Archetypes of incomplete stories in chronic illness medical encounters.

OBJECTIVE: During encounters, patients and practitioners engage in conversations to address health concerns. Because these interactions are time-pressured events, it may be inevitable that any story exchanged during these encounters will be incomplete in some way, potentially jeopardizing how quality and safety of care is delivered. In this study, we explored how and why incomplete stories might arise in health interactions. METHODS: Constructivist grounded theory methodology was used to explore how patients and practitioners approach their interactions during encounters. In this two-phase study, we interviewed patients (n = 21) then practitioners (n = 12). RESULTS: We identified three distinct archetypes of incomplete storytelling - the hidden story, the interpreted story, and the tailored story. Measured information sharing, triadic encounters and pre-planned agendas influenced these storylines, respectively. CONCLUSION: Both patient and practitioner participants focused on what each considered important, appropriate, and useful for productive encounters. While incomplete stories may be a reality, educating practitioners about how incomplete stories come about from both sides of the conversation creates new opportunities to optimize interactions at medical encounters for in-depth patient practitioner storytelling.

Neurocytomas: long-term experience of a single institution.

There is a lack of studies reporting on outcomes of control and treatment toxicities for neurocytomas. A 25-year retrospective review of a tertiary center's experience with neurocytomas was completed to report on these outcomes. All cerebral neurocytoma cases (19 patients; median age, 31 years; range, 18-62 years; 18 intraventricular and 1 extraventricular) treated between 1984 and 2009 were analyzed, including central pathology and radiology reviews. Median follow-up was 104.5 months (range, 0.75-261.7 months). Primary treatment was surgery alone (n = 18 patients), followed by surgery and adjuvant radiotherapy (n = 1). The crude local control rate after surgery was 68% for all cases (cerebral neurocytomas) and 74% for central neurocytomas. Salvage therapies included further surgery (n = 4), radiation (n = 3), and chemotherapy (n = 1). Ten-year Kaplan-Meier overall and relapse-free survival rates were 82% and 62% and 81% and 57%, respectively, for all cases and for central neurocytomas only. The median overall survival and relapse-free survival were 104.5 and 79.3 months, respectively, for all cases and for central neurocytomas. Ten patients had grade 3/4 toxicity, and 1 patient had a grade 5 perioperative hemorrhage that resulted in death 23 days after surgery. Late grade 3/4 toxicities occurred in 9 patients. Three patients had permanent grade 2 motor or cognitive deficits. We provide the first report outlining toxicities and survival outcomes in a series of 19 patients. Our experience suggests that initial surgery provides durable local control rates in two-thirds of patients, with low risk for significant permanent deficits. Salvage therapy with surgery and/or radiation provides durable local control in tumors that recur after surgery.

Low-grade glioma: correlation of short echo time 1H-MR spectroscopy with 23Na MR imaging.

BACKGROUND AND PURPOSE: There is considerable variability in the clinical behavior and treatment response of low-grade (WHO grade II) gliomas. The purpose of this work was to characterize the metabolic profile of low-grade gliomas by using short echo time (1)H-MR spectroscopy and to correlate metabolite levels with MR imaging-measured sodium ((23)Na) signal intensity. Based on previous studies, we hypothesized decreased N-acetylaspartate (NAA) and increased myo-inositol (mIns), choline (Cho), glutamate (Glu), and (23)Na signal intensity in glioma tissue. MATERIALS AND METHODS: Institutional ethics committee approval and informed consent were obtained for all of the subjects. Proton ((1)H-MR) spectroscopy (TR/TE = 2200/46 ms) and sodium ((23)Na) MR imaging were performed at 4T in 13 subjects (6 women and 7 men; mean age, 44 years) with suspected low-grade glioma. Absolute metabolite levels were quantified, and relative (23)Na levels were measured in low-grade glioma and compared with the contralateral side in the same patients. Two-sided Student t tests were used to test for statistical significance. RESULTS: Significant decreases were observed for NAA (P < .001) and Glu (P = .004), and increases were observed for mIns (P = .003), Cho (P = .025), and sodium signal intensity (P < .001) in low-grade glioma tissue. Significant correlations (r(2) > 0.25) were observed between NAA and Glu (P < .05) and between NAA and mIns (P < .01). Significant correlations were also observed between (23)Na signal intensity and NAA (P < .01) and between (23)Na signal intensity and Glu (P < .01). Ratios of NAA/mIns, NAA/(23)Na, and NAA/Cho were altered in glioma tissue (P < .001); however based on the t statistic, NAA/(23)Na (t = 9.6) was the most significant, followed by NAA/mIns (t = 6.1), and NAA/Cho (t = 5.0). CONCLUSION: Although Glu concentration is reduced and mIns concentration is elevated in low-grade glioma tissue, the NAA/(23)Na ratio was the most sensitive indicator of pathologic tissue.

Commissural myelotomy for intractable cancer pain: report of two cases.

PATIENTS: We describe two patients with cancer-related low back and bilateral lower extremity pain that failed pharmacologic treatment. RESULTS: In both cases, commissural myelotomy provided significant pain relief. The role of myelotomy in the management of cancer pain is discussed.

Loss of heterozygosity analysis of chromosomes 9, 10 and 17 in gliomas in families.

BACKGROUND: Studies of sporadic malignant gliomas have identified structural abnormalities in a number of chromosomal regions, especially losses of DNA on 9p, 10 and 17p. PURPOSE: We undertook the following molecular analysis in families with glioma to determine the frequency of chromosomal losses in these regions and to test the utility of microsatellite markers in demonstrating losses of heterozygosity. METHODS: Genomic DNA was extracted from tumor tissue and venous blood from 20 patients with a family history of glioma. Dinucleotide repeat polymorphisms (microsatellites) were analyzed by polymerase chain reaction to assess loss of constitutional heterozygosity (LOH) on 9p, 10 and 17p. Three polymorphic markers on chromosome 9 (D9S104, D9S161, D9S165), one on chromosome 10 (D10S209), and two on 17p (D17S786, D17S796) were used. Autoradiographic films were analyzed for LOH after radioactively labelled polymerase chain reaction products were resolved on denaturing formamide-acrylamide gels. RESULTS: Of 20 patients informative for at least one of three chromosome 9 markers, 12 (60%) showed LOH at one or more loci; of 9 informative for the chromosome 10 marker, 4 (44%) showed LOH; and of 16 informative for at least one of two chromosome 17 markers, 7 (44%) showed LOH at one or both loci. These LOH rates do not include instances of tumor nullizygosity (0-35%) and therefore represent minimum frequencies of chromosomal losses at these loci. CONCLUSIONS: Microsatellite markers can be used to detect LOH in archival glioma tissue. As in sporadic gliomas, frequent LOH was observed on 9p (9p21-22), 10 and 17p, supporting the notion that these regions may harbour tumor suppressor genes important in glioma development. Further work will be required to determine whether the proportion of LOH in these chromosomal regions is higher in familial gliomas than sporadic ones, as might occur with an inherited suppressor gene conferring susceptibility to gliomas in families.

Corticosteroid-induced magnetic resonance imaging changes in patients with recurrent malignant glioma.

PURPOSE: We studied corticosteroid-induced magnetic resonance (MR) scan changes in patients with recurrent malignant glioma to determine if corticosteroid therapy started concurrently with investigational treatment might yield false-positive responses. PATIENTS AND METHODS: Ten symptomatic patients not on corticosteroids when malignant glioma recurred had a baseline MR scan performed before corticosteroid treatment, followed by serial scans at weekly intervals for 1 month while on dexamethasone (16 mg/d). The maximum cross-sectional areas and volumes of the gadolinium-enhancing regions (tumor) and T2-weighted abnormalities (tumor plus edema) were compared quantitatively and qualitatively for each series of scans. RESULTS: Nine of 10 patients (90%) had a measurable reduction in the size of the gadolinium-enhancing region or T2-weighted abnormality with corticosteroid treatment. The maximum cross-sectional area and volume of the gadolinium-enhancing region decreased by at least 25% in three of 10 patients (30%). The maximum cross-sectional area and volume of the T2-weighted abnormality decreased by at least 25% in five of 10 patients (50%). Maximum measurable radiologic improvement was evident within 2 weeks in most patients. MR scans were judged improved by the reporting neuroradiologist in seven of 10 (70%). These subjective visual improvements were also evident within 2 weeks, but generally described as slight or modest. CONCLUSION: Corticosteroid-induced MR scan reductions in tumor size may confound the assessment of response of recurrent malignant gliomas to investigational agents. For patients who start corticosteroids for symptom control, investigational treatment should be delayed until a new baseline MR image is established 2 weeks later. Response is then judged by comparing subsequent MR scans with the new corticosteroid-influenced baseline image.