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Subtotal cholecystectomy is occasionally the management of choice in the patient with a hostile Calot's triangle but when it is not considered safe to close the cystic duct this often leads to a biliary fistula. In order to reduce this morbidity a novel strategy to seal the cystic duct with cyanoacrylate glue was introduced. The outcome of the two strategies have been compared.Patients who had a laparoscopic subtotal cholecystectomy where the cystic duct was left open, the Unsecured group, were compared with those where the duct orifice was occluded with cyanoacrylate glue, the Glued group. The outcome of the two strategies have been compared by duration of biliary drainage, whether a leak was shown on ERCP, time to removal of the drain, length of hospital stay, the re-operation and readmission rates.In 78 cases of laparoscopic subtotal cholecystectomy it was considered unsafe to close the cystic duct. 36 patients were managed without closure of the cystic duct, the Unsecured group and bile drainage continued for more than 3 days in 9 cases (25%) compared with 3 of 42 cases (7%) treated with glue, the Glued group (NS). Postoperative ERCP demonstrated a leak more frequently in the Unsecured group (The results suggest that glue may be a safe option to occlude the cystic duct orifice and reduce hospital stay when this cannot safely be closed at subtotal cholecystectomy.

Background: Several outcome measures have been identified for colorectal surgery and published in the literature. This study sought to compare outcomes of high volume laparoscopic colectomy by a single surgeon in a district hospital with outcomes from tertiary referral centres. Methods: This was a retrospective review of elective laparoscopic colectomy by a single laparoscopic general surgeon in a district hospital over a 51-month period using a prospectively maintained database. The key outcome measures studied were length of hospital stay, conversion to open, anastomotic leak, wound infection, re-admission and 30-day mortality. Results: 187 elective laparoscopic colectomies were performed at the Kent and Canterbury Hospital between July 2008 and October 2012. The median patient age was 69 years (range 22–90 years). Median length of hospital stay was 4 days (range 1–48 days). Anastomotic leak occurred in 4 (2.1%) patients. Seven (3.7%) patients underwent conversion to open surgery. Re-admission occurred in 4 (2.1%) patients for small bowel obstruction (1), wound infection (1), anastomotic leak (1) and colo-vaginal fistula (1). There was one post-operative death from severe chest infection (0.5%). These results are similar to those published by tertiary referral centres. Conclusions: This study of outcomes at a district hospital shows that the outcome reported from laparoscopic colorectal surgery in tertiary referral centres is reproducible at the district hospital level by a single surgeon with a high operative volume.

On the basis of psychological research, a group of philosophers known as 'situationists' argue that the evidence belies the existence of broad and stable (or 'global') character traits. They argue that this condemns as psychologically unrealistic those traditions in moral theory in which global virtues are upheld as ideals. After a survey of the debate to date, this article argues that the thesis of situationism is ill-supported by the available evidence. Situationists overlook the explanatory potential of a large class of global character traits, namely, vices that do not involve other-directed malevolence, such as laziness, cowardice, and selfishness. A detailed discussion of the relevant empirical studies bearing on moral psychology shows that the behavioral patterns observed in these studies are consistent with the widespread possession of such non-malicious vices. This means, contrary to the situationist thesis, that the empirical record is fully compatible with the common existence of global character traits.

Background\ud Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease.\ud \ud Methods\ud 37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size.\ud \ud Results\ud The proportion of women not having surgery increased from 7–10% at ages 35–69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ?1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70–79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0–39, the deprived and certain ethnic groups (p < 0.02).\ud \ud Conclusions\ud From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.

In this paper, we argue that the so-called Knobe-Effect constitutes an error. There is now a wealth of data confirming that people are highly prone to what has also come to be known as the ‘side-effect effect’. That is, when attributing psychological states—such as intentionality, foreknowledge, and desiring—as well as other agential features—such as causal control—people typically do so to a greater extent when the action under consideration is evaluated negatively. There are a plethora of models attempting to account for this effect. We hold that the central question of interest is whether the effect represents a competence or an error in judgment. We offer a systematic argument for the claim that the burden of proof regarding this question is on the competence theorist. We sketch an account, based on the notion of the reactive attitudes, that can accommodate both the idea that these sorts of judgments are fundamentally normative and that they often constitute errors.

Breast cancer is progressively diagnosed with increasing age. This study aimed to determine whether women who started using the oral contraceptive pill (OCP) at an early age developed breast cancer earlier than women who started using the OCP later in life. A database review of 1,010 breast cancer patients, who had used the OCP at some point in their life, was carried out. Associations of age at OCP start with age at breast cancer diagnosis were determined by multiple linear regression analysis, considering year of birth, year of diagnosis, age at first pregnancy, number of live births, age at menarche, and length of OCP use. There was evidence of a linear trend between age at OCP start and age at breast cancer diagnosis. Women who started using the OCP aged 18 years or younger were, on average, 4 years younger at breast cancer diagnosis than women who started using the OCP over the age of 30 years, and women who started using the OCP aged 22-25 years were, on average, 3 years younger (p-value for trend

Aim It has been recommended that patients with suspected colorectal cancer should proceed straight to an endoscopic test to increase speed of diagnosis, using only the information in the general practitioner’s referral letter. This study aims to establish whether the diagnostic accuracy of the first surgical outpatient assessment is significantly greater than the general practitioner’s assessment and if so by what means. Method Demographic variables, symptoms and signs were collected from the first surgical outpatient assessment letters and the general practitioners’ referral letters in 2-week-wait colorectal cancer referrals made between 2002 and 2005. Multiple logistic regression models derived from both the surgeons’ and the general practitioners’ letters were compared with receiver operator characteristic curves. Results Variables were collected from 978 2-week-wait colorectal cancer referrals. The median age was 69 years (range 19–98) and the male to female ratio was 1:2. Seventy-eight referrals were diagnosed with colorectal cancer. Surgeons’ models demonstrated significantly greater diagnostic accuracy than general practitioners’ models (area under the curve, 0.84 vs 0.73; P

The purpose of this study was to examine a\ud previous increase in male gallstone disease and to consider\ud the burden of gallstones in a necropsy study with matched\ud controls over a decade. Gallstone prevalence in 5,050\ud males fell from 20.2% to 19.1% (P = 0.022) and in 4,125\ud females fell from 30.4% to 29.0% (P = 0.03). Female\ud gallstone subjects had a higher BMI than controls 24.5 vs.\ud 23.3 (P\0.01), but males did not. Gallstones were twice\ud as common in diabetics, but not with coronary heart disease\ud (CHD). A third of elderly patients of both sexes had\ud gallstones, but cholecystectomy was more common in\ud females, 17:10%. Gallstone-related mortality was 0.7%.\ud The prevalence of gallstones fell slightly. The association\ud between gallstones and diabetes was confirmed, but not for\ud CHD, and for BMI this was confined to females. Gallstones\ud are very common in the elderly, but most are unoperated\ud and seldom cause death.

Background: The management of esophageal carcinoma is changing but before the introduction of\ud chemotherapy and multidisciplinary teams, surgery became more selective. The aim of this study was to confirm this\ud trend and to examine survival in a total population cohort 1985-94.\ud Results: Only a quarter of 413 patients had surgery but from 1989 even fewer were operated on but there were more longterm\ud survivors: 1/51 v. 7/58 (p

Aims Iron-deficiency anaemia (IDA) is a recognized complication of colorectal cancer (CRC) especially with right-sided tumours, and failure to investigate the anaemia in older patients may lead to a delay in diagnosis. The aims of this study were to establish the proportion of patients with CRC shown to have an IDA for more than six months before diagnosis and to establish the proportion of patients with IDA who subsequently prove to have CRC. Methods All patients presenting with confirmed CRC in a health district (catchment population 280000) in the 4 years 1996–9 were identified from the pathology database after ethical approval. The criteria for IDA were haemoglobin (Hb)

There is some evidence that more radical treatment of the axilla may improve survival in node-positive disease, but there are concerns about the resultant morbidity from axillary surgery and radiotherapy. The aim of this study was to compare the outcome of axillary node clearance with axillary sampling in similar patients by comparing loco-regional recurrence and overall survival. Patients with invasive breast cancer undergoing axillary surgery between 1986 and 1997 were included. The axillary procedure performed in these patients was either an axillary sample or a level III axillary clearance. To compare like with, the patients were separated into good, moderate and poor prognostic groups by the Nottingham Prognostic Index (NPI) and overall survival was compared by a Kaplan–Meier life table analysis and the log rank test. 734 consecutive patients with operable invasive breast cancer were treated by axillary clearance n =350 or sampling n =384. The mean follow-up in the clearance group was 65 months versus 66 months in the sampled group. Local recurrence in the clearance group was 11% versus 6% in the sampled group, regional recurrence 2% versus 3% and distant metastasis 28% versus 13%. Kaplan–Meier analysis of the three prognostic groups for the clearance versus sampled groups showed no differences in the absolute survival (log rank: P =0.3, P =0.8 and P =0.6 for the good, moderate and poor prognostic groups, respectively). A conservative surgical approach to the axilla did not significantly increase the incidence of local or regional recurrence and the expected survival benefit from a radical axillary clearance was not apparent.

There is uncertainty in the literature as to whether bilateral breast cancer carries a worse prognosis than unilateral disease because some studies suggest that the development of a second primary does not influence survival, while others report a decreased survival in patients suffering from bilateral disease.A prospectively accrued and regularly validated database of 1945 patients with breast cancer treated in a district general hospital between 1963 and 1999 was analysed for clinical and pathological tumour characteristics including family history, grade, type of tumour, treatment and outcome.Five per cent of patients (92) suffered from metachronous and 43 (2%) from synchronous bilateral breast cancer. A family history of breast cancer was more common in patients with metachronous bilateral breast cancer (38%), compared with the unilateral group (15%) and the synchronous bilateral breast cancer group (17%) (chi(2)=22.9, P0.001). Patients with synchronous bilateral breast cancer had a significantly worse overall survival when compared with those with metachronous bilateral or unilateral breast cancer (log-rank test chi(2)=6.1, P=0.047).Women with metachronous breast cancer were more likely to have positive family history, while those with synchronous bilateral breast cancer tend to have shorter survival when compared with those with unilateral breast cancer. Synchronous bilaterality is not, however, an independent risk factor on multivariate analysis.

Background Pneumothorax is a rare but recognized complication of diagnostic needle aspiration of the breast. Two recent court cases alleging negligence have reached opposing opinions on very similar findings. Methods A Medline literature search was carried out. Results The reported incidence of pneumothorax after diagnostic aspiration of the breast in seven series varied between three in 100 and one in 10 000, but the weight of evidence tended towards the latter rate. Two studies reported that the complication is more common in the hands of trainees. It is not always possible to maintain the aspirating needle parallel or tangential to the chest wall. Pleural puncture may be more common than is apparent, and is most common in the tail of the breast in a thin woman. Conclusion It is important that breast clinicians are aware of the risk of pneumothorax but, provided proper care has been taken, this complication is not the result of a negligent act.

Background There is evidence that delay in the diagnosis of breast cancer may prejudice survival. The aim of this study was to determine the incidence, time trends and causes of delay in a dedicated breast clinic. Methods The interval between first breast clinic visit and a definitive diagnosis was recorded in all patients with invasive breast cancer between 1988 and 1997. In all patients with a delay of 3 months or more, the case notes were reviewed for evidence of a triple assessment (clinical examination, imaging and needle biopsy). The principal cause of delay was identified. Results Of 1004 patients with invasive breast cancer, there was a delay in diagnosis of 3 months or more in 42 patients between 1988 and 1997, an incidence of 4·2 per cent. The median delay was 6 months and the median age at diagnosis was 53 (range 27–89) years. Triple assessment was undertaken in 30 patients; ten did not have a needle biopsy performed and three patients had no mammography. The principal cause of delay was: false-negative or inadequate fine-needle aspiration cytology (FNAC) in 19 patients, failure of follow-up in eight, clinical signs did not impress in five, FNAC not carried out in four, false-negative mammogram in three, failure of needle localization in two and one patient did not accept clinical advice. The annual incidence of delay in diagnosis did not change significantly over the 10-year interval. Conclusion Triple assessment is not sufficiently sensitive to detect every breast cancer and a small incidence of diagnostic delay is therefore inevitable with current techniques.

There is a consensus that open-access breast imaging for general practitioners is inappropriate since the process omits an expert clinical examination and fine needle aspiration cytology. However, it was decided to test this hypothesis by comparing the outcome of breast referrals in a district with both an open-access imaging and a one-stop clinic. The time from referral to definitive diagnosis in all women with breast cancer was compared over a 12 month period in 1996. Of 1049 women referred for open-access imaging 20 (2%) were found to have breast cancer compared with 91 (9%) of 995 women referred to the one-stop breast clinic. There was a longer interval before the diagnosis of breast cancer was made in cases referred for open-access imaging compared with cases referred to the one-stop breast clinic (mean 63 vs 35 days). However, if patients with advanced disease are excluded the mean interval was 63 vs 44 days. The mean tumour size of breast cancers in cases referred to open-access imaging was smaller (1.5 vs 2.3 cm), there were fewer grade 3 tumours (10% vs 39%), and there was a lower rate of axillary lymph node metastases (20% vs 32%) compared with cases referred to the one-stop breast clinic. The longer interval for the open-access patients was largely due to administrative delay and the 3 patients with a delay of more than 3 months had all had a triple assessment which was false negative. This study does not support the hypothesis that open-access mammography is unsafe and should be withdrawn.

OBJECTIVE: To examine the variation in surgical and adjuvant treatment of breast cancer of known histology and detected on screening in a large cohort of patients treated by the surgeons of a health region. DESIGN: Part prospective, part retrospective observational study using the databases of a region's breast screening programme and of the cancer registry. SETTING: The former South East Thames region. SUBJECTS: 600 women aged 49-79 who presented during 1991-2 with invasive breast cancer up to 20 mm in diameter that had been detected on screening. These patients were treated by 35 surgeons. MAIN OUTCOME MEASURES: Mastectomy rate by surgeon and the use of adjuvant treatment (radiotherapy, tamoxifen, and chemotherapy) were compared with risk factors, tumour grade, resection margins, and axillary node status. RESULTS: The mastectomy rate varied between nil and 80%, although the numbers at these extremes were small (0/13 v 8/10). Surgeons operating on more than 20 such cases had a lower mastectomy rate (15%) than surgeons treating fewer cases (23%), but this difference was confounded by variation in casemix. There were also wide variations in mastectomy rates and in axillary sampling rates that were independent of casemix or caseload. There was broad agreement on the use of adjuvant tamoxifen (94%), but few patients received chemotherapy (2.5%). 78 patients (19%) did not receive radiotherapy, including 51 out of 317 patients with unfavourable tumours, and 26 patients did not receive tamoxifen. Whether the patient received adjuvant treatment was more dependent on referral by the surgeon than the risk factors for local recurrence and was independent of caseload. CONCLUSION: Mastectomy rates for similar tumours vary widely by surgeon independently of casemix or caseload, but surgeons with a higher caseload tend to have a lower mastectomy rate. Omission of postoperative radiotherapy or tamoxifen after conservative treatment is not related to risk factors for local recurrence or caseload. Confidential feedback of treatment profiles to individual surgeons has been used, but when benefit has been established treatment should be guided by evidence based protocol.

The management of breast disease is becoming a recognized sub-speciality of general surgery. This paper describes the results of a survey undertaken in order to identify consultant general surgeons who would be willing to act as trainers of surgeons who may wish to declare an interest in breast disease. The survey has also given an insight into the workload of surgeons who are involved in the management of both symptomatic and screen-detected breast disease. The questionnaire was sent to all surgeons in England and Wales and to selected surgeons in Scotland and Northern Ireland. The response rate was 51%. The mean number of new cases of breast cancer seen per year by each surgeon was 66 with a range of 2–400. Half the surgeons were involved in the National Breast Screening Programme. The mean number of screening cases referred for biopsy per year was 46 for those involved in the screening programme. Approximately half of the surgeons who undertake breast work spend less than 20% of their time in the subject. The majority (97%) also take emergency admissions in general surgery. Twenty-five per cent carry out breast reconstructions themselves. The breast screening programme has not resulted in an excessive workload but this study has failed to show that the management of breast cancer is in the hands of those with a special interest in the subject.

Background: There may be an increased risk of colorectal cancer after cholecystectomy, but the literature is not consistent. It is also possible that any risk might be associated with gallstones rather than cholecystectomy. Methods: In a prospective necropsy study of 8563 cases, all 219 cases of a previous cholecystectomy were pair-matched to subjects with gallstones and to subjects with a normal gallbladder. In a second study all 192 cases of colorectal cancers were pair-matched to cancer-free subjects. Results: The odds ratio (OR) for developing colorectal cancer after cholecystectomy compared with a normal gallbladder was 1.0 (95% confidence interval, 0.30-3.34) and with unoperated gallstones was 0.88 (0.27-2.76). Conclusions: This study fails to support an association between cholecystectomy or gallstones and colorectal cancer. For those cases of colorectal cancer versus controls, the OR for previous cholecystectomy was 0.70 (0.23-2.04) and for gallstone disease was 0.93 (0.58-1.48).

Background The best management of large, diffuse or inflammatory breast cancers is uncertain and the place of radiotherapy and/or surgery is not clearly defined. Methods A cohort of 123 patients with non-metastatic locally advanced or inflammatory breast cancer 3cm or more in diameter or T4, was treated between 1989 and 2006. All patients received primary chemotherapy followed by radiotherapy, 40Gy in 15 fractions with 10Gy boost. Patients with ER positive tumours received Tamoxifen. Assessment was carried out 8 weeks post-treatment and surgery was reserved for residual or recurrent disease. Results For each stage there were T2/3: 63, T4b: 31 and T4d: 29 patients. 80 had complete clinical response (65%) but 18 patients were never free of inoperable local disease. 25 patients had residual operable disease at assessment and 12 patients who initially had a complete response developed operable local recurrence (LR). 37 Patients (30%) had surgery at a mean of 15 months post diagnosis. At 5 years, overall survival (OS) of the two surgical groups was not significantly different from those 68 patients who had complete remission without surgery, p =0.218, HR 1.46 (0.80–2.55). Surgery as an independent variable to predict survival was not significant on a Cox proportional hazards model ( p =0.97). LR in the surgical groups was 13.5% vs 17.5% in the non-surgical patients. The median OS was 64.5 months and disease-free survival (DFS) was 52.5 months. 5-Year OS was 54% and DFS survival 43%. Conclusion In patients with a complete or partial response to chemo-radiotherapy for locally advanced or inflammatory breast cancer, reserving surgery for those with residual or recurrent local disease did not appear to compromise survival. This finding would support examination of this treatment strategy by a randomised controlled trial.

The incidence of local recurrence (LR) after conservative surgery for early breast cancer without adjuvant therapy is unacceptably high even with favourable tumours. The aim of this study was to examine the effect of adjuvant therapies in tumours with excellent prognostic features.Patients with primary invasive breast cancer2 cm diameter, grade 1 or good prognosis special type, and node negative, treated by wide local excision (WLE) with clear margins were randomised into a 2 × 2 clinical trial of factorial design with or without radiotherapy and with or without tamoxifen. Trial entry was allowed to either comparison or both.The actuarial breast cancer specific survival in 1135 randomised patients at 10 years was 96%. Analysis by intention to treat showed that LR after WLE was reduced in patients randomised to radiotherapy (RT) (HR 0.37, CI 0.22-0.61 p0.001) and to tamoxifen (HR 0.33, CI 0.15 - 0.70 p0.004). Actuarial analysis of patients entered into the four-way randomisation showed that LR after WLE alone was 1.9% per annum (PA) versus 0.7% with RT alone and 0.8% with tamoxifen alone. No patient randomised to both adjuvant treatments developed LR. Analysis by treatment received showed LR at 2.2%PA for surgery alone versus 0.8% for either adjuvant radiotherapy or tamoxifen and 0.2% for both treatments.Even in these patients with tumours of excellent prognosis, LR after conservative surgery without adjuvant therapy was still very high. This was reduced to a similar extent by either radiotherapy or tamoxifen but to a greater extent by the receipt of both treatments.

The Qualitator is a daily diary card to measure Quality of Life, developed for use in chemotherapy trials for patients with advanced breast cancer. In a trial at King's College Hospital, 29 patients completed the Qualitator and their scores were compared with scores in the Linear Analogue Self-Assessment and Nottingham Health Profile taken four-weekly. In a separate study at Guy's Hospital, 31 patients completed the diary. The Qualitator offers accurate prognostic data regarding subsequent UICC response and survival and is simple to use.

The prognostic value of Body Mass Index (BMI) on breast cancer outcome is controversial and previous studies from this unit have not shown any significant relation to survival. The aim of this study was to re-examine any impact of a raised BMI on recurrence and survival related to age and disease stage at the time of diagnosis. Breast cancer patients (2,298) were reviewed and divided in groups by BMI. Recurrence Free Survival (RFS), Breast Cancer Specific Survival (BCSS), and Overall Survival (OS) were compared by Kaplan-Meier life table analysis. Known prognostic factors including BMI were tested for independent prognostic significance in a Cox's regression model. Obese patients (417) had on average larger tumors (median 2.3 versus 2.1 cm, p < 0.01). A trend to an increased positive node status (37% versus 33%) was not significant, p = 0.18. Seven-year RFS was 82% versus 77% in the obese, p < 0.01, BCSS was 87% versus 85%, p = 0.046 and OS 81% versus 77%, p = 0.02. BMI was independently associated with RFS in multivariate analysis (HR: 1.43, p < 0.01). In subgroup analysis, survival differences were most prominent in patients with node positive disease and in patients

Summary In a randomized prospective trial of prophylactic antibiotics in at-risk abdominal surgery, one dose of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. Wound infection rates which included minor and delayed infections were very similar in those given one dose: 48/449 (10.7%) compared with those given three doses: 49/451 (10.9%) 95% confidence limits - 4.25% + 3.9%. There were more septic and sepsis-related deaths in those patients given one dose (14 deaths) than in those given three doses (7 deaths) P > 0.1 95% CL - 0.4% + 3.0%. However, there were more very elderly patients in the one dose group: 64% of the deaths were aged over 80 and all but one had an emergency operation. There was no difference in the other outcome measures studied which included non-fatal deep sepsis, length of postoperative hospital stay, duration of postoperative fever or the use of antibiotics for postoperative infection. One dose of a suitable intravenous antibiotic gives prophylaxis against wound infection in at-risk abdominal surgery which is at least as effective as multiple doses. However, there may be a risk of overwhelming systemic sepsis in very elderly patients having emergency surgery.

Abdominal wound infection rates were significantly related to obesity, as measured by Body Mass Index, in two large clinical trials of prophylactic antibiotics in at-risk abdominal surgery. Obesity is a risk factor that should be taken into account in any study in which wound infection is an outcome measure.

A prospective study of the prevalence of gall stone disease at necropsy in a stable population has been undertaken over a 10 year period up to June 1988. In women, the prevalence of gall stone disease remained static but in men aged 50-59 years it rose from 7% (n = 148) in the first three years to 18% (n = 138) in the last three years (p less than 0.01) and in men aged 60-69 it rose from 12% (n = 370) to 20% (n = 366, p less than 0.01). In the latter age group the female: male ratio fell from 2:1 to 0.8:1. The proportion of deaths from coronary heart disease in men fell slightly in those over 70 during the study period. There was a fall in deaths from coronary heart disease in all age groups in women. Men with gall stones were less likely to have had a cholecystectomy than women, and overall 88% of gall stones remained in situ. In a parallel clinical study, the number of cholecystectomies carried out in the same district fell by 18% over the 10 years without any apparent change in the provision of resources. Cholecystectomy remained almost three times more frequent in women. National data indicate that there have been major changes in the average diet before and during the period of study in favour of reducing coronary heart disease. There has been no change in mortality from coronary heart disease in young men but if the observed increase in the prevalence of gall stones in men and the decrease in deaths from coronary heart disease in women are real phenomena, it seems likely that they are diet related.

BACKGROUND: Data collection for screen-detected breast cancer in the United Kingdom is fully funded, which has led to improvements in clinical practice. However, data on symptomatic cancer are deficient, and the aim of this project was to monitor the current practice. METHODS: A data set was designed together with surrogate outcome measures to reflect best practice. Data from cancer registries initially required the consent of clinicians, but in the third year anonymised data were available. RESULTS: The quality of data improved, but this varied by region and only a third of the cases were validated by clinicians. Regional variations in mastectomy rates were identified, and one-third of patients who underwent conservative surgery for the treatment invasive breast cancer were not recorded as receiving radiotherapy. CONCLUSION: National data are essential to ensure that all patients receive appropriate treatment for breast cancer, but variations still exist in the United Kingdom and further improvement in data capture is required.

Background: There has been an increase in the use and effectiveness of adjuvant treatment for operable breast cancer and the aim of this\ud study was to examine whether this has resulted in improved survival for all prognostic groups.\ud Methods: A retrospective study of 1517 patients with invasive breast cancer treated between 1980 and 2002 was carried out. The use of\ud adjuvant treatment was compared between two time periods in patients based on nodal status, and survival was calculated by Kaplane\ud Meier life table analysis. Independent predictors for recurrence-free survival (RFS) were determined by Cox regression analysis.\ud Results: The use of adjuvant therapy increased for all prognostic groups. On multivariate analysis the use of radiotherapy and endocrine\ud therapy was positively associated with RFS which was significant in the second time period. Outcome in node positive patients improved:\ud five-year RFS from 59% to 76%, p < 0.01 and breast cancer specific survival (BCSS) from 70% to 83%, p < 0.01. However, there was no\ud survival improvement in the larger group of node negative patients; BCSS 93% versus 95%, p ¼ 0.99. Within the node negative group,\ud patients with tumours ? 2 cm had an improved RFS from 80% to 88%, p ¼ 0.02.\ud Conclusion: The increased use of adjuvant therapy was associated with an improved outcome in node positive patients. For node negative\ud patients with good prognostic features the evidence of benefit was marginal.

Background The role of cavity biopsy (CB) at the time of wide local excision (WLE) for primary breast cancer has not been evaluated fully. This study compared four groups of patients to determine the significance of margins and CB histology on tumour characteristics and outcome. Methods This was a retrospective study of patients undergoing WLE and CB in one institution over 21 years. Demographic data, tumour characteristics and survival information were obtained. Four subgroups of patients were compared according to their margin and cavity status (positive or negative). Results A total of 957 patients had WLE. The median 10-year survival was 85·6 per cent and breast cancer-specific survival was 92·4 per cent. Tumour size, grade, node and oestrogen receptor status were independent predictors of survival. There was poor concordance between positivity of resection margins and CB (32·0 per cent); a negative margin carried a 10·8 per cent risk of demonstrable residual disease. A positive CB, but not a positive margin, was associated with reduced overall survival and breast cancer-specific survival. Conclusion Cavity status was more significant with regard to survival than margin status. CB is important in identifying residual and multifocal disease, as margin and cavity positivity are often not concordant.

Hormone replacement therapy (HRT)-related breast cancer may carry a better prognosis since there is no increase in breast cancer deaths. We looked at the prognostic risk factors and outcome inpatients who had ever taken HRT compared to those who had not, in a case control study. Subgroups of recent-users and those using HRT for >5 years were also compared to controls. Tumor size, grade, vascular invasion, lymph node, and estrogen receptor status as well as median Nottingham Prognostic Indicator (NPI) were compared between cases and controls. Absolute survival between ever-users and never-users was compared by life table analysis. There was no difference between all the cases and their controls for the five prognostic factors. NPI in each group was also similar. Absolute survival between ever-users and never-users was not significantly different either (p = 0.678). There was no evidence that HRT-related breast cancer has a more favorable outcome.

Background The decision on whether to operate on a sick elderly person with an intra-abdominal emergency is one of the most difficult in general surgery. A predictive risk-score would be of great value in this situation. Methods A Medline search was performed to identify those predictive risk-scores relevant to sick elderly patients in whom emergency surgery might be life-saving. Results Many of the risk scores for surgical patients include the operative findings or require tests which are not available in the acute situation. Most of the relevant studies include younger patients and elective surgery. The Glasgow Aneurysm Score and Hardman Index are specific to ruptured aortic aneurysm while the Boey Score and the Hacetteppe Score are specific to perforated peptic ulcer. The Reiss Index and Fitness Score can be used pre-operatively if the elements of the score can be completed in time. The ASA score, which includes a significant element of subjective clinical judgement, can be augmented with factors such as age and urgency of surgery but no test has a negative predictive value sufficient to recommend against surgical intervention without clinical input. Conclusion Risk scores may be helpful in sick elderly patients needing emergency abdominal surgery but an experienced clinical opinion is still essential.

Aim\ud To investigate differences in the 3-year survival of patients with recurrent breast cancer dependent on recurrence site.\ud \ud Methods\ud The study was a review of 294 patients from a breast cancer database, who were treated for operable breast cancer and subsequently developed a recurrence between 1989 and 2003. Patients were divided into four groups according to the site of first recurrence (local, lymph node, bone or visceral). Breast Cancer Specific Survival (BCSS) was compared using Kaplan–Meier life table analysis and the log rank test.\ud \ud Results\ud Patient and tumour characteristics were comparable between the four groups. Survival rates between the recurrence site groups were significantly different. Patients in whom first recurrence was local had the best prognosis with a 3-year BCSS of 83% compared to 33% for patients with first node recurrence (p < 0.001), 23% for patients with first bone recurrence (p = 0.03) and 13% for patients with first visceral recurrence (p = 0.004).\ud \ud Conclusion\ud Survival of patients with recurrent breast cancer is associated with the site of first recurrence. The prognosis from recurrence is progressively worse with local, regional, bone and visceral metastasis.

The introduction of time-limited surgical training in the UK in 1994 following the Calman report raised concerns over the hands-on experience of trainees, heightened by the hours reduction demanded by the New Deal. From 1994, junior doctors' on-duty hours of work for hard-pressed posts were targeted to a limit of 56 hours but SpRs were allowed a voluntary extension from 73 on-duty hours to a maximum of 83 hours per week. By 1995 concern was being expressed at the reduction in training time and continuity of patient care and although calls for more targeted training were made, evidence of a negative impact on training has continued to surface.

The Breast Cancer Clinical Outcome Measures (BCCOM) Project aims to audit the clinical management of symptomatic breast cancers in the United Kingdom. The information needed for the audit is obtained by tapping into existing sources such as the data currently collected by cancer registries and individual clinicians. In collaboration with the UK cancer registries and 191 breast surgeons registered with the UK Association of Breast Surgery at BASO, data for a total of 16,407 breast cancers diagnosed in 2002 were collected. In the data for year 1 of the BCCOM Project, the proportion of patients not receiving surgery increased from 6% in those aged 50–64 to 41% in those aged 80 and above. Overall, 48% of the surgically treated cases received a mastectomy, but mastectomy rates varied between surgeons from 19% to 92%. The proportion of patients treated with radiotherapy and chemotherapy fell sharply with age, while the proportion treated with hormone therapy increased with age. The proportion of cancers with known nodal status decreased from 68% in patients aged 50–64 to 30% in those aged 80 and above. Nodal positivity varied between 12% for small cancers (diameter 50 mm). Year 2 of the BCCOM Project, which will examine clinical outcomes for symptomatic breast cancers diagnosed in 2003, was launched in January 2006.

A prospective study of all out‐of‐hours operations performed in a district general hospital was undertaken over two periods. During the first period (1 month) facilities for emergency operating were reviewed and it was concluded that out‐of‐hours operating should be reduced and several tactics to improve the situation were agreed. A re‐audit was undertaken over 4 months (second period) and results of the two periods compared. Orthopaedic cases performed out‐of‐hours in both periods of study were 38% vs 40%. Mean theatre delay for general surgical cases in both periods was 5 h 30 min vs 5 h 21 min and theatre usage after midnight during weekdays showed no significant difference (23% vs 28%). 50% of operations performed after midnight in both periods could possibly have been avoided. The attempt to reduce out‐of‐hours operating failed because there was no protocol. In order to reduce inappropriate operating after midnight, a dedicated daytime emergency theatre is necessary in addition to an increase in the number of daytime orthopaedic trauma lists. Failure to close the audit cycle loop suggests that a more determined effort is required to reduce unsupervised emergency surgery and unnecessary sleep deprivation.

We have produced antibodies to the NRG2-alpha, NRG2-beta, NRG3 and NRG4 proteins and used these, and previously described antibodies to NRG1-alpha and NRG1-beta, to detect expression of each ligand by immunocytochemical staining in a series of 45 breast cancers. Each protein was expressed in a proportion of cases. Statistical analysis suggested that expression of one factor was associated with a high probability that other members of the family were co-expressed. NRG2-alpha expression was associated with node positivity (p-value = 0.005). The mRNAs for NRG1, 2, 3 and 4 were found in established breast cancer cell lines and NRG1, 2 and 3 mRNAs were detected in primary breast cancers. Expression of NRG4 mRNA was shown by in situ hybridization in sections from primary breast cancers. This data demonstrates that each member of the NRG family of ligands is expressed in breast cancer and suggests that they may be involved in regulating cell behaviour.

Delay in the diagnosis of breast cancer is an important cause of medical malpractice claims which if trends continue, will threaten healthcare budgets. Most malpractice claims are made by younger women. Delay is most frequently due to the physician failing to be impressed with the clinical findings, or to a false negative mammogram report. Diagnosis of breast cancer is more difficult in younger women, because of the poor sensitivity of diagnostic tests and the high prevalence of benign disease in this age group. Models of tumour growth suggest that the potential to metastasize may be present before the tumour is clinically detectable and that if the growth rate of a given tumour is constant, any clinical delay is a small proportion of the lifespan of the tumour. Patient delay is generally associated with more advanced lesions at presentation, but the effect of delay on survival or what period of delay is significant remains uncertain. Delay in the diagnosis of breast cancer is likely to cause the patient considerable anxiety, especially when the public understands that the aim of mammographic screening is to diagnose breast cancer at an early stage in order to effect a cure. For a plaintiff to successfully claim in court she must prove that she has suffered an injury, and that the injury was the result of negligent medical practice. It is easier to defend a case of delay in diagnosis if the documentation is in order and all the appropriate tests have been performed.

Summary A woman’s build, the risk of breast cancer and its subsequent prognosis\ud seem to be related. In most but not all case–control and prospective cohort studies,\ud an inverse relationship has been found between weight and breast cancer among\ud premenopausal women. However, most large epidemiological studies have found\ud that overweight or obese women are at increased risk of developing postmenopausal\ud breast cancer. It is suggested that higher body mass index is associated with a more\ud advanced stage of breast cancer at diagnosis in terms of tumour size but data on\ud lymph node status is not so consistent. All treatment modalities for breast cancer\ud such as surgery, radiotherapy, chemotherapy and hormonal treatment may be\ud adversely affected by the presence of obesity. The overall and disease-free survival\ud is worse in most but not all studies of prognosis of obese pre- and postmenopausal wmen with breast cancer.

Summary Obesity, measured by high body mass index (BMI430 kg/m2) is associated\ud with an increased risk of postmenopausal breast cancer but the effect of obesity\ud on prognosis is not clear. A prospectively accrued and regularly validated database\ud of 1579 patients with breast cancer treated in a district general hospital between\ud 1963 and 1999 was analysed for clinical and pathological tumour characteristics\ud including the family history, grade, tumour type, treatment and outcome. The\ud risk factors and outcome of obese and non-obese patients were compared.\ud Breast cancer in obese women was associated with significantly larger tumour\ud size and worse Nottingham prognostic index. There was no statistically\ud significant difference in overall and disease-free survival between obese and nonobese\ud group. Hazard ratios (95% Cl) were 0.81 (0.62–1.06) and 0.80 (0.63–1.01),\ud respectively. In the present study, obesity is not an indicator of worst prognosis of breast cancer.

Aim The routine tumour grading of invasive ductal carcinoma of the breast has been shown to be a robust determinant of outcome but pathologists have been reluctant to grade lobular cancers. The aim of this study was to determine the prognostic significance of the routine reporting of lobular grade. Methods All patients with invasive lobular carcinoma (ILC) treated between 1981 and 1996 were reviewed. Patients with ILC which had been graded were included in the study. These cases were matched with two control patients with invasive ductal carcinoma (IDC) who were operated on in the same year and were closest to the patients in age. Recurrence-free survival was compared with grade for ILC cases and IDC controls using life-table analysis. Similar comparisons were made with the Nottingham Prognostic Index (NPI) between the different prognostic groups. Results Of 139 cases with ILC, 33 were excluded from the study because 24 were ungraded, five had advanced disease and four had mixed tumours. The mean length of follow-up for ILC cases was 75 months vs 70 months for IDC controls. Recurrence rates for grade I were 10% ILC vs 24% IDC, for grade II 32%vs 32% and for grade III 33%vs 49%. The reported grades for ILC and IDC both showed the expected trend for an increased recurrence rate with more severe tumour grade, but this was only significant for IDC grade II vs grade III (P

Background: It has been suggested that there is an increased risk of colorectal cancer after cholecystectomy due to increased levels of secondary bile acids. Some studies suggest the risk is higher for women and for the development of right-sided tumours. Methods: A review of the literature yielded 95 relevant studies, of which 35 were suitable for a meta-analysis involving age- and sex-matched controls. Results: The pooled odds ratio for a positive association between cholecystectomy and colorectal cancer was 1.11 (95% confidence interval (CI), 1.02 to 1.21). For women the odds ratio was 1.14 (95% CI, 1.01 to 1.28), and for right-sided cancer 1.86 (95% CI, 1.31 to 2.65). Conclusions: It is possible that this small observed association may be due to a publication bias for positive results or bias within the included studies. If it is indeed a real effect, the risk to an individual is very small.

Marcovitch describes the failure of an independent body to investigate research fraud because of lack of mandatory powers and long term funding,1 and, although Kennedy reassures us that the UK Research Integrity Office is still …