No abstract

Between November 1979 and December 1986, 263 patients were treated for primary breast cancer by local excision and radiotherapy at the City Hospital, Nottingham. Local recurrence within the treated breast occurred in 56 patients (21 per cent), in 18 (6.8 per cent) of whom it was gross and uncontrollable. An analysis of clinicopathological features shows patient age, nodal status, tumour size, presence of definitive vascular invasion, adjacent ductal carcinoma in situ and grade to be predictive of local recurrence. A Cox's multivariate analysis of these factors shows the first four to be independently significant. The factors can be combined as a prognostic index which allows identification of patients at high risk of local recurrence. On the basis of these findings we have altered our selection policy for patients suitable for breast conservation.

This report presents the results of a study into the effect of breast self-examination (BSE) in a large defined population within the City of Nottingham since 1979. We have examined the effect of breast self-examination in a group of patients invited to attend for education in BSE compared with a group of historical controls. No overall survival advantage has been demonstrated for the study group but within the latter group patients who had attended for instruction in BSE had a significantly better actuarial survival at 13 years than those who did not (P less than 0.001). Patients in the study group presented with significantly smaller tumours which were more likely to be of better histological grade and lymph node stage. A case-control study has demonstrated the value of attendance for BSE particularly in post-menopausal women. Although BSE is not as sensitive as mammographic screening, patients who practise it present with more favourable tumour characteristics and its value in post-menopausal women supports its use as an adjunct to mammographic screening.

Fumarate hydratase deficiency (FHD) caused by biallelic alterations of the FH (fumarate hydratase) gene is a rare disorder of the tricarboxylic acid cycle, classically characterized by encephalopathy, profound psychomotor retardation, seizures, a spectrum of brain abnormalities and early death in childhood. Less common milder phenotypes with moderate cognitive impairment and long-term survival have been reported. In addition, heterozygous mutations of the FH gene are responsible for hereditary leiomyomatosis and renal cell cancer (HLRCC). There is currently no recommended disease modifying treatment for FHD and only isolated reports of unsuccessful dietary modifications. Herein, we describe the safe and possibly disease modifying effect of a high fat, low carbohydrate diet in a 14-year-old female with severe FHD.

Objective-To determine differences in coronary risk factors between women and men and their relation to in-hospital mortality associated with coronary artery bypass grafting. Design-Prospective observational study. Setting-A regional cardiothoracic centre. Patients-482 (362 (75%/6) men and 120 (25%) women) consecutive patients who had primary isolated coronary artery bypass grafting. Results-The women were on average three years older than the men (63 v 60 years, P < 0.001). Women more frequently had hypertension (47% v 33%, P < 0.01), diabetes mellitus (21% v 10%, P < 0.005), hypothyroidism (90/o v 2%, P < 0.003), and a family history of premature coronary heart disease (49% v 31%, P < 0.0006). More of the men were cigarette smokers (67% v 45%, P > 0.00001).Many of the women and men had dyslipidaemia. Postmenopausal women had a higher concentration of serum total cholesterol than men of a comparable age, (7.3 mmoUl v 6 5 mmol/l, P = 0.0002).Although arterial grafts were often used in both sexes, they were more often used in men than in women (91% v 78% respectively, P = 0.0003). In-hospital mortality was 2-1% (1.4% in men and 4-2% in women, P = 0.14). The estimated one year probability of survival in men who had survived 30 days was 0 99 with 95% confidence interval 0-98 to approximately 1 while that for women was 0Q97 with 95% confidence interval 0-91 to approximately 1. Univariate analysis showed that preoperative history of diabetes mellitus was a predictor of mortality (P = 0.03).Conclusion-There were differences in the incidence and type of risk factors in men and women who had coronary artery bypass grafting. Preoperative diabetes mellitus was a predictor of in-hospital mortality. (Br HeartJ' 1994;71:408-412) In the United Kingdom coronary heart disease is the leading cause of death in women over 65 years of age and a major contributor to mortality in younger women.' Whereas the disease is less prevalent in premenopausal women than in men, its incidence increases rapidly after the menopause so that rates of coronary disease are almost equal in women and men over sixty.2In 1991 in England and Wales 68 479 women and 81 611 men died of coronary heart disease.' The latest data available from the World Health Organisation show that mortality from coronary heart disease in women is highest in Scotland (121/100 000) where it is almost double that in the United States (67/100 000).3At all ages the incidence of coronary artery disease in women has increased and its outcome seems worse than that in men suggesting a different type of disease4 and possibly a different set of risk factors. Most studies showed that the immediate and long-term prognosis in women is worse than that in men after myocardial infarction5-7 and after therapeutic interventions such as coronary balloon angioplasty. Coronary artery bypass grafting (CABG) remains the most commonly used form of myocardial revascularisation, however, there is perceived to be a possible bias against women in terms of the application of coronary angiograph...