There is substantial geographic variation in the use of breast-conserving surgery, which cannot be explained by differences in hospital characteristics. Hospital characteristics that were independently redictive of greater use of breast-conserving surgery were the size of the metropolitan area, the status of the institution as a teaching hospital, and the availability of radiation therapy and geriatric services.

Ten years ago, we studied the clinical and radiographic manifestations of gout in 60 patients and described 3 patterns of disease. To determine the consequences of management over a 10-year period, we recently reassessed the 39 available patients of this population. We found that although reduced tophaceous deposition on physical examination correlated with normalization of the serum urate concentration, no correlation existed between radiographic changes and mean serum urate concentrations. Progression of gouty changes on radiography reflected progressive deformity on physical examination, We have described the radiographic changes that occurred in a well-characterized Population of subjects with gout over 10 years and determined that serum urate concentrations alone may not provide an effective means of monitoring the progression of tophaceous disease in bone. Gouty arthritis remains a management problem in some populations, despite the availability of a precise diagnostic test and effective serum u r a t e lowering medications. Ten years ago, we reported a clinical, biochemical, and radiographic evaluation of a population in which tophaceous gout was frequent (1).We concluded 1) that tophi develop in bone before becoming apparent on physical examination; 2) that bony changes can occur in joints that were never the site of acute gout; and 3) that the development of tophi is a direct consequence of the seventy and duration of the disease. A reassessment of these patients was undertaken to determine the consequences of medical management over the intervening decade, and those findings form the basis of this report.

Myoadenylate deaminase (MADA) deficiency has been associated with symptoms of postexertional aches, cramps, weakness, and skeletal muscle dysfunction. Measurement of plasma lactate and ammonia concentrations after forearm ischemic exercise has been suggested as a screening test for this disorder. We performed forearm ischemic tests on 3 patients with histochemically defined MADA deficiency and 13 healthy control subjects, in a standardized fashion. Our results demonstrated that subject effort and/or performance during the exercise portion of testing is a critical variable. In addition to lactate and ammonia, plasma purine compounds (adenosine, inosine, and hypoxanthine) were measured. The finding of decreased purine release after exercise in MADA-deficient patients compared with that in normal individuals increases the specificity of the test and supports the hypothesis that disordered purine metabolism occurs in MADA deficiency.Myoadenylate deaminase (MADA) (EC 3.5.4.6) catalyzes the deamination of AMP to IMP in skeletal muscle and plays an important role in the purine

We measured 5'-nucleotidase (5NT) activity in synovial fluid from 159 patients with various diagnoses. The activity of 5NT was compared with activities of nucleotide pyrophosphohydrolase, alkaline and neutral phosphatases, and adenosine deaminase, in the same samples. Higher levels of 5NT activity occurred in synovial fluid from osteoarthritic joints than from joints of patients with gout, pseudogout, or rheumatoid arthritis. The highest levels of 5NT activity were found in synovial fluid from patients with Milwaukee shoulder syndrome and from osteoarthritis patients in whom deposition of calcium-containing crystals was also present.The metabolic derangements that underlie osteoarthritis (OA) and arthropathies associated with calcium-containing crystals, including calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, basic calcium phosphate (BCP) crystal deposition arthropathy (1,2), and Milwaukee shoulder syndrome (MSS) (3), are poorly understood. Previous observations indicate that purine catabolic enzymes may play a role in these processes (4-14) (Figure 1). We measured the activity of 5'-nucleotidase (5NT) in synovial fluids from 159 patients with wellcharacterized arthropathies and compared that activity with the activity of synovial fluid nucleoside triphosphate pyrophosphohydrolase (NTPPPH), alkaline phosphatase (AP), neutral phosphatase (NP), and adenosine deaminase (ADA), in a broad selection of the same fluid samples. In contrast with the results reported by others (9), we observed higher 5NT activity in fluids from OA joints than from joints of patients with rheumatoid arthritis (RA). The highest levels of 5NT activity were found in the subset of fluids from osteoarthritic joints that also contained calcium crystal (CPPD and/or BCP) deposits, and in fluids from the shoulders of patients with MSS. of noninflammatory synovial fluid (leukocyte count 5 1,OOOl mm3), and 4) the presence of synovial fluid BCP crystals (3,181. Synovial fluid collection. Synovial fluid was drawn from the joint into a plastic syringe, and a portion of the sample was submitted for routine synovianalysis. The remainder was transferred immediately into a plastic tube containing 200 units of heparin (beef lung; Upjohn, Kalamazoo, MI) and 5 mg of hyaluronidase (beef testes; Worthington, Freehold, NJ), incubated at room temperature for 30 minutes, and centrifuged at 28,OOOg for 20 minutes. The supernatant fluids were stored at -70°C. The pellets were resuspended in 100 mM Tris HC1, pH 8.0, in a volume equal to that of the removed supernatant, and stored at -70°C until assay for BCP content, which was performed within 10 days. PATIENTS AND METHODSBCP assay. BCP crystals were detected and quantified in the centrifuged synovial fluid pellets, using the a:4182-20.ct14C-EHPP binding method (Proctor & Gamble, Cincinnati, OH) (I). The assay is specific for hydroxyapatite and, as performed, was able to quantitate BCP crystal mass equivalent to 2 3 pg of hydroxyapatite standard per ml.PP, assay. Synovial fluid PP, concentration ...