Factors associated with emotional and behavioural problems among school age children of breast cancer patients

To identify factors linked with emotional and behavioural problems in school age (6- to 17-year-old) children of women with breast cancer. Reports of children's emotional and behavioural problems were obtained from patient mothers, their healthy partners, the children's teacher and adolescents using the Child Behaviour Checklist and Mental Health subscale of the Child Health Questionnaire. Parents reported on their own level of depression and, for patients only, their quality of life. Family functioning was assessed using the Family Assessment Device and Cohesion subscale of the Family Environment Scale. Using a cross-sectional within groups design, assessments were obtained (N=107 families) where the patients were 3-36 months postdiagnosis. Risk of problems in children were linked with low levels of family cohesion, low affective responsiveness and parental over-involvement as reported by both child and mother. Adolescents reported family communication issues, which were associated with externalising behaviour problems. Maternal depression was related to child internalising problems, particularly in girls. Whether the mother was currently on or off chemotherapy was not associated with child problems nor was time since cancer diagnosis. These findings held across child age. Where mothers have early stage breast cancer, a substantial minority of their school-aged children have emotional and behavioural problems. Such cases are characterised by the existence of maternal depression and poor family communication, rather than by the mother's treatment status or time since diagnosis. Targeted treatments, which focus on maternal depression and family communication may benefit the children and, through improved relationships, enhance the patients' quality of life.

The Vulvodynia Guideline

OBJECTIVE

To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia.

MATERIALS AND METHODS

Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition.

RESULTS

Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient.

CONCLUSIONS

Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Malignant perivascular epithelioid cell tumor (PEComa) arising in the broad ligament

Malignant perivascular epithelioid cell tumor (PEComa) is an extremely rare mesenchymal neoplasm mostly composed of HMB-45-positive epithelioid cells with clear-to-eosinophilic cytoplasm, a propensity for perivascular distribution and a coexpression of smooth muscle markers. The uterus seems to be one of the most prevalent sites of involvement, although only 14 cases of uterine PEComa have been described. We report the case of a 51-year-old woman with a PEComa arising in the broad ligament. She was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic radiation, and remains without evidence of disease 15 months after diagnosis. This is, to the best of our knowledge, the first report of a malignant PEComa arising in the broad ligament. To correctly diagnose PEComa, an extensive immunohistochemical panel is essential. As PEComas can behave in an aggressive manner, careful follow-up is warranted.

Subsets of vulvodynia: overlapping characteristics

OBJECTIVE

To determine the characteristics of vulvar pain as to location and provocation by touch and pressure in order to confirm that current International Society for the Study of Vulvovaginal Disease definitions of vulvar vestibulitis (provoked vestibulodynia) and vulvodynia (generalized vulvodynia) effectively describe and differentiate these 2 subsets.

STUDY DESIGN

The charts of all women diagnosed with vulvodynia at their initial clinic visit between November 2002 and June 2003 were reviewed for this study. Each patient was evaluated by questionnaire, interview in person and by physical examination to ascertain the location and provoked vs. spontaneous nature of the pain as primary criteria for the differentiation of provoked vestibulodyniafrom generalized vulvodynia.

RESULTS

Sixty patients were included in the analysis. Four (6.7%) described provoked pain only in the vestibule (vulvar vestibulitis, provoked vestibulodynia), and 5 women (8.3%) experienced only unprovoked pain that was not confined to the vestibule (dysesthetic vulvodynia, unprovoked generalized vulvodynia). Other patients fell into patterns not specifically recognized or identified by a name. Sixteen (26.7%) experienced both provoked and unprovoked pain always limited to the vestibule, and 21 (35.0%) described provoked and unprovoked pain that extended beyond the vestibule at least occasionally. Six (10.0%) patients described only provoked pain primarily but not limited to the vestibule, and 8 patients each described a unique pattern.

CONCLUSION

This study suggests that the criteria of location and only provoked vs. only unprovoked pain alone do not describe 2 distinct subsets of vulvodynia; rather, there is overlap in provoked vs. unprovoked pain and location.

Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis

BACKGROUND

No safe and convenient regimen has proved to be effective for the management of recurrent vulvovaginal candidiasis.

METHODS

After inducing clinical remission with open-label fluconazole given in three 150-mg doses at 72-hour intervals, we randomly assigned 387 women with recurrent vulvovaginal candidiasis to receive treatment with fluconazole (150 mg) or placebo weekly for six months, followed by six months of observation without therapy. The primary outcome measure was the proportion of women in clinical remission at the end of the first six-month period. Secondary efficacy measures were the clinical outcome at 12 months, vaginal mycologic status, and time to recurrence on the basis of Kaplan-Meier analysis.

RESULTS

Weekly treatment with fluconazole was effective in preventing symptomatic vulvovaginal candidiasis. The proportions of women who remained disease-free at 6, 9, and 12 months in the fluconazole group were 90.8 percent, 73.2 percent, and 42.9 percent, as compared with 35.9 percent, 27.8 percent, and 21.9 percent, respectively, in the placebo group (P< 0.001). The median time to clinical recurrence in the fluconazole group was 10.2 months, as compared with 4.0 months in the placebo group (P<0.001). There was no evidence of fluconazole resistance in isolates of Candida albicans or of superinfection with C. glabrata. Fluconazole was discontinued in one patient because of headache.

CONCLUSIONS

Long-term weekly treatment with fluconazole can reduce the rate of recurrence of symptomatic vulvovaginal candidiasis. However, a long-term cure remains difficult to achieve.

Cost effectiveness analysis of neonatal extracorporeal membrane oxygenation based on four year results from the UK Collaborative ECMO Trial

OBJECTIVE

To assess the cost effectiveness of extracorporeal membrane oxygenation (ECMO) for mature newborn infants with severe respiratory failure over a four year time span.

DESIGN

Cost effectiveness analysis based on a randomised controlled trial in which infants were individually allocated to ECMO (intervention) or conventional management (control) and then followed up to 4 years of age.

SETTING

Infants were recruited from 55 approved recruiting hospitals throughout the United Kingdom. Infants allocated to ECMO were transferred to one of five specialist regional centres. Follow up of surviving infants was performed in the community.

SUBJECTS

A total of 185 mature (gestational age at birth >or= 35 weeks, birth weight >or= 2000 g) newborn infants with severe respiratory failure (oxygenation index >or= 40).

MAIN OUTCOME MEASURES

Incremental cost per additional life year gained; incremental cost per additional disability-free life year gained.

RESULTS

Over four years, the policy of neonatal ECMO was effective at reducing known death or severe disability (relative risk = 0.64; 95% confidence interval 0.47 to 0.86; p = 0.004). After adjustment for censoring and discounting at 6%, the mean additional health service cost of neonatal ECMO was pound 17367 (95% confidence interval pound 12072 to pound 22224) per infant ( pound UK, 2001 prices). Over four years, the incremental cost of neonatal ECMO was pound 16707 ( pound 9828 to pound 37924) per life year gained and pound 24775 ( pound 13106 to pound 69690) per disability-free life year gained. These results remained robust after variations in the values of key variables performed as part of a sensitivity analysis.

CONCLUSIONS

The study provides rigorous evidence of the cost effectiveness of ECMO at four years for mature infants with severe respiratory failure.

The diagnosis and treatment of infectious vaginitis

Inflammation of the vagina as a result of infectious agents is very common, both as an overgrowth of normal or common colonizers, or as a frank infection. The most common causes of infectious vaginitis are yeast, bacteria, protozoa, viruses, and parasites. Infections of the vagina produce an increase in vaginal secretion, vulvar symptoms of itching or irritation from contact with irritating vaginal fluid, and sometimes odor. A careful microscopic examination of vaginal secretions generally yields the correct diagnosis, but atypical or recalcitrant disease deserves a confirmatory culture, as noninfectious inflammatory processes can produce similar symptoms.

Vulvar fissures: causes and therapy

Vulvar fissures occur in two main patterns: at the posterior fourchette, and within skin folds and creases. The cause of posterior fourchette splitting is not known, and the treatment is a perineoplasty. Skin-fold fissures occur in response to several inflammatory dermatoses or infections, and therapy consists of elimination of any underlying infection and the (sometimes prolonged) use of a topical corticosteroid ointment.

Diagnosis and therapy of anogenital lichen planus

Genital lichen planus is a fairly common disease of genital skin that exhibits a widely variable morphology. Lichen planus occurring on the mucosal surfaces is chronic, and most often erosive and painful, frequently producing debilitating scarring. Mild, non-erosive disease is controllable with topical corticosteroids. Although erosive disease is much more difficult to manage, the use of topical corticosteroids, sometimes in combination with other topical or systemic medications, maximizes comfort and preserves function, especially with careful attention to local care and secondary infection.

242GLUTATHIONE CONTENT AND EXPRESSION OF ANTIOXIDANT ENZYME MRNAS IN SHEEP OOCYTES

Reactive oxygen species (ROS) are normal products of embryo metabolism;; however, oxidative injury may negatively impact development if ROS production exeeds antioxidant defense mechanisms. Protection of the embryo against ROS is dependent, in part, upon the pool of antioxidant enzyme mRNA and products stored in the oocyte. Previous work has demonstrated that retinol administration to superovulated ewes, followed by natural service, resulted in embryos with improved competence to develop in vitro. In other cell systems, retinoids have been shown to participate in the antioxidant network and redox system. The objectives of this study were to analyze glutathione content and characterize antioxidant enzyme mRNA expression in mature ovine oocytes and test the hypothesis that retinol administration affects levels of these products. Ewes were superovulated and administered retinol on the first and last day of FSH injection. Oocytes were collected from oviducts 60h later and either prepared for glutathione (GSH) analysis or subjected to RNA isolation. Glutathione was quantified by the recycling assay of the enzyme 5,5-dithiobis-(2-nitrobenzoic acid)-glutathione reductase using a total of more than 260 oocytes. Transcripts encoding for manganese superoxide dismutase (Mn-SOD), copper zinc superoxide dismutase (Cu-Zn SOD), glutathione synthetase (GS) and glutathione transferase pi (GSTp) were analyzed in a total of 86 single oocytes by semi-quantitative RT-PCR using a histone H2a transcript as the internal control. Chi-square analysis was performed to detect differences due to treatments. Glutathione content did not differ significantly between oocytes collected from retinol-treated (6.78±3.81pmol/oocyte) and control (6.38±1.58pmol/oocyte) ewes. Transcripts encoding for Mn-SOD, Cu-Zn SOD, GS and GSTp were detected in greater than 95% of the oocytes analyzed. Relative abundance of these transcripts did not differ between treatments. For the first time, glutathione content and antioxidant enzyme mRNA expression has been analyzed in in vivo-matured sheep oocytes. Retinol treatment did not appear to affect the expression of these products. Results demonstrate the existence of endogenous antioxidant defense products, stored as mRNA and protein, in sheep oocytes.

Dermatologic therapy of chronic genital disease

The adaptation of dermatology for the genital area requires several modifications of standard therapy. This unique area produces issues of both psychological sensitivity and unique environmental factors of constant moisture, warmth, and friction. These issues become far more important when symptoms are chronic. Recognition of normal variants, the multifactorial nature of many genital symptoms, and the avoidance of creating secondary iatrogenic disease are all important.

New concepts in vulvodynia

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted.