A review of patients with advanced cervical cancer presenting to palliative care services at Queen Elizabeth Central Hospital in Blantyre, Malawi.

BACKGROUND: Cervical cancer is the commonest cancer affecting women in Malawi, which has the highest rate of this disease in the world. Most cases are diagnosed at an advanced stage. AIM: To describe the symptom burden, palliative care interventions, and outcomes of cervical cancer patients who entered care at Tiyanjane Clinic in Blantyre, Malawi, between January and December 2012. METHODS: We reviewed the case files of 72 patients presenting to our hospital-based palliative care service over one year. RESULTS: The mean age was 49.5 years. Twenty-six patients (36%) were HIV-positive and the majority of these (n = 22; 85%) were on antiretroviral medication at presentation to palliative care. Pain (n = 66; 92%), vaginal discharge (n = 44; 61%), and unpleasant odour (n = 37; 51%) were commonly reported. Over a third of patients (n = 26; 36%) reported pain in two or more sites. Fourteen patients (19%) reported vaginal bleeding. Spousal breakdown (through widowhood or divorce) was noted in over half (n = 41; 57%) of all cases. Pain relief was provided to 69 (96%) of the patients (morphine to 40 patients; 56%). Common interventions provided included metronidazole tablets (used vaginally), sanitary items, and counselling. At the end of the study period, 18 patients (25%) were still under the care of palliative services. CONCLUSIONS: Access to medications such as morphine, metronidazole and tranexamic acid can improve quality of life, even when radiotherapy is limited. Health care teams require necessary skills and training, including how to perform a comprehensive assessment, with an emphasis on the provision of psychosexual counselling, to assist with the complexity of symptoms occurring in this vulnerable group.

A Prospective Study Assessing Tumour Response, Survival, and Palliative Care Outcomes in Patients with HIV-Related Kaposi's Sarcoma at Queen Elizabeth Central Hospital, Blantyre, Malawi.

Background. Human-Immunodeficiency-Virus- (HIV-) related Kaposi's sarcoma (KS) has a high prevalence in Africa; however, there is minimal published data on treatment and outcomes in this population. Objective and Design. This was a prospective study of 50 patients, aiming to assess the impact of vincristine therapy on tumour response and survival and to assess palliative care outcomes in patients with HIV-related KS. Methods. 50 consecutive patients were recruited during 2008. Vincristine therapy and highly active antiretroviral therapy (HAART) were given. Tumour response, survival, and chemotherapy-related toxicities were documented. Palliative care outcomes were assessed using the African Palliative Care Association (APCA) Palliative Outcome Scale (POS). Results. The majority of patients were male, and the median age was 33 years. At baseline assessment, the median CD4 T-cell count was 263, and 50% patients had evidence of peripheral neuropathy. The overall response rate was 64% at 6 weeks, and median progression-free survival was 30 weeks. Treatment was generally well tolerated, with peripheral neuropathy the main dose-limiting toxicity. Conclusion. The combination of vincristine and HAART is feasible and effective in a low resource setting, although peripheral neuropathy is a dose-limiting factor. This patient group carries a high mortality and as such adequate access to palliative care is crucial.

Twenty-year survivors of heart transplantation at Stanford University.

Human heart transplantation started 40 years ago. Medical records of all cardiac transplants performed at Stanford were reviewed. A total of 1446 heart transplantations have been performed between January 1968 and December 2007 with an increase of 1-year survival from 43.1% to 90.2%. Sixty patients who were transplanted between 1968 and 1987 were identified who survived at least 20 years. Twenty-year survivors had a mean age at transplant of 29.4 +/- 13.6 years. Rejection-free and infection-free 1-year survivals were 14.3% and 18.8%, respectively. At their last follow-up, 86.7% of long-term survivors were treated for hypertension, 28.3% showed chronic renal dysfunction, 6.7% required hemodialysis, 10% were status postkidney transplantation, 13.3% were treated for diabetes mellitus, 36.7% had a history of malignancy and 43.3% had evidence of allograft vasculopathy. The half-life conditional on survival to 20 years was 28.1 years. Eleven patients received a second heart transplant after 11.9 +/- 8.0 years. The most common causes of death were allograft vasculopathy (56.3%) and nonlymphoid malignancy (25.0%). Twenty-year survival was achieved in 12.5% of patients transplanted before 1988. Although still associated with considerable morbidity, long-term survival is expected to occur at much higher rates in the future due to major advances in the field over the past decade.

A novel mitochondrial DNA point mutation in the tRNA(Ile) gene: studies in a patient presenting with chronic progressive external ophthalmoplegia and multiple sclerosis.

We report a new mutation, a G to A transition at nucleotide position 4298 within the mitochondrial tRNA(Ile) gene in a patient with chronic progressive external ophthalmoplegia and multiple sclerosis. The mutation, which alters an evolutionary conserved nucleotide within the anticodon stem, was heteroplasmic in skeletal muscle but was not present in the patient's blood. Single fibre PCR analysis revealed significantly higher levels of the G4298A mutation in cytochrome c oxidase (COX) negative fibres than in COX-positive fibres. This mutation represents the seventh pathogenic nucleotide substitution to be found in this gene and as such confirms the tRNA(Ile) gene as a susceptible "hot spot" for mitochondrial DNA point mutations. Of particular interest is that this patient has the clinical features of both multiple sclerosis and a mitochondrial DNA disorder.

Ovarian activity in progesterone treated mares following administration of pregnant mare serum gonadotropin.

Twelve non-pregnant, non-lactating mares were randomly assigned to four treatment groups using a 2x2 factorial arrangement with three replicates per group. Mares were administered PGF(2alpha) (10 mg, IM) on days -14 and 0, followed by HCG (3000 IU, IM) on day 5. The following treatments were administered: Group A received PMSG on days 2 (4000 IU, IM) and 5 (1000 IU, IV); Group B received PMSG (4000 IU, IM) on day 2; Group C received PMSG (1000 IU, IV) on day; Group D received no PMSG. Mares received progesterone (25 mg, IM) on days 1 through 4. Reproductive tracts were recovered at necropsy on day 16 (10 days post-ovulation). Ovaries were weighed, CL number and weight determined, follicles counted and measured, and volume of follicular fluid quantified. Mean ovarian weight (g) and number of CL per mare, respectively were: Group A, 100.0+/-15.6, 1.7+/-.7; Group B, 128.6+/-40.4, 1.3+/-.7; Group C, 92.4+/-21.0, 2.0+/-.0; Group D, 93.3+/-12.3; .3+/-.3. Mean number of follicles >10 mm and total volume (ml) of follicular fluid per mare, respectively, were: Group A, 9.4+/-2.0, 21.8+/-10.9; Group B, 1.3+/-.3, 32.2+/-28.9; Group C, 4.3+/-1.8, 5.4+/-2.3; Group D, 6.0+/-4.5, 24.0+/-10.3. There was no difference (P>.05) in mean ovarian weight, CL number, CL weight, follicular fluid volume, number of follicles, or size of follicles between treatment groups. These results show no significant effect on ovarian activity in progesterone treated mares following administration of exogenous PMSG.

Effect of progesterone impregnated vaginal sponges and PMSG administration on estrus synchronization in mares.

Estrus synchronization trials with mares were carried out using progesterone impregnated vaginal sponges and pregnant mare serum gonadotropin (PMSG) injections. In Phase 1, 10 non-pregnant, non-lactating mares were administered 1 g progesterone via vaginal sponges (5 x 6 cm) without regard to stage of estrous cycle. Sponges were replaced on day 7 of trial for an additional seven days. On day 12, PMSG (1000 IU, IM) was administered to five mares (Group A); five control mares (Group B) received no injections. There was no difference (P>.05) in estrus synchronization between Group A and Group B. Total sponge retention was 75%. In Phase 2, 11 non-pregnant, non-lactating mares were administered 2 g progesterone via vaginal sponges (10 x 6 cm) without regard to stage of estrous cycle. Sponges were replaced on day 7 of trial for an additional seven days. Estrus behavior was exhibited in 54.5% of mares by day 19. Total sponge retention was 95.4%. There was no difference (P>.05) in estrus synchronization or sponge retention between Phase 1 and Phase 2. The larger Phase 2 sponges showed less (P<.01) posterior movement within the vagina than the smaller Phase 1 sponges.