The feasibility of a randomised control trial to assess physiotherapy against surgery for recurrent patellar instability.

BACKGROUND: Patellar instability is a relatively common condition that leads to disability and restriction of activities. People with recurrent instability may be given the option of physiotherapy or surgery though this is largely driven by clinician preference rather than by a strong evidence base. We sought to determine the feasibility of conducting a definitive trial comparing physiotherapy with surgical treatment for people with recurrent patellar instability. METHODS: This was a pragmatic, open-label, two-arm feasibility randomised control trial (RCT) with an embedded interview component recruiting across three NHS sites comparing surgical treatment to a package of best conservative care; 'Personalised Knee Therapy' (PKT). The primary feasibility outcome was the recruitment rate per centre (expected rate 1 to 1.5 participants recruited each month). Secondary outcomes included the rate of follow-up (over 80% expected at 12 months) and a series of participant-reported outcomes taken at 3, 6 and 12 months following randomisation, including the Norwich Patellar Instability Score (NPIS), the Kujala Patellofemoral Disorder Score (KPDS), EuroQol-5D-5L, self-reported global assessment of change, satisfaction at each time point and resources use. RESULTS: We recruited 19 participants. Of these, 18 participants (95%) were followed-up at 12 months and 1 (5%) withdrew. One centre recruited at just over one case per month, one centre was unable to recruit, and one centre recruited at over one case per month after a change in participant screening approach. Ten participants were allocated into the PKT arm, with nine to the surgical arm. Mean Norwich Patellar Instability Score improved from 40.6 (standard deviation 22.1) to 28.2 (SD 25.4) from baseline to 12 months. CONCLUSION: This feasibility trial identified a number of challenges and required a series of changes to ensure adequate recruitment and follow-up. These changes helped achieve a sufficient recruitment and follow-up rate. The revised trial design is feasible to be conducted as a definitive trial to answer this important clinical question for people with chronic patellar instability. TRIAL REGISTRATION: The trial was prospectively registered on the International Standard Randomised Controlled Trial Number registry on the 22/12/2016 (reference number: ISRCTN14950321). http://www.isrctn.com/ISRCTN14950321.

Technical report: lymph node enhancement at MRI with MnDPDP in primary hepatic carcinoma.

AIMS: To report two cases of lymph node enhancement in primary hepatic carcinoma following the administration of Mangafodipir trisodium (MnDPDP, Teslascan(R), Nycomed Amersham U.K.), an hepatocyte specific magnetic resonance imaging (MRI) contrast agent. To review our experience with this contrast agent and the literature to establish if such enhancement occurs in normal lymph nodes or has been previously described in hepatocellular carcinoma (HCC) or other lesions. MATERIALS AND METHODS: The radiological reports of all MnDPDP enhanced abdominal MRI examinations were reviewed for lymph node enlargement. The MR images from examinations with reported nodal enlargement were re-evaluated for evidence of nodal enhancement and the hospital notes and histological reports were reviewed. Nodal enhancement was considered present if lymph node signal intensity was greater than that of the spleen following MnDPDP. Literature searches were performed on Medline and PubMed for previous descriptions of lymph node enhancement following MnDPDP. RESULTS: The reports of 90 MnDPDP abdominal MRI examinations were reviewed. Of 18 cases of lymph node enlargement, two had evidence of lymph node enhancement following MnDPDP. These two cases had hepatocellular carcinoma and fibrolamellar hepatocellular carcinoma, respectively, confirmed on liver biopsy. No reports of lymph node enhancement following MnDPDP were identified in the literature. CONCLUSION: Two cases of lymph node enhancement following MnDPDP have been presented. Although histological confirmation of the lymph nodes was not obtained, the authors propose that the lymph node enhancement was due to functioning hepatocytes in lymph node metastases from the patients' histologically confirmed hepatocellular carcinomas. Burkill, G. J. C., Mannion, E. M. & Healy, J. C. (2001). Clinical Radiology56, 67-71.

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival.

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.

Well-differentiated squamous cell carcinoma of the eyelid arising during a 20-year period.

An 81-year-old man had a keratotic eyelid lesions for 20 years. He eventually sought treatment by ophthalmic plastic surgery. Clinically, the lesion resembled a keratoacanthoma. Findings from histologic examination of the excision biopsy specimen showed a squamous cell carcinoma. The lesion was completely excised. This case demonstrates the difficulty in making a correct clinical diagnosis of a keratotic eyelid lesion. Performing a histologic examination of nonregressed keratotic lesions is essential to exclude a squamous cell carcinoma.

The current role of surgery in the management of residual disease.

The increasing interest in surveillance rather than primary retroperitoneal lymph node dissection for clinical stage I testis cancer has led to retroperitoneal lymph node dissection being performed mostly after chemotherapy for stage II-IV disease. In most centres residual masses of 2-3 cm or more are removed; those smaller than this are most likely to be necrotic. The aim is to remove all residual disease even if this necessitates nephrectomy or excision of adjacent vascular structures. Laparoscopic approaches are hazardous in these circumstances. Thoraco-abdominal surgical approaches enable excellent access to retroperitoneal masses and synchronous excision of ipsilateral pulmonary metastases and thoracic lymph nodes. Retroperitoneal lymph node dissection also appears to be worthwhile in chemotherapy-resistant disease ('desperation retroperitoneal lymph node dissection'), although the relapse rate is higher in this group.

Solitary fibrous tumour of the deep soft tissues of the neck.

A case of a solitary fibrous tumour arising in the deep soft tissues of the neck is reported. This rare tumour has not previously been described in this site. We discuss the clinical presentation and pathological features.

Community care for adults with Williams syndrome: how families cope and the availability of support networks.

A study of the adjustment difficulties and needs of 70 adults with Williams syndrome found that the majority continued to live at home and remained heavily dependent on their families for their self-care. Twenty-nine families (41.4%) had had no contact with a social worker in the preceding 2 years, and 34 out of the 48 families whose children still lived at home (70.8%) had no access to respite care. Advice regarding benefits, and appropriate living and occupational arrangements for the adults was also patchy. Despite progressive medical problems, and high rates of behavioural and emotional difficulties, only 20 adults (29%) were receiving regular health checks, while 21 (30%) had had some contact with a mental health service in the preceding 2 years. In the majority of cases, families continued to shoulder the main burden of care for their sons and daughters with Williams syndrome well into adulthood, with little support from statutory and voluntary agencies. The implications of these findings are considered with regard to the principles of community care.

Reducing the culture clash in family-provider relationships: a bilateral perspective.

This chapter uses the concept of culture clash to take a fresh look at the slow progress toward family-provider collaboration. The authors discuss an intervention that targets both family culture and provider culture.

Increased contact with community mental health resources as a potential benefit of family education.

OBJECTIVE: This study examined the hypothesis that families of adults with severe mental illness who participate in either a group family education workshop or individual family consultation will try to seek more assistance from community services than those in a control group assigned to a waiting list. METHODS: A total of 225 family members who agreed to participate in the study were randomly assigned to one of three conditions: a ten-week group workshop, individual family consultation, or a waiting list (control group). Family members were interviewed about the extent of their contact with mental health professionals, providers, and community resources at baseline, termination of the interventions, and at six months after termination. RESULTS: No differences were found between conditions in the extent of family members' contact with three types of services: conventional, psychosocial, and ancillary mental health services. CONCLUSIONS: Neither of the educational interventions produced any change in behaviors of families seeking advice and assistance on behalf of their ill relative from the three types of services examined. Modifications in the interventions may be worthwhile. Increasing family members' contacts with community resources on behalf of their ill relative may increase the benefits of the intervention to the family as well as to the ill relative.

N-acetyltransferase 2 genotype in colorectal cancer and selective gene retention in cancers with chromosome 8p deletions.

BACKGROUND: Genetic polymorphisms in N-acetyltransferase (NAT2) can change the normally fast acetylation of substrates to slow acetylation, and have been associated with the development of some cancers. The NAT2 locus may also suffer dysregulation during cancer progression, as the gene resides on chromosome 8p22, a region which is frequently deleted in colorectal cancer. SUBJECTS AND METHODS: A polymerase chain reaction based method was used to determine NAT2 genotype in 275 patients with colon cancer and 343 normal control DNAs. Within the cancer group, 65 cases known to contain deletions in chromosome 8p were examined for loss of heterozygosity at the NAT2 locus. RESULTS: Overall, there was no statistical difference in frequency or distribution of NAT2 alleles and genotype between colon cancer and control groups. There was a significant association between the slow acetylation genotype and early age of onset. NAT2 genotype did not vary with other clinical features of colon cancer, which included Dukes's stage, site of tumour, and sex. Of 48 informative cases, only three (6%) showed loss of heterozygosity, indicating that the NAT2 locus is not commonly deleted in colorectal cancer. This suggests that NAT2 is retained during the process of allele loss possibly because of its proximity to a gene necessary for cell viability. CONCLUSIONS: NAT2 does not play a major role in colorectal cancer risk, but may influence risk in some age groups. The nature of the loss of heterozygosity at the chromosome 8p site is complex and is worthy of further study.

Effectiveness of two models of brief family education: retention of gains by family members of adults with serious mental illness.

The retention of benefits from two models of family education was compared with maturational effects in an untreated control group. The three-month interventions showed an initial effect for self-efficacy regarding a mentally ill relative that did not significantly diminish during the following six months. However, no significant differences on this measure were found between the treated groups and the untreated controls. Ways of refining the interventions and measures so as to improve gains and retain them over time are discussed.

Applying research on family education about mental illness to development of a relatives' group consultation model.

Results from a random field trial of family education interventions were applied to create a new model of family education programs. This paper reviews the family education literature, the random field trial results, and the pre-piloting of an adapted service model called group consultation. The new model emphasizes a more interactive approach to the conventional group workshop model as opposed to adherence to a pre-planned curriculum. Pre-pilot group participants were all past members of group workshops. In a process evaluation these group members were questioned about their reactions to the new group format and its usefulness.

Impact of brief family psychoeducation on self-efficacy.

One hundred eighty-three relatives of people with serious mental illnesses were randomly assigned to receive individualized consultation or group psychoeducation or were placed on a 9-month wait list. Analysis of variance and multiple regression revealed that the individualized consultation increased the family members' sense of self-efficacy regarding mentally ill relatives. Group psychoeducation was helpful in increasing self-efficacy of family members who had never participated in a support or advocacy group for relatives of psychiatrically disabled individuals.

Designing psychoeducational services for spouses of persons with serious mental illness.

Psychoeducational and support groups for families of mentally ill adults may not be adequately addressing the needs of spouses with mentally ill partners. This paper describes a group psychoeducational approach which has been developed and implemented through collaboration between professionals and well spouses. The high attrition of spouses in a general family psychoeducational group was dramatically reduced in this spouse psychoeducational group. Significant improvements were found in well spouse knowledge about the illness and coping strategies, personal distress, and negative attitudes towards the ill spouse over the 3-month intervention and at 1-year followup. Implications for practitioners and researchers are discussed.