Effectiveness of the "Living with Cancer" peer self-management support program for persons with advanced cancer and their relatives: study protocol of a non-randomized stepped wedge study.

BACKGROUND: Persons with advanced cancer and their relatives experience physical, emotional, and psychosocial consequences of the illness. Most of the time, they must deal with these themselves. While peer self-management support programs may be helpful, there is little evidence on their value for this population. We present the research protocol of our SMART study that will evaluate the effectiveness of the "Living with Cancer" peer self-management support program, aimed at improving self-management behaviors, self-efficacy, and health-related quality of life of persons with advanced cancer and their relatives. METHODS: We will conduct a non-randomized stepped wedge study in the Netherlands. We will include 130 persons with advanced cancer and 32 relatives. Participants can choose to either start the program within 4 weeks after inclusion or after eight to 10 weeks. The "Living with Cancer" is a peer self-management support program, based on the Chronic Disease Self-Management Program. It consists of six 1,5 hours video-conferencing group meetings with eight to 12 participants, preceded by two or three preparatory audio clips with supportive text per session. The program has the following core components: the learning of self-management skills (action-planning, problem-solving, effective communication, and decision-making), discussing relevant themes (e.g. dealing with pain and fatigue, living with uncertainty, and future planning), and sharing experiences, knowledge, and best practices. The primary outcome for both persons with advanced cancer and relatives is self-management behavior assessed by the subscale "constructive attitudes and approaches" of the Health Education Impact Questionnaire. Secondary outcomes are other self-management behaviors, self-efficacy, health-related quality of life, symptoms, depression and anxiety, and loneliness. Participants complete an online questionnaire at baseline, and after eight and 16 weeks. After each session, they complete a logbook about their experiences. Group meetings will be video recorded. DISCUSSION: SMART aims to evaluate an innovative program building on an evidence-based self-management program. New features are its use for persons with advanced cancer, the inclusion of relatives, and the video-conferencing format for this population. The use of both quantitative and qualitative analyses will provide valuable insight into the effectiveness and value of this program. TRIAL REGISTRATION: This study was registered in the Dutch Trial Register on October 2021, identifier NL9806 .

Primary versus secondary tracheoesophageal puncture for voice rehabilitation in laryngectomy patients: A systematic review.

BACKGROUND: Among voice restoration options following laryngectomy, tracheoesophageal puncture (TEP) appears to be the most common. Currently, there is no consensus that exists with regard to the timing of performing TEP and the decision to perform a primary or secondary TEP has mostly been based on physician preference and expert opinion rather than data. OBJECTIVE OF REVIEW: The objective of this study was to compare primary and secondary tracheoesophageal puncture (TEP) for voice rehabilitation in laryngectomy patients in terms of success and complication rates. TYPE OF REVIEW: A systematic review of studies in the English literature was conducted for studies that directly compared primary and secondary TEP. SEARCH STRATEGY: A comprehensive search of MEDLINE (January 1948-15 July 2016), EMBASE (January 1974-15 July 2016) and Web of Science (January 1970-15 July 2016) was performed. EVALUATION METHOD: Two authors (KL/BAC) independently reviewed titles and abstracts, read full-text papers, extracted data and assessed quality. Disagreements were resolved via consensus. A third author (DV) resolved disagreements between reviewers when consensus was not possible. RESULTS: Eleven retrospective clinical cohort studies were included. No randomised controlled trials were identified. Newcastle-Ottawa score for assessment of quality ranged from 5 to 7. Success rate was defined differently across most studies. Two studies found higher success with primary TEP compared to secondary TEP; nine studies found no difference. Voice outcomes were inconsistently measured; no difference between groups was found in 4 studies. Complication rates were divided into TEP site related, infectious and stenosis. No difference between primary and secondary TEP was found in all but one study which showed a higher rate of pharyngocutaneous fistula in the primary TEP group in salvage laryngectomy patients. CONCLUSIONS: There is no robust evidence to suggest that primary TEP is associated with poorer outcomes compared to secondary TEP. A well-designed randomised controlled trial is required to appropriately answer this question.

Evaluation of a low-fidelity ear surgery simulator in a low-resource setting.

OBJECTIVE: The provision of healthcare education in developing countries is a complex problem that simulation has the potential to help. This study aimed to evaluate the effectiveness of a low-cost ear surgery simulator, the Ear Trainer. METHODS: The Ear Trainer was assessed in two low-resource environments in Cambodia and Uganda. Participants were video-recorded performing four specific middle-ear procedures, and blindly scored using a validated measurement tool. Face validity, construct validity and objective learning were assessed. RESULTS: The Ear Trainer provides a realistic representation of the ear. Construct validity assessment confirmed that experts performed better than novices. Participants displayed improvement in all tasks except foreign body removal, likely because of a ceiling effect. CONCLUSION: This study validates the Ear Trainer as a useful training tool for otological microsurgical skills in developing world settings.

A model-based meta-analysis of the effect of latanoprost chronotherapy on the circadian intraocular pressure of patients with glaucoma or ocular hypertension.

Several reports have demonstrated that the efficacy of latanoprost is influenced by the time of dosing. This model-based meta-analysis validates previous findings that evening dosing is superior to morning dosing and predicts the optimal time for dosing, based on the quantitative assessment of baseline and latanoprost-treated 24-h circadian intraocular pressure (IOP) curves. The results confirm the importance of the time of dosing as a factor that influences the extent of reduction in IOP and underline the need to take this factor into consideration in the design of glaucoma trials and therapy.

Endogenous Pseudallescheria boydii endophthalmitis in a patient with ring-enhancing brain lesions.

A 46-year-old man, status post liver transplantation and taking immunosuppressive medications, was admitted after suffering a generalized seizure. Magnetic resonance imaging of the brain revealed two ring-enhancing lesions and treatment was begun for presumed toxoplasmic encephalitis. He was already receiving amphotericin B for a skin lesion suspected to be caused by candidiasis. One day after the seizure, he complained of photophobia in the left eye. Intraocular inflammation and a small infiltrate in the macula were seen. Vision deteriorated over the next three days. Vitreous tap and injection of amphotericin B and vancomycin were performed, but the intraocular inflammation continued to increase. On day 15, a vitrectomy was performed. The vitreous specimen ultimately grew Pseudallescheria boydii. The patient died on hospital day 30 from complications of the brain abscesses. Pseudallescheria boydii should be considered in the differential diagnosis of endophthalmitis, especially in patients with immunosuppression, serious medical disease, or ring-enhancing brain lesions.

Late endophthalmitis associated with glaucoma drainage implants.

OBJECTIVE: To report the clinical course of a series of patients who had late endophthalmitis develop after glaucoma drainage implant (GDI) surgery. DESIGN: Noncomparative, interventional, consecutive case series. PARTICIPANTS: Four patients were identified with late endophthalmitis associated with Baerveldt glaucoma implants. METHODS: The medical records of all patients with endophthalmitis associated with a GDI treated at the Bascom Palmer Eye Institute or University of Florida between January 1, 1987 and December 31, 1999 were retrospectively reviewed. Patients with culture-positive endophthalmitis diagnosed more than 1 month after GDI surgery were included in this series. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure (IOP). RESULTS: Late endophthalmitis associated with Baerveldt glaucoma implants developed 7 weeks to 2 years postoperatively. Exposure of the GDI tube was present in all cases. The implant was removed in three of four patients. Visual acuity worsened from preinfection level in two of four cases. IOP was controlled at last follow-up in all patients, although replacement of the explanted GDI was required in one patient. CONCLUSIONS: Late endophthalmitis may occur after GDI surgery. Exposure of the GDI tube seems to represent a major risk factor for these infections. To prevent this potentially devastating complication, we recommend prophylactic surgical revision with a patch graft in all cases in which there is an exposed GDI tube.

Intravitreal antiviral injections as adjunctive therapy in the management of immunocompetent patients with necrotizing herpetic retinopathy.

PURPOSE: To report the use of intravitreal antiviral injections as adjunctive therapy in the management of three immunocompetent patients with necrotizing herpetic retinopathy. METHOD: Case series. RESULTS: Three patients with necrotizing herpetic retinopathy received intravitreal antiviral injections for treatment of progressive retinitis, despite standard intravenous acyclovir therapy. The retinitis resolved and visual acuity improved after a minimum of 6 months of follow-up in each case. CONCLUSION: Intravitreal antiviral injections may be a safe and efficacious adjunctive therapy in the management of patients with necrotizing herpetic retinopathy.

Endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum: a case report and literature review.

OBJECTIVE: We report the first case of clinically diagnosed endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum in a patient with the acquired immune deficiency syndrome. DESIGN: Interventional case report and literature review. INTERVENTION: Pars plana vitrectomy and scleral buckling procedure in the left eye with intravenous and intravitreal amphotericin in both eyes. MAIN OUTCOME MEASURES: The clinical features, culture results, visual outcome, and complications were studied. RESULTS: This case demonstrates a bilateral endophthalmitis with severe subretinal exudation, choroidal granulomas, and intraretinal hemorrhage leading to exudative bilateral retinal detachments. Vitreous cultures grew H. capsulatum var. capsulatum. Treatment consisted of intravenous amphotericin, intravitreal amphotericin (both eyes), pars plana vitrectomy (left eye), and scleral buckling procedure (left eye) with resulting counting fingers vision (right eye) and 20/300 (left eye). Four cases of Histoplasma endophthalmitis have been reported previously, all of which had a documented history of disseminated histoplasmosis and resulted in enucleation. CONCLUSIONS: H. capsulatum should be considered a possible etiologic agent of endophthalmitis, especially in patients with a history of disseminated histoplasmosis and/or immune deficiency.

Zinc ligand-disrupted recombinant human Endostatin: potent inhibition of tumor growth, safety and pharmacokinetic profile.

Endostatin, a potent endogenous inhibitor of angiogenesis, inhibits the growth of primary tumors without induction of acquired drug resistance in mice. We report that a soluble recombinant human (rh) Endostatin produced with characteristics of the native Endostatin, effectively inhibited the growth of primary tumors and pulmonary metastases in a dose-dependent manner. We also show that deletion of two of the four zinc ligands of rhEndostatin did not affect this potent tumor inhibiton. The growth of established Lewis lung primary tumors implanted into mice was inhibited (80-90%) upon systemic treatment with 50 mg/kg/12 h of rhEndostatin. Using the B16-BL6 murine experimental pulmonary metastases model, rhEndostatin administered at 1.5 mg/kg/day or 4.5 mg/kg/day beginning 3- or 11-days post tumor cell injection, respectively, resulted in an approximate 80% inhibition of tumor growth. At effective anti-tumor doses of 1.5 and 50 mg/kg, pharmacokinetic modeling in mice showed (a) the protein was 100% bioavailable, (b) the AUC ranged from 16 to 700 ng ml/h and (c) the Cmax ranged from 161 to 4582 ng/ml. At the highest dose tested (300 mg/kg), delivered as a single bolus, no drug-related toxicity was observed in a Cynomolgus monkey infused with rhEndostatin. No toxicity was observed even at AUC and Cmax values that were 1.3- to 56-fold higher than those observed in mice with tumors that were potently inhibited. Our production system yields a well characterized, soluble and potent rhEndostatin at quantities sufficient for human use. The preclinical studies described herein are an important first step toward the assessment of Endostatin in the clinic.

Use of CD and FT-IR to determine the secondary structure of purified proteins in the low-microgram range.

The spectroscopic characterization of protein secondary structure is often partially unreliable when samples are not extremely pure and abundant. This problem may be overcome by the combination of circular dichroism (CD) and Fourier transform infrared spectroscopy (FT-IR). We used these methods to characterize the secondary structure of two proteins of neurobiological interest, calexcitin (CE) and the cellular isoform of prion protein (PrPC). Both proteins were purified with multiple chromatographic steps and were obtained in buffer with high purity (> 95%) and in low amount (approximately 2 micrograms). The samples were analyzed by circular dichroism (down to 184 or 182 nm), recovered, and deposited on films for infrared analysis. The spectral deconvolution from the two methods yielded secondary structures in good agreement with each other as well as with theoretical predictions based on amino acid sequence. The conformation of CE was found to be dependent on its concentration and on calcium binding. The secondary structure of cellular native PrP varied dramatically with the detergent used. In conclusion, the combination of CD and FT-IR analysis is suitable for the characterization of the conformational changes induced by ligand binding and/or by different solvent conditions when the protein of interest is only scarcely available. The methods used here provide valuable insights into the putative correlation between protein structure and activity.

Secondary structure and Ca2+-induced conformational change of calexcitin, a learning-associated protein.

Calexcitin/cp20 is a low molecular weight GTP- and Ca2+-binding protein, which is phosphorylated by protein kinase C during associative learning, and reproduces many of the cellular effects of learning, such as the reduction of potassium currents in neurons. Here, the secondary structure of cloned squid calexcitin was determined by circular dichroism in aqueous solution and by Fourier transform infrared spectroscopy both in solution and on dried films. The results obtained with the two techniques are in agreement with each other and coincide with the secondary structure computed from the amino acid sequence. In solution, calexcitin is one-third in alpha-helix and one-fifth in beta-sheet. The conformation of the protein in solid state depends on the concentration of the starting solution, suggesting the occurrence of surface aggregation. The secondary structure also depends on the binding of calcium, which causes an increase in alpha-helix and a decrease in beta-sheet, as estimated by circular dichroism. The conformation of calexcitin is independent of ionic strength, and the calcium-induced structural transition is slightly inhibited by Mg2+ and low pH, while favored by high pH. The switch of calexcitin's secondary structure upon calcium binding, which was confirmed by intrinsic fluorescence spectroscopy and nondenaturing gel electrophoresis, is reversible and occurs in a physiologically meaningful range of Ca2+ concentration. The calcium-bound form is more globular than the apoprotein. Unlike other EF-hand proteins, calexcitin's overall lipophilicity is not affected by calcium binding, as assessed by hydrophobic liquid chromatography. Preliminary results from patch-clamp experiments indicated that calcium is necessary for calexcitin to inhibit potassium channels and thus to increase membrane excitability. Therefore the calcium-dependent conformational equilibrium of calexcitin could serve as a molecular switch for the short term modulation of neuronal activity following associative conditioning.

Metabolic response to radiation therapy in patients with cancer.

The effect of radiation therapy on substrate metabolism was evaluated in five patients with head and neck or lung cancer. Stable isotope tracer methodology was used to determine urea, amino acid, glucose, and lipid kinetics during postabsorptive conditions before initiation, near the midpoint (after receiving 2,672 +/- 36 rads), and at completion (after receiving 6,072 +/- 307 rad) of a 6- to 8-week course of radiation therapy. Nutritional status was maintained throughout the treatment period by providing supplemental enteral feedings as needed. Postabsorptive plasma insulin, catecholamine, and amino acid concentrations did not change during the course of treatment. Before radiation therapy was initiated, values for the plasma rate of appearance (Ra) of urea (3.35 +/- 0.33 micromol x kg(-1) x min(-1)), alpha-ketoisocaproate ([alpha-KIC] 2.16 +/- 0.19 micromol x kg(-1) x min(-1)), phenylalanine (0.59 +/- 0.052 micromol x kg(-1) x min(-1)), and glucose (10.56 +/- 1.31 micromol x kg(-1) x min(-1)) were in the normal range. However, glycerol and palmitate Ra values (3.11 +/- 0.30 and 2.01 +/- 0.33 micromol x kg(-1) x min(-1), respectively) were 25% higher than values observed previously in normal subjects. Substrate flux did not change during radiation therapy, and measurements obtained during the midpoint and at completion of treatment were similar to initial values. These results demonstrate that large doses of radiation therapy, administered over 6 to 8 weeks to the upper body, do not cause significant metabolic stress.

Effect of weight loss on whole body and cellular lipid metabolism in severely obese humans.

We evaluated the effect of diet-induced weight loss on whole body and cellular lipid metabolism in persons with severe upper body obesity in two study protocols. In protocol 1, palmitate and glycerol rates of appearance (Ra) in plasma were determined during basal conditions in seven subjects [initial body mass index (BMI) = 41.3 +/- 2.2 kg/m2] before and after 20.4 +/- 3.0 kg weight loss. Total glycerol and palmitate Ra decreased from 231.0 +/- 19.4 and 166.2 +/- 16.6 mumol/min, respectively, before weight loss to 162.7 +/- 9.5 and 105.0 +/- 9.7 mumol/min, respectively, after weight loss (P < 0.01). However, glycerol and palmitate Ra expressed per kilogram fat mass were similar both before and after weight loss. In protocol 2, subcutaneous abdominal adipose tissue was obtained before and after 14.4 +/- 2.1 kg weight loss in five subjects (initial BMI = 41.6 +/- 2.6 kg/m2). Weight loss caused a 38 +/- 8% decrease in adipocyte hormone-sensitive lipase concentration (P < 0.05) but was not associated with any consistent changes in the concentrations of GTP-dependent regulatory proteins, Gi1 alpha, Gi2 alpha, and G3 alpha. We conclude that diet-induced weight loss ameliorates the increase in basal lipolytic rates in persons with severe upper body obesity. These alterations are associated with changes in cellular hormone-sensitive lipase but not GTP-dependent regulatory protein concentrations.

Corrosion of a nonprecious metal post: a case report.

This paper describes a case in which an endodontically treated molar, which was restored with a post-retained cast restoration, was eventually lost following corrosion of the nonprecious metal post and fracture of the distal root.

Suppression of hemodynamic change before extubation--lidocaine through modified endotracheal tube.

Twenty females, aged 31 to 49 years, scheduled for abdominal total hysterectomy were randomly divided into two groups in this study. An epidural catheter was placed at T11-12 before general anesthesia. All patients receive the combination of epidural anesthesia and general anesthesia for the operation and relief of pain postoperatively. The modified endotracheal tube we used is shown in Fig. 1. For patients in group I (Lidocaine group), 2 mL 4% lidocaine solution was injected through the catheter to desensitize the tracheal mucosa around the cuff after the surgeon had removed the uterus. In group II (Control group), no special management was made. All patients were not extubated until they were considered to be awake. Systolic blood pressure at three and one minute before extubation and pulse rate recorded at one minute before extubation showed in patients of group I were statistically smoother than those recorded in group II (p less than 0.01). All patients had gag reflex just after awake extubation.

The application of pulse oximeter for supraclavicular brachial block.

The subclavian artery is the most important landmark of the supraclavicular brachial block. However, it is difficult to locate the artery by palpation in the patients with poor landmark. The present study was aimed to compare two localizing methods of the subclavian artery by a pulse oximeter or by palpation. One hundred patients were divided into three groups. Group A (Slim Group): 6 patients, Group B (Normal Weight Group): 75 and Group C (Obese Group): 19. All patients received both methods to locate the subclavian artery. The first method was by palpating the pulsation of the subclavian artery. The second was by observing the wave depression of the pulse oximeter while pressing supraclavicular area. It was found that the detection rate of the first method was 83.3% in Group A, 52.0% in Group B, 26.3% in Group C and 49.0% in overall patients. However, the detection rate of the second method was 100% in each group. It shows a significant difference between the two methods in Group B, Group C and all patients (P less than 0.001), but no difference in Group A (P = 0.68). There were 13 patients among the 100 patients undergoing surgery of the upper extremity. Seven of them whose pulsation was not clearly palpated but could be located exactly by pulse oximeter. Supraclavicular brachial block was still completed successfully in these 13 patients. No pneumothorax was found. Utilizing pulse oximeter in supraclavicular block provides a high detection rate of the pulsation of the subclavian artery and improves the reliability of the block, especially in the patients with poor landmark.

Estimation of the length of nasopharyngeal airway in Chinese adults.

Nasopharyngeal airway should be placed to reach the tongue base without contact with the epiglottis. The correct length of the nasopharyngeal airway in Chinese adults was estimated in seventy-three surgical patients under general anesthesia (30 males and 43 females, aged 18-82 yr). Measurements were performed with a soft, uncuffed, ID 6.0 mm endotracheal tube (Portex) introduced through the nasopharyngeal passage. The proper tip placement of the tube was evaluated under direct laryngoscopy. The Nostril-epiglottis distance (N-E distance) is 15.31 +/- 1.09 cm (mean +/- SD) for all cases, 16.03 +/- 1.04 cm for male cases and 14.97 +/- 0.95 cm for female cases. There are correlation between the N-E distance and the height (p less than 0.001, r = 0.41), and between the N-E distance and the N-A distance (The distance from nose tip to mandibular angle) (p less than 0.004, r = 0.324). Linear regression analysis relating the N-E distance to the height and the N-E distance to the N-A distance were also statistically significant (p less than 0.001 and p less than 0.01, respectively).