Caregivers in home palliative care: gender, psychological aspects, and patient's functional status as main predictors for their quality of life.

PURPOSE: This study aims to investigate the impact of possible predictors of quality of life (QoL) in a group of Italian caregivers assisting a cancer patient in home palliative care. METHODS: Data from 570 adult informal caregivers and their cancer-affected relatives were collected. A multivariate regression analysis was conducted to assess the effect of three groups of variables on Caregivers Quality of Life Index-Cancer (CQOLC) scale: (a) socio-demographic characteristics of caregivers; (b) psychological characteristics of caregivers assessed by Profile Mood of States (POMS), Caregiver Burden Inventory (CBI), and Preparedness for Caregiving Scale (PCS); (c) Socio-demographic characteristics and functional status of the patients assessed by Karnofsky Performance Status (KPS), Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). RESULTS: Regression analysis shows that some variables from each of these clusters are significantly associated with CQOLC, in particular: (a) the gender of the caregiver (st.ß = .115, t = 2.765, p = .006) and the time spent for caregiving (st.ß = - .165, t = - 3.960, p < .001); (b) the scores obtained by the caregivers in POMS,CBI (st.ß = - .523, t = - 16.984, p < .001 and st.ß = - .373, t = - 12.950, p < .001, respectively) and PCS (st.ß = .092, t = 3.672, p < .001); (c) the gender (st.ß = - .081, t = - 1.933, p = .045) and the IADL score (st.ß = .195, t = 4.643, p < .001) of the patient. CONCLUSIONS: A multidimensional evaluation is a key strategy to identify the most vulnerable caregivers. Apart from the condition of the patient, the gender of the caregivers, the time spent for caregiving and, above all, their psychological condition are strong predictors of caregivers' QoL.

Fluoroscopy-guided biodegradable spacer implantation using local anesthesia: safety and efficacy study in patients with massive rotator cuff tears.

BACKGROUND: The management of massive rotator cuff tears (MRCTs) is challenging and associated with a high failure rates. Studies have shown that advanced age, lower American Society of Anesthesiologists physical status score and concomitant comorbidities are associated with higher risks of death and postoperative complications. This study was designed to assess the safety and efficacy of fluoroscopy-guided biodegradable spacer implantation under local anesthesia, in patients with MRCT and comorbidities completely or partially contraindicating surgeries under general anesthesia. METHODS: In this open-label, single arm, prospective study, subjects with MRCTs underwent subacromial fluoroscopy-guided implantation with a biodegradable spacer (InSpace™ system) under local anesthesia. Fifteen patients were treated and assessed. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant (CS) and American Shoulder and Elbow Society (ASES) scores. RESULTS: All patients demonstrated an overall improvement in the total CS and ASES beginning at 6 weeks and sustained by at least 12 months postoperatively. Of the 15 patients who reached the 1-year follow-up, 85% showed a clinically significant improvement of at least 15 points in their Constant score starting at 6 weeks postoperation and maintained throughout the entire follow-up period. CONCLUSIONS: We conclude that in this initial patient's cohort, fluoroscopy-guided implantation of InSpace™ system under local anesthesia, represented an effective alternative to the existing procedures. This procedure may be considered as a treatment option for elderly patients or for patients with multiple comorbidities complicating or contraindicating surgery under general anesthesia. Technically easy, this technique can be an effective tool in the armamentarium of most orthopedic surgeons. Level of proof: single-arm prospective study, Level II.

Galaxy evolution. Evidence for mature bulges and an inside-out quenching phase 3 billion years after the Big Bang.

Most present-day galaxies with stellar masses ≥10(11) solar masses show no ongoing star formation and are dense spheroids. Ten billion years ago, similarly massive galaxies were typically forming stars at rates of hundreds solar masses per year. It is debated how star formation ceased, on which time scales, and how this "quenching" relates to the emergence of dense spheroids. We measured stellar mass and star-formation rate surface density distributions in star-forming galaxies at redshift 2.2 with ~1-kiloparsec resolution. We find that, in the most massive galaxies, star formation is quenched from the inside out, on time scales less than 1 billion years in the inner regions, up to a few billion years in the outer disks. These galaxies sustain high star-formation activity at large radii, while hosting fully grown and already quenched bulges in their cores.

A galaxy rapidly forming stars 700 million years after the Big Bang at redshift 7.51.

Of several dozen galaxies observed spectroscopically that are candidates for having a redshift (z) in excess of seven, only five have had their redshifts confirmed via Lyman α emission, at z = 7.008, 7.045, 7.109, 7.213 and 7.215 (refs 1-4). The small fraction of confirmed galaxies may indicate that the neutral fraction in the intergalactic medium rises quickly at z > 6.5, given that Lyman α is resonantly scattered by neutral gas. The small samples and limited depth of previous observations, however, makes these conclusions tentative. Here we report a deep near-infrared spectroscopic survey of 43 photometrically-selected galaxies with z > 6.5. We detect a near-infrared emission line from only a single galaxy, confirming that some process is making Lyman α difficult to detect. The detected emission line at a wavelength of 1.0343 micrometres is likely to be Lyman α emission, placing this galaxy at a redshift z = 7.51, an epoch 700 million years after the Big Bang. This galaxy's colours are consistent with significant metal content, implying that galaxies become enriched rapidly. We calculate a surprisingly high star-formation rate of about 330 solar masses per year, which is more than a factor of 100 greater than that seen in the Milky Way. Such a galaxy is unexpected in a survey of our size, suggesting that the early Universe may harbour a larger number of intense sites of star formation than expected.

The role of black holes in galaxy formation and evolution.

Virtually all massive galaxies, including our own, host central black holes ranging in mass from millions to billions of solar masses. The growth of these black holes releases vast amounts of energy that powers quasars and other weaker active galactic nuclei. A tiny fraction of this energy, if absorbed by the host galaxy, could halt star formation by heating and ejecting ambient gas. A central question in galaxy evolution is the degree to which this process has caused the decline of star formation in large elliptical galaxies, which typically have little cold gas and few young stars, unlike spiral galaxies.

Cold streams in early massive hot haloes as the main mode of galaxy formation.

Massive galaxies in the young Universe, ten billion years ago, formed stars at surprising intensities. Although this is commonly attributed to violent mergers, the properties of many of these galaxies are incompatible with such events, showing gas-rich, clumpy, extended rotating disks not dominated by spheroids. Cosmological simulations and clustering theory are used to explore how these galaxies acquired their gas. Here we report that they are 'stream-fed galaxies', formed from steady, narrow, cold gas streams that penetrate the shock-heated media of massive dark matter haloes. A comparison with the observed abundance of star-forming galaxies implies that most of the input gas must rapidly convert to stars. One-third of the stream mass is in gas clumps leading to mergers of mass ratio greater than 1:10, and the rest is in smoother flows. With a merger duty cycle of 0.1, three-quarters of the galaxies forming stars at a given rate are fed by smooth streams. The rarer, submillimetre galaxies that form stars even more intensely are largely merger-induced starbursts. Unlike destructive mergers, the streams are likely to keep the rotating disk configuration intact, although turbulent and broken into giant star-forming clumps that merge into a central spheroid. This stream-driven scenario for the formation of discs and spheroids is an alternative to the merger picture.

Lost and found dark matter in elliptical galaxies.

There is strong evidence that the mass of the Universe is dominated by dark matter, which exerts gravitational attraction but whose exact nature is unknown. In particular, all galaxies are believed to be embedded in massive haloes of dark matter. This view has recently been challenged by the observation of surprisingly low random stellar velocities in the outskirts of ordinary elliptical galaxies, which has been interpreted as indicating a lack of dark matter. Here we show that the low velocities are in fact compatible with galaxy formation in dark-matter haloes. Using numerical simulations of disk-galaxy mergers, we find that the stellar orbits in the outer regions of the resulting ellipticals are very elongated. These stars were torn by tidal forces from their original galaxies during the first close passage and put on outgoing trajectories. The elongated orbits, combined with the steeply falling density profile of the observed tracers, explain the observed low velocities even in the presence of large amounts of dark matter. Projection effects when viewing a triaxial elliptical can lead to even lower observed velocities along certain lines of sight.

Self-health attitudes and practices of obstetrics and gynecology nurses in Israel.

OBJECTIVE: To assess the attitude of obstetrics and gynecology nurses towards their own health and their health-related behaviors. METHODS: Two hundred and ninety community obstetrics and gynecology nurses in Israel were asked to complete a questionnaire on attitude to self-health, way of life, smoking habits, and regular breast, blood and PAP smear examinations. RESULTS: The average body mass index of the responders was 25.2 kg/m2. However, more than half the nurses (163/287, 56.8%) considered themselves as being above-average in weight, and only 41.1% as being appropriate in weight; 55% were on weight-loss diets. Smoking was reported by 44.8%. Blood tests, PAP smears and breast evaluations were regularly done by 72.5%, 83.0% and 55.7%, respectively. CONCLUSION: Obstetrics and Gynecology nurses in Israel are aware of the importance of their own health and have good health habits, except for cigarette smoking, which remains a problem among this group.

Subsidised oocyte donation in Israel (1998-2000): results, costs and lessons.

BACKGROUND: Israeli law stipulates that all women aged 45-51 who need oocyte donation are entitled to as many donations as necessary, up to the birth of one child. Only oocytes donated by women who themselves are undergoing assisted reproduction are allowed. The government subsidizes all oocyte donation cycles through the medical insurer of the recipient, whether or not the procedure is performed in a public or private institution. The aim of the present study was to investigate the success of oocyte donation cycles in Israel for the period 1998-2000 and to estimate costs and pregnancy rates. METHODS: Data were derived from the Dan District Registry of the General Health Services (Sheirutei Bri'ut Clalit), the largest medical insurer in Israel. RESULTS: 171 women underwent 254 oocyte donation cycles within these 3 years, and 45 babies were born, for a positive outcome of 17.7%. Average annual cycle cost was US$1742 and average annual cost per patient, US$2521. The total annual cost for the district accounted for only 0.05% of the budget. CONCLUSIONS: These findings suggest that IVF with donated oocytes is relatively efficient and that government funding of oocyte donation cycles ensures a reasonable cost.

Munchausen syndrome in obstetrics and gynecology.

Munchausen syndrome (MS) is a well-defined clinical psychiatric entity. Furthermore, it is a complicated and intriguing problem in medicine in general and in obstetrics and gynecology in particular. The proportion of MS cases in obstetrics and gynecology is rising. This review covers relevant reports from the last four decades. Emphasis is put on the clinical expression of MS cases in obstetrics and gynecology. A discussion about their validity as such is included. Awareness of attending physicians to this type of illness in the era of patient rights, on the one hand, and the existence of defensive medicine on the other, is crucial.

Real-time intraoperative ultrasound guidance: the transrectal approach.

OBJECTIVE: To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures. DESIGN: In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy. RESULTS: The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful. CONCLUSIONS: On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

10% hydroxyethyl starch for plasma expansion in the treatment of severe ovarian hyperstimulation syndrome. A case report.

BACKGROUND: Severe ovarian hyperstimulation syndrome is a complication of hormonal therapy for in vitro fertilization and carries the risk of renal failure. The injection of 6% hydroxyethyl starch has been used as a preventive measure. CASE: A 33-year-old woman was admitted with severe ovarian hyperstimulation syndrome after receiving gonadotropins as part of our in vitro fertilization protocol. Despite treatment with saline, albumin and abdominal taps, oliguria developed on the third day. The patient was transferred to the general intensive care unit and treated with 10% hydroxyethyl starch, furosemide and a further abdominal tap. Recovery was rapid. CONCLUSION: Ten percent hydroxyethyl starch is an efficient plasma expander. It is safe, biohazard free and cost-effective. It seems to effectively control severe ovarian hyperstimulation syndrome and to overcome acute prerenal failure. Larger prospective studies are necessary to further evaluate its role in the treatment of severe ovarian hyperstimulation syndrome.

Spectrum of normal intrauterine cavity sonographic findings after first-trimester abortion.

OBJECTIVE: To characterize the sonographic appearance of the uterine cavity after uncomplicated first-trimester abortion. METHODS: Women who underwent uterine evacuation for first-trimester abortion were referred for endovaginal sonographic examination within the week after the procedure. Special attention was directed to characterizing the intrauterine cavity. Demographic and clinical parameters were collected. A repeated postmenstrual examination was carried out in selected cases. RESULTS: In all, 57, 10, and 7 sonographic examinations were performed after termination of pregnancy, incomplete (spontaneous) abortion, and missed abortion, respectively. Fifty-seven (77%) of the 74 examinations showed considerable amounts of intrauterine content with various echogenicities (anteroposterior thickness range, 7-61 mm). No association could be documented between the pattern of appearance and gravidity, parity, gestational age, or type of abortion procedure. All postmenstrual reevaluations of patients with excessive amounts of intrauterine material at the initial examination (n = 7) showed empty intrauterine cavities. CONCLUSION: Within the week after first-trimester abortion, the uterine cavity is seldom empty. Thick heterogeneous material is an expected finding after examination. By being familiar with this normal range of appearances, clinicians can avoid unnecessary repeated invasive evacuation procedures. A follow-up sonographic evaluation during the follicular phase of the next menstrual cycle is recommended to confirm the absence of retained products of pregnancy.

Early sonographic detection of a 'human tail': a case report.

We report on a newborn in whom an echogenic protrusion arising in the caudal region was detected at 12 weeks' gestation. Subsequent ultrasound examinations at weeks 15 and 22 failed to demonstrate this finding. After birth, the infant was found to have a pilonidal sinus. The pilonidal sinus may represent a remnant of the embryonic appendage ('human tail') that usually disappears by the end of the 8th week of gestation. This case might support the theory of congenital pilonidal sinus origin.

[Microlaparoscopy in diagnostic and operative gynecologic procedures].

A recent further development in laparoscopic surgery is microlaparoscoopy. The technique is identical to standard 10 mm laparoscopy except for the use of small, 2 mm scopes and trocars. We used this technique in 19 patients treated from June 1998 to February 1999. The advantages of microlaparoscopy are: smaller incisions, less risk of damage to pelvic organs and less postoperative pain. However, the use of microlaparoscopy for operative procedures is limited to simple operations due to the limited field of vision. We urge our colleagues to consider microlaparoscopy whenever diagnostic laparoscopy is needed.

[Spontaneous bilateral ectopic pregnancy--an rare and dangerous occurrence].

Bilateral, spontaneous ectopic pregnancy is rare (1 in 125-1580 ectopic pregnancies). We describe a 30-year-old, unmarried woman with no predisposing factors for ectopic pregnancy who presented in hypovolemic shock, in the 7th week of gestation, complaining of abdominal pain. On immediate laparoscopy there were found blood and clots in the abdominal cavity, a left ampullar pregnancy (5 cm in diameter), and there was active bleeding from the fimbria of the right tube. Bilateral salpingectomy was performed and she received 3 units of packed red cells. She was discharged in good condition 3 days later. The pathologic diagnosis was pregnancy in each tube. This case emphasizes the need for thorough sonographic and laparoscopic observation in order not to miss the presence of bilateral ectopic pregnancy.

Severe unilateral hydrothorax as the only manifestation of the ovarian hyperstimulation syndrome.

BACKGROUND: Unilateral hydrothorax is rarely the sole manifestation of the ovarian hyperstimulation syndrome (OHSS) and is suggestive of the severity of the disease. CASE: A 35-year-old woman presented with mild dyspnea 2 weeks after ovarian stimulation with hMG and hCG and IVF-ET. Chest X-ray revealed a large pleural effusion on the right side. Three consecutive thoracocenteses were needed to drain a total of 6,800 cm(3) of fluid. Following drainage, the respiratory symptoms disappeared. An uneventful pregnancy is in progress. CONCLUSIONS: Thoracocentesis is safe and efficient for the treatment of hydrothorax and may be repeated as often as necessary. Clinicians should be aware of the possibility of unilateral hydrothorax as the sole symptom of OHSS.