Common Medical Emergencies ey Teatedtonls Haematemesis and Malena Meow esa hom eVect eae esos oe ate it Is the GI bleed fresh or altered? Causes of the bleed Ulcerative or erosive Siena Brier enn Rr Slime rer arate) Renee ls/ecueh VeVi ae Tyo es uae Ces One sees eae ieee en Ey ein Colle tented ie Erect neers Oe aire) Menor Rarer ... Causes of the bleed Re erro Se Se fear) Tear eg Sereneur us et ete} Romney Eeteora on mrceemtr an rat cin eto et one Daur ue ar el eary oyna fe See Breer accel See er Oe ter Teaser e)P) Nate) em Use Ucn Monon |Paracetamol OD “Cj egfarall Weiiejauiens arin stoles Resuscitation Eres reno yo teaser on) Era remenmnaiie Oy ai vier deieniaetcunarit ere) x Welee eee ee eter Nomogram NAC infusion Tides “ital ieaci Paracetamol OD. Guslaea) Wavesjenian! PAnclyles Endiofintusionandstilisyorried, awoublivar dasselge ? Sree auot soar ens hee aon eit mite cone tant to = Keep going until there is clinical and biochemical evidence of improvementTeng ed ened Hyperkalacmia ern (ec madiver ene reueny nyo: eats Stabilize eardiae membranes with calcium Hyperkalacmia RY emerge rent Hlacamodialy ost176 _Herbons etal dificultes with determinacy are still to be handled. The line of pursuit the authors attempt to follow, having incorporated the rhythm into their mechanical system, is to look for “calibration points.” By this term ‘they mean postion-load configurations where ‘one or more muscular forees are suficiently and accurately determined, say within 10%. ‘The search for calibration points will be done by computer scanning of the system. Once the totality of such points (if any) is found, the program is ready for results obtained by EMG or intramuscular pressure (IMP) meth- ‘ods; the calibration points will be used for their generic purpose, Ze, to calibrate the relevant absolute measuring characteristics of the EMG and/or IMP measurements. Such ‘measurements are presently being performed. ‘Considering what muscles and positions are ‘covered, however, the library of results i still ‘expected to be incomplete, Some comparative sequences of experiments may still have to bbe conducted afer all calibration points are found. EpipeMioLocy ‘The turnover among welders in the ship- yard is high, sometimes on the order of 305. ‘This makes it difficult to avoid missing data completely. In the context of the current investigation, this does not invalidate the results because there is no reason to believe that the dropout group would have fewer problems in the shoulder than did the group that was accessible for clinical follow-up study. Musculoskeletal problems are one of several factors contributing to the high turn- cover in such industry, Another methodologic remark concerns the age distribution in the welders and the plate-workers on the one hand, and the office clerks on the other. Since the clerks are on ‘an average older than the other two groups, there would be a higher likelihood of age- induced tendinitis in this group. However, the hypothesis is that those with a high physical workload have tendinitis toa greater extent than normal ‘The study points clearly at the risk in ‘evaluating problems in the musculoskeletal system on the basis of questionnaires only ‘ire, the reported prevalence ratio in welders and plate-workers was around 30%, compared with the validated figures of 16%-18%. The false-negative responses in the questionnaire were few, however. The questionnaire may therefore’ provide information on general tends in the material, but it does not offer a base for quantitative reporting. ‘This study has clearly shown that supraspi- natus tendinitis is not exclusively an aging phenomenon. It is also common in younger welders, which indicates that the welding work contributes to the development of the symptoms. Different degrees of inflammatory ‘changes are manifested with a similar clinical picture of impingement syndrome™ in differ- ‘ent age groups. Nevertheless, age is most likely an important factor in terms of the progres of the disorder: in younger people, the pain disappears after rest or change of work in the elderly, the changes tend to become irreversible ‘A fact of interest in this investigation ‘that supraspinatus tendinitis is equally com- ‘mon in the two groups studied, but it appears at an carlier age in the welders than it does in the plate-workers. The single important difference between the two types of occupa- tions is that welding can be characterized as fan almost exclusively static work, whereas plate-working is dynamic in character. The possibility that static work entails a higher tisk for chronic shoulder pain is of course of the greatest interest from the point of view of occupational health. It has direct bearing ‘on ergonomic planning of welders’ work and work places ACKNOWLEDGMENTS The autor patly acknowledge the consibton ‘of personal atthe Gitaverien Arendal Shier ad ‘he Gotaverken Heath Cae Serves in Gatchorg REFERENCES, Allender, E: Presence, icience and remision ‘ts of some common rheumatic dian x5 Gromer Sand Rheumatol 3185 1978 ‘Anderson, G0.) Onempen ad Shula, A ‘Analy and measrement of the leas o8 the ‘amber apne daring work ta be. J. Bloch 1355, 190, Bateman. Jn The Shoulder and Neck, od, 2. Phiephia, WB Saunders 197% pp. i624 a3 Bile, A. Hagberg M. and Michaelson, = Cine and enomie facto in prolonged shold pain Song indus workers Sand’ J; Work Enron ‘eh $305, 1979, Belle, A. Hager. M. and Michacion, G: Ou ‘ona and nds tore cat shoe eck diorder among insinal woeken BI nd Met. 336 198 CGhafin, D8: Located mane figue—Defiiton Sed measurement J, Osc. Me 186,197 Deana, A Fin Srey oe Shou. Pia pha JB. Lippncot 1950, Faubendey iH. Gand Wegner. K: Morpholge tnd Pathopneses dex Wesieheamatmes Rheumaforcbung. 32385. 1973 Fraga, J. System, Mand Eiblom, B: A. mor sty of delayed muscle sone. Ee fenua 37506, 1981 age, Mi Work lod and fie in rept sam cevatons. Ergonomics 24:54 1981 Haber, Mt Eletompopapic suns of shoulier Iu aque in wo devated arm postions Am, J. Phys Med 6:11, 198 Hagberg, M: Loca’ shoulder muse sin— Symptoms and dsders J Hum. Erol 1199, ee Herbert, Pond Kader, RA study of pital Soule in'welders Acta Onhop. Scand. 44381, 996 Herbers, P, Kadefors R. and Anderson, G: ‘Shoulder pi ia faust: An epidemiology fon weer Acta Onhop Sab 19 181, 1981 Herter P Kade, Rab Brom, Ho Arm Prtioning in manual as An eectomvoeaphic Sty of oad muscle age Epopomis 28635, Inger, BE: The struct of tendons at various ‘ue and unr dient funconal condition. ‘eta Anat 6193. 198 KRedfor Kaiser E_and Peenén, 1: Dynami Spectum analysis f myepatentas wah yea Feeenc 0 muscle fatigue Bromo 82, i974 Kado, Petes sand Herons, P: Maer Investigation Ergonomice 1954, 1976. ele, Jc Hand Uswrenc, J 8 Rdcumatie inter. Par He Xery std Be J.T. Med sisi 983 Kearmatom, S: Occurence of msculoseeta dis- orden in 2 manufacturing Indus. wih pel a a Shoulder Pain 177 ssenion to oscupatina shoulder disorders Sean 1 Renata M. Suppl) & 198. Kamer, Pur FAlmsrtim, C.. Anderson, GB). fiers P. Kaden, R, Palmer. ©. Sa! Zaire C= ihe flaion of imams Dreie 1 te fore output and mocecic sna fate meicle 3. Orthop. Res (ln press, 1984) omer, Parker, P Ami, C, Heer P Sod Kadelore The relation between spectral ‘Shanes the mycket seal andthe tram Sar presse of human skstal mule Eat. ‘pi. Phys in pres 198) wrens, H. = Rheumatism in coal miner, Part ‘Occpational actor Be Tad. Med. 12:20, 1958 Lawrence, J. H. and DeLuca. C.J: Myodteti ‘gna tess fre relationship in ire oman ‘mcs App Pack: Regi Environ Exerc Phys S46) 1683 1983, Lindblom, K: On pathogenesis of ruptures ofthe ‘eno aponeros the soul int Acta Radi. Bases, 1, Linas, 1, and Magnuson, R-: Interetaton ff voce power spear A" model and Spotcatone Poe TEEE 65855, 197 Lins, L, Magno, R and’ Petea, Muscultfaigue and acon potential conduction ‘los chang sid th Requeney anal a EMG ign Elsromyogr ‘Cin. Newophysiot rosa, B70 Loa, T:, Kouina, 1, Viralainen, Mand FHmber, M. Presale of enosyoovts ander Injures ofthe upper extemiies i epee wot Scand Work Envir, Heath Supp.) 38,1979 MacNab Rotator cf tendini Ann. Col Sunp Engl $8271, 1973, ‘MaeNL: Depthoopsche Grundig dr sone {nen Rotatorenmanshene: Tends: Onopae Toast, 18 Maeda, K: Oncupational cervcobranchialdsrder hd ie cauve factor 3. Hom. Ergot 193, 1977 Magy Rol, 1 Lindstrom, L Peer LOncngen, R.Br, Herbert P and Ka. ors Re Menarementofcaied mute pc in buiding work Eponomis 28:95. 1981 Mortimer J.T, Maghusion. R. and Peter, 1 Conduction vel im cbeme muscle et on TEMG feqeneysgectum. Am. J. Pys 219124, wn. tthe rotator caf ofthe sould Bove sat Sore 458780, 1963. FNes.€-S Tl Asterraromiogaty fo the chronic tan repre J Bone Jit Surg S444, 1973 Nec ©. Ik Impingement lesions Clin. Ortop. 10, 198, Olson, 0: Degenetive changes of the sbouder Joint and thi connection wi shower pa Act Ghir, Sc (Spt) 181 983 Peterson, CJ Depeneaion of the leno-hureraBreast cancer before age 40 249 ou 92. 93, 94 ‘S.year follow-up of the ABCSG-12 bone-mineral density substudy. Lancet Oncol. 2008:9:8409. Collaborative Group on Hormonal Factors in Breast ‘Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies in ‘cluding $8,209 women with breast cancer and 101,986 women without the disease, Lancet. 2001;358:138999. Peto J, Mack T. High constant incidence in twins and ‘other relatives of women with breast cancer. Nat Genet. 2000;26:411-4, LB, Fraumeni J. Softtissue sarcomas, breast cancer, and other neoplasms, A familial syndrome? Ann Intern Med. 1969:71:747-52. Nelen M, Padberg G, Peeters E, et al. Localization of the gene for Cowden disease 10 chromosome 10q2223, Nat Genet. 1996;13:114-46, Ford D, Easton D, Stratton M, et al. Genetic heteroge neity and penetrance analysis of the BRCAL and BRCAZ genes in breast cancer families, The Breast Cancer Link. ‘age Consortium. Am J Hum Genet. 1998;62:67689. Chen 8, Parmigiani G. Metaanalysis of BRCA1 and BRCA2 penetrance. J Clin Oncol. 2007;25:1329-33. Saslow D, Boetes C, Burke W, et al. American Cancer Society Guidelines for breast screening with mei as an adjunct to mammography. CA Cancer J Clin, 2007;57 7589. 100. 101. 102. Vogel V, Costantino J, Wickerham D, et al. Effects of tamoxifen vs raloxifene on the risk of developing inva sive breast cancer and other disease outcomes: the [NSABP study of tamoxifen and raloxifene (STAR) P-2 trial. JAMA. 2006;295:2727-41 Fisher B, Costantino J, Wickerham D, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 study. J Natl Cancer Inst, 1998;9018:1371-88. King M, Wieand 5, Hale K, et al. Tamoxifen and breast cancer incidence among women with inherited muta tions in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial. JAMA. 2001;286:2251.6. Schain W, d’Angelo T, Dunn M, Lichter A, Pierce L. ‘Mastectomy versus conservative surgery and radiation ‘therapy. Psychosocial consequences. Cancer. 199: 12218 Ganz P, Greendale G, Petersen L, Kahn B, Bower J Breast cancer in younger women: reproductive and late health effects of treatment. J Clin Oncol. 2003:21 418693 Phillips K, Osbome R, Giles G, et al. Psychosocial fac tors and survival of young women with breast cancer: a population-based prospective cohort study. J Clin On: col, 2008;26:4666-71248 59. 60, 61, 02. 63. 6s. 6. 6. 69. 70. n. B. Adjuvant Study Group 02 randomized trial. J Clin ‘Oncol, 2000:18:271827, Davidson NE, N'Neill AM, Vukov AM, et al, Chemorendo- crine therapy for premenopausal women with axillary lymph node-positive, steroid hormone receptor positive breast cancer results from INT O101 (E 5188), J Clin ‘Oncol, 2005;23:597382 Jakesz R, Hausmaninger H, Kubista E, et al, Randomized adjuvant teal of tamoxifen and goserelin versus cyclo- phosphamide, methotrexate, and fluorouracil: evidence for the superiority of treatment with endocrine blockade in premenopausal patients with hormone responsive breast cancer—Austrian Breast and Colorectal Cancer Study Group trial 5. J Cin Oncol. 2002;20:46217 Bleyer A, Barr R, Hayestattin B, Thomas D, Ellis C, Anderson B. The distinctive biology of cancer in ado- lescents and young adults. Nature Rev Cancer. 20088: 288.98, Newman L, Bunner S, Carolin K, etal. Ethnicity related differences in the survival of young breast carcinoma patients, Cancer. 2002:95:21-7. De Jesus MA, Fujita M, Kim KS, Goldson AL. Retrospec- live analysis of breast cancer among young African American females. Breast Cancer Res Treat. 2003:78 817. Bf W, Myers A, Franciose R. Is breast cancer in young Latinas a diferent disease? Am J Surg. 2001;182:596-600, Foo C, Su D, Chong C. Breast cancer in young Asian ‘women: study on survival. Aust NZ J Surg. 2008:75, 36672 Lee K, Chen S, Chan C, et al. Increased risk for second primary malignancies in women with breast cancer diagnosed at young age: a population-based study in ‘Taiwan, Cancer Epidemiol Biomarkers Prev. 2008;17: 2647-5. Hooning M, Aleman B, Hauptmann M, et al. Roles of radiotherapy and chemotherapy in the development of ‘contralateral breast cancer. J Clin Oncol. 2008;26:5561.8. lee $, Schover I, Partridge A, et al. American Society of Clinical Oncology recommendations on fertility preserva tion in cancer patients. J Cin Oncol. 2006,24:2917-31 Partridge A, Gelber S, Peppercorn J, et al. Web-based survey of fertility issues in young women with breast ceancer, J Clin Oncol, 2004:22:4174783. Reh A, Oktem ©, Oktay K. Impact of breast cancer ‘chemotherapy on ovarian reserve: a prospective obser. vational analysis by menstrual history and ovarian re- serve markers. Fertil Steril. 2008;90:16359. IsmailKhan R, Minton , Cox C, Sims I, Lacevic M, GrossKing M. Preservation of ovarian function in young women treated with neoadjuvant chemotherapy for breast cancer: a randomized trial using the GnRH agonist (triptorelin) during chemotherapy. (abstract '524]. J Clin Oncol ASCO Annual Meeting Proceedings (Post Meeting Edition). 2008;26:156. Azim AA, CostantiniFerrando M, Oktay K. Safety of fertility preservation by ovarian stimulation with letro- zole and gonadotropins in patients with breast cancer: prospective controlled study. J Clin Oncol. 2008;26: 26305 Smith L, Dalrymple J, Leiserowitz G, Danielsen B, Gil- bert W. Obstetrical deliveries associated with maternal 7B. 79. aL 82 83, 85. 89. Gk. Anders et al malignancy in California, 1992 through 1997. Am J Obstet Gynecol, 2001;184:150412 Anderson B, Petrek J, Byrd D, Senie R, Borgen P. Preg nancy influences breast cancer stage at diagnosis in ‘women 30 years of age or younger. Ann Surg Oncol 1996;3:204-11 Noyes R, Spanos W, Montague E. Breast cancer in ‘women aged 30 and under. Cancer. 1982;49:13027. Mueller B, Simon M. Childbearing and survival after breast carcinoma in young women. Cancer Causes Con- trol. 2003;98:1131-40, Byrd B, Bayer D, Robertson J, Stephenson S. Treatment of breast tumors associated with pregnancy and lacta: tion. Ann Surg. 1962:155:9407. Samuels T, Liu F, Yaffe M, Haider M. Gestational breast cancer, Can Assoc Radiol J. 1998;49:172.80, Yang WT, Dryden MJ, Gwyn K, Whitman GJ, Theriault 1, Imaging of breast cancer diagnosed and treated with ‘chemotherapy during pregnancy. Radiology. 2006:239: 5260. Loibl S, Minckwitz GV, Gwyn K, etal. Breast carcinoma during pregnancy. Cancer, 2006;106:237-6, Hahn K, Johnson P, Gordon N, et al. Treatment of pregnant breast cancer patients and outcomes of chil dren exposed to chemotherapy in utero. Cancer. 2006; 107:1219-26. Mir O, Berveiller P, Ropert 8, et al. Emerging therapeu tic options for breast cancer chemotherapy during pregnancy. Ann Oncol. 2008;19:607-13, Shrim A, GarciaBournissen F, Maxwell C, Farine D, Koren G. Trastuzumab treatment for breast cancer dur. ing pregnancy. Can Fam Phys, 2008:54:31-2 Bonnier P, Romain , Dilhuydy J, ct al. Influence of pregnancy on the outcome of breast cancer: a case control study. Int J Cancer. 1997:72:720-7 Kalder M, Hadji P. Bone health in postmenopausal ‘women (PMW) with hormone-sensitive breast cancer (HSBC) receiving adjuvant aromatase inhibitor (AD, therapy [abstract 11556). J Clin Oncol ASCO Annual Meeting Proceedings (Post Meeting Edition), 2008:26; 158, Shapiro CL, Halabi S, Gibson G, et al. Effect of zoledronic acid (ZA) on bone mineral density (BMD) in premenopausal women who develop ovarian failure (OF) due to adjuvant chemotherapy (AUC): First results from CALGB trial 79809 [abstract 512]. J Clin Oncol ASCO Annual Meeting Proceedings (PostMecting Edi- tion). 2008;26:155. Hershman D, McMahon D, Crew K, et al. Zoledronic acid prevents bone loss in premenopausal women un- dengoing adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol. 2008;26:4739-45, Gnant M, Mlinertsch B, Schippinger W, et al. Adjuvant ovarian suppression combined with tamoxifen or anasiro- zole, alone oF in combination with zoledronic acid, in ‘premenopausal women with hormone responsive, stage I and Il breast cancer: first efficacy results from ABCSG-12 [abstract LBA) J Clin Oncol ASCO Annual Meeting Pro- ‘ceedings (PostMecting Edition), 2008:26:15S, Gnant M, Mlineritsch B, Luschin-Ebengreuth G, etal [Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with earlystage breast cancer:Breast cancer before age 40 29, 30. 32. 33. 34 35, 36 37, 38 40. a 2. 4B 4 45, Holl K, Isola J, Effect of age on the survival of breast cancer patients. Eur J Cancer. 1997;33:4258 Colleoni M, Rotmens® N, Robertson C, etl. Very young ‘women (<35 years) with operable breast cancer: fea tures of disease at presentation. Ann Oncol. 2002:13, 2739. ‘Anders C, Hsu D, Broadwater G, et al. Young age at diagnosis correlates with worse prognosis and defines a subset of breast cancers with shared patterns of gene expression. J Clin Oncol. 2008;26:3324-30. AAlbain KS, Allred DC, Clark GM. Breast cancer out comes and predictors of outcome: are there age differ tentials? J Natl Cancer Inst Monogr. 1994;16:35-42 Kollias J, Elston CW, Ellis 1, et al. Early onset breast ‘cancer—histopathological and prognostic consider ations. Br J Cancer. 1997;75:1318-23. de la Rochefordiere A, Assclain B, Campana F, etal. Age fs prognostic factor in premenopausal breast carci noma, Lancet. 1993;341:103943. Nixon AJ, Neuburg D, Hayes DF, et al. Relationship of patient age to pathologic features of the tumor and prognosis for patients with stage I and Il breast eancer. J Clin Oncol, 1994:12:888.94 GGnerlch J, Deshpande A, Jeffe D, Sweet A, White N, ‘Mangenthaler J, Elevated breast cancer mortality in young ‘women (<40 yrs) compared with older women is atrib> ‘ted to poorer survival in early stage disease, 2008 Amer ican College of Surgeons Clinical Congress, 2008. Margenthaler J. Younger women diagnosed with early stage breast cancer more likely to die than older women. American College of Surgeons Clinical Con- ‘gress; October 12:16, 2008, San Francisco, CA. Lund MJ, Trivers KF, Porter PL, etal. Race and triple negative threats to breast cancer survival: a population- based study in Atlanta, GA. Breast Cancer Res Treat 12009:113;357-70. ‘Shannon C, Smith I, Breast cancer in adolescents and ‘young women. Eur } Cancer. 2003;39:2632-42 Kurtz J, Jacquemier J, Amalsic R, ct al. Why are local recurrences after breast-conserving therapy more fre- {quent in younger patients? J Clin Oncol. 199038:591-8. ‘Voogd A, Nielsen M, Peterse J, et al. Differences in risk factors for local and distant recurrence after breast conserving therapy or mastectomy for stage 1 and Il breast cancer: pooled results of two large European randomized trials, J Clin Oncol. 2001;19:168897. Goldhirsch A, Glick J, Gelber R, et al. Meeting high: lights: International Consensus Panel on the Treatment ‘of Primary Breast Cancer. Seventh International Confer. fence on Adjuvant Therapy of Primary Breast Cancer. {J Clin Oncol. 2001;19:3817.27, “Aebi S, Gelber S, CastiglioneGertsch M, et al. Is che: ‘motherapy alone adequate for young women with oes trogenreceptor-positive breast cancer? Lancet. 2000; 355:1869-74 Kroman N, Jensen M, Wohlfuhrt J, Mouridsen H, “Andersen P, Melbye J. Factors influencing the effect of age on prognosis in breast cancer. population based study. BMJ, 2000;320:4748. ‘Xiong Q, Valero V, Kau V, et al. Female patients with, breast carcinoma age 30 years and younger have a poor 48. 0 50. 31 52 54 35 57. 247 prognosis: the MD. Anderson Cancer Center experience. ‘Cancer. 2001;92:25258 Levine M, Bramwell V, Pritchard K, et al. Randomized. trial of intensive cyclophosphamide, epirubicin, and fluorouracil chemotherapy compared with cyclopho- sphamide, methotrexate, and fluorouracil in premeno- ppausal women with node-positive breast cancer. Na tional Cancer Institute of Canada Clinical Trials Group. Jin Oncol. 1998;16:26518 EBCTG. Early Breast Cancer Trialists’ Collaborative Group. Polychemotherapy for early breast cancer: an ‘overview of the randomised trials. Lancet. 1998:352: 930-42. ‘Tamoxifen for early breast cancer: an overview of the randomised trials, Early Breast Cancer Trialists’ Collab orative Group, Lancet. 198;351:1451-67, Henderson 1, Berry D, Demetri G, et al. Improved out ‘comes from adding sequential paclitaxel but not from ‘escalating doxorubicin dose in an adjuvant chemother. apy regimen for patients with node-positive primary breast cancer. J Clin Oncol. 2003;21:97683. Mamounas E, Lembersky B, Fisher B, et al. Paclitaxel following doxorubicin/cyclophosphamide as adjuvant ‘chemotherapy for node-positive breast cancer: results from NSABP B28. J Clin Oncol. 2005;23:368696, 1M, Pienkowski T, Mackey J, etal. Adjuvant do- ‘cetaxel for node-positive breast cancer, N Engl J Med. 2005;352:2802-13. Citron M, Berry D, Cirroncione C, et al. Randomized trial of dose-dense versus conventionally scheduled and Sequential versus concurrent combination chemother apy as postoperative adjuvant treatment of node-pos: tive primary breast cancer: first report of Intergroup, trial C9741/Cancer and Leukemia Group B trial 9741. {J Clin Oncol. 2003:21:1431-9. ‘Bianco A, Del Mastro L, Gallo C, etal. Prognostic role of, amenorshea induced by adjuvant chemotherapy in pre- ‘menopausal patients with early breast cancer. Br J Can- cer. 1991;63:799:803, Goldhirsch A, Gelber R, Castiglione M. The magnitude ‘of endocrine effects of adjuvant chemotherapy for pre ‘menopausal breast cancer patients. The Intemational Breast Cancer Study Group. Ann Oncol. 1990;1:1838. Jonat W, Kaufmann M, Sauerbrei W, ct al. Goserelin ‘versus cyclophosphamide, methotrexate and fluoroura- ‘las adjuvant therapy in premenopausal patients with rnode-positive breast cancer. The Zoladex Early Breast Cancer Research Association Study. J Clin Oncol. 2002; 20462835, Richards M, O'Reilly §, Howell A, et al, Adjuvant eyclo- phosphamide, methotrexate, and fluorouracil in px tients with axillary node-positive breast cancer: an up date of the Guy's/Manchester tral. J Clin Oncol. 1990; 8:20329. ‘Goodwin P, Ennis M, Pritchard K, Trudeau M, Hood N. Risk of menopause during the first year after breast cancer diagnosis. J Clin Oncol, 1999;17:236570 ‘Boccardo F, Rubagotti A, Amoroso D, et al, Cyclophos phamide, methotrexate, and fluorouracil versus tamox: ifen plus ovarian suppression as adjuvant treatment of estrogen receptorpositive pre/perimenopausal breast cancer patients: results of the Italian Breast Cancer