 = 6.76; (d.f. = 1): P < 0.001, small cell size chi 2 = 4.49; (d.f. = 1): P = 0.034, higher S-phase fraction chi 2 = 4.71; (d.f. = 1): P = 0.03 and lack of c-erbB-2 protein overexpression chi 2 = 7.96; (d.f. = 1): P < 0.01 were identified. No significant associations of ER expression and patient age, histological grade of necrosis in DCIS, or DNA ploidy were found. ER expression is detectable in less than one third of symptomatic and screening detected cases of DCIS, implying that endocrine therapy of DCIS may be a more appropriate form of management for morphological subtypes of DCIS which show higher rates of oestrogen receptor expression, particularly those of non-comedo and small cell type.
Adult↗
p53 protein expression in human breast carcinoma: relationship to expression of epidermal growth factor receptor, c-erbB-2 protein overexpression, and oestrogen receptor.
The expression of p53 protein, oestrogen receptor protein, epidermal growth factor receptor (EGFR) and overexpression of the c-erbB-2 oncoprotein was examined in a series of 149 primary symptomatic breast carcinomas. Expression of p53 was present in 62 of 146 cases (42.5%) of the invasive carcinoma and one of three cases (33.3%) of ductal carcinoma in situ (DCIS) examined. Statistical associations of tumour oestrogen receptor positivity and lack of p53 protein expression, chi 2 = 19.78 (d.f. = 1), P less than 0.001, positive tumour p53 status and poor tumour grade; chi 2 = 14.1 (d.f. = 2), P less than 0.001, EGFR expression chi 2 = 7.07, (d.f. = 1), P less than 0.01 and tumour c-erbB-2 protein overexpression; chi 2 = 4.61 (d.f. = 1), P = 0.032 were identified. Expression of p53 is rare in invasive lobular carcinoma of classical type (8.3% of cases examined) in contrast to other common types of mammary carcinoma. Non-significant trends of p53 protein expression and increased regional tumour recurrence; chi 2 = 3.20 (d.f. = 1), P = 0.074 and also poorer patient survival; chi 2 = 3.76 (d.f. = 1), P = 0.053 were identified. p53 protein expression is a common event in human breast cancer and is present in both DCIS and invasive mammary carcinoma. Abnormal expression of p53 protein is a feature of both in situ and invasive breast carcinoma, implying that the abnormal p53 protein expression may be implicated in the early stages of mammary carcinoma progression.
Biomarkers, Tumor↗
Pathological prognostic factors in breast cancer. II. Histological type. Relationship with survival in a large study with long-term follow-up.
The histological tumour type determined by current criteria has been investigated in a consecutive series of 1621 women with primary operable breast carcinoma, presenting between 1973 and 1987. All women underwent definitive surgery with node biopsy and none received adjuvant systemic therapy. Special types, tubular, invasive cribriform and mucinous, with a very favourable prognosis can be identified. A common type of tumour recognized by our group and designated tubular mixed carcinoma is shown to be prognostically distinct from carcinomas of no special type; it has a characteristic histological appearance and is the third most common type in this series. Analysis of subtypes of lobular carcinoma confirms differing prognoses. The classical, tubulo-lobular and lobular mixed types are associated with a better prognosis than carcinomas of no special type; this is not so for the solid variant. Tubulo-lobular carcinoma in particular has an extremely good prognosis similar to tumours included in the 'special type' category above. Neither medullary carcinoma nor atypical medullary carcinoma are found to carry a survival advantage over carcinomas of no special type. The results confirm that histological typing of human breast carcinoma can provide useful prognostic information.
Breast Neoplasms↗
Paraoesophageal hiatal hernias: when to operate.
Between 1979 and 1988, 29 cases of paraoesophageal hernia presented to one surgeon (F.D.S.). There were 23 women and six men and the mean(s.e.m.) age was 66.3(4.1) years. All were symptomatic and 13 hernias (45%) were complicated by gastric volvulus, haemorrhage or perforation. Ten (34%) had evidence of gastro-oesophageal reflux, suggesting a sliding component in these cases. Operation, mostly transthoracic, consisted of hernial reduction, crural repair and, if indicated, an antireflux procedure. There were three deaths. Two occurred as a result of spontaneous, intrathoracic perforation of the hernia. The third followed dilatation of a benign stricture 2 months after surgery. The only major complication was a pulmonary embolus with full recovery. The mean(s.e.m.) follow-up time was 47.6(7.8) months and there were no recurrences. This series confirms that symptomatic paraoesophageal hernias warrant early repair because of the frequency and severity of associated complications. Although debate continues as to whether this policy should be extended to asymptomatic paraoesophageal hernias, we suggest that this should be so.
Adult↗