Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer.

Existential distress is of clinical concern in patients with terminal illness. Although existential distress has been used to describe a broad spectrum of psychological disturbances, its narrower definition may be confined to distress that arises when the meaning and value of one's life is unclear, and is comorbid with feelings of loneliness and low self-worth. To promote further study, we developed and pilot-tested a 10-item Existential Distress Scale (EDS). Twenty-one patients with advanced cancer were recruited from a palliative care unit. Measures of existential distress, death anxiety, depression, performance status and physical symptom burden were collected. The EDS showed promising psychometric properties, including significant associations with death anxiety and depression. Thirty-eight per cent of the sample reported great or unbearable distress on at least one existential concern. The EDS may be administered to measure existential distress in patients with advanced cancer and clinicians may find the instrument useful to initiate a structured discussion about this symptom.

Accuracy and completeness of pathology reporting--impact on partial breast irradiation eligibility.

AIMS: Accelerated partial breast irradiation (APBI) is an alternative to whole breast irradiation that is delivered over a shorter period of time with less toxicity. Appropriate patient selection is critical to its success and the American Society for Radiation Oncology (ASTRO) has published detailed selection criteria for 'suitable' patients. This study evaluated the effect of those selection criteria on APBI eligibility based on pathology reports. MATERIALS AND METHODS: From March 2004 to March 2007 all patients referred to a single cancer centre for breast radiotherapy were screened for participation in a phase I/II trial of permanent breast seed implant brachytherapy. Eligible patients underwent a computed tomography simulation and those referred from an outside institution had a secondary expert breast pathology assessment. Initial and expert pathology reports were compared regarding completeness and accuracy. RESULTS: In total, 143 patients were eligible for the trial; 79 patients had surgery carried out outside our institution. In the initial pathology report, the most frequently missing critical information was the resection margin width (29.1%) and the presence of extensive in situ carcinoma (11.4%). Comparing initial and reviewed pathology, the agreement was higher than 90% for most features. The main source of disagreement was the width of the negative resection margin, with 34.4% disagreement (P=0.016), although it changed eligibility in only 3.6%. There was major disagreement in the evaluation of lymphovascular invasion. Overall, pathology review changed the eligibility for a patient from 'suitable' for APBI to 'cautionary' in 18.6% of the cases. CONCLUSION: Using stringent eligibility criteria has a direct effect on patient screening for APBI. The use of synoptic pathology reporting and a quality assurance programme with secondary expert assessments are recommended.

Lunotriquetral arthrodesis using cancellous bone graft.

Previous reports of lunotriquetral arthrodesis suggest relatively low rates of primary fusion without the use of permanent fixation and/or prolonged immobilization. We performed 26 lunotriquetral arthrodeses in 24 patients with a technique using cancellous bone graft to fill a biconcave space created in the adjoining bones with parallel K-wire fixation. The indications included symptomatic lunotriquetral instability and degenerative arthritis. All patients received conservative treatment before surgery. Primary fusion was achieved in all wrists in an average of 50 days. Postoperative wrist flexion/extension averaged 77%/80% of unaffected sides. Radial/ulnar deviation averaged 95%/91% of unaffected sides. Pain relief was good or very good in 83%. Eight-eight percent returned to the workforce. This study shows reliable, effective results with a technique that adheres to the principles of intercarpal arthrodesis and avoids permanent internal fixation.

One thousand intercarpal arthrodeses.

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienbock's disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

The natural progression of scaphoid instability.

Wrist injury or repeated wrist sprains probably result in injury to the scapholunate ligament more commonly than previously recognized, which may allow abnormal scaphoid skid under load. This results in a common clinical entity termed DWS. Scaphoid instability is a spectrum condition ranging from minor, asymptomatic findings (seen in 20% of normal adults) through symptomatic findings in patients with normal radiographs to abnormal instability on radiographs, to degenerative change, and, ultimately, to SLAC wrist (see Fig. 1). Appropriate diagnosis and management of each of these wrist disorders are highly dependent upon a keen understanding of normal periscaphoid anatomy as well as the anatomic derangements that occur within the wrist that predispose a given patient to subsequent degenerative changes. With that understanding, the appropriateness of conservative therapy, SL exploration and arthroplasty, ligament repair, triscaphe arthrodesis, or SLAC reconstruction can be readily determined in each case.