Professionals' barriers in female oncofertility care and strategies for improvement.

STUDY QUESTION: What are healthcare professionals' barriers and strategies for improvement in female oncofertility care? SUMMARY ANSWER: Professionals perceived barriers in knowledge, attitude and organization of oncofertility care and suggested strategies to improve oncofertility care. WHAT IS KNOWN ALREADY: The potential loss of fertility is one of the most important undesirable side effects of cancer treatment in women of reproductive age. Unfortunately, despite guideline recommendations, not all patients are informed about their fertility risks and referred for fertility preservation (FP) counselling. Insight into barriers for discussing FP and appropriate referral is necessary before improvements can be made. STUDY DESIGN, SIZE, DURATION: The aim of this was study was to identify barriers and gather improvement suggestions through semi-structured in-depth interviews conducted with 24 professionals working in oncofertility care. Subsequently, an expert panel meeting was held to reach consensus on a set of improvement strategies. PARTICIPANTS/MATERIALS, SETTING, METHODS: Oncological professionals were recruited from the three Dutch expertise hospitals for female FP and their affiliated hospitals. The expert panel consisted of six healthcare professionals, five survivors and two researchers. In the Dutch setting, financial aspects do not play a role in oncofertility care. MAIN RESULTS AND THE ROLE OF CHANCE: Barriers were identified and categorized into the patient level (e.g. focus on surviving cancer), the professional level (e.g. lack of awareness, knowledge, time, and attitude), or the organizational level (e.g. unavailable written information, disagreement on who is responsible for discussing infertility risks). The expert panel reached consensus on essential elements for a multifaceted improvement programme: development of information materials (leaflets, online decision aid), education of professionals, a role for specialized oncology nurses in informing patients and patient navigators at the fertility department to facilitate referral and counselling, medical record reminders, standard consultations with a gynaecologist and agreement on responsibility. LIMITATIONS, REASONS FOR CAUTION: Selection bias could have occurred because it is likely that only professionals with interest in oncofertility care participated. However, this would mean that the barriers were underestimated. WIDER IMPLICATIONS OF THE FINDINGS: This study forms the basis for the development of a multifaceted oncofertility programme, which is essential to increase adherence to the national clinical guideline. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by the Radboud university medical center. The authors have declared no competing interests. Prof. Dr Braat reports unrestricted grants from Ferring BV, Serono and Goodlife, outside the submitted work. TRIAL REGISTRATION NUMBER: N/A.

Decision-making in female fertility preservation is balancing the expected burden of fertility preservation treatment and the wish to conceive.

STUDY QUESTION: What are the decisive factors in fertility preservation (FP) decision-making in young women scheduled for gonadotoxic therapy? SUMMARY ANSWER: FP decision-making in young women scheduled for gonadotoxic therapy is mainly based on weighing two issues: the intensity of the wish to conceive a child in the future and the expected burden of undergoing FP treatment. WHAT IS KNOWN ALREADY: Future fertility is of importance for young cancer patients whose reproductive function is being threatened by oncological therapy. To prevent or reduce severe psychological effects of infertility as well as feelings of regret about their FP decision after cancer treatment, the quality of fertility preservation counselling (FPC) should be improved. To improve care, those issues forming a decisive factor in FP decision-making for patients should be clarified, as these issues deserve extensive discussion during FPC. Until now, decisive factors have not been isolated from the complex interplay of all aspects of FP that women contemplate during FP decision-making. STUDY DESIGN, SIZE, DURATION: By using a mixed methods methodology, a questionnaire developed after qualitative research involving a selected group of five women who previously received FPC was retrospectively sent to eligible patients (n = 143) who had received FPC (1999 - July 2013) and to whom at least one FP option was offered. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients had received FPC at a university hospital in the Netherlands, in a setting where financial factors do not play a role in FP. They were aged ≥16 years and were scheduled for gonadotoxic treatment. The relationship between patients' baseline characteristics, their attributed importance to 28 relevant importance items and their FP choices was investigated. MAIN RESULTS AND THE ROLE OF CHANCE: After five interviews, 28 importance items for FP decision-making were identified and included in our questionnaire. Of these 28 importance items, 24 items could be clustered into seven importance themes. A total of 87 patients (61%) responded to our questionnaire. After performing a multivariable logistic regression analysis, proceeding with FP was related to higher attributed importance during FP decision-making to the theme 'Wish to conceive (in the future)' (odds ratio (OR) 10.8, 95% confidence interval (CI) 3.5-34.4) and the item 'Having a stable partner relationship' (OR 2.0, 95% CI 1.0-4.1), while higher attributed importance to the theme 'Expected burden of FP' during FP decision-making (OR 0.08, 95% CI 0.02-0.3) more often resulted in refraining from treatment. LIMITATIONS, REASONS FOR CAUTION: Besides possible recall and selection bias, the fact that this study was performed in Dutch patients aged ≥16 years counselled in a single centre, where finance was not an additional consideration, possibly limits the generalizability of our results to a broader European population of cancer patients. Furthermore, we are not able to draw conclusions about the causality of the associations observed in our study. WIDER IMPLICATIONS OF THE FINDINGS: The wish to conceive and the expected burden of FP treatment should be discussed carefully with patients during FP decision-making, either by the referring healthcare provider or by reproductive medicine specialist. Prospective research is needed to explore the causality of the associations found in this study. Furthermore, in order to deliver high quality patient-centred care, the development of tools to explore patients' wish to conceive (for example in different age categories) and tools to provide clear information about the burden of FP treatments (using the preferred information channels suggested by patients) is needed. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the Radboud Institute for Health Sciences (research school affiliated to the Radboud university medical center). The authors have declared no conflicts of interest with respect to this work.

Isokinetic Evaluation of Knee Extensor/Flexor Muscle Strength in Behcet's Patients.

BACKGROUND: Behçet's disease (BD) is an idiopathic, multisystemic, progressive disease. The purpose of this study is to compare the knee flexor and extensor isokinetic muscle strengths of Behcet's patients with that of healthy subjects. METHODS: Twenty-five (13 male and 12 female) patients with BD and 25 (15 male and 10 female) healthy individuals were included in the study. Velocities of 90°/sec, 120°/sec, and 150°/sec were used for the isokinetic muscle strength testing. Patients with active inflammatory knee arthritis were excluded. Peak torque (Nm) and peak torque adjusted to body weight (%) were taken into consideration for comparison between study groups. RESULTS: Compared to healthy controls, there was a statistically significant decrease in both the bilateral knee extensor and flexor muscle isokinetic peak torques(Nm) as well as the peak torques adjusted to body weight (%) at velocities of 90°/sec, 120°/sec and 150°/sec in patients with BD (p < 0.05). However, there was no significant difference in the agonist-antagonist ratio of the isokinetic peak torques of knee muscles between the two groups. CONCLUSION: In light of these findings, we have concluded that both knee flexor and extensor isokinetic muscle strengths are lower in BD. We therefore recommend careful monitoring of patients with BD in terms of muscle strength.

Characterization of bacterial knot disease caused by Pseudomonas savastanoi pv. savastanoi on pomegranate (Punica granatum L.) trees: a new host of the pathogen.

UNLABELLED: This study aimed to isolate and identify the causal organism causing hyperplastic outgrowths (knots) on stems and branches of pomegranate trees in the Eastern Mediterranean region of Turkey. Bacterial colonies were isolated from young knots on plates containing selective nutrient media. Biochemical tests, fatty acid analysis and PCR were performed to identify possible causal disease agent. Representative isolates were identified as Pseudomonas.pv.savastanoi (Psv) using biochemical tests, fatty acid profiling and PCR. Following inoculation of pomegranate plants (cv. hicaz) with bacterial suspensions, 25 of 54 bacterial isolates caused typical knots at the site of inoculation. PCR analysis, using specific primer for Psv, generated a single amplicon from all isolates. The similarity of the sequence of Turkish pomegranate isolate was 99% similar to the corresponding gene sequences of Psv in the databases. Based on symptoms, biochemical, molecular, pathogenicity tests and sequence analyses, the disease agent of knots observed on the pomegranate trees is Psv. To the best of our knowledge, this research has revealed pomegranate as a natural host of Psv, which extends the list of host plant species affected by the pathogen in the world and Turkey. SIGNIFICANCE AND IMPACT OF THE STUDY: Pomegranate trees were affected by the disease with outgrowths (galls or knot) disease. Currently, there is no published study on disease agent(s) causing the galls or knots on pomegranate trees in worldwide. Bacterial colonies were isolated from young knots. The causal agent of the knot Pseudomonas savastanoi pv.savastanoi (Psv) was identified based on symptoms, biochemical, molecular methods, pathogenicity tests and sequence analysis. To the best of our knowledge, this is the first report of Psv on pomegranate as a natural host, which extends the growing list of plant species affected by this bacterium in the world and Turkey.

Referral for fertility preservation counselling in female cancer patients.

STUDY QUESTION: What changes can be detected in fertility preservation (FP) counselling (FPC) over time and what are the determinants associated with the referral of newly diagnosed female cancer patients, aged 0-39 years, to a specialist in reproductive medicine for FPC? SUMMARY ANSWER: Although the absolute number of patients receiving FPC increased over time, only 9.8% of all potential patients (aged 0-39 years) were referred in 2011 and referral disparities were found with respect to patients' age, cancer diagnosis and healthcare provider-related factors. WHAT IS KNOWN ALREADY: Referral rates for FPC prior to the start of gonadotoxic cancer treatment are low. Determinants associated with low referral and referral disparities have been identified in previous studies, although there are only scarce data on referral practices and determinants for FPC referral in settings with reimbursement of FP(C). STUDY DESIGN, SIZE, DURATION: We conducted a retrospective observational and questionnaire study in a Dutch university hospital. Data on all female cancer patients counselled for FP in this centre (2001-2013), as well as all newly diagnosed female cancer patients aged 0-39 years in the region (2009-2011) were collected. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were retrieved from medical records (FPC patients), cancer incidences reported by the Dutch Cancer Registry (to calculate referral percentages) and referring professionals (to identify reasons for the current referral behaviour). MAIN RESULTS AND THE ROLE OF CHANCE: In 2011, a total of 9.8% of the patients were referred for FPC. Patients aged 20-29 years or diagnosed with breast cancer or lymphoma were referred more frequently compared with patients under the age of 20 years or patients diagnosed with other malignancies. The absolute numbers of patients receiving FPC increased over time. Healthcare provider-related determinants for low referral were not starting a discussion about fertility-related issues, not knowing where to refer a patient for FPC and not collaborating with patients' associations. LIMITATIONS, REASONS FOR CAUTION: Actual referral rates may slightly differ from our estimation as there may have been patients who did not wish to receive FPC. Sporadically, patients might have been directly referred to other regions or may have received ovarian transposition without FPC. By excluding skin cancer patients, we will have underestimated the group of women who are eligible for FPC as this group also includes melanoma patients who might have received gonadotoxic therapy. WIDER IMPLICATIONS OF THE FINDINGS: The low referral rates and referral disparities reported in the current study indicate that there are opportunities to improve referral practices. Future research should focus on the implementation and evaluation of interventions to improve referral practices, such as information materials for patients at oncology departments, discussion prompts or methods to increase the awareness of physicians and patients of FP techniques and guidelines. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the Radboud university medical center and the Radboud Institute for Health Sciences. The authors have declared no conflicts of interest with respect to this work. TRIAL REGISTRATION NUMBER: Not applicable.

Deciding about fertility preservation after specialist counselling.

STUDY QUESTION: How do female patients experience fertility preservation (FP) consultation (FPC) with a specialist in reproductive medicine and subsequent decision-making on FP? SUMMARY ANSWER: Most patients had positive experiences with FPC, but negative experiences were found to be associated with decisional conflict and decision regret. WHAT IS KNOWN ALREADY: When confronted with a need for gonadotoxic treatment, girls and young women will have to make an irreversible decision with regard to FP. Patients may experience decisional conflict and develop regret about their decision during follow-up. Patients' opportunities to ask questions during FPC and their knowledge about FP have been inversely related to decisional conflict. STUDY DESIGN, SIZE, DURATION: A questionnaire on experiences with FPC, designed after qualitative research, was retrospectively distributed to 108 patients to whom FP was offered after FPC between July 2008 and July 2013. Aiming to minimize recall bias, we defined a subgroup of patients counselled since 2011 who had not yet tried to conceive after FPC. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients were aged ≥16 years and had either cancer or a benign disease that required gonadotoxic therapy. They received FPC in a single university hospital in the Netherlands. Apart from patients' experiences, patients' characteristics, decisional conflict and decision regret were assessed. MAIN RESULTS AND ROLE OF CHANCE: A total of 64 patients (59.3%) responded to the questionnaire. Patients generally had positive experiences with FPC, but indicated room for improvement. Negative experiences were associated with decisional conflict regarding the FP decision (not enough time for counselling: P < 0.0001; not having the opportunity to ask all questions during FPC: P < 0.0001; not feeling supported by the counsellor during decision-making: P = 0.0003; not all applicable options were discussed: P = 0.0001; benefits and disadvantages of FP options were not clearly explained: P = 0.0005). Decisional conflict was correlated to decision regret (P < 0.0001). In the subgroup of patients counselled after 2011 who had not tried to conceive (n = 33), similar results as for the total study population were found for the association of patient experiences with decisional conflict. LIMITATIONS, REASONS FOR CAUTION: Given our retrospective design, we were not informed about the causality of the associations observed. We studied Dutch patients who were counselled in a single centre and were at least 16 years old when filling in the questionnaire. This may limit the generalizability of our data to other settings and populations. WIDER IMPLICATIONS OF THE FINDINGS: More attention should be paid to improving FPC care. Interventions aiming at improving patients' comprehension of the topic of FP and their feelings of being supported in decision-making are advisable. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the Radboud Institute for Health and an unconditional grant from Merck Serono. The authors have declared no conflicts of interest with respect to this work.

First Report of Bacterial Blight of Pomegranate Caused by Xanthomonas axonopodis pv. punicae in Turkey.

Pomegranate (Punica granatum L.) is an increasingly important fruit crop that is widely cultivated in Turkey. Typical bacterial blight symptoms were observed since spring of 2011 in pomegranate orchards located in Antalya Province. Symptoms were characterized by dark brown, angular to irregularly shaped spots on leaves and fruit; cankers on stems, branches, and trunks; and split trunks. The pathogen was isolated from leaf spots on naturally infected plants showing typical symptoms onto yeast dextrose chalk agar. Bright yellow bacterial colonies were consistently isolated. Bacterial strains were characterized as gram negative, oxidase negative, catalase positive, tobacco hypersensitivity positive, and able to produce acid from L-arabinose, D-galactose, D-glucose, and D-mannitol but not from D-xylose. Pathogenicity of the representative bacterial strain Serik-4 was performed on 2-year-old pomegranate plants cv. Hicaz. Leaves were sprayed until runoff with bacterial cell suspensions containing 107 CFU/ml. Inoculated plants were covered with transparent plastic bags to maintain moisture for 48 h. Negative control plants were inoculated with sterile distilled water. Plants were then incubated in a greenhouse at 30°C for 14 days. Symptoms on leaves included dark brown, angular to irregularly shaped water soaked lesions along the veins of the inoculated plants 10 days after inoculation. No lesions developed on the control plants. The symptoms on inoculated plants were similar to those on naturally infected plants. Yellow bacterial colonies were re-isolated from the inoculated plants and identified as the same as the original strain by conventional tests and FAME analysis, thus fulfilling Koch's postulates. Fatty acid methyl ester profiling of the representative strain Serik-4 using GC-MIDI (Microbial Identification Inc, Newark, DE) identified the genus of the bacterium as Xanthomonas. The identity of Serik-4 was further confirmed by amplifying the 16S rRNA gene with the universal primers 27F and 1492R (3) and sequence analysis (GenBank Accession No. KM007073). The 16S rRNA gene sequences of Serik-4 was 99% identical to the corresponding gene sequences of the Xanthomonas axonopodis pv. punicae strain present in the NCBI database (JQ067629.1). High incidence of bacterial blight caused by X. axonopodis pv. punicae on pomegranate has been previously reported in India (2), Pakistan (1), and South Africa (4). To our knowledge, this is the first report of bacterial blight on pomegranate caused by X. axonopodis pv. punicae in Turkey. References: (1) M. A. Akhtar and M. H. R. Bhatti. Pakistan J. Agric. Res. 13:95, 1992. (2) R. Chand and R. Kishun. Indian Phytopathol. 44:370, 1991. (3) D. J. Lane. Page 115 in: Nucleic Acid Techniques in Bacterial Systematics, 1991. (4) Y. Petersen et al. Australas. Plant Pathol. 39:544, 2010.

Can the patient-reported outcome instruments determine disease activity in rheumatoid arthritis?

OBJECTIVES: The aim of this study was to investigate the indicative value of the patient-reported outcome instruments (PROs) on disease activity in rheumatoid arthritis (RA). METHODS: Three hundred sixty eight patients with RA were included in this cross-sectional study. Disease activity was evaluated using both the Disease Activity Score 28 (DAS 28) and the Clinical Disease Activity Index (CDAI). Patients who had DAS 28 score < 3.60 points and CDAI score <10.00 points were allocated into the "low disease activity" group and those who had DAS 28 score > or = 3.60 points and CDAI score > or = 10.00 points into the "moderate or high disease activity" group. The Health Assessment Questionnaire (HAQ), Nottingham Health Profile (NHP), Rheumatoid Arthritis Quality of Life (RAQoL), and Short Form 36 (SF 36) were used as PROs. Logistic regression analysis was used to find variables, which had an indicative value for disease activity. RESULTS: HAQ, pain and emotional reaction subscales of NHP, and bodily pain, general health and social functioning subscales of SF 36 had independent indicative values, when DAS 28 was used as dependent variable. On the other hand, HAQ, pain and emotional reaction subscales of NHP, and general health and emotional role limitation subscales of SF 36 had indicative values when CDAI was used as dependent variable. DAS 28 and CDAI both showed HAQ as the parameter with the highest odds ratio (OR). But RAQoL had shown no independent indicative value for projecting disease activity. CONCLUSION: It was concluded that HAQ could determine disease activity in RA better than other PROs included in this study (Tab. 4, Ref. 36).

Vitamin D and muscle strength, functional ability and balance in peritoneal dialysis patients with vitamin D deficiency.

25(OH)D deficiency has been associated with significantly worse physical performance in individuals with normal renal function. We examined the physical function, muscle strength and balance in age- and gender-matched 25 Stage 3 - 4 CKD patients and 47 Stage 5 CKD patients on peritoneal dialysis (PD) with vitamin D deficiency by objective methods and evaluated the effect of vitamin D replacement on physical performance tests: the "timed up and go" (TUG) test, gait velocity test, timed chair stand test, stair climb test, dynamic balance tests (TUG test, dynamic postural stability test), static balance test (functional reach test) and muscle strength in these two groups. At baseline 25(OH)D in the Stage 3 - 4 CKD patients and patients on PD were 6.9 ± 3.5 ng/ ml (17.2 ± 8.7 nmol/l) and 5.7 ± 3.3 ng/ml (14.2 ± 8.2 nmol/l), respectively (p > 0.05). Mean (± SD) 25(OH)D in Stage 3 - 4 CKD patients and those on PD were 52.0 ± 40.9 ng/ml (129.7 ± 102.2 nmol/l) and 41.9 ± 21, ng/ml (104,5 ± 52,6 nmol/l) respectively after vitamin D replacement (p > 0.05). When both Stage 3 - 4 CKD and dialysis patients became vitamin D-sufficient after vitamin D replacement, they took a significantly shorter time to complete the TUG test, gait velocity test, the timed chair stand test and stair climb test. Results of physical performance tests, static and dynamic balance tests and isometric strength tests improved in both groups after the treatment (p < 0.05). In conclusion, our results show that vitamin D supplementation improves muscle strength, functional ability and balance in both CKD and dialysis patients.

Gain in visual acuity after cataract surgery improves postural stability and mobility.

OBJECTIVES: Vision plays an important role in postural stability. It has also been shown that visual information from the environment and visual cues significantly contribute to balance skills. The aim of this study was to investigate the effects of visual acuity on postural stability and mobility before and after cataract surgery. METHODS: The study group was composed of 25 male and 11 female patients (age 57-84, mean 66.6 +/- 4.7) who had been operated for age-related cataract. Postural stability and mobility were assessed before and four weeks after the surgery by means of Biodex stability system (BSS), Tinetti, Time up and go (TUG) and Functional reach (FR) tests, as well as by gait analysis (gait velocity, step length, step width, cadence, stride length). RESULTS: Postoperative visual acuity was significantly improved. Gait velocity and cadence increased significantly but step length, stride length, and step width did not change significantly. Postoperative improvement of Tinetti balance, TUG and FR tests were significant. Similarly, antero-posterior stability index (APSI), mediolateral stability index (MLSI) and overall stability index (OSI) that were examined with BSS improved significantly after the cataract surgery. CONCLUSION: These results demonstrated that gain in visual acuity after cataract surgery improves the postural stability and mobility of patients (Tab. 2, Fig. 1, Ref. 29). Full Text in free PDF www.bmj.sk.