The less hydrophobic addition reaction silicones and polyethers are preferable in taking elastomeric impressions for cast restorations. Hydrocolloid is the material of choice in case of a large number of preparations. An accurate impression requires a solid tray. A metal stock tray is money-saving compared to the expensive custom tray. Automix dispensing guns offer a number of practical advantages. Success in impression making rather depends on making proper preparations and correct processing than on impression techniques and the quality of the impression material. Crossinfection via impressions can be prevented by immersion in a sodium hypochlorite solution for ten minutes.
The Susan Britton Wills Unit at the Bristol General Hospital is a small and busy multidisciplinary psychiatric unit, providing a wide range of in-patient, out-patient and day-patient services for the residents of Bristol Health District.
The present book is aimed at general practitioners, paediatricians, and trainee dermatologists, though nurses and senior medical students would also find it helpful and interesting. It provides a concise and up-to-date illustrated account of the clinical features and treatment of the skin conditions which occur in babies and children in the U.K. and all but the very rarest diseases have been included. The great strength of the book is the profusion of very high quality colour photographs, which not only beautifully illustrate the features described in the text, but have also been very well reproduced. One knows how difficult it can be to find the right patient, to take an excellent photograph of just the right area, and then to get the right colour tones and sharpness on the printed page, and the fact that all of the
the Indian Government House on the outskirts of the city. At first the battered taxi could only crawl through the crush of pedestrians, beggars, handcarts, bicycles, cows, holy men, pilgrims and mobile wood-stacks that clogged the streets of the city centre, Gradually however the crowd thinned slightly, the driver put his foot down and after a certain amount of stuttering and coughing, the ailing vehicle slowly built up speed. Thereafter the driver's technique for dealing with any obstacle was to blow his horn and accelerate towards it. Miraculously the obstacle would melt away at the very last moment, or if it didn't, we simply swerved around it without slackening speed. Considering the alarming degree of play in the steering wheel, this was quite a feat. I began to believe that the plastic Hindu gods which dangled in profusion from the windscreen, partially obscuring the driver's view, really were all-powerful, or else the hazards (old ladies, toddling babies, dogs and all) were mirages. At length however we succeeded in knocking a man off his bicycle. My driver leapt out, and paused only long enough to ascertain that the man was not seriously hurt before we sped off again, leaving the cyclist shaking his head over his badly buckled wheel. Shortly afterwards the road ahead was blocked by a large red and white mound, half-hidden under a flapping mass of vultures. The lorry which had caused this carnage lay wrecked in a ditch nearby. The accident had apparently happened a day or two previously, but neither the lorry nor the bullock carcase could be moved until compensation had been paid to the bullock's owner. We travelled several miles through the inner suburbs, a depressing area of endless repair shops of various kinds, half-built houses, bill-boards and powerlines. Eventually the bill-boards disappeared, the houses began to be more widely spaced, the roads became even more rutted, and we entered the residential area favoured by the affluent businessmen, lawyers, doctors, dentists and colonels. Each large villa with its well-kept garden was distinguished by a smart brass name-plate on the white-painted gatepost. Most gateposts appeared to have a dirty bundle of rags piled against them, but these turned out to be the gate-keepers, who drowsily squatted beside the gates all day, waiting to fling them open and kow-tow at the approach of the villa's illustrious owner. At one such gate we swept up the drive, …
Mammography remains the main investigation in the detection of breast carcinoma, both for screening and where clinical suspicion of the tumour exists. Once a tumour of the breast has been diagnosed using mammography, staging of the tumour occurs. This may involve surgical removal of the tumour and axillary lymph nodes as the first procedure, but more frequently further radiological techniques are used to determine the extent and site of any spread. The most often used additional investigations are the plain chest film, followed by the isotope bone scan. These methods detect much of the metastatic disease as the chest and bones are major sites of metastases. Problems do arise however, in detecting local spread involving the chest wall and in those areas where metastases can occur alongside other disorders which may also appear abnormal on the investigations used currently. This is particularly true in the spine where a bone scan may demonstrate 'hot spots' associated with degenerative disase, infection, osteoporotic crush fractures and previous surgery. These 'hot spots' may also remain as such for many months. Computed tomography has helped in the detection of both local spread and distant spread to the chest, particularly mediastinal nodes, and to the spine. This technique also has CASE 1 A 50 year old woman with known carcinoma of the breast who presented with backache. An isotope bone scan had demonstrated an isolated hot spot in the upper lumbar spine. An MR scan was performed and demonstrated unequivocal evidence of metastasis of L2 and a small unsuspected metasta-sis in L3 (figure 1). its limitations. It has been shown, in the absence of bone destruction, to be insensitive in the detection of chest wall involvement by tumours. Further, the detection of metastatic disease of the spine may require many axial 'slices' to examine the relevant areas of suspicion. Mediastinal node enlargement may also prove to be difficult to detect in some cases, without the use of a large bolus of contrast medium to delineate vessels. Magnetic Resonance Imaging has been made available more recently and is demonstrating its use in many areas. It is already an established tool in the investigation of the central nervous system. It has shown its use in the evaluation of bone tumours and other skeletal abnormalities more recently. Currently it is showing great promise in the investigation of many primary tumours including breast carcinoma and sarcoma. To demonstrate the use …
The Committee studied a number of overseas trials of breast screening, particularly the Health Insurance Programme from New York and the more recent Two Counties Trial in Sweden and trials in Holland. Reports from these trials record up to 30% reduction in the mortality from breast cancer for ten years, concentrated in women aged fifty and over. The effect on mortality in the forty-forty-nine age group is still uncertain. The evidence from these trials led the committee to conclude that breast screening can reduce the mortality from breast cancer and this was, therefore, recommended. The whole matter then took on a political significance and it was decided to implement a countrywide screening programme within a very short period, (i.e. by 1990) considering the limited number of staff and facilities available so to do. There is no countrywide breast screening programme to provide guidelines for the U.K., this being much more complex than organising a trial such as has been taking place in the U.K. since 1979. The Jarvis Screening Centre in Guildford and the Edinburgh Centre were the main centres for breast screening by mam-mography in the U.K. trial. In England and Wales the Jarvis Centre has become the first training centre for the national undertaking. The Jarvis Centre has trained centres in Manchester, Nottingham and King's College, London, and these, in turn, will, with Guildford, be responsible for the training required throughout the regions in England. Wales and Scotland will undertake their own training. Radiographers and Radiologists have to be trained in this specia-lised field, as do the Histo-and Cytopathologists. The Surgeons and Radiotherapists have to decide on the appropriate form of treatment for the often small lesions found during screening. It is recognised that, for the whole endeavour to succeed, extremely high standards have to be achieved and monitored through carefully planned quality assurance programmes , from identifying the patients, through to treatment of any discovered lesions. It was intended that the four training centres, and one centre per region should be running by Spring, 1988, and that the remaining centres should be developed over the following two years. Thus, the first centre in the South West is in Cornwall, based at the Treliske Hospital. Detailed training programmes for Radiographers and Radiologists have been produced by the College of Radiographers and the Royal College of Radiologists and are under way. The Royal College of Pathologists and the British …
urethra (figs 2 and 3). The cuff when inflated compresses the urethra maintaining continence. If the patient wishes to micturate he/she squeezes the control pump which is situated in the scrotum or labia. This pumps fluid from the cuff to the balloon reservoir thus deflating the cuff and allowing micturition. The cuff refills automatically over a few minutes. The AMS 800 also has a deactivation button on the control pump which prevents fluid returning from the balloon to the cuff.
Wide local excision followed by radiotherapy was offered as an alternative to mastectomy to 93 women on 96 occasions. Complications attributable to the surgery occurred in 4 per cent whilst 37.5 per cent developed complications secondary to the radiotherapy. The complications were generally of a mild nature. Nine patients (9.3%) have developed regional recurrence and seventeen (17.7%) distant metastases with a mean follow up of 53.4 months.
Broadly speaking we are in a mess over breast carcinoma. It has always been so and anyone industrious enough to study the literature in depth will have realised it. Despite the past twenty years of frenetic investigation, therapeutic revolution and comprehensive trials, the end results are not improved. Perhaps the only time when I recall that the whole enterprise was seemingly well appreciated lay during my student and early surgical trainee days?the 1950s. Cooke, Tasker, Jackmann, Milnes Walker, supported by the best of national and international authorities, saw most of these cases fairly advanced. Immediate admission; excision biopsy and frozen section which, if positive was followed by radical mastectomy and irradiation was the vogue. A few small voices stood against this fiercely held dogma, McWhirter in Edinburgh and our own Gordon Paul (almost surreptitiously), performed simple mastectomy coupled with irradiation. Things are somewhat more refined now, but do our results show much benefit? What is reasonably established fact for this disease; what has been revealed in the interim? Well, for age adjusted breast cancer mortality per 1 ()(),()()() women (1982-3) England and Wales at 34.5 leads the world! Many cases present earlier than formerly and for many centres, both here and abroad, preoperative diagnosis by fine needle aspiration biopsy (FNAB) is the method of choice and frozen section is infrequently necessary. Apart from a few 'diehards' radical mas-tectomy is abhorrent and simple mastectomy with some form of axillary 'adventure' is popular. The style of axillary surgery varies enormously from a four node 'scratch out1 to a formal tidy block removal of level I and II nodes. Less extensive breast surgery; variously assigned and often loosely termed segmental mastectomy and lumpectomy is practised. Subtotal mastectomy?if one may use the term can suffice for local control until the patient dies of metastases, on the other hand it is realistic to state that its application should involve very careful rules of assessment. Mammography constitutes a great boon for the surgeon and a fascinating extra burden for the radiologist. It is around 90% sensitive for proven breast cancers and can detect preclinical breast cancer. How will it perform in Great Britain within the proposed screening plan? It should come as no surprise to realise that despite the Forrest Report and fervent hopes (Baum 1988, and Rodway 1988) that there are cogent voices of scepticism (Skrabanek 1088, Andersson 1988). Sadly, under the age of 50, …
