Nodal presentation of seminoma

We report a 38 year old male with metastatic seminoma in an inguinal lymph node and regression of the primary testis tumour with a past history of orchiopexy--an extremely rare occurrence.

Implementation of a cost-effective optical comb source in a WDM-PON with 10.7 Gb/s data to each ONU and 50 km reach

The performance of a cost-effective optical comb source using commercial off the shelf (COTS) components in a WDM passive optical network is demonstrated. Eight comb modes are individually modulated at 10.7 Gb/s and transmitted over 50 km of single mode fiber for downlink transmission. Error free performance is obtained for each comb line and a maximum performance difference of 1.4 dB is experienced between the eight channels. Colorless operation of the optical network unit is achieved by utilizing an integrated module consisting of a tunable laser and an electro-absorption modulator as an uplink transmitter. Finally the predicted downstream performance of the system, when all the channels are transmitted simultaneously, is numerically simulated.

Outcomes from the trial implementation of a multidisciplinary online learning program in rural mental health emergency care

INTRODUCTION

Emergency Departments (EDs) are often the first point of contact for people with acute mental health problems. The impact of the Mental Health Emergency Care (MHEC) online learning program on the knowledge and skills development of clinicians and support staff was evaluated, and options for sustainable implementation of the program were proposed.

METHODS

Participants were recruited from the four rural health services and the rural areas of one metropolitan health service in New South Wales, Australia. The MHEC course was conducted online over 24 weeks and comprised four sequential modules, each based on a clinical scenario that demonstrated a typical, acute mental health presentation to a general hospital ED. The course was designed to model collaborative practice in mental health emergency care.

RESULTS

Participants were surveyed before and after completing the MHEC course. Statistically significant improvements were detected in participant confidence in managing key mental health problems, perceived self-efficacy in dealing with challenging, aggressive behaviours and confidence in key online learning skills. Participants also reported very positive experiences in relation to the course content and structure, instructor support, multidisciplinary discussion and feedback, and improvements in their knowledge and skills about emergency mental healthcare.

CONCLUSIONS

This study provides evidence for the effectiveness and acceptability of an online educational program in developing the capacity of front-line staff to respond effectively to people who present to EDs with acute mental health problems. The positive outcomes and evaluations of the MHEC course provide support for the deployment of online learning programs that address mental health emergency care.

Frequency of zoledronic acid (ZOL) administration to prevent aromatase inhibitor-associated bone loss (AIBL)

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Background: Cancer patients (pts) are at increased risk of osteoporosis because of cancer treatment-induced bone loss. A hypogonadal state can increase bone resorption and turnover. Estrogen depletion with aromatase inhibitors (AIs), the preferred adjuvant treatment in postmenopausal women with early breast cancer (EBC), is associated with accelerated bone resorption and increased fracture risk. Several studies have demonstrated that IV ZOL can prevent AIBL in pts with EBC. ZOL to prevent AIBL was shown to be effective when administered every 6 mo in 4 large, randomized phase III trials. It is unknown if this is the optimal regimen. Methods: Pts who were receiving adjuvant breast cancer therapy with an AI and had a urinary N-telopeptide (uNTX) level > 50 nmol/mmol creatinine (Cr) and a bone density T-score < 1.5 at screening were treated with a single dose of ZOL 4 mg IV. Serum C-telopeptide (sCTX) and uNTX were obtained at baseline and then every 2 mo. Data are presently available from 10 pts who were followed for at least 6 mo and 1 pt followed for 2 mo after receiving ZOL. Wilcoxon signed-rank tests were performed for % change from baseline values. Results: Median baseline uNTX in these patients was 57.5 nmol/mmol Cr (range, 42.7 to 104.5). Median suppression of uNTX from baseline was 76.7% (range, 55.0% to 81.4%; P = .008) at 1 mo after therapy. At 6 mo, suppression of uNTX from baseline was 56.5% (range, 3.5% to 72.6%; P = .03). Similar significant suppression of sCTX up to 6 mo was observed. Continued suppression of uNTX and sCTX (approximately 50% decrease in median from baseline) was observed out to mo 12, although the number of pts studied is too small (n = 5 for uNTX and 4 for sCTX) to draw significant conclusions at this time. Pt accrual continues. Conclusions: A single dose of ZOL significantly suppressed bone resorption markers for at least 6 mo in pts receiving an adjuvant AI. It is not necessary to administer ZOL more frequently to prevent AIBL. These data suggest that ZOL administered every 6 mo is sufficient to prevent AIBL in this population. Further study will define whether this suppression of bone resorption markers continues for longer periods of time.

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Down's syndrome and hip arthropathy

We report a case of a 19 year old male with Down's syndrome who presented with severe functional disability and pain secondary to bilateral hip arthritis. He had longstanding developmental dysplasia of the hip (DDH) that had evolved into end stage arthritis. Following a comprehensive assessment and counselling, he underwent bilateral total hip replacements. At last follow up, he had excellent outcome for function and pain relief. This case highlights the good results achievable with aggressive management of musculo-skeletal conditions (especially hip arthropathy) in those with Down's syndrome and the need for increased recognition of these conditions.

Control, uncertainty, and expectations for the future: a qualitative study of the impact of drought on a rural Australian community

Many rural Australian communities continue to endure a prolonged drought. The mental health effects of short-term natural disaster are well known; those of a long-term and chronic natural disaster such as drought are less well understood. However, in addition to immediate distress there are likely to be feelings of loss, grief and hopelessness, all of which are implicated in an increased risk of subsequent psychiatric morbidity. Furthermore, rural Australia is at a relative disadvantage for early and effective mental health intervention due to a lack of resources, compared with urban Australia. This qualitative research investigates the experience of drought in two farming communities in the state of New South Wales. Farmers, farm and non-farm businesspeople, and health workers took part in focus group discussions of the effects of drought on themselves, their families and their community. In addition to current distress related to financial and workload problems, people reported experiencing significant distress from the emotional impact of environmental degradation, from loss of hope for the future of their community, and from feelings of being misunderstood by the wider Australian community. The stressors affecting farming communities during times of drought are likely to be associated with increased risk of mental health problems.

HIV in prisons: the London experience

The commissioning of health services for all prisoners in publicly run prisons in England was transferred to local Primary Care Trusts in April 2006, pledging to provide an equivalent standard of health care as that in the community. We reviewed our experience of providing a specialist in-reach HIV service by performing a retrospective case notes review of all HIV-positive prisoners who accessed care from the prison genitourinary medicine service in three London prisons. A total of 112 HIV-positive prisoners were seen by the prison health-care service between April 2004 and 2006. This is the first study to look at how well HIV services are being provided during this transitional period of commissioning health services and provides insight into the challenges facing prison health-care providers. Good HIV outcomes are possible in prison but frequent transfers within the prison system and lack of effective HIV training among prison staff represent barriers to good care.

Clinical supervision for mental health nurses in Northern Ireland: formulating best practice guidelines

Nurses work in a constantly challenging and changing environment. Within this context, there is a continuing need for support. Such support will help increase morale, decrease strain and burnout, and encourage self-awareness and self-expression. Clinical supervision address all these issues and enhances the quality of care for patients. While clinical supervision is a policy imperative in Northern Ireland, it was clear that there were problems in its implementation in mental health nursing. The aim of this project was to explore ways to make clinical supervision available to all mental health nurses and to improve and evaluate their contribution to patient care. The research team undertook a comprehensive literature review and a baseline survey of relevant stakeholders. Results represent the outcome of the group work. They will assist healthcare providers to develop local policies and procedures on clinical supervision for practising mental health nurses.

Physician initiated cancer screening discussions and patient intention to engage in screening behavior

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Background: Cancer screening for colon, breast, and prostate cancer remains underutilized. Physician (MD)-patient discussions of screening are common but the impact of these discussions is unknown. Methods: 2489 40–70 year old subjects completed a national survey of cancer prevention information acquisition and decision making (median age 53, 49% male, 77% white, 59% married, 61% some college). Subjects reported whether their MD initiated discussions (MDID) about colonoscopy, mammography, & PSA within the past year. Age eligible subjects were “non-routine screeners” (NRS: never screened or colonoscopy >10 yrs, mammography >2 yrs or PSA>2 yrs prior) or “routine screeners” (RS).The endpoint was intention to screen when next eligible. Results: 46%, 75% and 60% of subjects reported intentions to obtain colonoscopy, mammography and/or PSA. Logistic regression was used to determine the association between MDID and intentions to screen controlling for sociodemographics and recency of screening. For colonoscopy and mammography, MDID was significantly associated with intention to screen for NRS but not RS groups; the opposite was true for PSA. For the NRS group: comparing those saying no versus yes to MDID, intentions were 15% vs. 43% for colonoscopy, 29% to 61% for mammography (RS: 85% vs. 91% and 82% vs. 85%). For PSA, NRS: 46% vs.52% but RS group 65% vs. 85%. All interactions (screening by MDID) were significant, p<.001. Conclusions: Given high intentions to undergo colon and breast cancer screening among patients who have been screened routinely, physician discussion preferentially increases intentions for colon and breast cancer screening among patients who are not routinely undergoing the screening test. Conversely, physician discussion preferentially influences prostate cancer screening intentions among patients who have been screened in the past two years- perhaps because men who have not undergone screening are more resolved in their decision not to screen. These results define subgroups of patients where physician attention may have the greatest impact on screening adherence.

No significant financial relationships to disclose.

18F-FDG PET changes management and improves prognostic stratification in patients with colorectal cancer: results of a prospective, multi-centre study

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Background: The aims were to: 1) examine the impact of PET in changing management in patients with proven or suspected recurrence of colorectal cancer and, 2) assess the impact of management change on disease free survival. Methods: Symptomatic patients (Group A) with a residual structural lesion suspicious for recurrent tumour, or patients (Group B) with pulmonary or hepatic metastases, which were potentially resectable as determined by conventional imaging, underwent PET scans. Pre- and post-PET management plans were documented blinded to PET results. Patients were followed for 12 months to determine actual management and to assess clinical outcomes. Results: A total of 191 patients (118M:73F, mean age 66 yrs) were recruited. PET detected additional sites of disease in 48.4% of Group A and 43.9% of Group B patients. Importantly, a change in planned management was documented in 65.6% of Group A and 49.0% of Group B patients. Follow-up confirmed implementation of management plans in 96% of patients. Analysis of follow-up data to 12 months post- PET showed that in Group A progressive disease was identified in 60.5% of patients with additional lesions detected on PET compared with conventional imaging, and 36.2% patients with no additional lesions detected by PET (p=0.0364); in Group B progressive disease was identified in 65.9% of patients with additional lesions detected on PET and 39.2% patients with no additional lesions detected by PET (p=0.0198). Patient follow-up also showed that PET provided valuable prognostic information in patients stratified into curative/palliative intent groups. Conclusions: These data unequivocally demonstrate the significant impact of PET on management and outcomes in patients with suspected recurrent colorectal cancer.

No significant financial relationships to disclose.

Audit of a diabetes clinic at Tawam hospital, United Arab Emirates, 2004-2005

The aim of this audit was to determine the current management of patients with diabetes compared to international standards and to benchmark the results against current international standards. A retrospective audit of medical records of diabetic patients attending Tawam Hospital, a tertiary healthcare facility in the Al Ain region in the Emirate of Abu Dhabi, United Arab Emirates was performed. A random sample of 30 patients (5% of the target group) was selected from the total number of 600 patients who visited the diabetes clinics in August 2005. An audit form was developed based on the priority aims and measures contained in the Institute for Clinical Systems Improvement (ICSI) Guidelines for the management of type 2 diabetes mellitus. Data analysis was carried out based on measurement specifications in the ICSI Guidelines. All patients had their blood pressure checked at their most recent appointment. All except one patient had an HbA1c test and a lipid profile performed during the study period. Although 75% of patients were referred for a dilated eye examination, only 47% complied. Approximately two-thirds of all patients had evidence of self-monitoring of blood glucose. Less than half of the patients were referred to the nutritionist and only a relatively small proportion of patients had advice on diet and exercise documented in their medical record. There was also lack of documentation, particularly for smoking status, foot examination, and body mass index (BMI). All patients received aspirin (ASA) treatment. The majority had a systolic blood pressure of 130 mmHg or less; just under half of patients had HbA1c of less than 7%. In comparison to the Center for Diseases Control (CDC) targets, we exceeded targets in three areas in relation to HbA1c testing, ASA treatment, and self-report monitoring blood glucose. We did not meet the stated target of 75% for patients having a dilated eye exam due to lack of patient compliance (more than three-quarters of all patients were referred but did not attend for appointment). Documentation of a comprehensive foot examination was present for only one-quarter of all patients compared to the recommended target of three-quarters of patients. Documentation of advice on diet and exercise was present for 40%, which did not meet the CDC target of 60%. Overall, the audit highlighted that Tawam Hospital is providing a good level of care to diabetic patients and compares favorably with international targets; however, key recommended actions have been identified for implementation to improve patient care and maintain a continuous improvement process through effective monitoring with prioritization to those related to preventative care.

In vitro Paclitaxel and Radiation Effects on the Cell Types Responsible for Vascular Stenosis: A Preliminary Analysis

Hemodialysis vascular access dysfunction as a result of venous neointimal hyperplasia in dialysis access grafts and fistulae is currently a huge clinical problem. The aim of this study was to assess the effects of paclitaxel and radiation, both singly and in combination on the proliferation of cell types present within the lesion of venous neointimal hyperplasia (vascular smooth muscle cells, fibroblasts and endothelial cells within the neointimal microvessels). Vascular smooth muscle cells, fibroblasts and endothelial cells were plated onto 96-well plates and exposed to different concentrations and doses of paclitaxel and radiation, respectively (both individually and in combination). Growth inhibition was assessed with an MTT assay. Both paclitaxel and radiation resulted in significant growth inhibition of all three cell types. However, even small doses of paclitaxel appeared to attenuate the antiproliferative effect of radiation on these cell types. Further experiments to elucidate the mechanism behind these findings could result in a better understanding of combination antiproliferative therapies.

Cancer information acquisition differs by patient characteristics

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Background: While cancer patients have access to multiple sources of information, including mass media, the internet and personal and professional contacts, little is known about use of these sources in decision making. Methods: 43 patients with one of three cancer types (37% breast, 28% colon and 35% prostate, 58% stage 1) randomly recruited through the Pennsylvania Cancer Registry completed semi-structured in-person interviews about cancer related information acquisition and decision making. (Median age 59 (range 40–71), 47% male, 79% white, 74% married, mean education 14.6 years (SD = 2.48). Separate analyses were performed for actively looking for information (seeking) vs. passively coming across information (scanning). The primary endpoint was patient use of information sources in cancer related decision making. Results: All cancer patients reported use of both interpersonal and mass media information sources in making cancer related decisions. Patients with more advanced cancer (stage 3 vs. stage 1 or 2), higher education, and younger age were more likely to actively seek cancer information (χ2 = 4.7, p = .095, χ2 = 10, p = .04 and χ2 = 8.6, p = .07). Breast cancer patients and women were more likely to report passively coming across information (χ2 = 9.1, p = .058 and χ2 = 5.1, p = .078). Conclusions: Cancer information acquisition varied according to patient characteristics. Seeking was reported more in younger patients and those with higher formal education, and more advanced cancer. Highly educated and younger patients may be better at navigating the information environment; patients with more advanced cancer may have increased anxiety causing them to actively seek information. Scanning was more common among breast cancer patients and women. Women may attend to general health related information more than men or information about breast cancer may be more accessible and pervasive than information on colon or prostate cancer.

No significant financial relationships to disclose.

Distinct requirements for host CD80/CD86 costimulatory molecules in cardiac versus islet rejection

The role of B7 family members CD80 and CD86 in providing costimulatory signals to T cells is well established. Interestingly, previous studies show that host CD80/CD86 expression is required for cardiac allograft rejection. However, the role for host costimulation by CD80/CD86 molecules for the rejection of neovascularized islet allografts and xenografts is unknown. The purpose of this study was to determine whether islet allografts and/or rat islet xenografts required host CD80/CD86 molecules for acute rejection. Streptozotocin-induced diabetic C57Bl/6 (B6, H-2(b)) or B6 CD80/CD86 double-deficient mice were grafted with allogeneic BALB/c (H-2(d)) islet allografts or with WF (RT1(u)) islet xenografts. Nondiabetic B6 mice were grafted with BALB/c heterotopic cardiac allografts. Consistent with previous reports, BALB/c islet allografts were acutely rejected in wild-type B6 mice could survive long-term (>100 days) in B6 CD80/CD86-deficient animals. In stark contrast, both islet allografts and WF rat islet xenografts demonstrated acute rejection in both control B6 and in B6 CD80/CD86 deficient hosts. In conclusion, varied studies imply that the inherent pathways for rejecting primarily vascularized versus cellular allografts or xenografts may be distinct. The present study illustrates this concept by showing a marked difference in the role of host-derived CD80/CD86 costimulatory molecules for cardiac allograft versus islet allograft/xenograft rejection in vivo. Although such costimulation is rate limiting for cardiac allograft rejection, these same molecules are not necessary for acute rejection of either islet allografts or xenografts.

Increasing face validity of a vascular interventional training system

BACKGROUND

Many aspects of medical training take place on real patients in a live environment thus incurring risk. Apart from the obvious risks to patients there is the issue of X-ray exposure to both staff and trainees. Image quality used during interventional procedures is low to ensure minimum X-ray radiation dose. A virtual interventional system may be used to simulate the interventional cardiology training environment therefore reducing overall risk. The purpose of this project was to determine the appropriate image quality settings on a virtual training system to accurately simulate interventional cardiology and increase the face validity of the overall system.

METHODS

Real image data was obtained from patients undergoing diagnostic interventional cardiology examinations in the Royal Victoria Hospital, Belfast. The images were obtained during catheter placement and contrast enhancement around the region of the heart. The diagnostic views were left anterior oblique, right anterior oblique, left lateral, caudal and the spider view. These five views were simulated on a virtual interventional training system (VIST, Mentice Medical Simulation AB, Sweden) by adjusting x-ray tube and table position at 20 different image quality settings. Signal to noise ratio and image contrast were measured for each of these views using soft tissue and vertebra. The results from the real image data and the VIST image data were compared. Calibration curves were compiled to determine the appropriate VIST image quality setting for each procedure.

RESULTS

Average SNR ranged from 2.94 to 74.0 and IC ranged from 0.009 to 0.61 on the real image data. This indicates the very wide range of image quality encountered in interventional cardiology. Calibration curves for each view with the corresponding range of real patient image quality were produced. These calibration curves enabled the appropriate VIST image quality setting to be determined and therefore simulate the real examination image quality as closely as possible.

CONCLUSIONS

The VIST system has been calibrated in terms of image quality for interventional cardiology examinations. This has increased the face validity of the system.

Factors associated with the wish to hasten death: a study of patients with terminal illness

BACKGROUND

There is considerable debate regarding the clinical issues surrounding the wish to hasten death (WTHD) in the terminally ill. The clinical factors contributing to the WTHD need further investigation among the terminally ill in order to enhance understanding of the clinical assessment and treatment needs that underlie this problem. A more detailed understanding may assist with the development of appropriate therapeutic interventions.

METHOD

A sample of terminally ill cancer patients (N = 256) recruited from an in-patient hospice unit, home palliative care service and a general hospital palliative care consulting service from Brisbane Australia between 1998-2001 completed a questionnaire assessing psychological (depression and anxiety), social (family relationship, social support, level of burden on others) and the impact of physical symptoms. The association between these factors and the WTHD was investigated.

RESULTS

A high WTHD was reported by 14 % of patients. A discriminant function analysis revealed that the following variables were associated with a high WTHD (P < 0.001): higher levels of depressive symptoms, being admitted to an in-patient hospice setting, a greater perception of being a burden on others, lower family cohesion, lower levels of social support, higher levels of anxiety and greater impact of physical symptoms.

CONCLUSIONS

Psychological and social factors are related to a WTHD among terminally ill cancer patients. Greater attention needs to be paid to the assessment of psychological and social issues in order to provide appropriate therapeutic interventions for terminally ill patients.

Benefit from endoscopic sinus surgery

Benefit and satisfaction following endoscopic sinus surgery were assessed using the Glasgow Benefit Inventory (GBI) and a validated outcome satisfaction score. In total, 140 patients were invited to participate; 101 (71%) responded. ESS produces significant benefit as assessed by the GBI and satisfaction, and the benefit compares favourably with other otorhinolaryngological procedures. Greatest benefit was derived by patients undergoing surgery for polyp disease. Patients whose cardinal preoperative symptom was nasal obstruction or headache tended to report higher benefit. Co-existent asthma, allergic rhinitis or aspirin intolerance appeared not to result in a significant decrease in benefit after surgery, except in patients with non-polyp disease, who also have both aspirin intolerance and asthma. Also, for non-polyp disease, postoperative medication with nasal steroids or antihistamines does not appear to influence benefit.

Sputum retention after lung operation: prospective, randomized trial shows superiority of prophylactic minitracheostomy in high-risk patients

BACKGROUND

Sputum retention after lung operation is a potentially life-threatening condition. The minitracheostomy (Minitrach II, SIMS Portex, Hythe, Kent, UK) is a 4-mm percutaneous cricothyroidotomy device, which allows immediate and repeated aspiration of the tracheobronchial tree by minimally trained staff, and can effectively treat sputum retention. This trial was designed to test the hypothesis that prophylactic minitracheostomy could prevent sputum retention in a high-risk group.

METHODS

Between March 1997 and October 1999, 102 patients undergoing lung procedures and considered to be at high risk were prospectively randomized to postoperative, prophylactic minitracheostomy insertion in the recovery room with regular aspiration, or to standard postoperative respiratory therapy.

RESULTS

Sputum retention developed in 15 patients (30%) in the standard group (n = 52) compared to 1 patient (2%) in the minitracheostomy group (n = 50) (p < 0.005). There were three deaths related to sputum retention in the standard group compared to none in minitracheostomy group during the perioperative period.

CONCLUSIONS

It is possible to identify a group of patients at high risk for sputum retention who will benefit from prophylactic therapy. Minitracheostomy is effective as prophylaxis and treatment.

Terminally ill cancer patients' wish to hasten death

This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSR-NUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed.

Abdominal aortic aneurysm and stent graft phantom manufactured by medical rapid prototyping

A novel human aorta phantom built by medical rapid prototypingfor use in computed tomography (CT) scanning is described. The phantom contained a stent graft that was deployed internally to mimic a repaired aortic aneurysm. The phantom was produced to allow assessment of the CT appearance of a stent graft inside an aorta using the new virtual intravascular endoscopy image presentation technique. The stent graft utilized contained suprarenal components (metalfixation struts), and these were placed with these struts covering the renal artery ostia. The phantom was filled with iodinated contrast medium at a concentration that produced a density similar to that found in normal CT angiographic scanning. The model was scanned at a variety of slice thicknesses, pitch and image reconstruction intervals. Visualization of the stent suprarenal components in relation to the renal artery ostia is shown and the overestimation of stent wire strut diameter demonstrated.