Breast cancer patients' narrative experiences about communication during the oncology care process: a qualitative study.

To analyse the perception about the information and communication received to evaluate oncologic care of breast cancer patients in Spain. Qualitative study based on conducting in-depth interviews. An inductive thematic analysis of the illness narratives was performed. Intentional theoretical sampling of 41 people diagnosed with breast cancer. The information provided during care process is assessed as appropriate, as it includes personalised skills focused on communication and considers organisational and contextual issues. In some cases, the information was considered partial, heterogeneous and at times contradictory, which revealed a lack of continuity. To provide and adequately cover information needs from the patient perspective, it is necessary to ensure access, both in its physical (material) and intellectual (comprehension) dimension, keeping in mind elements of social capital (social networks) and cultural capital (values, beliefs, non-verbal language) that facilitate or hinder access. The current state of transition to a horizontal model in the doctor-patient relationship, could account for the difficulties, deficits and contradictions in communication and information that breast cancer patients perceive in many contexts.

Peri-Operative Inflammatory Cytokines in Plasma of the Elderly Correlate in Prospective Study with Postoperative Changes in Cognitive Test Scores.

Increasingly, postoperative cognitive dysfunction (POCD) is recognized as a complication after surgery in the elderly; but it's etiology remains unclear. Here we examine changes in cytokine levels during both the pre-operative and postoperative period, comparing them with long term variation in cognitive test scores. Forty-one patients aged 65 and older undergoing major surgery with general anesthesia were recruited after written consent in this IRB approved study. Thirty went on to complete this prospective, non-interven-tional and non-randomized study. Plasma levels of cytokines Il-6, Il-8, Il-10, and TNF were determined using ELISA with MILLIPLEX Multi-Analyte Profiling (Billerica, MA). All subjects had neurocognitive tests pre-operatively and 6 months post-surgery, including Paragraph Recall Immediate and Delayed, Digit Span Forward (DSF) and Backward (DSB), and Trail Making A and B. Spearman's Rho and repeated measure rank analysis were used to examine the dependence of z score changes in cognitive tests (baseline versus 6 months) as a function of 3 cytokine time points (presurgical, post anesthesia care unit (PACU), and post-operative day one (POD1)). A greater increase in PACU inflammatory burden correlated with a greater decline in performance on the DSB (IL6, IL8; r>-0.560; p<= 0.008). DSF changes correlated slightly better with pre-surgical cytokines, declining more with higher cytokines (IL6, r= -0.551, p=0.002; IL8, -0.468, 0.009). TNF, examining all 3 values, changed only slightly postoperatively, but still correlated with a decline in DSB (p=0.014). Thus, cognitive performance, over 6 months post surgery, declines with elevated perioperative inflammation. Specific cytokines at specific perioperative times may impact specific cognitive functions, serving as diagnostics as well as contributing causation.

Induction of labor versus conservative management of pregnant diabetic women.

Reasons for inducing labor at term in pregnancies complicated by diabetes include the avoidance of fetal demise and the prevention of excessive fetal growth and its concomitant conditions, shoulder dystocia and Cesarean delivery. Objectively evaluating the risks and benefits of labor induction is potentially confounded by the status of the cervix at the time of initiation of induction, early determination of an arrest disorder and physician bias toward Cesarean delivery for women who have diabetes. In non-diabetic women, incorporating estimates of fetal weight in deciding the route of delivery has not diminished the incidence of shoulder dystocia, and may have increased the incidence of Cesarean deliveries. Currently available evidence suggests that, while induction of labor for women who have diabetes may not carry much maternal or fetal risk, the benefit of this procedure is unclear.

Irritable bowel syndrome and lactose maldigestion in recurrent abdominal pain in childhood.

BACKGROUND: The aim of this study was to evaluate the impact of irritable bowel syndrome (IBS) and lactose maldigestion in children with recurrent abdominal pain. METHODS: Children who had abdominal pain associated with defecation or change in bowel habit, disordered defecation, and distension were diagnosed with IBS, and lactose maldigestion was defined by lactose breath hydrogen testing. Children with IBS were managed with increased fiber intake, while those with lactose maldigestion restricted dietary lactose. A telephone survey was conducted to determine the response to treatment. RESULTS: The mean age of the 59 boys and 87 girls was 9.5 +/- 3.0 years. Children with IBS and lactose maldigestion had more frequent abdominal pain than children without these conditions, but they required less medication for relief of symptoms. CONCLUSIONS. Lactose maldigestion may be a contributory factor in children with IBS, and lactose avoidance in these patients may reduce medication use to relieve symptoms.

Characterization of failure to imbibe in infants.

The term failure to imbibe is proposed to describe infants with failure to thrive due to poor feeding. Feeding assessment was performed in 128 patients: 43 healthy controls, 53 diseased controls, 12 with nonorganic failure to thrive, and 20 with failure to imbibe. Infants with failure to imbibe required a significantly longer time to feed compared with other infants. In contrast to other infants with nonorganic failure to thrive, patients with failure to imbibe were more likely to need pediatric subspecialty care and nasogastric or gastrostomy tube feeding. Since these patients may have treatable conditions, infants with failure to imbibe merit further investigation.

Aortocoronary saphenous vein bypass aneurysm--an unusual presentation.

Aneurysms of aortocoronary saphenous bypass grafts are an unusual and rare complication of coronary artery bypass surgery. Approximately 30 such cases have been reported in the literature. Atheromatous aneurysms usually appear late (more than 10 years after grafting). They are usually asymptomatic, but may manifest for investigation as a lesion altering the mediastinal contour. We report a further case of an atherosclerotic aortocoronary saphenous vein graft aneurysm in which the patient presented with angina due to aneurysmal compression of the host vessel.

Conscious sedation with high-dose midazolam for pediatric gastrointestinal endoscopy.

BACKGROUND: Midazolam is used frequently to sedate children for gastrointestinal endoscopy. The sedative dosage of intravenous midazolam commonly reported in children is up to 0.3 mg/kg. We hypothesized that larger doses of midazolam could be used for pediatric endoscopy. METHODS: We retrospectively reviewed the medical records of 116 pediatric patients (aged 1 year to 18 years) who had endoscopy. The efficacy and side effects of sedation in 45 patients who received midazolam doses of > or = 0.3 mg/kg were compared with the same effects in 71 children who received < 0.3 mg/kg. RESULTS: All patients received approximately 1 mg/kg meperidine (up to 50 mg) intravenously. The blood pressure, pulse rate, respiratory rate, oxygen saturation, degree and duration of sedation, and incidence of side effects such as hypotension, hypoxia, or vomiting were similar in both groups. CONCLUSIONS: Intravenous doses of midazolam > 0.3 mg/kg can be used for conscious sedation in children.

Comparison of oral sodium phosphate to polyethylene glycol-based solution for bowel preparation for colonoscopy in children.

Thirty-four patients, aged 3 to 17 years, were randomized to receive oral sodium phosphate solution or a polyethylene glycol-based solution in preparation for elective colonoscopy. Nineteen patients received two doses of oral sodium phosphate solution (45 mL/1.7 m2/ dose) and 15 received polyethylene glycol-based solution (4 L/1.7 m2). Compliance with oral sodium phosphate solution was judged as easy or tolerable in 15 of 19 patients, but only in 5 of 15 who were given polyethylene glycol-based solution. The quality of colon cleansing was rated by an endoscopist who was blinded to the colon preparation method used. The bowel preparation was excellent or good (only liquid remaining in the colonic lumen) in 18 of 19 patients who received oral sodium phosphate solution and in 6 of 15 who received polyethylene glycol-based solution. The incidence of vomiting was similar in both groups, but abdominal pain occurred more frequently in the polyethylene glycol-based solution group. Hyperphosphatemia developed in patients who received oral sodium phosphate solution (serum phosphorus = 2.3 +/- 0.7 mmol/L (7.2 +/- 2.2 mg/dL; mean +/- SD), but only in 1 of 15 patients in the polyethylene glycol-based solution group. Patients did not exhibit symptoms of hyperphosphatemia and serum calcium concentrations were similar in both groups. In summary, oral sodium phosphate solution is better tolerated than polyethylene glycol-based solution for bowel preparation in children. However, hyperphosphatemia occurred frequently in patients who received oral sodium phosphate solution. Further studies are needed to determine the optimal dose for safety and efficacy for the use of these solutions in children.

Successful treatment of recurrent non-immune hydrops secondary to fetal hyperthyroidism.

BACKGROUND: Non-immune fetal hydrops is a heterogeneous disorder with a mortality rate of 50-98%. Resolution of non-immune fetal hydrops is rare but has been reported to occur spontaneously or after targeted therapeutic measures. CASE: A euthyroid gravida with Graves disease presented with a history of three prior perinatal deaths between 26 and 28 weeks' gestation, all associated with fetal hydrops. In the current pregnancy, the fetus developed hydrops at 24 weeks' gestation. Fetal hyperthyroidism, with high-output cardiac failure, was diagnosed with fetal blood sampling. After maternal therapy with propylthiouracil, resolution of the non-immune hydrops were documented and a healthy neonate subsequently delivered to term. The neonate developed transient hyperthyroidism after delivery, which required treatment for 10 weeks. CONCLUSION: Non-immune hydrops occurring as a result of fetal hyperthyroidism with high output cardiac failure is treatable with propylthiouracil.

Symptoms of gastritis due to Helicobacter pylori in children.

Infection due to Helicobacter pylori may be associated with gastritis and peptic ulcer disease in children. The aim of this study was to compare the presentation of gastritis due to H pylori with that of gastritis not associated with H pylori infection. The medical records of 296 children who had esophagogastroduodenoscopy were reviewed; 23 (8%) had H pylori gastritis, and 51 had primary gastritis without H pylori infection. Of patients with H pylori, 43% had antral nodularity and 17% had duodenal ulcers. The incidence of epigastric pain, nocturnal pain, postprandial pain, family history of peptic ulcer disease, water brash, vomiting, weight loss, fecal occult blood, and hematemesis was similar between both groups. Periumbilical pain was less common in children with gastritis than epigastric pain, and pain in the periumbilical region was present in only 4% of children with H pylori infection, compared with 31% of patients who had gastritis without H pylori infection. The presence of H pylori should be sought in children having endoscopy for evaluation of upper gastrointestinal mucosal disease.

Disseminated mucormycosis: report of a successfully treated immunosuppressed child with clinical, radiographic and pathological findings.

Disseminated mucormycosis is an uncommon condition with a high mortality rate and is infrequently diagnosed ante mortem. It is most frequently seen in immunosuppressed patients who are at risk for other unusual infections. The radiological features are not specific. We report the case of a 12-year-old girl in second haematological remission who was successfully treated for a brain abscess due to cerebral mucormycosis and for mucormycosis of the kidney which presented as a pyelonephritis. In her first haematological remission she was diagnosed as having a non-specific pneumonitis, which in retrospect may have been due to mucormycosis. Early diagnosis and appropriate management are associated with improved prognosis and require an awareness of the infection and a high index of suspicion.

Early proliferative events following intestinal resection in the rat.

Partial resection of the small intestine results in compensatory proliferation and adaptation in the remaining small intestinal mucosa. The molecular mechanisms governing the proliferative response are not known, nor has the timing of events associated with proliferation been adequately defined, particularly during the period just after resection. We designed experiments to characterize early (within 24 h) proliferative events associated with proximal intestinal resection and sought to determine the cell type that first responds to proliferative stimuli. Twenty-one day old male Sprague-Dawley rats underwent a 70% proximal intestinal resection or transection (control). Poly(A) RNA was isolated from the distal (ileal) remnants. Northern blots showed a marked induction of the immediate early genes zif-268, nup-475, and c-myc 1-3 h following resection, but not following transection. Immunohistochemical analysis of c-myc expression in ileal crypt epithelial cells showed a biphasic induction that was most marked 6 h after resection and less prominent 24 h after resection. Immunostaining with 5-bromodeoxyuridine (5-BrdU) was restricted to ileal crypt nuclei and was maximal 24 h after resection. All these events were observed in the absence of nutrient intake. Taken together, these data show that a potent nutrient-independent stimulus for intestinal epithelial cell proliferation occurs within minutes of partial small intestinal resection and that the first targets of this stimulus are crypt epithelial cells in the residual intestine.

Neural arch tuberculosis: a morbid disease. Radiographic and computed tomographic findings.

We have reviewed the clinical features, together with the radiographs and computerised tomography, in 9 patients with tuberculosis of the vertebral body and neural arch. All presented with paraparesis or paraplegia. The morbidity associated with this disease is so serious that it is essential to have an accurate means of evaluating the lesion as early as possible. Routine radiographs can only indicate the level of the disease and the loss of disc space, but cannot define the full extent of the lesion. Computed tomography shows details of the tuberculous involvement of the neural arch, as well as the vertebral body and spinal canal; the site and extent of the soft tissue lesions can also be seen. This is essential for evaluation of the neural arch involvement which will enable the clinician to select the appropriate treatment, and so prevent neurological complications.

Failure to remove the resected tube in salpingectomy for tubal pregnancy. A case report.

Operative laparoscopy has offered a revolution in gynecologic surgery. However, as with all new techniques, unique complications will be found. We present a case in which the surgical specimen, an ectopic gestation, was set aside while bleeding was addressed. Upon return to where the specimen was placed, it was found that the specimen had "wandered" away and could not be retrieved laparoscopically. Suggestions for the management of this and similar occurrences are offered.

Diagnosis and management of paediatric brainstem gliomas.

A review of paediatric brainstem gliomas (BSGs) treated in the Department of Radiation Oncology of the University of the Witwatersrand teaching hospital group is presented. Eleven patients between the ages of 4 years and 9 years were seen in the period 1982-1992. Of these cases, 9 were diffuse, 1 focal and 1 exophytic; the radiological features classifying these primary brainstem tumours are described. The survival from initiation of treatment was longest for the exophytic type BSG (72 weeks), while little difference in survival between the 9 diffuse type BSGs (mean 21.5 weeks) and the single focal type BSG (21 weeks) was found. The treatment is described and the role of hyperfractionated radiotherapy is reviewed.

Intracranial placement of a nasogastric tube after complex craniofacial trauma.

The complication of intracranial placement of a nasogastric tube in patients with complex facial and skull base fractures is rarely seen. A case report of a patient with complex craniofacial injury after trauma in whom a computerized tomogram scan showed passage of a nasogastric tube via a fracture of the anterior cranial fossa floor into the skull vault is presented. This case stresses the caution to be exercised in the emergency room resusitation of patients with craniofacial injury requiring nasogastric tube placement.