Evaluating unmet needs in patients undergoing surgery for colorectal cancer: a patient reported outcome measures study.

AIM: Patient reported outcome measures (PROMs) are self-reported measures of patients' health status or health-related quality of life at a single point in time. We aimed to evaluate the use of a colorectal PROM and conducted a focus group to further explore this and other unmet needs in our patient population treated surgically for colorectal cancer. METHOD: A multidisciplinary research group consisting of colorectal surgeons, nurse specialists, psychologists, sociologists and patient representatives devised a composite tool of new and existing outcome measures which was piloted in our local population (n = 35). Participants were subsequently invited to attend a semi-structured focus group during which the PROM was reviewed and an unmet needs analysis was performed. Thematic analysis of focus group transcripts was undertaken for emergent themes. RESULTS: Initial consensus was for a tool including the EQ-5D, Functional Assessment of Cancer Therapy - Colorectal (FACT-C), the distress thermometer, a validated measure of stigma, an unmet needs analysis, and questions assessing the psychological impact of cancer. Median and interquartile range values suggested that all metrics were discriminatory with the exception of FACT-C. All participants agreed that the tool was acceptable and reflected the current state of their health and emotions. Thematic analysis of focus group transcripts identified four major themes: physical symptoms, emotional response, information provision and coping mechanisms. CONCLUSION: Through expert consensus, local piloting and patient focus groups we have evaluated a novel PROM for colorectal cancer. Furthermore, through our direct engagement with patients we have identified several unmet needs which we are currently exploring within the clinical service.

Special observations in forensic psychiatric practice: gender issues of the watchers and the watched.

Special observations in psychiatric practice may create tensions for both the patient under surveillance and the staff undertaking the procedure. This study reports on special observations undertaken in forensic settings focusing specifically on the gender-sensitive issues. The aim of the study was to investigate the specific gender issues relating to special observations in relation to those under the procedure and those engaged in observing. Three medium secure units in the UK formed the sampling frame, and the population studied was eight female and seven male clinical Registered nurses. Semi-structured interviews were conducted, audio-tape-recorded and transcribed for analysis. The analysis involved a Grounded Theory approach to explicate categories and formulate two overarching themes: (1) the psychosocial fusion; and (2) the private as spectacle. There are implications for practice in relation to policy formulation and the implementation of special observations following risk assessment and individual skill identification. It is concluded that gender issues are extremely important for all concerned in this intrusive practice.

Pre-operative oral iron supplementation reduces blood transfusion in colorectal surgery - a prospective, randomised, controlled trial.

INTRODUCTION: Allogeneic blood transfusion confers a risk to the recipient. Recent trials in colorectal surgery have shown that the most significant factors predicting blood transfusion are pre-operative haemoglobin, operative blood loss and presence of a transfusion protocol. We report a randomised, controlled trial of oral ferrous sulphate 200 mg TDS for 2 weeks' pre-operatively versus no iron therapy. PATIENTS AND METHODS: Patients diagnosed with colorectal cancer were recruited from out-patient clinic and haematological parameters assessed. Randomisation was co-ordinated via a telephone randomisation centre. RESULTS: Of the 49 patients recruited, 45 underwent colorectal resection. There were no differences between those patients not receiving iron (n = 23) and the iron-supplemented group (n = 22) for haemoglobin at recruitment, operative blood loss, operation duration or length of hospital stay. At admission to hospital, the iron-supplemented group had a higher haemoglobin than the non-iron treated group (mean haemoglobin concentration 13.1 g/dl [range, 9.6-17 g/dl] versus 11.8 g/dl [range, 7.8-14.7 g/dl]; P = 0.040; 95% CI 0.26-0.97) and were less likely to require operative blood transfusion (mean 0 U [range, 0-4 U] versus 2 U [range, 0-11 U] transfused; P = 0.031; 95% CI 0.13-2.59). This represented a cost reduction of 66% (47 U of blood = pound4700 versus oral FeSO(4) at pound30 + 15 U blood at pound1500). At admission, ferritin in the iron-treated group had risen significantly from 40 microg/l (range, 15-222 microg/l) to 73 microg/l (range, 27-386 microg/l; P = 0.0036; 95% CI 46.53-10.57). CONCLUSIONS: Oral ferrous sulphate given pre-operatively in patients undergoing colorectal surgery offers a simple, inexpensive method of reducing blood transfusions.

Use of a pneumatic tourniquet improves outcome following trans-tibial amputation.

BACKGROUND: It is traditionally taught that a pneumatic tourniquet is contraindicated for trans-tibial amputations in patients with peripheral arterial disease. However, tourniquets are used successfully during total knee arthroplasty in elderly patients. Vascular patients undergoing a trans-tibial amputation have a high perioperative mortality and morbidity-notably the need for wound revision or a higher amputation level. We hypothesised that a tourniquet, used during amputation, would reduce blood loss and subsequent complications without compromising healing. METHODS: This was a prospective non-randomized study of 89 adult patients who underwent a trans-tibial amputation between January 2001 and December 2003. The endpoints were: haemoglobin levels, the need for blood transfusion, perioperative morbidity, revision rate and mortality. Patients were divided into two groups: a group with a pneumatic tourniquet (n=42) and a group without (n=47). RESULTS: The haemoglobin fall was 14.8% in the non-tourniquet group and 5.6% in the tourniquet group, with a higher need for transfusion in the non-tourniquet group. The revision rate was 14.3% in the tourniquet group and significantly higher in the non-tourniquet group (38.3%). Mortality was similar in both groups: 7.1% for the tourniquet and 6.4% for the non-tourniquet group. CONCLUSION: The use of a pneumatic tourniquet is safe and significantly reduces both blood loss and transfusion requirements during trans-tibial amputation. A pneumatic tourniquet reduces revision rates by over 50%, with subsequent cost savings.

Distinctive effects of G-CSF, GM-CSF and TNFalpha on neutrophil apoptosis in systemic lupus erythematosus.

OBJECTIVE: To investigate the influence of culture with G-CSF GM-CSF and TNFalpha on neutrophil apoptosis, comparing neutrophils from SLE patients with rheumatoid arthritis (RA) patients and healthy control subjects. METHODS: Neutrophils were isolated from SLE (n= 10), RA (n= 10) and healthy control subjects (n= 10), and cultured with two different concentrations of G-CSF, GM-CSF and TNFalpha. Proportion of apoptotic neutrophils at T=0, T=2hrs and T=24hrs was measured using FITC-labelled annexinV and flow cytometry. RESULTS: Significantly more neutrophils were apoptotic at T=0 in the SLE subjects than in the other groups (median, range--Control 3.5% (0.3-7.9) SLE 9.5% (2.9-29.1) RA 3.0% (0.4-23.0) p<0.05). Following culture for 24 hours with 1ng/ml G-CSF the proportion of apoptotic neutrophils from SLE subjects was significantly increased (median, range = 51.6% (27.0-84.0) without G-CSF v 66.8% (31.8-89.2) with G-CSF p<0.05). This was not observed with RA or control subjects, in whom the trend was towards inhibition of apoptosis. Similar trends were seen with GM-CSF There was significant induction of apoptosis in SLE neutrophils after 2 hr culture with 1ng/ml TNFalpha (median, range = 2.3% (0.1-8.0) without TNFalpha v 5.2% (1.0-22.4) with TNFalpha). No significant change was seen in the other groups. There was an inverse correlation between total neutrophil count and the degree of induction of apoptosis by G-CSF and GM-CSF, determined at a range of time-points and cytokine concentrations CONCLUSIONS: Neutrophils from SLE patients display resistance to the apoptosis-inhibiting effects of G-CSF and possibly GM-CSF, and appear more susceptible to the apoptosis-inducing action of TNFalpha, the greatest resistance being observed in the more neutropenic patients.

A study of bone mineral density in women with forearm fracture in Northern Ireland.

A group of Northern Ireland women aged 40-75 years of age with low-trauma forearm fracture were studied to determine the incidence of such fractures and the prevalence of osteoporosis in this fracture population. A total of 1,147 subjects were identified in 1997 and 1998 throughout Northern Ireland following low-trauma forearm fractures, as well as 699 residents in the Eastern Health and Social Services Board (EHSSB), enabling calculation of the annual incidence rate of new low-trauma forearm fractures at 2.69/1,000 population aged 40-75. A total of 375 participants consented to have bone mineral density (BMD) measurements undertaken at the femoral neck, spine, and forearm using a Lunar Expert bone densitometer. Osteoporosis at the femur was present in 14% of women, at the spine in 29%, and at the forearm in 32%. A total of 45% were osteoporotic at one or more measured sites, but only 18% were on treatment for osteoporosis. Additional significant risk factors identified included an early menopause in 24.5% and current or previous corticosteroid use in 13%. Only 1.6% received information on treatment of osteoporosis at the time of fracture. Increased awareness is needed in both primary and secondary care including fracture services to improve treatment of women with low-trauma fracture.

Limited form of Churg-Strauss syndrome presenting as a mass in the neck.

A 53-year-old man was referred to the ENT department with a large mass in the left supraclavicular fossa. The histological diagnosis showed the mass to have arisen due to a granulomatous vasculitis consistent with Churg-Strauss syndrome (CSS). CSS usually comprises asthma, eosinophilia and systemic vasculitis although limited forms of the disease exist where one of these diagnostic criteria is missing. This is one such case as the patient was non-asthmatic.

Some specific problems of secluding female patients.

This paper reports on a study of secluded female patients in a special hospital. A random selection of seclusions occurring within one week of initiation were chosen and data were collected by a structured interview, involving nurses who had made the decision to initiate the seclusion. The interview schedule contained 18 items and the analysis utilized chi square test for categorical data and Speraman's rank coefficient for correlation on the scores on two variables. The results indicated that there was an erratic use of alternative approaches attempted prior to the use of seclusion and that the stripping of patients as they are secluded is rationalized as 'in the interest of their safety'. It is argued that further research is urgently required to interview the female patients concerned and to explore the specific issues pertaining to the seclusion of female patients. We question whether a high security psychiatric hospital is the most appropriate placement for females.

Teenage pregnancy: on the road to social death.

This paper describes research into perceptions of teenage pregnancy at two different demographical locations in the UK. Ninety-five semi-structured interviews were conducted on a teenage pregnant population and a non-pregnant teenage population. Thematic analysis revealed three levels of influence causing social pressures on the teenage pregnancy and were structured as primary, secondary and subordinate depending on the emphasis within the discourse analysis. From this binary oppositions were identified which formed the theoretical constructs relating to the transition from one state to another which can be termed 'becoming'. When these states are negatively perceived they cause a form of impending doom and create social exclusion for the recipient. Finally, it was revealed that they succumb to the weight of social sanction and feel the prophecy of a 'social death'

Simian immunodeficiency virus replicates to high levels in naturally infected African green monkeys without inducing immunologic or neurologic disease.

African green monkeys can maintain long-term persistent infection with simian immunodeficiency viruses (SIVagm) without developing AIDS and thus provide an important model for understanding mechanisms of natural host resistance to disease. This study assessed the levels and anatomic distribution of SIVagm in healthy, naturally infected monkeys. Quantitative competitive reverse transcriptase PCR assays developed to measure SIVagm from two African green monkey subspecies demonstrated high levels of SIV RNA in plasma (>6 x 10(6) RNA copies/ml) in sabaeus and vervet monkeys. Infectious virus was readily recovered from plasma and peripheral blood mononuclear cells and shown to be highly cytopathic in human cell lines and macrophages. SIVagm DNA levels were highest in the gastrointestinal tract, suggesting that the gut is a major site for SIVagm replication in vivo. Appreciable levels of virus were also found within the brain parenchyma and the cerebrospinal fluid (CSF), with lower levels detected in peripheral blood cells and lymph nodes. Virus isolates from the CSF and brain parenchyma readily infected macrophages in culture, whereas lymph node isolates were more restricted to growth in human T-cell lines. Comparison of env V2-C4 sequences showed extensive amino acid diversity between SIVagm recovered from the central nervous system and that recovered from lymphoid tissues. Homology between brain and CSF viruses, macrophage tropism, and active replication suggest compartmentalization in the central nervous system without associated neuropathology in naturally infected monkeys. These studies provide evidence that the nonpathogenic nature of SIVagm in the natural host can be attributed neither to more effective host control over viral replication nor to differences in the tissue and cell tropism from those for human immunodeficiency virus type 1-infected humans or SIV-infected macaques.

Sudden sensorineural hearing loss with fracture of the stapes footplate following sneezing and parturition.

Three rare cases of sudden high frequency sensorineural hearing loss with longitudinal fracture of the stapes footplate are presented. In two patients it occurred after they suppressed a sneeze. In the third patient after the exertion of parturition. At exploratory tympanotomy all were found to have longitudinal fractures of the stapes footplate and two had a perilymph fistula at that site. The history and audiometric profiles in such patients should raise a high index of suspicion regarding the possibility of a stapes footplate fracture.

Amplification of simian retroviral sequences from human recipients of baboon liver transplants.

Investigations into the use of baboons as organ donors for human transplant recipients, a procedure called xenotransplantation, have raised the specter of transmitting baboon viruses to humans and possibly establishing new human infectious diseases. Retrospective analysis of tissues from two human transplant recipients with end-stage hepatic disease who died 70 and 27 days after the transplantation of baboon livers revealed the presence of two simian retroviruses of baboon origin, simian foamy virus (SFV) and baboon endogenous virus (BaEV), in multiple tissue compartments. The presence of baboon mitochondrial DNA was also detected in these same tissues, suggesting that xenogeneic "passenger leukocytes" harboring latent or active viral infections had migrated from the xenografts to distant sites within the human recipients. The persistence of SFV and BaEV in human recipients throughout the posttransplant period underscores the potential infectious risks associated with xenotransplantation.

Characterization of new simian foamy viruses from African nonhuman primates.

Simian foamy viruses (SFV) are exogenous retroviruses present in most if not all nonhuman primate species. Baboons and other African monkey species are known to harbor SFVs, yet there is presently no data in regard to their genetic relationship. Here we studied SFVs from baboons as compared to other SFVs isolated from a Hamlyn's guenon, a patas monkey, and a vervet. By Western blot analysis, the gag precursor proteins (p74/p70) were detected from all SFVs. In addition, the envelope glycoproteins from a vervet isolate (SFV-Agm2) were comparable in size to the env precursor gp130, the exterior glycoprotein (gp70), and the transmembrane protein (gp48) as detected by lentil lectin binding and radioimmunoprecipitation (RIPA). Molecular comparison of PCR amplified products from pol and LTR regions of each SFV demonstrated a close relationship among baboon SFVs while SFVs from patas, Hamlyn's guenon, and vervet clustered together. The baboon viruses only varied by 4% among each other in the LTR region; however, as much as 26% variation was noted when compared to the other African monkey SFVs. To determine the prevalence rate of SFV-Bab in our baboon colony, we employed both Western blotting and PCR analysis. Antibodies to SFV gag precursor proteins were seen in 7 of 10 infants; however, none were positive by PCR, suggesting that these infants were virus negative and that their antibodies were maternal in origin. Only one juvenile (1/10) and all adults (38/38) were infected with SFV. Taken together these results suggest that SFVs have arisen and diverged along with the evolution of their natural hosts. Furthermore, the high prevalence rates to SFV seen in adult baboons strongly suggest a sexual or oral routes of transmission.