The road less travelled: Australian women's experiences with vulval cancer.

Despite advances in surgical treatments and the availability of more conservative treatment options, women treated for vulval cancer still experience significant complications such as urinary incontinence, lymphoedema, pruritus, sexual and intimacy issues. These issues can profoundly impact a woman's quality of life. The subjective experience of women diagnosed and treated for vulval cancer in the literature is limited, possibly due to its comparable rarity to other gynaecological and female cancers and because it was traditionally seen mainly in the elderly female population. Nonetheless, younger women are also being diagnosed with vulval cancer. This paper reports the findings from a qualitative study about twelve women's experiences with vulval cancer from diagnosis, through treatment and recovery. Women's feelings of isolation, their unmet information and support needs, physical concerns arising from vulval cancer, particularly after surgery, and the consequences for their body image and intimate relationships with partners, were highlighted within the data. The central findings from this study emphasise the need for further research to develop appropriate interventions for women with vulval cancer. It also highlights opportunities to improve clinical practice into the supportive care of women with this isolating disease.

Republished paper: assessment of doctors' consultation skills in the paediatric setting: the Paediatric Consultation Assessment Tool.

OBJECTIVE: To determine the utility of a novel Paediatric Consultation Assessment Tool (PCAT). DESIGN: Developed to measure clinicians' communication behaviour with children and their parents/guardian, PCAT was designed according to consensus guidelines and refined at a number of stages. Volunteer clinicians provided videotaped real consultations. Assessors were trained to score communication skills using PCAT, a novel rating scale. SETTING: Eight UK paediatric units. PARTICIPANTS: 19 paediatricians collected video-recorded material; a second cohort of 17 clinicians rated the videos. MAIN OUTCOME MEASURES: Itemised and aggregated scores were analysed (means and 95% confidence intervals) to determine measurement characteristics and relationship to patient, consultation, clinician and assessor attributes; generalisability coefficient of aggregate score; factor analysis of items; comparison of scores between groups of patients, consultations, clinicians and assessors. RESULTS: 188 complete consultations were analysed (median per doctor = 10). 3 videos marked by any trained assessor are needed to reliably (r > 0.8) assess a doctor's triadic consultation skills using PCAT, 4 to assess communication with just children or parents. Performance maps to two factors - "clinical skills" and "communication behaviour"; clinicians score more highly on the former (mean (SD) 95% CI 0.52 (0.075)). There were significant differences in scores for the same skills applied to parent and child, especially between the ages of 2 and 10 years, and for information-sharing rather than relationship building skills (2-tailed significance < 0.001). Conclusions The PCAT appears to be reliable, valid and feasible for the assessment of triadic consultation skills by direct observation.

Assessment of doctors' consultation skills in the paediatric setting: the Paediatric Consultation Assessment Tool.

OBJECTIVE: To determine the utility of a novel Paediatric Consultation Assessment Tool (PCAT). DESIGN: Developed to measure clinicians' communication behaviour with children and their parents/guardian, PCAT was designed according to consensus guidelines and refined at a number of stages. Volunteer clinicians provided videotaped real consultations. Assessors were trained to score communication skills using PCAT, a novel rating scale. SETTING: Eight UK paediatric units. PARTICIPANTS: 19 paediatricians collected video-recorded material; a second cohort of 17 clinicians rated the videos. MAIN OUTCOME MEASURES: Itemised and aggregated scores were analysed (means and 95% confidence intervals) to determine measurement characteristics and relationship to patient, consultation, clinician and assessor attributes; generalisability coefficient of aggregate score; factor analysis of items; comparison of scores between groups of patients, consultations, clinicians and assessors. RESULTS: 188 complete consultations were analysed (median per doctor = 10). 3 videos marked by any trained assessor are needed to reliably (r>0.8) assess a doctor's triadic consultation skills using PCAT, 4 to assess communication with just children or parents. Performance maps to two factors--"clinical skills" and "communication behaviour"; clinicians score more highly on the former (mean (SD) 95% CI 0.52 (0.075)). There were significant differences in scores for the same skills applied to parent and child, especially between the ages of 2 and 10 years, and for information-sharing rather than relationship-building skills (2-tailed significance <0.001). CONCLUSIONS: The PCAT appears to be reliable, valid and feasible for the assessment of triadic consultation skills by direct observation.

Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids.

OBJECTIVE: To compare the outcome of urgent haemorrhoidectomy with conservative treatment for prolapsed thrombosed internal haemorrhoids. METHODS: A prospective randomised study of 50 patients with prolapsed thrombosed internal haemorrhoids was carried out using clinical and ultrasonic outcome measures. Peri-operative bed occupancy and the presence of symptoms at 6 and 24 months were compared. Endoanal ultrasonic scanning was carried out to investigate anal sphincter integrity in those patients willing to be studied. RESULTS: The median length of hospital stay for the group treated conservatively; 2 nights (range 1-9 nights) was significantly shorter than for the group treated by urgent haemorrhoidectomy; 4 nights (range 1-12 nights, P < 0.01). There was no difference between treatment groups in the number of patients with symptoms at six or 24 months. Urgent haemorrhoidectomy was associated with a significantly higher incidence of endosonographically detected anal sphincter damage in 18 patients: 66%vs 0% (P = 0.009). CONCLUSION: Conservative treatment for prolapsed thrombosed internal haemorrhoids is associated with shorter in patient stay and less anal sphincter damage compared with operative treatment.

Effects of a course in neonatal resuscitation--evaluation of an educational intervention on the standard of neonatal resuscitation.

BACKGROUND: Appropriate assessment and resuscitation is an important part of neonatal care provided during the first minutes of life. Midwifery and junior medical staff are often in the frontline of neonatal resuscitation. Appropriate education and training of midwifery staff is therefore essential if the standard of care delivered to babies in the delivery suite is to be improved and maintained. Evaluation of any such educational interventions is necessary to assess their effectiveness. AIM: To assess the effect of a course in neonatal resuscitation introduced in 1995 aimed at midwifery staff, on the standard of care provided to babies immediately after birth. Prior to this, training in neonatal resuscitation was largely theoretical. METHODS: Naturalistic design observational study conducted in a maternity unit with a tertiary neonatal intensive care unit in the North of England. We compared two groups of babies born before and after the course was introduced. Use of naloxone in the delivery suite and appropriateness of its use, and temperature on admission to neonatal intensive care unit were used as proxy markers for standard of care and compared in the two groups. We also looked at the use of mask intermittent positive pressure ventilation (IPPV) and tracheal intubation in the delivery suite. RESULTS: Use of naloxone fell dramatically from 13.2% of all babies born in 1994 to 0.5% in 2003. Inappropriate use of naloxone before other resuscitation measures were initiated declined from 75% of babies given naloxone in 1994 to 10% in 2003. The incidence of hypothermia (<35 degrees C) on admission to neonatal unit declined from 9% of all admissions to 2.3% in 2003. There was a trend towards increased use of mask ventilation in the delivery suite with a corresponding trend towards less tracheal intubation. CONCLUSION: We have shown that the intervention has been related temporally to an improvement in the quality of care delivered by midwifery staff to newborn babies. Practical courses in neonatal resuscitation can contribute to improvements in the quality of care provided to babies immediately after birth. These courses are more effective than theoretical teaching alone.

Prevalence and distribution of petechiae in well babies.

AIMS: To determine the prevalence of petechial spots in well babies. METHODS: A total of 116 babies under the age of 12 months were fully examined at child health surveillance clinics. The number and site of petechiae were recorded together with details of possible causes. RESULTS: A total of 27.6% of babies had one or more petechiae, 8.6% had two or more petechiae, and 2.6% had more than two. None of these babies subsequently developed sepsis. CONCLUSIONS: Many well infants examined in the community are likely to have petechial spots. In this setting one or two petechiae are common and their presence should not be taken as pathological without other clinical signs. Recognition of this fact may also be helpful when examining otherwise well infants with petechiae in a secondary care setting.

Light ethanol consumption enhances liver regeneration after partial hepatectomy in rats.

BACKGROUND & AIMS: The effects of "social drinking" on the liver have yet to be fully documented. The aim of this study was to document the effects of daily light, moderate, and heavy ethanol exposure on hepatic regenerative activity in the rat. METHODS: Adult male Sprague-Dawley rats underwent daily gavages with 1.0 (light), 2. 0 (moderate), or 4.0 (heavy) g/kg of ethanol or tap water (controls) for 30 days before 70% partial hepatectomy (PHx). Hepatic regenerative activity was then documented on days 1, 3, 5, and 7 after PHx. RESULTS: Compared with controls, restitution of liver mass, [(3)H]thymidine incorporation, and proliferating cell nuclear antigen expression were decreased in the heavy (-10%, -60%, and -36%, respectively), unchanged in the moderate (-4%, -8%, and -16%, respectively), and increased in the light (+6%, +38%, and +29%, respectively) ethanol groups. Messenger RNA differential display of resected livers at PHx identified a band present only in the light ethanol group that encodes a unique 47-kilodalton protein with growth-promoting features designated light ethanol-induced stimulatory protein. CONCLUSIONS: The results indicate that light ethanol consumption enhances hepatic regenerative activity after PHx in rats. Further studies are required to determine the mechanism involved and whether social drinking has beneficial or adverse effects on the natural history of acute or chronic liver disease in humans.

Effect of oral antibiotics on intestinal production of propionic acid.

BACKGROUND: Propionic acid derived from colonic bacterial fermentation contributes substantially to overall propionate load in children with disorders of propionate metabolism, and its reduction is important for adequate metabolic control. AIMS: To evaluate the in vitro and in vivo effects of antibiotic treatment on propionate production by colonic bacteria, and plasma propionate concentrations in a child with propionic acidaemia. METHODS: In vitro fermentation techniques were used to study the effects of addition of antibiotics (metronidazole, clindamycin, erythromycin, and vancomycin) on net faecal production of short chain fatty acids including propionic acid. Courses of oral antibiotics of 7 days duration were used to assess the in vivo effects on faecal propionate production and metabolic control including plasma propionate concentrations. RESULTS: Metronidazole produced the largest and most consistent reduction (77-84%) in the production in vitro of propionate from faecal homogenates. Oral administration of metronidazole reduced faecal propionate production by 43% within 24 hours of treatment; a 7 day course virtually eliminated it for the next 3 weeks. These reductions were accompanied by substantially lowered plasma propionate concentrations during the same period. CONCLUSIONS: Intermittent courses of oral metronidazole might be as effective as continuous treatment in reducing gut propionate production in children with disorders of propionate metabolism.

Duodenal leiomyosarcoma presenting with iron deficiency anemia.

Failed iron therapy warrants investigation to rule out disorders of iron absorption or intestinal blood loss. The authors report the third case of duodenal leiomyosarcoma in childhood, which presented with iron deficiency anemia. Endoscopy failed to elicit the cause of this problem. Wide surgical resection, sparing the pancreas, was possible.

Cytomegalovirus infection after liver transplantation in children.

Post-liver transplant cytomegalovirus (CMV) infection (seroconversion or virus isolation) and CMV disease (infection plus clinical signs and symptoms) were studied in relation to pretransplant recipient and donor serology, age, nutritional status and the effect of paediatric versus adult (reduced size) grafts. Of 70 children receiving 79 transplants, 26 (37%) had evidence of CMV infection, and eight (11.5%) had evidence of CMV disease, four of whom died. The primary infection rate (where the recipients were CMV negative) was 71% with mortality of 7% with most receiving a CMV-positive graft. The active secondary infection rate (reactivation or reinfection, where the recipients were CMV positive) was 60% with mortality of 12.5%. No significant differences in infection or disease rates were found comparing malnourished versus well-nourished patients, or between those who received whole or reduced-size grafts. The high prevalence of CMV infections supports the view that clinical signs alone are inadequate to direct investigations for CMV. Both primary and active secondary CMV infection can result in serious morbidity and mortality in children receiving liver transplants. These data do not support the strategy of providing immunoprophylaxis to seronegative recipients only, at least in paediatric liver transplantation.

Changes in nocturnal oximetry after treatment of exacerbations in cystic fibrosis.

Sleep related arterial oxygen desaturation has been described in clinically stable young adults with cystic fibrosis. The incidence and severity of nocturnal oxygen desaturation in children during infective exacerbations and the changes that occur with treatment were examined. Forty five children with proved cystic fibrosis, median age 8.9 years, admitted to the Regional Cystic Fibrosis Unit underwent clinical evaluation, spirometry, and measurement of peak flow and nocturnal oxygen saturation on admission and after 10 days' treatment. There was a significant improvement in all the above measurements, with the averaged overnight saturation changing from a mean (SD) 92.7 (2.7)% to 94.3 (2.0)%, mean (SE) difference 1.58 (0.37). The time spent with a saturation 4% or more below their clinic value showed a marked improvement from 122 (152) minutes on the first night to 21 (30.7) on the second, mean (SE) difference 101 (22.4). Eight young children could not perform pulmonary function tests, all desaturated on the admission night. Nocturnal hypoxaemia is a common finding in young cystic fibrosis patients during infective exacerbations but improves with treatment. Overnight oximetry is simple to perform, well tolerated, and identifies patients with marked nocturnal desaturation.

Amyloid beta-peptide is produced by cultured cells during normal metabolism.

Alzheimer's disease is characterized by the extracellular deposition in the brain and its blood vessels of insoluble aggregates of the amyloid beta-peptide (A beta), a fragment, of about 40 amino acids in length, of the integral membrane protein beta-amyloid precursor protein (beta-APP). The mechanism of extracellular accumulation of A beta in brain is unknown and no simple in vitro or in vivo model systems that produce extracellular A beta have been described. We report here the unexpected identification of the 4K (M(r) 4,000) A beta and a truncated form of A beta (approximately 3K) in media from cultures of primary cells and untransfected and beta-APP-transfected cell lines grown under normal conditions. These peptides were immunoprecipitated readily from culture medium by A beta-specific antibodies and their identities confirmed by sequencing. The concept that pathological processes are responsible for the production of A beta must not be reassessed in light of the observation that A beta is produced in soluble form in vitro and in vivo during normal cellular metabolism. Further, these findings provide the basis for using simple cell culture systems to identify drugs that block the formation or release of A beta, the primary protein constituent of the senile plaques of Alzheimer's disease.

Targeting of cell-surface beta-amyloid precursor protein to lysosomes: alternative processing into amyloid-bearing fragments.

Progressive cerebral deposition of the amyloid beta-peptide is an early and invariant feature of Alzheimer's disease. The beta-peptide is released by proteolytic cleavages from the beta-amyloid precursor protein (beta APP), a membrane-spanning glycoprotein expressed in most mammalian cells. Normal secretion of beta APP involves a cleavage in the beta-peptide region, releasing the soluble extramembranous portion and retaining a 10K C-terminal fragment in the membrane. Because this secretory pathway precludes beta-amyloid formation, we searched for an alternative proteolytic processing pathway that can generate beta-peptide-bearing fragments from full-length beta APP. Incubation of living human endothelial cells with a beta APP antibody revealed reinternalization of mature beta APP from the cell surface and its targeting to endosomes/lysosomes. After cell-surface biotinylation, full-length biotinylated beta APP was recovered inside the cells. Purification of lysosomes directly demonstrated the presence of mature beta APP and an extensive array of beta-peptide-containing proteolytic products. Our results define a second processing pathway for beta APP and suggest that it may be responsible for generating amyloid-bearing fragments in Alzheimer's disease.