An insight into clinicians' practices in breaking bad news of oral cancer diagnosis.

Communication is an integral component of effective healthcare delivery to patients, and this includes breaking bad news (BBN). However, clinicians in dentistry are rarely exposed to diseases that can negatively and seriously affect an individual's view of their future and pose a mortality risk, except for oral cancer. The aim of this study was to assess clinician practices in BBN of oral cancer diagnosis in Malaysia. An exploratory sequential mixed-methods study design was used. A qualitative study was conducted among 12 clinicians to gather relevant information regarding their practices in BBN of oral cancer diagnosis using a descriptive-interpretive approach. The themes that emerged were preparation for BBN, BBN setting, communication, emotional aspects, and summarizing the session. These themes were used to develop a questionnaire with 34 items. In the quantitative study, this questionnaire was sent to 87 clinicians who had experienced BBN of oral cancer diagnosis in the past 5 years; the response rate was 100%. An arbitrary cut-off score between the third and fourth quartiles was set to distinguish 'good' and 'poor' practice in BBN among the clinicians. The data analysis was performed using IBM SPSS Statistics version 23.0. Overall, at least two-thirds of the clinicians had good practices in BBN of oral cancer diagnosis. The clinicians' designation (oral and maxillofacial surgery consultant/specialist vs dental officer) and BBN experiences were factors associated with their practices in BBN of oral cancer diagnosis.

Genomic Degeneration and Reduction in the Fish Pathogen Mycobacterium shottsii.

Mycobacterium shottsii is a dysgonic, nonpigmented mycobacterium originally isolated from diseased striped bass (Morone saxatilis) in the Chesapeake Bay, USA. Genomic analysis reveals that M. shottsii is a Mycobacterium ulcerans/Mycobacterium marinum clade (MuMC) member, but unlike the superficially similar M. pseudoshottsii, also isolated from striped bass, it is not an M. ulcerans ecovar, instead belonging to a transitional group of strains basal to proposed "Aronson" and "M" lineages. Although phylogenetically distinct from the human pathogen M. ulcerans, the M. shottsii genome shows parallel but nonhomologous genomic degeneration, including massive accumulation of pseudogenes accompanied by proliferation of unique insertion sequences (ISMysh01, ISMysh03), large-scale deletions, and genomic reorganization relative to typical M. marinum strains. Coupled with its observed ecological characteristics and loss of chromogenicity, the genomic structure of M. shottsii is suggestive of evolution toward a state of obligate pathogenicity, as observed for other Mycobacterium spp., including M. ulcerans, M. tuberculosis, and M. leprae. IMPORTANCE Morone saxatilis (striped bass) is an ecologically and economically important finfish species on the United States east coast. Mycobacterium shottsii and Mycobacterium pseudoshottsii were originally described in the early 2000s as novel species from outbreaks of visceral and dermal mycobacteriosis in this species. Biochemical and genetic characterization place these species within the Mycobacterium ulcerans/M. marinum clade (MuMC), and M. pseudoshottsii has been proposed as an ecovar of M. ulcerans. Here, we describe the complete genome of M. shottsii, demonstrating that it is clearly not an M. ulcerans ecovar; however, it has undergone parallel genomic modification suggestive of a transition to obligate pathogenicity. As in M. ulcerans, the M. shottsii genome demonstrates widespread pseudogene formation driven by proliferation of insertion sequences, as well as genomic reorganization. This work clarifies the phylogenetic position of M. shottsii relative to other MuMC members and provides insight into processes shaping its genomic structure.

Changes in health-related quality of life of oral cancer patients treated with curative intent: experience of a developing country.

This study aimed to assess changes in oral cancer patients' health-related quality of life (HRQOL) and the impact of disease stage on HRQOL scores. HRQOL data were collected from seven hospital-based centres using the Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) version 4.0 instrument. The independent samples t-test, χ2 test, and paired samples t-test were used to analyse the data. A total of 300 patients were recruited. The most common oral cancer sub-site was tongue and floor of mouth (42.6%). Surgical intervention (41.1%) was the most common treatment modality. Significant differences in ethnicity and treatment modality were observed between early and late stage patients. Pre-treatment HRQOL scores were significantly lower for late than early stage patients. At 1 month post-treatment, the functional and head and neck domains and the FACT-H&N (TOI) summary scores showed significant deterioration in both early and late stage patients. In contrast, the emotional domain showed a significant improvement for early and late stage patients at 1, 3, and 6 months post-treatment. Although HRQOL deterioration was still observed among early and late stage patients at 6 months post-treatment, this was not statistically significant. In conclusion, advanced disease is associated with poorer HRQOL. Although ethnic differences were observed across different disease stages, the influence of ethnicity on patient HRQOL was not evident in this study.

The feasibility of using Patients Concerns Inventory (PCI) in managing Malaysian oral cancer patients.

The feasibility of using the Patients Concerns Inventory (PCI) to identify oral cancer patient concerns during consultation in oral and maxillofacial specialist clinics in Malaysia was assessed. A cross-sectional study was conducted using a consecutive clinical sampling technique of all new and follow-up oral cancer patients. Surgeons and counter staff were also recruited. Two-thirds of patients were elderly, 63.9% female, 55.6% Indian, 63.9% of lower-level education, and half had the lowest level household income. Patient status was mostly post-treatment (87.5%) and most were at cancer stage III/IV (63.9%); 59.7% had surgery. Patients took an average 5.9 min (95% CI 5.1-6.7 min) to complete the PCI. Physical domain appeared highest (94.4%); social/family relationship issues (4.2%) were lowest. Significant associations included patient age-personal function (P=0.02); patient education level-emotional status (P=0.05) and social/family relationship issues (P=0.04), and patient TNM staging-personal function (P=0.03). The patients' mean feasibility score for the PCI was 5.3 (95% CI 5.1-5.5) out of 6. Patients (93.1%) and surgeons (90%) found the PCI to be feasible. Only 57.1% of counter staff agreed on the use of the PCI during patient registration. Overall, the PCI was considered feasible, thus favouring its future use in routine oral cancer patient management.

Attitudes towards the use of fluorides for oral health among Islamic clerics in Kelantan Province, Malaysia.

OBJECTIVE: To assess the knowledge, attitudes and practices of Imams (Islamic clerics) concerning fluoride toothpaste and fluoridated water to improve oral health in Kelantan. BASIC RESEARCH DESIGN: Cross sectional study of Imams in 65 registered mosques in Pasir Puteh district, Kelantan. METHOD AND PARTICIPANTS: Face-to-face interview, using structured questionnaire and some open ended questions. RESULTS: Most of the 83 interviewees (82% participation rate) were unsure whether their toothpaste contained fluoride (64%), only 25% were sure. More than one-third (37%) were using fluoridated piped water. Most (87%) had little knowledge of fluorides and more than two-thirds (69%) had lacked positive attitudes towards its use. Television (54%) was the most common source of information about fluorides, followed by newspapers (9%). The main reasons given among the few who opposed fluoride use were i) fear of dangerous side effects (4%) and ii) uncertainty about the halal status of fluoride (2%), Attitudes were not associated with the use of fluoridated water supply (p=0.999), age (p=0.103), income (p=0.540) and location (p=0.999). CONCLUSION: Over two-thirds of Imams had little knowledge of and lacked positive attitudes towards fluoride use in toothpaste and piped water supplies.

Validity of the FACT-H&N (v 4.0) among Malaysian oral cancer patients.

To assess the cross-sectional construct validity of the Malay-translated and cross-culturally adapted FACT-H&N (v 4.0) for discriminative use in a sample of Malaysian oral cancer patients. A cross-sectional study of adults newly diagnosed with oral cancer. HRQOL data were collected using the FACT-H&N (v 4.0), a global question and a supplementary set of eight questions ('MAQ') obtained earlier in pilot work. Of the 76 participants (61.8% female; 23.7% younger than 50), most (96.1%) had oral squamous cell carcinoma; two-thirds were in Stages III or IV. At baseline, patients' mean FACT summary (FACT-G, FACT-H&N, FACT-H&N TOI, and FHNSI) and subscale (pwb, swb, ewb, fwb, and hnsc) scores were towards the higher end of the range. Equal proportions (36.8%) rated their overall HRQOL as 'good' or 'average'; fewer than one-quarter rated it as 'poor', and only two as 'very good'. All six FACT summary and most subscales had moderate-to-good internal consistency. For all summary scales, those with 'very poor/poor' self-rated HRQOL differed significantly from the 'good/very good' group. All FACT summary scales correlated strongly (r>0.75). Summary scales showed convergent validity (r>0.90) but little discriminant validity. The discriminant validity of the FHNSI improved with the addition of the MAQ. The FACT-H&N summary scales and most subscales demonstrated acceptable cross-sectional construct validity, reliability and discriminative ability, and thus appear appropriate for further use among Malaysian oral cancer patients.

A matched case-control study: investigating the relationship between youth assets and sexual intercourse among 13- to 14-year-olds.

BACKGROUND: The number of teenagers engaging in sexual intercourse has consistently changed over the past several years. This can become a major challenge when trying to determine why teens continue to have sex. The purpose of this paper was to investigate the relationship between youth assets and sexual intercourse among 13- to 14-year-olds. METHODS: Cross-sectional data were collected using in-person at-home interviews from a random sample of inner-city neighbourhood 13- to 14-year-old teenagers (n = 64 matched pairs; 36% 13-year-olds, 53% female, 45% white, 28% African-American, 16% Hispanic and 11% Native American). Nine individual youth assets were analysed using conditional logistic regression (matching for several demographic variables) to assess the association between assets and abstinence in younger teens. RESULTS: Conditional logistic regression analyses showed that two assets, positive Peer Role Models [odds ratios (OR) = 4.67, 95% confidence intervals (CI) = 1.93, 11.27] and Use of Time (Religion) (OR = 2.20, 95% CI = 1.04, 4.65), were significantly related (P < 0.05) to younger teens never having engaged in sexual activity. CONCLUSION: These findings suggest, when considering abstinence behaviour, involvement in religious activities and having positive peer role models appear to be protective factors related to delaying sexual intercourse among teens aged 13-14 years.

Mutations in the gene encoding c-Abl-binding protein SH3BP2 cause cherubism.

Cherubism (MIM 118400) is an autosomal dominant inherited syndrome characterized by excessive bone degradation of the upper and lower jaws followed by development of fibrous tissue masses, which causes a characteristic facial swelling. Here we describe seven mutations in the SH3-binding protein SH3BP2 (MIM 602104) on chromosome 4p16.3 that cause cherubism.

A randomized, controlled trial of oral and intramuscular dexamethasone in the prevention of neonatal respiratory distress syndrome.

OBJECTIVE: The study's objective was to compare the efficacies of oral and intramuscular antenatal administration of dexamethasone in reducing neonatal respiratory distress syndrome. STUDY DESIGN: Subjects at high risk for preterm delivery between 24 and 33 weeks' gestation were prospectively randomly assigned to receive either 6 mg intramuscular dexamethasone or 8 mg oral dexamethasone every 12 hours for 4 doses. The regimen was repeated weekly until 34 weeks' gestation if delivery had not yet occurred. A blinded data review was performed. The primary outcome of the trial was respiratory distress syndrome. Data were analyzed in an intent to treat fashion. Comparisons were made with an unpaired t test, chi2 or Fisher exact test, and survival analysis. P <.05 was considered significant. RESULTS: The study was discontinued at 39% enrollment after a blinded review of available outcomes. A total of 170 women with 188 fetuses were randomly assigned. The oral and intramuscular groups had similar mean gestational ages at enrollment (29.9 weeks vs 29.2 weeks) and similar median latencies (9.5 vs 10 days). No difference in the frequency of respiratory distress syndrome was found between the oral and intramuscular groups, (34.3% vs 29.8%). Neonatal sepsis (10.1% vs 1.2%, P =.01) and intraventricular hemorrhage (10.1% vs 2. 4%, P =.04) were significantly higher in the oral group. There were no statistical differences in the frequencies of necrotizing enterocolitis or neonatal death. A subgroup analysis of 112 patients who were delivered at <34 weeks' gestation revealed no statistical difference in respiratory distress syndrome between the groups; however, oral dexamethasone was associated with a significant increase in sepsis (15.9% vs 1.6%, P =.009) and intraventricular hemorrhage (15.9% vs 3.3%, P =.03). CONCLUSION: Oral administration increases neonatal morbidity without demonstrable benefit and should not at this time be used clinically for induction of fetal pulmonary maturation.

Comparison between oral and intramuscular dexamethasone in suppressing unconjugated estriol levels during the third trimester.

OBJECTIVES: Unconjugated estriol production depends on fetal adrenal androgen precursors. Fetal exposure to exogenous glucocorticoids results in adrenal suppression with a subsequent decrease in maternal serum unconjugated estriol levels. We compared the efficacy between oral and intramuscular dexamethasone in maternal serum unconjugated estriol suppression at 48 hours after the initial dose among women at risk for preterm delivery. STUDY DESIGN: Twenty-four gravidas at risk for preterm delivery were randomized to receive either 6 mg intramuscular or 8 mg oral dexamethasone every 12 hours for a total of 4 doses. Blood samples (9 mL) were obtained before the initial dexamethasone administration and again after the fourth dose. Serum was separated and frozen at -70 degreesC and subsequently underwent batch analysis. Unconjugated estriol levels were determined by radioimmunoassay with intra-assay and interassay coefficients of variation of 7.9% and 5.5%, respectively. All values are reported as mean +/- SD. The primary statistical analysis was a t test, with P <.05 considered significant. RESULTS: At the time of dexamethasone administration, gestational ages in both groups were similar. Predexamethasone and postdexamethasone unconjugated estriol levels were also similar between the intramuscular and oral groups (5.39 +/- 3.99 vs 1.80 +/- 2.49 ng/mL and 6.05 +/- 3.00 vs 1.61 +/- 1.03 ng/mL, respectively, P >.05). No difference in percent decrease in unconjugated estriol levels was found between the intramuscular (0.67 +/- 0.24) and oral (0.65 +/- 0.39) groups. CONCLUSION: Oral dexamethasone (8 mg) produces similar maternal serum unconjugated estriol suppression compared with intramuscular dexamethasone (6 mg) when evaluated 48 hours after administration.

Immunohistochemical localization of chromogranin A in endocrine tissues and endocrine tumors of dogs.

Chromogranin A is present in the secretory granules of endocrine cells and functions in hormone packaging, secretory granule stabilization, and regulation of hormone secretion. Immunohistochemical identification of chromogranin A can facilitate diagnosis of endocrine neoplasia. Normal and neoplastic canine tissues were stained immunohistochemically for chromogranin A. Staining of normal endocrine tissues demonstrated chromogranin A in chromaffin cells of the adrenal medulla, C cells of the thyroid gland, and pancreatic islets. The parathyroid chief cells and anterior pituitary stained lightly positive for chromogranin A. Pheochromocytomas (7/7), chemodectomas (5/7), islet cell carcinomas (2/6), pituitary adenomas (4/6), parathyroid adenomas (3/7), and a C-cell carcinoma (1/1) stained positive for chromogranin A. The data indicate that chromogranin A is widely distributed in canine endocrine tissues, and immunohistochemical staining of chromogranin A can be used to confirm the presence of secretory granules in endocrine tumors.

Psoriatic arthritis of the temporomandibular joints with ankylosis. Literature review and case reports.

Psoriatic arthritis is currently defined as psoriasis associated with chronic, erosive inflammatory arthritis, which is seronegative for rheumatoid factor. A review of the etiology, pathogenesis, diagnosis, and treatment is accompanied by two unusual case reports of psoriatic arthritis affecting the temporomandibular joints with ankylosis.

Total implants for hyperthermia application and thermometry.

Tests have been performed in saline phantoms on a 6.78 MHz hyperthermia applicator designed for complete implantation; no conductors would penetrate the skin following the implant procedure. Energy is coupled across the skin from an external to an internal loop antenna: the latter is connected by transmission line to conventional r.f. tissue electrodes which are typically either parallel plates or arrays of cylindrical pins. In phantoms the technique produces deep, localized heating at a selected site without significant hearing at the 'subdermal' receiving antenna near the surface. In addition, the hyperthermia applicator may have potential as an indicator of temperature for the tissue volume at the deep site, since complex impedance at the external antenna is a function of tissue resistivity/temperature at the electrodes. Specifically, temperature at the deep site can be controlled effectively by regulation of the phase angle between voltage and current at the external antenna. A separate passive implantable electromagnetic-reflectance thermometer, energized by external electromagnetic fields, has been designed. This device, also tested in gel and water phantoms, is energized and interrogated by external r.f. fields and tracks a thermocouple to within +/- 0.1 degree C over the range of interest in clinical hyperthermia. The intended application for these devices is repeated, long-term hyperthermic treatment and thermometry of deep-seated malignant tumours following a single invasive procedure.

Completely implantable hyperthermia applicator with externalized temperature monitoring: tests in conductive gel.

Development is underway on a hyperthermia applicator intended for complete implantation and long-term use. Radio frequency energy is transmitted from an external antenna to a closely coupled subdermal antenna. This internal antenna is connected via a transmission line to deeply implanted electrodes. Changes in temperature at the electrodes result in a change in tissue resistivity which modifies the complex impedance seen at the external antenna terminals. This variation in antenna impedance (magnitude and/or phase angle) can, in principle, be utilized to indirectly monitor and regulate tissue temperature at the electrode location. Test results from conductive-gel tissue phantom experiments are presented.

Simulation of automatic temperature control in tissue hyperthermia calculations.

Calculations of transient tissue temperature distributions are enhanced by the use of an algorithm to simulate automatic temperature regulation by negative feedback. This feature is quite useful in treatment planning, enabling the physicist to predict the effects on the treatment of variations in temperature regulation system parameters, such as temperature sensor placement and feedback loop gain.

Calculation of electric fields in conductive media.

A method is presented, based upon finite-difference forms of Laplace's equation, for the iterative calculation of three-dimensional electric field distributions in electrically conductive media. The method, while generally applicable to any conductive media, will be presented with emphasis on its use for the prediction of power density in tissue when radio-frequency hyperthermia is utilized in the treatment of cancer. A computer code which performs these calculations has been written in BASIC so that is may be adapted to relatively inexpensive desktop computers for use in treatment planning. Example calculations of the distributions of electric potential, gradient, and power density with specific electrode configurations are presented. Applications and limitations of the technique are discussed.

A new model for the assessment of regional ventricular wall motion.

A new model is proposed for the quantitative analysis of segmental left ventricular wall motion from contrast left ventriculograms and scintigraphic cardiac-gated blood-pool images. This model was tested in dogs using implanted lead beads in the myocardium and contrast left ventriculography. Measured values of bead position and displacement were in good agreement with the estimated values determined by the model. Segmental left ventricular wall motion was also measured in 21 patients in whom both cardiac-gated blood-pool scintigrams and contrast left ventriculograms were obtained within minutes of one another. Wall motion values obtained using the end diastolic and end systolic frames of the gated blood-pool studies and the contrast left ventriculograms correlated favorably in the 60 degrees left anterior oblique view.

Intestinal parasites in Southeast Asian refugees.

A survey of intestinal parasitism in 6,241 Southeast Asian refugees (3,576 males and 2,665 females) indicated that 32.9 percent of the refugees had one or more intestinal parasites. A total of 1,178 (57.3 percent) males and 878 (42.7 percent) females harbored the parasites, with helminths representing the most frequent isolate. Intestinal parasitic infections may be considered minimal public health threats in the United States because of effective hygienic practices and sanitation facilities. However, it is important to emphasize that the attack rate also will be influenced by continued health education, job activities, and diagnosis and treatment of the refugees for these parasites.

Preliminary report of Los Alamos Keratoplasty Techniques.

We have found that intrastromal diathermy heat to the cornea spares the epithelium and endothelium, while preferentially allowing contraction of the midstromal corneal collagen. Extensive animal studies have demonstrated a potentially useful dosage range for primate corneal diathermy. We have initiated cautious preliminary human studies utilizing the Los Alamos Keratoplasty unit in the last 12 months to reshape the corneas of keratoconus patients who were referred for penetrating keratoplasty. The steepest area of the cone may be flattened from 4 to 57 diopters, thereby allowing a return to contact lens use. We recommend the technique of Los Alamos Keratoplasty as an alternative to penetrating keratoplasty in patients who have been successful in contact lens wear, but whose cone progression precludes continued satisfactory fitting. The procedure appears effective in this preliminary study. The eventual safety and long-them efficacy of this experimental keratorefractive surgical technique requires extensive further study.