Screening for distress can predict loss of follow-up and treatment in cancer patients: results of development and validation of the Distress Inventory for Cancer Version 2

INTRODUCTION

The evidence suggests that in most instances distress from cancer goes unrecognised. There has been substantial work in screening for distress leading to development in practice guidelines recommending screening for distress. There is a need to identify distress early in the continuum, where suitable and timely interventions will benefit the patient. The Distress Inventory for Cancer (DIC) was designed for this.

METHODS

The present study reports the improved psychometric properties of the second version of the DIC (DIC 2). A standardisation sample of 520 patients was administered the 73-item draft questionnaire as well as the Functional Assessment of Cancer Therapy-General (FACT-G). Additional 240 patients were administered Hospital Anxiety and Depression Scale (HADS) besides the final DIC 2 and FACT-G. Internal consistency was measured with the Cronbach's alpha. Chi-square, odds ratio, and binary logistic regression were used to compare the results of three tools and to establish validity.

RESULTS

A principal factor analysis of the 73-item draft questionnaire with varimax rotation in a six-factor structure resulted in 33 items. Activity of daily living emerged as a single item domain. The FACT-G scores negatively correlated with DIC 2 scores, while emotional distress of DIC 2 overlapped with anxiety in HADS. DIC 2 significantly predicted patient non-compliance to treatment and follow-up.

CONCLUSION

The results show a suitable internal consistency, construct, and convergent/divergent validity of the global distress measure (DIC 2). The DIC 2 also demonstrates a predictive function for future negative clinical behaviour, the knowledge of which may facilitate better intervention triage.

Non-smokers are more prone to pulmonary oedema than smokers during acute coronary syndrome

OBJECTIVES

Acute coronary syndrome (ACS) patients are prone to develop pulmonary oedema with varied degree of hypoxaemia. The aim was to compare the risk for pulmonary oedema and related complications during ACS amongst non-smokers vs. smokers.

METHODS

Prospective, observational study was performed in consecutive 68 patients presenting with ACS. They were divided into two groups; group 1 (n = 33) non-smokers and group 2 (n = 35) chronic smokers. Standard conservative treatment was given to maintain mean arterial pressure >or= 60 mmHg, oxygen saturation > 95%. The bedside chest x-ray was graded for Battler grading (0-4) for pulmonary oedema. All patients were evaluated for troponin, serial creatinine kinase, echocardiography, arterial blood gas, renal function and correlated with inotropes requirement, active respiratory support, coronary care unit (CCU) stay and hospital outcome.

RESULTS

Patients in both the groups had similar cardiac involvement for cardiothoracic ratio, troponin, ejection fraction and creatinine kinase muscle and brain (CK-MB). The bedside chest x-ray revealed significant (p < 0.05) lung oedema grades (3 and 4) in 60% non-smokers (group 1) vs. smokers (11%). These patients (group 1) also presented with significant (p < 0.001) hypoxaemia (lower PaO(2)/FiO(2)-201 +/- 44), metabolic acidosis (higher lactate; 2.1 +/- 0.72 mmol/l, base deficit; -5.1 +/- 4.8) and hypocarbia (28 +/- 2.9 mmHg) than smokers (group 2). The risk estimates for active respiratory support (OR =1.716) and inotrope use (OR = 1.836) was three times higher in non-smokers than smokers.

CONCLUSIONS

The higher degree of pulmonary oedema and hypoxemia probably contributed to poor short-term outcome in non-smokers than smokers. It would be important to recognise and treat hypoxaemia in non-smokers during ACS.

Raman spectroscopic investigations of nanoparticles of Sn(x)Ti(1-x)O2 solid solution

SnO2 nanoparticles dispersed in TiO2 matrix are prepared at a relatively low temperature of approximately 185 degrees C. Nanoparticles of Sn(x)Ti(1-x)O2 solid solution without significant aggregation have been prepared by annealing them at approximately 500 and 900 degrees C. X-ray diffraction and high-resolution transmission electron microscopy studies have clearly established the nano-size nature of the samples. Raman spectroscopic investigations of these samples show mixed vibrational modes, some of them being similar to TiO2 (A(1g), E(g)), while some of them are similar to SnO2 (B(2g)). The E(g) mode shows significant red shift and B(2g) mode shows significant blue shift. Unlike this A(1g) mode remains unaffected. These results are explained based on the combined effects of random alloy formation and the nano-size nature of samples.

A hernia in the inguinal region is not always an inguinal hernia

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.

Taurine fails to protect against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced striatal dopamine depletion in mice

Taurine, a known antioxidant and neuroprotector has been investigated for its free radical scavenging action in vitro in isolated mitochondria, and tested whether it protects against 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced dopaminergic neurodegeneration in mice. Taurine (0.1-10 mM) did not affect 1-methyl-4-phenyl pyridinium-induced hydroxyl radical production in isolated mitochondria. Systemic administration of taurine (250 mg/kg, i.p.) caused a small, but significant loss of dopamine levels in the striatum of mice. Taurine failed to reverse MPTP-induced striatal dopamine depletion, but caused significant increase in dopamine turnover in these animals. In the light of the present study it may be suggested that consumption of taurine may neither help in scavenging of neurotoxic hydroxyl radicals in the brain mitochondria, nor would it help in blocking the process of neurodegeneration.

Seed mucilage from Ipomoea dasysperma

A non-ionic water-soluble galactomannan, having galactose and mannose in 1:6 molar ratio, was isolated from endosperm of the seeds of Ipomoea dasysperma. The seed mucilage was found to have a structure having a linear chain of beta (1-->4) linked mannopyranosyl units with D-galactose side chains attached through alpha (1-->6) linkage to the main chain. I. dasysperma seed gum possesses non-ionic characteristics of commercial seed gums and has potential to be used in food and pharmaceutical industries.

Arsenic contamination in the Kanker district of central-east India: geology and health effects

This paper identifies newer areas of arsenic contamination in the District Kanker, which adjoins the District Rajnandgaon where high contamination has been reported earlier. A correlation with the mobile phase episodes of arsenic contamination has been identified, which further hinges on the complex geology of the area. Arsenic concentrations in both surface and groundwater, aquatic organisms (snail and water weeds) soil and vegetation of Kanker district and its adjoining area have been reported here. The region has been found to contain an elevated level of arsenic. All segments of the ecoysystem are contaminated with arsenic at varying degrees. The levels of arsenic vary constantly depending on the season and location. An analysis of groundwater from 89 locations in the Kanker district has shown high values of arsenic, iron and manganese (mean: 144, 914 and 371 microg L(-1), respectively). The surface water of the region shows elevated levels of arsenic, which is influenced by the geological mineralised zonation. The most prevalent species in the groundwater is As(III), whereas the surface water of the rivers shows a significant contamination with the As(V) species. The analysis shows a bio-concentration of the toxic metals arsenic, nickel, copper and chromium. Higher arsenic concentrations (groundwater concentrations greater than 50 microg L(-1)) are associated with sedimentary deposits derived from volcanic rocks, hence mineral leaching appears to be the source of arsenic contamination. Higher levels of arsenic and manganese in the Kanker district have been found to cause impacts on the flora and fauna. A case study of episodic arsenical diarrhoea is presented.

A case of human thelaziasis from Himachal Pradesh

Small, chalky-white, threadlike, motile worms were isolated from the conjunctival sac of a 32 year-old woman residing in the Himalaya mountains. They were identified as both male and female worms of Thelazia callipaeda. To the best of our knowledge, this is the second case report of human thelaziasis from India.

Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore needle: a randomised, prospective, clinical study

In this prospective, randomised study, consented adult patients of both genders were divided into two groups. In group 1 (n = 79) patients, during internal jugular vein cannulation, the pilot needle was removed before the wide bore needle (18G) puncture. In group 2 (n = 78) patients, the internal jugular vein was anchored by leaving the pilot needle in place during wide bore needle puncture. In demographically similar groups, the first attempt success rate improved from 64% in group 1 to 81% in group 2 (p < 0.05). Internal jugular vein puncture was more frequently detected at the entry of the needle with anchoring (group 2: 78%) than without (group 1: 53%); p < 0.05. Ultrasonography of a further 30 internal jugular vein punctures in each group demonstrated that the anchoring manoeuvre (group 2b) significantly (p < 0.05) prevented an indenting effect of the puncture needle, with a higher vertical to horizontal diameter ratio of the internal jugular vein when there was anchoring (0.97; SD 0.004) than without pilot needle anchoring (0.65; SD 0.008). In conclusion, when using surface landmarks, anchoring of the internal jugular vein with the pilot needle facilitated its puncture.

Mandibular invasion in oral squamous cell carcinoma: investigation by clinical examination and orthopantomogram

Assessing the relationship of oral squamous carcinoma with the mandible prior to definitive therapy poses a perplexing problem for the head and neck oncologist. We carried out a prospective open study of 51 (21 female and 30 male; mean age of 53.4 years) patients undergoing mandibular resections for oral squamous cell carcinoma to examine the incidence of mandibular bone invasion and to assess the predictive capabilities of clinical and radiological examination in detecting bone involvement. A detailed clinical examination was followed by radiographic evaluation of mandible for bone invasion. After resection, the mandible was sectioned serially at every cm to find the pathological bone involvement. Sensitivity, specificity, and positive and negative predictive values of clinical and radiological findings were calculated. Specimens from 25 patients (49%) (4 segmental 21 hemi) demonstrated tumour invasion on histological examination. Clinical impression of mandibular invasion showed a sensitivity of 96% and specificity of 65%, whereas radiological examination had a sensitivity of 92% and specificity of 88%. When considered together, clinical and radiological examinations were able to detect all the cases of bone invasion, but specificity was only 58%. This study advocates careful correlation of clinical and radiological findings prior to definitive therapy, as clinical examination tends to over diagnose bone invasion in tumours adjacent to the mandible. The specificity of imaging was also found to be low pointing towards the need for more specific diagnostic tools in doubtful cases. Aggressive surgical therapy, namely segmental or hemi resection of mandible is warranted in case of tumours of the lower alveolus with definite bone invasion. In case of carcinomas of the buccal mucosa and tongue the mandibular resection can be limited to that required for clearance of margins provided the radiology is negative.

Squamous cell cancer of the buccal mucosa in young adults

BACKGROUND

Squamous cell carcinoma of the buccal mucosa is predominantly a cancer of elderly people and is seen rarely in young adults. Although many aetiological factors have been postulated, tobacco alone has been implicated as the main factor in the aetiology of such cancers at any age.

PATIENTS AND METHODS

A retrospective analysis of 46 patients with cancer of the buccal mucosa who were under the age of 35 years at the time of presentation was made to evaluate their survival and predictors of survival. The details were extracted from the computerised records and case records of the Regional Cancer Centre, Trivandrum, India. These were analysed with particular emphasis on risk factors, clinical extent, and treatment. Survival was analysed by the Kaplan-Meier method, and differences in survival were compared using the log-rank test.

RESULTS

The male:female ratio was 6.7:1. Almost all the patients (n = 42, 91%) used either tobacco or alcohol, with tobacco chewing being the most common. The 3 and 5 years disease-free survival were 72 and 61%, respectively. Non-smokers and patients with an advanced T stage at presentation had significantly worse prognoses.

FACT-G: reliability and validity of the Malayalam translation

BACKGROUND

Emphasis is currently being placed on the need for quality of life in cancer survivors. There is a great need to identify an appropriate tool for quality of life estimation in these linguistically and culturally different settings.

PATIENTS AND METHOD

The Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire was translated into the Malayalam language complying with the standard cross-cultural translation methodology. The tool was validated and used for estimating quality of life (QOL) of 214 cancer patients undergoing treatment with curative intent.

RESULTS

Cronbach's alpha for the Malayalam version of the FACT-G was 0.8, and for the subscales it ranged from 0.64 to 0.83, compared to source tool alpha of 0.89, with the subscale's ranging from 0.63 to 0.89. The mean overall FACT-G score was 79.8 (standard deviation [SD] = 18.7). Socio-economic factors such as education, education of the spouse, occupation of the spouse, and family income were found to influence FACT-G scores.

CONCLUSION

Despite cultural variations, the local Malayalam language version of the FACT-G scale was found to be reliable like the source scale and sensitive cross-culturally. The instrument makes it possible to identify domains influencing QOL and thereby may help direct interventions to them.

Enteric perforation--single-layer closure

A hundred cases of enteric perforation, treated surgically by single- or double-layer closure, were studied prospectively. Mortality and morbidity rates were 10-18 and 37-42% and comparable in the two groups. The presence of preoperative shock was the single most important prognostic indicator observed in this study. Hence it is good closure of the perforation rather than single- or double-layer closure that determines the outcome in patients with enteric perforation.

Intrathoracic pulmonary artery catheter allocation in the background of left atrial dilatation

AIM

The aim of the study was to find out whether dilatation of the left atrium (LA) influences the intra-thoracic distribution of thermodilution pulmonary artery (TPA) catheter in either branch of pulmonary artery and compare the measured cardiac output.

METHODS

In this prospective study of 132 consecutive patients in a university hospital setting, LA size and ejection fraction was assessed by echocardiography, in the preoperative period. In 66 patients posted for coronary artery bypass grafting (Group 1), a standard anaesthesia regimen was used and TPA catheter was floated through the right internal jugular. In another 66 patients of long-standing mitral stenosis for mitral valve repair/replacement (Group 2), TPA catheters were similarly floated. Intrathoracic placement of the tip of the TPA catheter into the right or left pulmonary artery (PA) was confirmed on chest X-ray. TPA catheter length to its wedging, intra-arterial pressure, heart rate, PA pressure, pulmonary artery wedge pressure (PAWP) and cardiac output by thermodilution technique were noted.

RESULTS

Leftwards TPA catheter placement was significantly (p<0.001) more frequent (71%) in mitral stenosis patients (group 2) than the CABG (group 1), (18%). On regrouping the observations of rightwards placed TPA (Group R) and leftwards placed TPA (Group L), we observed that large LA (> or = 25 mm3/m2) body surface area (BSA) and high PAWP (> or = 20 mmHg) was associated with significantly (p<0.001) higher incidence of leftwards TPA catheters. Positive predictive value of both the factors in combination was significantly higher (96%) than individual factors large LA (81%) and high PAWP (88%).

CONCLUSION

In long standing mitral stenosis, left atrium enlargement, with high PAWP and the hypokinesia of left atrium (atrial fibrillation) likely to influence the angulation of left PA with main PA and so the predominant entry of TPA catheter tip in left PA.

Lifestyle, parity, menstrual and reproductive factors and risk of gallbladder cancer

Together with thyroid cancer, cancer of the gallbladder is the only non-sex hormone-related cancer displaying a female preponderance, with incidence being 3-4 times more common among women. We carried out this study to evaluate the role of menstrual, reproductive and lifestyle factors in gallbladder carcinogenesis. A case-control study involving 64 newly diagnosed cases of gallbladder cancer and 101 cases of cholelithiasis was carried out. A detailed menstrual and reproductive history was illustrated beside detailed lifestyle history, in particular consumption of betel nut, tobacco and alcohol and smoking, odds ratio was calculated. Mean age of the patients with cancer was 51+/-1.2 years while it was 40.9+/-1.2 years for gallstones; 69% of cancer patients and 90% of gallstones patients were females. More than half of the cancer patients (53%) and 43% of the gallstone patients were illiterate. A past history of typhoid was present in 22% of cancer patients and 13% of gallstone patients, while 35% of cancer and 25% of gallstone patients were chewers, 18.1 and 9.9% were smokers, and 10% of cancer and 2% of gallstone patients consumed alcohol. Mean age of menarche was 13.4+/-1.2 years among female patients with cancer while it was 14.0+/-1.4 years for gallstone patients. Higher age at menarche (>13 years, OR 2.48, 95% confidence interval (CI) 1.16-5.3), higher number of childbirths(>3 births, OR 3.92; 95% CI 1.4-10.3), higher number of pregnancies (>3 pregnancies, OR 6.66, 95% CI 1.8-23.4), and higher age at last childbirth (>25 years, OR 2.97, 95% CI 1.04-8.5) were found to have significantly higher risk of developing gallbladder cancer. In conclusion, tobacco chewing and smoking are associated with increased odds of gallbladder cancer. Similarly early menarche, late menopause, multiple pregnancies and childbirth increased the risk of gallbladder cancer.