Living with metastatic breast cancer (LIMBER): experiences, quality of life, gaps in information, care and support of patients in the UK

PURPOSE

To determine the experiences, information, support needs and quality of life of women in the UK living with metastatic breast cancer (MBC) to provide content for educational materials.

METHODS

An online survey, hosted for 3 months on a UK MBC charity website, comprised sections covering issues such as communication about MBC treatment and management, helpful and less helpful things that healthcare professionals, family and friends did or said and completion of the Patient Roles and Responsibilities Scale (PRRS).

RESULTS

A total of 143 patients participated; 48/143(33%) presented de novo; 54/143(38%) had been living with MBC > 2 years. PRRS analysis revealed that MBC imposed a serious impact upon most respondents' own caring abilities and social lives. A majority 98/139 (71%) wished they had known more about MBC before their diagnosis; 63/134(47%) indicated that they still did not fully understand their illness; merely 78/139(56%) had access to a specialist nurse and only 69/135(51%) had been offered any additional support. Respondents reported little consideration given to their lifestyle/culture during consultations and inconsistent information, support services, continuity of care or access to clinical trials. They commented upon things health care professionals/friends and family did or said that were useful and cited other behaviours that were especially unhelpful.

CONCLUSIONS

MBC exerted a deleterious impact upon patients' activities of daily living which were exacerbated in part by significant gaps in support, communication and information.

IMPLICATIONS FOR CANCER SURVIVORS

LIMBER results are informing the content of educational materials currently being developed for patients' formal and informal carers.

Evaluation of Temporal Changes in Urine-based Metabolomic and Kidney Injury Markers to Detect Compound Induced Acute Kidney Tubular Toxicity in Beagle Dogs

Urinary protein biomarkers and metabolomic markers have been leveraged to detect acute Drug Induced Kidney Injury (DIKI) in rats; however, the utility of these indicators to enable early detection of DIKI in canine models has not been well documented. Therefore, we evaluated temporal changes in biomarkers and metabolites in urine from male and female beagle dogs. Gentamicin- induced kidney lesions in male dogs were characterized by moderate to severe tubular epithelial cell degeneration/necrosis, epithelial cell regeneration and dilation; and a unique urinebased metabolomic fingerprint. These metabolite changes included time and treatment-dependent increases in lactate, taurine, glucose, lactate, alanine, and citrate as well as 9 other known metabolites. As early as 3 days post dose, gentamicin induced increases in urinary albumin, clusterin, neutrophil gelatinase associated protein (NGAL) and total protein concentrations. Urinary albumin, clusterin, and NGAL showed earlier and more robust elevations than traditional kidney safety biomarkers, blood urea nitrogen and serum creatinine. Elevations in urinary kidney injury molecule 1 (KIM-1) were less reliable for detection of gentamicin nephrotoxicity in dogs based on values generated utilizing multiple first-generation, canine-specific KIM-1 immunoassays. The metabolic fingerprint was further evaluated in male and female dogs that received Compound A which induced slightly reversible renal tubular alterations characterized as degeneration/necrosis and concurrent significant increases in urinary taurine amongst other markers. These data support further investigations to demonstrate the value of urinary metabolites, albumin, clusterin, NGAL and taurine as promising markers to enable early detection of DIKI in dogs.

CANDLE Syndrome: orodfacial manifestations and dental implications

A South African girl with CANDLE Syndrome is reported with emphasis on the orodental features and dental management. Clinical manifestations included short stature, wasting of the soft tissue of the arms and legs, erythematous skin eruptions and a prominent abdomen due to hepatosplenomegaly. Generalized microdontia, confirmed by tooth measurement and osteopenia of her jaws, confirmed by digitalized radiography, were previously undescribed syndromic components. Intellectual impairment posed problems during dental intervention. The carious dental lesions and poor oral hygiene were treated conservatively under local anaesthetic. Prophylactic antibiotics were administered an hour before all procedures.

Due to the nature of her general condition, invasive dental procedures were minimal. Regular follow-ups were scheduled at six monthly intervals. During this period, her overall oral health status had improved markedly.

The CANDLE syndrome is a rare condition with grave complications including immunosuppression and diabetes mellitus. As with many genetic disorders, the dental manifestations are often overshadowed by other more conspicuous and complex syndromic features. Recognition of both the clinical and oral changes that occur in the CANDLE syndrome facilitates accurate diagnosis and appropriate dental management of this potentially lethal condition.

The tricho-rhino-phalangeal syndrome: oral manifestations and management

Tricho-rhino-phalangeal Syndrome (TRPS) is a rare inherited dysplasia affecting hair, nasal structure and fingers. A literature review indicated that since first described, three types of manifestations have been identified. A Table summarising the oral manifestations demonstrates the variety of presentations. A South African male child presented with the syndrome and was found to show premature eruption of permanent teeth, a finding that has not been previously reported. His oro-facial manifestations also included malaligned and unerupted crowded teeth, bulbosity of the nasal tip and an elongated philtrum and evidence of mild intellectual impairment. A protocol has been developed to guide the future management of these cases.

Discrimination of agonist and antagonist forms of CXCL10 in biological samples

The ready access to commercially available multiplex assays and the importance of inflammation in disease pathogenesis has resulted in an abundance of studies aimed at identifying surrogate biomarkers for different clinically important questions. Establishing a link between a biomarker and disease pathogenesis, however, is quite complex, and in some instances this complexity is compounded by post-translational modifications and the use of immunoassays that do not always discriminate between the different forms of the same protein. Herein, we provide a detailed description of an assay system that has been established to discriminate the agonist form of CXCL10 from the NH(2) -terminal truncated form of the molecule generated by dipeptidylpeptidase IV (DPP4) cleavage. We demonstrate the utility of this assay system for monitoring agonist and antagonist forms of CXCL10 in culture supernatant, patient plasma and urine samples. Given the important role of CXCL10 in chronic inflammatory diseases and its suggested role as a predictive marker in managing patients with chronic hepatitis C, asthma, atopic dermatitis, transplantation, tuberculosis, kidney injury, cancer and other diseases, we believe that our method will be of general interest to the research and medical community.

Association between periodontitis and systemic inflammation in patients with end-stage renal disease

Patients with end-stage renal disease (ESRD) experience a significantly increased rate of atherosclerotic complications. Inflammation plays a central role in the pathogenesis of these complications and C-reactive protein (CRP) has been found to be predictive of all-cause and cardiovascular mortality. Many patients have elevated CRP levels without an apparent infection. Periodontal diseases in the general population have been associated with both an increased prevalence of atherosclerotic complications and an elevation in serum CRP values. This study examined the association between periodontal disease and elevated CRP in patients with ESRD on chronic dialysis.

METHODS

Eighty patients on chronic dialysis were included in the study. Demographic information, medical history and CRP levels were recorded. Periodontal examination was carried out by a single calibrated examiner and included gingival index (GI), bleeding on probing (BoP), probing depths (PD) and clinical attachment loss (CAL). These measurements were recorded in relation to the Ramfjord teeth. The presence in any one sextant of PD > or =4 mm or clinical loss of attachment > or =3 mm was diagnosed as periodontitis.

RESULTS

Mean age of subjects was 50.3 +/- 9.06 years with a median time on dialysis of 24 months. 57.5% (n=46) of subjects were diagnosed as having periodontitis; of these 52.2% had CRP levels >10 mg/l. Of the 34 subjects with healthy periodontium, only 10 (29.4%) had elevated CRP levels. The serum CRP levels between these two groups were significantly different (p = 0.004).

CONCLUSION

The results of the study showed significantly elevated levels of CRP in ESRD patients with periodontitis. Periodontal diseases may be an overlooked source of inflammation in ESRD patients.

The composite interleukin-1 genotype in South Africa

OBJECTIVE

The objective of this study was to evaluate the association between the interleukin-1 composite gene polymorphism and the severity of periodontal disease in the Xhosa population of South Africa.

BACKGROUND

Periodontitis is a bacterially-induced chronic inflammatory disease that destroys the tooth supporting tissues. A specific pattern of interleukin-1 polymorphisms (known as the composite IL-1 genotype) has been found to influence the severity of chronic periodontitis in some ethnic groups.

METHODS

Ninety-nine subjects, 35-60 years of age, of Xhosa descent, who were non-smokers and free of systemic disease, were enrolled in a case-control study depending on their periodontal status (healthy to mild vs. moderate to severe disease). A buccal smear was obtained from each subject; the DNA was isolated then amplified using the polymerase chain reaction (PCR). Allele identification was either by real-time PCR or by size fractionation following restriction digestion and separation on a polyacrylamide gel.

RESULTS

The prevalence of the composite genotype was only 6% in the 99 subjects of the study population, which occurred more frequently in "cases" (8.2%) than in "controls" (4%). The frequency of IL-1A +4845 allele 2 genotype was 47% in cases and 22% in controls (p = 0.009), and that for IL-1B +3954 was 14.3% in cases and 20% in controls (p = 0.595).

CONCLUSIONS

This study demonstrated that the IL-1 composite polymorphism occurred among only few subjects in the Xhosa population of South Africa, and so was not significantly associated with the severity of chronic periodontitis in this population.

Prevalence and severity of periodontal disease: type 2 diabetics versus non-diabetics

OBJECTIVE

To compare the periodontal status of a group of diabetic Coloured and Black communities of South Africa with a non-diabetic group.

STUDY DESIGN

Sixty-seven type 2 diabetics (mean age: 49.3 +/- 8.97) and 67 non-diabetics (mean age: 47.6 +/- 8.85) were examined. The plaque index (P1I), gingival index (GI), probing depth (PD) and clinical attachment loss (CAL) were recorded on Ramfjord index teeth or their substitutes. Previous dental care, smoking status, alcohol consumption and socio-economic status were also assessed.

RESULTS

Diabetics had significantly higher mean GI (p = 0.001), PD (p = 0.031) and CAL (p = 0.022) than non-diabetics. The mean P1I (p = 0.531) was not significantly different between the two groups.

CONCLUSION

This study showed that diabetics had more severe and a higher prevalence of periodontal disease. Diabetics and their health care givers should be informed of these findings so that diabetics can seek early management of periodontal disease.

Osteoglophonic dysplasia: dental and orthodontic implications

AIMS AND OBJECTIVES

Documentation of dental and orthodontic implications of osteoglophonic dysplasia (OGD).

SETTINGS AND PARTICIPANTS

Case report describing oral and dental manifestations of a female with OGD, aged 39 years, who was first documented three decades ago.

RESULTS

This rare genetic disorder manifests with gross stunting of stature, associated with severe craniofacial malformation and multiple unerupted teeth. Radiographically, multiple lucent lesions were present in the tubular bones and mandible as well as several impacted teeth.

CONCLUSION

We concluded that prosthetic dental replacement in this patient would be difficult because of the distorted jaw relationship and large alveolar ridges. Equally, craniofacial reconstruction might be compromised by obstruction of the nasal airways, difficulty in intubation and postoperative respiratory problems.

Freeman-Sheldon syndrome: dental and orthodontic implications

The manifestations of the Freeman-Sheldon syndrome (FSS) in four members of a South African family of Xhosa stock have been documented. Orofacial manifestations are a major syndromic component and warrant early, specialized orthodontic intervention. Our protocol for dental management is outlined and suggestions for holistic oro-dental care are provided.

Crouzonodermoskeletal syndrome

Crouzon craniostenosis [MIM 123500], is identified on the basis of the additional phenotypical manifestations of acanthosis nigricans, vertebral changes and cementomas of the jaws. Choanal atresia and hydrocephalus are other features. The molecular defect in CDSS is a point mutation in the FGFR3 gene on chromosome 4p, whereas, the mutation in the Crouzon syndrome is in the FGFR2 gene at 10q25.3-26. An affected girl aged 2 years presented at the UWC dental genetics unit with a prior diagnosis of Crouzon syndrome. Choanal atresia had necessitated a permanent tracheostomy, and hydrocephalus was managed by a shunt operation. Clinical examination revealed acanthosis nigricans in the axilliary regions, a diagnosis confirmed by a biopsy of the lesion. Eruption of the primary dentition was delayed with only six out of twenty teeth present. Radiographic examination conducted shortly after birth revealed the presence of several tooth buds in both the maxillae and the mandible. The delayed eruption of the teeth will be of significance in future orthodontic and maxillofacial measures for the improvement of the patient's facial Crouzonodermoskeletal syndrome (CDSS) was separated from the classical appearance. Molecular investigations in the girl and her parents are underway. If the specific mutation in FGFR3 is observed, a positive diagnosis of CDSS will be confirmed and the status of her parents and other family members will be determined. On this basis, appropriate genetic management can be offered to the kindred.

Getting the scale right: a comparison of analytical methods for vulnerability assessment and household-level targeting

This paper introduces broad concepts of vulnerability, food security and famine. It argues that the concepts and theories driving development and implementation of vulnerability assessment tools are related to their utility. The review concludes that socio-geographic scale is a key issue, and challenge. It analyses three vulnerability assessment (VA) methods, using Ethiopia as a case study. Facing the challenges of vulnerability assessment and early warning requires providing accurate information at the required scale, useful for multiple decision-makers within realistic institutional capacities.

Minimally invasive treatment for coronary artery disease

Coronary artery disease is the leading cause of morbidity and mortality in the United States. One advancement in the treatment of this disease is the minimally invasive direct coronary artery bypass (MIDCAB) procedure, which is an alternative to the traditional open heart bypass procedure. The MIDCAB procedure is becoming a viable alternative to the traditional coronary artery bypass grafting procedure for a select group of patients. With further experience and follow-up, this procedure will offer lower hospital costs by decreasing lengths of stay and offering patients the optimal conduit for coronary artery bypass grafting without the complications of cardiopulmonary bypass.

Differential rate of neuropsychological dysfunction in psychiatric disorders: comparison between the Halstead-Reitan and Luria-Nebraska batteries

This report examined the rate of agreement between scores of the Halstead-Reitan and Luria-Nebraska Neuropsychological Batteries in the classification of impaired and nonimpaired performance of 55 schizophrenic and 64 affective disorder patients: 65.2% for schizophrenics and 67.5% for those with affective disorder, with greater impairment on the Halstead-Reitan battery.

3H-collagen turnover in non-cross-linked and aldehyde-cross-linked dermal collagen grafts

Using trypsin-purified rat dermal collagen labelled with tritiated hydroxyproline and proline, a study has been made of hydroxyproline turnover in non-cross-linked and glutaraldehyde- and formaldehyde-cross-linked collagen when implanted s.c. in unlabelled isogenic rats. Grafts cross-linked with 0.01% glutaraldehyde maintained their collagen mass over a 22-week period, loss of original collagen being balanced by the gain in new collagen (22% at 22 weeks). Cross-linking with 5% formaldehyde temporarily inhibited collagen loss as compared with non-cross-linked grafts. However, at 22 weeks both had lost some 30% of their collagen mass, the gain of new collagen (some 8%) only partially compensating for the loss of original implant collagen.

Formaldehyde as a pre-treatment for dermal collagen heterografts

The preparation, stability both in vitro and in vivo and resistance to bacterial collagenase of trypsin-purified pig dermal collagen cross-linked with a range of concentrations of formaldehyde in phosphate-buffered saline, was studied using 14C-labelled formaldehyde as a tracer. Washing in phosphate-buffered saline at 37 degrees C produced rapid loss of formaldehyde over 6 weeks before stability was reached. After 19 weeks washing, 12-20% of the initial radioactivity remained, representing 6, 18 and 35 mumol formaldehyde/g of collagen after 21 days reaction with 0.1, 1 and 5% formaldehyde, respectively. Collagen, incorporating stable-bound formaldehyde arising from reaction with formaldehyde in concentrations of 0.5% or over, was totally resistant to bacterial collagenase. The stabilizing effect of formaldehyde cross-linking was also demonstrated by implants of fibrous pig dermal collagen in rats. After 8 weeks a significant constant amount of formaldehyde was retained in all implants. There was no net loss of mass over a 24 week period when pre-treated with 1% formaldehyde but some loss when pre-treated with 0.1% formaldehyde.

Some approaches to the evaluation of milieu therapy

Milieu therapy is an increasingly popular approach to the treatment of psychiatric patients and a model of general application. It places emphasis on social and group interaction, on the sharing of responsibility and decision-making, on the freeing of communication on both vertical and horizontal planes and on dealing with the realities of the here-and-now. Its introduction has been accompanied by considerable enthusiasm and a sense of ‘rightness’ which parallel the existence of comparable movements in society as a whole. Partly because of this fervour, and mainly because of the methodological problems involved, intensive scientific evaluation of this mode of therapy has been difficult, though necessary.

This paper describes the beginnings of a number of ongoing multidisciplinary studies, conducted on six wards in three institutions - the purpose being to provide a definition of milieu therapy, to describe its methods and objectives and to establish means of evaluation.

The broad areas of the research project are: a statistical review of patients discharged before and following the adoption of milieu therapy; an in-depth analysis of the structure and functions of each of the units in the research setting; and a comparative study of the process and thera. peutic results of the six wards including two wards of other collaborating hospitals. Several constituent pilot projects have been reviewed. The advantages of an ongoing inhospital research consortium are discussed, and it is suggested that every sizeable unit should have one in the interests of the assessment of service. All that may be required is the mobilization of already existing personnel and volunteers, summer students and petty funds.