Facilitators and barriers of implementing end-of-life care volunteering in a hospital in five European countries: the iLIVE study

BACKGROUND

End-of-life (EoL) care volunteers in hospitals are a novel approach to support patients and their close ones. The iLIVE Volunteer Study supported hospital volunteer coordinators from five European countries to design and implement an EoL care volunteer service on general wards in their hospitals. This study aimed to identify and explore barriers and facilitators to the implementation of EoL care volunteer services in the five hospitals.

METHODS

Volunteer coordinators (VCs) from the Netherlands (NL), Norway (NO), Slovenia (SI), Spain (ES) and United Kingdom (UK) participated in a focus group interview and subsequent in-depth one-to-one interviews. A theory-inspired framework based on the five domains of the Consolidated Framework for Implementation Research (CFIR) was used for data collection and analysis. Results from the focus group were depicted in radar charts per hospital.

RESULTS

Barriers across all hospitals were the COVID-19 pandemic delaying the implementation process, and the lack of recognition of the added value of EoL care volunteers by hospital staff. Site-specific barriers were struggles with promoting the service in a highly structured setting with many stakeholders (NL), negative views among nurses on hospital volunteering (NL, NO), a lack of support from healthcare professionals and the management (SI, ES), and uncertainty about their role in implementation among VCs (ES). Site-specific facilitators were training of volunteers (NO, SI, NL), involving volunteers in promoting the service (NO), and education and awareness for healthcare professionals about the role and boundaries of volunteers (UK).

CONCLUSION

Establishing a comprehensive EoL care volunteer service for patients in non-specialist palliative care wards involves multiple considerations including training, creating awareness and ensuring management support. Implementation requires involvement of stakeholders in a way that enables medical EoL care and volunteering to co-exist. Further research is needed to explore how trust and equal partnerships between volunteers and professional staff can be built and sustained.

TRIAL REGISTRATION

NCT04678310. Registered 21/12/2020.

Self-efficacy of advanced cancer patients for participation in treatment-related decision-making in six European countries: the ACTION study

PURPOSE

Many patients prefer an active role in making decisions about their care and treatment, but participating in such decision-making is challenging. The aim of this study was to explore whether patient-reported outcomes (quality of life and patient satisfaction), patients' coping strategies, and sociodemographic and clinical characteristics were associated with self-efficacy for participation in decision-making among patients with advanced cancer.

METHODS

We used baseline data from the ACTION trial of patients with advanced colorectal or lung cancer from six European countries, including scores on the decision-making participation self-efficacy (DEPS) scale, EORTC QLQ-C15-PAL questionnaire, and the EORTC IN-PATSAT32 questionnaire. Multivariable linear regression analyses were used to examine associations with self-efficacy scores.

RESULTS

The sample included 660 patients with a mean age of 66 years (SD 10). Patients had a mean score of 73 (SD 24) for self-efficacy. Problem-focused coping (B 1.41 (95% CI 0.77 to 2.06)), better quality of life (B 2.34 (95% CI 0.89 to 3.80)), and more patient satisfaction (B 7.59 (95% CI 5.61 to 9.56)) were associated with a higher level of self-efficacy. Patients in the Netherlands had a higher level of self-efficacy than patients in Belgium ((B 7.85 (95% CI 2.28 to 13.42)), whereas Italian patients had a lower level ((B -7.50 (95% CI -13.04 to -1.96)) than those in Belgium.

CONCLUSION

Coping style, quality of life, and patient satisfaction with care were associated with self-efficacy for participation in decision-making among patients with advanced cancer. These factors are important to consider for healthcare professionals when supporting patients in decision-making processes.

Vascular complications and associated comorbidities in newly diagnosed pre-diabetes: is it the tip of the iceberg?

OBJECTIVE

The aim of this study was to investigate the prevalence of microvascular and macrovascular diabetic complications and the associated comorbidities in newly diagnosed pre-diabetic individuals.

PATIENTS AND METHODS

This cross-sectional study includes 100 newly diagnosed pre-diabetic individuals. Fasting plasma glucose, HbA1c, and oral glucose tolerance (OGTT) were tested according to the American Diabetes Association's diagnostic criteria for pre-diabetes, besides anthropometric measurements, lipid profiles, and demographic and biochemical parameters. Comorbidities like hypertension, obesity, dyslipidemia etc., were evaluated. All participants were screened for microvascular (retinopathy, nephropathy, neuropathy) and macrovascular [coronary artery disease (CAD) and cerebrovascular event-peripheral artery disease] complications.

RESULTS

Microvascular complications were found in 12% of the participants (neuropathy: 4%, nephropathy: 8%) and 19% had macrovascular complications. Of the participants, 21% of the cases presented hypertension, 21% dyslipidemia and 48% obesity. A high probability of developing non-alcoholic fatty liver disease-related fibrosis [estimated using non-alcoholic fatty liver disease fibrosis score (NFS)] was found in 68% of cases. History of dyslipidemia (OR: 5.00, 95% CI: 1.10-22.56; p=0.037) was an independent risk factor for the development of vascular complications.

CONCLUSIONS

Diabetic vascular complications were found in approximately one-third of pre-diabetic cases. Dyslipidaemia was found to be an important risk factor for the development of vascular complications in these individuals.

Meaning-making following loss among bereaved spouses during the COVID-19 pandemic (the CO-LIVE study)

This study investigates how individuals construe, understand, and make sense of experiences during the first wave of the COVID-19 pandemic. Seventeen semi-structured interviews were conducted with bereaved spouses focusing on meaning attribution to the death of their partner. The interviewees were lacking adequate information, personalized care, and physical or emotional proximity; these challenges complicated their experience of a meaningful death of their partner. Concomitantly, many interviewees appreciated the exchange of experiences with others and any last moments together with their partner. Bereaved spouses actively sought valuable moments, during and after bereavement, that contributed to the perceived meaning.

EFFECTS OF DIABETES AND FIRST-WEEK HYPERGLYCEMIC EPISODE FREQUENCY ON THE MORTALITY AND INFLAMMATION IN CRITICALLY ILL COVID-19 PATIENTS: A CASE-CONTROL STUDY

Background

We know that mortality had increased in diabetic patients with COVID-19 pneumonia. The aim of this study was to compare the mortality and inflammation parameters difference in critically ill COVID-19 patients according to their admission HbA1c levels and diabetes mellitus status. Secondary aim was to evaluate the effect of the first week hyperglycemic episode frequency on mortality.

Methods

Critically ill COVID-19 patients who were tested for HbA1c levels on ICU admission were analyzed retrospectively.

Results

Of 218 COVID PCR(+) patients, 139 met the inclusion criteria in study period. The median age was 67 [57-76] years and 55(40%) of them were female. Seventy-six (55%) of the patients required invasive mechanical ventilation (IMV). The IMV requirement was higher in diabetic patients (p=0.01). When the groups were compared in terms of inflammatory parameters no significant difference was found except for admission and first week's highest fibrinogen levels (p=0.02 and p=0.03, respectively). In multivariate analysis, fibrinogen levels were not determined as a risk factor for mortality. Overall ICU mortality was 43% (60/139). In group-1 23 (37%), in group-2 27 (57%), and in group-3 10 (34%) patients had died. There was no statistically significant difference between groups in terms of mortality (p=0.05). Records of 96 (69%) patients revealed there were more than five glucose readings over 180mg/dL during the first week. Mortality was higher in patients with more frequently hyperglycemic recordings (p=0.03).

Conclusions

There was no significant mortality and inflammatory parameters difference in patients with and without diabetes. However, more than five glucose readings over 180mg/dL during the first week were found with increased mortality.

Dying in times of COVID-19: Experiences in different care settings - An online questionnaire study among bereaved relatives (the CO-LIVE study)

BACKGROUND

The COVID-19 pandemic and restricting measures have affected end-of-life care across different settings.

AIM

To compare experiences of bereaved relatives with end-of-life care for a family member or friend who died at home, in a hospital, nursing home or hospice during the pandemic.

DESIGN

An open observational online survey was developed and disseminated via social media and public fora (March-July 2020). Data were analyzed using descriptive statistics and logistic regression analyses.

PARTICIPANTS

Individuals who lost a family member or friend in the Netherlands during the COVID-19 pandemic.

RESULTS

The questionnaire was filled out by 393 bereaved relatives who lost a family member or friend at home (n = 68), in a hospital (n = 114), nursing home (n = 176) or hospice (n = 35). Bereaved relatives of patients who died in a hospital most often evaluated medical care (79%) as sufficient, whereas medical care (54.5%) was least often evaluated as sufficient in nursing homes. Emotional support for relatives was most often evaluated as sufficient at home (67.7%) and least often in nursing homes (40.3%). Sufficient emotional support for relatives was associated with a higher likelihood to rate the place of death as appropriate. Bereaved relatives of patients who died at a place other than home and whose care was restricted due to COVID-19 were less likely to evaluate the place of death as appropriate.

CONCLUSION

End-of-life care during the COVID-19 pandemic was evaluated least favourably in nursing homes. The quality of emotional support for relatives and whether care was restricted or not were important for assessing the place of death as appropriate.

Adherence to dietary guidelines and cognitive decline from middle age: the Doetinchem Cohort Study

BACKGROUND

Diet, in particular the Mediterranean diet, has been associated with better cognitive function and less cognitive decline in older populations.

OBJECTIVES

To quantify associations of a healthy diet, defined by adherence to either the Mediterranean diet, the WHO guidelines, or Dutch Health Council dietary guidelines, with cognitive function and cognitive decline from middle age into old age.

METHODS

From the Doetinchem Cohort Study, a large population-based longitudinal study, 3644 participants (51% females) aged 45-75 y at baseline, were included. Global cognitive function, memory, processing speed, and cognitive flexibility were assessed at 5-y time intervals up to 20-y follow-up. Adherence to the Mediterranean diet was measured with the modified Mediterranean Diet Score (mMDS), adherence to the WHO dietary guidelines with the Healthy Diet Indicator (HDI), and adherence to the Dutch Health Council dietary guidelines 2015 with the modified Dutch Healthy Diet 2015 index (mDHD15-index). The scores on the dietary indices were classified in tertiles (low, medium, high adherence). Linear mixed models were used to model level and change in cognitive function by adherence to healthy diets.

RESULTS

The highest tertiles of the mMDS, HDI, and mDHD15-index were associated with better cognitive function compared with the lowest tertiles (P values <0.01), for instance at age 65 y equal to being 2 y cognitively younger in global cognition. In addition, compared with the lowest tertiles, the highest tertiles of the mMDS, HDI, and mDHD15-index were statistically significantly associated with 6-7% slower global cognitive decline from age 55 to 75 y, but also slower decline in processing speed (for mMDS: 10%; 95% CI: 2, 18%; for mDHD15: 12%; 95% CI: 6, 21%) and cognitive flexibility (for mDHD15: 10%; 95% CI: 4, 18%).

CONCLUSIONS

Healthier dietary habits, determined by higher adherence to dietary guidelines, are associated with better cognitive function and slower cognitive decline with aging from middle age onwards.

The influence of chronic diseases and multimorbidity on entering paid employment among unemployed persons - a longitudinal register-based study

Objectives This study aimed to investigate the influence of chronic diseases and multimorbidity on entering paid employment among unemployed persons. A secondary objective was to estimate the proportion of persons not entering paid employment that can be attributed to specific chronic diseases across different age groups. Methods Data linkage of longitudinal nationwide registries on employment status, medication use and socio-demographic characteristics was applied. Unemployed Dutch persons (N=619 968) were selected for a three-year prospective study. Cox proportional hazards analyses with hazard ratios (HR) were used to investigate the influence of six common chronic diseases on entering paid employment, stratified by age. The population attributable fraction (PAF) was calculated as the proportion of all persons who did not enter paid employment that can be attributed to a chronic disease. Results Persons with chronic diseases were less likely to enter paid employment among all age groups. The impact of a chronic disease on maintaining unemployment at population level was largest for common mental disorders (PAF 0.20), due to a high prevalence of common mental disorders (6%), and for psychotic disorders (PAF 0.19), due to a high likelihood of not entering paid employment (HR 0.21), among persons aged 45-55 years. Multimorbidity increased with age, and the impact of having multiple chronic diseases on remaining unemployed increased especially among persons aged ≥45 years. Conclusion Chronic diseases and multimorbidity are important factors that reduce employment chances among all age groups. Our results provide directions for policy measures to target specific age and disease groups of unemployed persons in order to improve employment opportunities.

Chronic diseases and multimorbidity among unemployed and employed persons in the Netherlands: a register-based cross-sectional study

OBJECTIVES

The first objective of this study was to describe the age-specific prevalence of chronic diseases and multimorbidity among unemployed and employed persons. The second objective was to examine associations of employment status and sociodemographic characteristics with chronic diseases and multimorbidity.

DESIGN

Data linkage of cross-sectional nationwide registries on employment status, medication use and sociodemographic characteristics in 2016 was applied.

SETTING

Register-based data covering residents in the Netherlands.

PARTICIPANTS

5 074 227 persons aged 18-65 years were selected with information on employment status, medication use and sociodemographic characteristics.

OUTCOME MEASURES

Multiple logistic regression analysis and descriptive statistics were performed to examine associations of employment and sociodemographic characteristics with the prevalence of chronic diseases and multimorbidity. The age-specific prevalence of six common chronic diseases was described, and Venn diagrams were applied for multimorbidity among unemployed and employed persons.

RESULTS

Unemployed persons had a higher prevalence of psychological disorders (18.3% vs 5.4%), cardiovascular diseases (20.1% vs 8.9%), inflammatory diseases (24.5% vs 15.8%) and respiratory diseases (11.7% vs 6.5%) than employed persons. Unemployed persons were more likely to have one (OR 1.30 (1.29-1.31)), two (OR 1.74 (1.73-1.76)) and at least three chronic diseases (OR 2.59 (2.56-2.61)) than employed persons. Among unemployed persons, psychological disorders and inflammatory conditions increased with age but declined from middle age onwards, whereas a slight increase was observed among employed persons. Older persons, women, lower educated persons and migrants were more likely to have chronic diseases.

CONCLUSION

Large differences exist in the prevalence of chronic diseases and multimorbidity among unemployed and employed persons. The age-specific prevalence follows a different pattern among employed and unemployed persons, with a relatively high prevalence of psychological disorders and inflammatory conditions among middle-aged unemployed persons. Policy measures should focus more on promoting employment among unemployed persons with chronic diseases.

The concurrence of chronic diseases among unemployed and employed persons: a register-based study

Background

The first aim of this study was to describe the prevalence of chronic diseases and multimorbidity among employed and unemployed persons. The second aim was to investigate associations of sociodemographic characteristics with the prevalence of chronic diseases and multimorbidity.

Methods

Data linkage of large-scale registries on employment status, medication use and sociodemographic characteristics for all Dutch residents in 2016 was applied. In total, 5,074,227 subjects aged 18-65 years were included in the study. The prevalence of six common chronic diseases and multimorbidity was investigated among unemployed and employed persons. Multivariate logistic regression analyses were performed to examine associations of sociodemographic characteristics with the prevalence of chronic diseases and multimorbidity.

Results

Unemployed persons had a higher prevalence of psychological disorders (18.3% vs 5.4%), cardiovascular disease (20.1% vs 8.9%), inflammatory diseases (24.5% vs 15.8%), and respiratory illness (11.7% vs 6.5%) compared to employed persons. Unemployed persons were more likely to have one (OR 1.30, 95% CI 1.29-1.31), two (OR 1.74, 95% CI 1.73-1.76) and at least three chronic diseases (OR 2.59, 95% CI 2.56-2.61) than employed persons. Older persons, women, lower educated persons and migrants were more likely to have one, two, and at least three chronic diseases. Especially at younger ages, psychological disorders and inflammatory conditions were more prevalent but declined from middle age onwards among unemployed persons, whereas as slight increase from middle age onwards was observed among employed persons.

Conclusions

Using objective data, this study provided evidence for inequalities in the prevalence of chronic diseases and multimorbidity, indicating employment status to be an important determinant of health. Policy measures and health interventions should target chronic diseases and multimorbidity, especially among unemployed persons.

Key messages

Using objective data, this study showed that unemployed persons had a higher prevalence of chronic diseases and multimorbidity compared to employed persons. In particular older persons, women, lower educated persons and migrants were more likely to have chronic diseases and multimorbidity.

A Novel Approach to Patients with Equivocal Non-Traumatic Acute Abdominal Pain

Introduction

Patients with acute abdominal pain are sometimes held under long-term observation because of failure to make a certain diagnosis. This study investigates the effectiveness of utilising laboratory and clinical variables to choose between surgical and medical treatment to reduce costs and speed up the evaluation period.

Methods

In a university hospital setting, 165 patients with abdominal pain who had undergone surgical (n=115) or nonsurgical (n=50) treatment after observation were prospectively analysed. Upon presentation body temperature, white blood cell count, neutrophil count, seroreactive protein, and malonyl dialdehyde levels were determined. The area under the ROC curve and logistic regression analyses were performed. Surgical probability formula was prepared by using parameters.

Results

Body temperature, white cell count, neutrophil count, C-reactive protein were higher in the surgical group (p=0.0001). Sensitivity of C-reactive protein was higher in determining patients who required surgical treatment. Multivariate analysis showed that above mentioned variables (except neutrophil count) along with malonyl dialdehyde levels were effective in determining optimal treatment strategy.

Conclusions

It is possible to identify patients who need to undergo surgery by implementation of a ‘probability of surgery’ model using certain laboratory values from blood samples obtained from patients with abdominal pain and unknown diagnosis, upon presentation in the emergency room.

Effects of radiological extent on neutrophil/lymphocyte ratio in pulmonary sarcoidosis

OBJECTIVE

Determining the severity of sarcoidosis is based on the clinical and radiological findings of the disease and the changes in pulmonary function test results. On the other hand; studies are ongoing for objective and easy markers in this respect. Neutrophil/lymphocyte ratio (NLR) is shown as a good prognostic marker for inflammation due to tissue damage in recent clinical trials. In this study, we aimed to identify the possible relationship between NLR and radiological extent of sarcoidosis.

PATIENTS AND METHODS

Data of 122 patients included in the study were evaluated retrospectively in terms of age, gender, complete blood count parameters, erythrocyte sedimentation rate (ESR) and radiological findings at the time of diagnosis.

RESULTS

Mean NLR and ESR were significantly different between radiological stages according to chest radiography and also total HRCT score (THS) groups according to parenchymal involvement in thorax tomography (p <0.05). Mean NLR was found to be 1.28 in stage 0, 1.65 in stage 1, 2.88 in stage 2,5.47 in stage 3 and 8.48 in stage 4; 1.63 in THS group 1, 2.01 in group 2, 3.47 in group 3 and 5.46 in group 4. There were statistically significant positive correlations between NLR and WBC, NLR and THS, NLR and ESR, THS and ESR, ESR and platelet, WBC and #neutrophil, WBC and #lymphocyte.

CONCLUSIONS

Our findings suggest that NLR might be used as a prognostic marker in pulmonary sarcoidosis.

Association between red cell distribution width and mean platelet volume with appendicitis: a myth or a fact?

OBJECTIVES

The aim of our study was to identify if there was a relation between red cell distribution width, mean platelet volume, platelet distribution width, leukocyte count and thrombocyte count at the time of presentation to hospital and acute appendicitis.

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Misinterpretation of symptoms and findings in acute appendicitis may lead to removal of normal appendix and delayed diagnosis can result in perforation and peritonitis. Many studies tried to delineate the relation between acute appendicitis and laboratory findings. Latest studies focused on components of complete blood count such as red cell distribution width and mean platelet volume.

METHODS

This was a retrospective clinical study that enrolled 638 patients with abdominal pain and open appendectomy for acute appendicitis. Complete blood count results including red cell distribution width were retrieved from medical charts of patients and analyzed.

RESULTS

There was no statistically significant difference between appendicitis, non pathological appendix and perforated appendicitis in terms of red cell distribution width or other blood count components except leukocyte level.

CONCLUSION

Despite current findings in medical literature indicating predictive value of red cell distribution width in acute appendicitis; its utility for differential diagnosis might be overestimated (Tab. 1, Ref. 22).

Weight-sparing effect of insulin detemir: a consequence of central nervous system-mediated reduced energy intake?

Insulin therapy is often associated with adverse weight gain. This is attributable, at least in part, to changes in energy balance and insulin's anabolic effects. Adverse weight gain increases the risk of poor macrovascular outcomes in people with diabetes and should therefore be mitigated if possible. Clinical studies have shown that insulin detemir, a basal insulin analogue, exerts a unique weight-sparing effect compared with other basal insulins. To understand this property, several hypotheses have been proposed. These explore the interplay of efferent and afferent signals between the muscles, brain, liver, renal and adipose tissues in response to insulin detemir and comparator basal insulins. The following models have been proposed: insulin detemir may reduce food intake through direct or indirect effects on the central nervous system (CNS); it may have favourable actions on hepatic glucose metabolism through a selective effect on the liver, or it may influence fluid homeostasis through renal effects. Studies have consistently shown that insulin detemir reduces energy intake, and moreover, it is clear that this shift in energy balance is not a consequence of reduced hypoglycaemia. CNS effects may be mediated by direct action, by indirect stimulation by peripheral mediators and/or via a more physiological counter-regulatory response to insulin through restoration of the hepatic-peripheral insulin gradient. Although the precise mechanism remains unclear, it is likely that the weight-sparing effect of insulin detemir can be explained by a combination of mechanisms. The evidence for each hypothesis is considered in this review.

Low intensity conduction states in FeS2: implications for absorption, open-circuit voltage and surface recombination

Pyrite (FeS2), being a promising material for future solar technologies, has so far exhibited in experiments an open-circuit voltage (OCV) of around 0.2 V, which is much lower than the frequently quoted 'accepted' value for the fundamental bandgap of ∼0.95 eV. Absorption experiments show large subgap absorption, commonly attributed to defects or structural disorder. However, computations using density functional theory with a semi-local functional predict that the bottom of the conduction band consists of a very low intensity sulfur p-band that may be easily overlooked in experiments because of the high intensity onset that appears 0.5 eV higher in energy. The intensity of absorption into the sulfur p-band is found to be of the same magnitude as contributions from defects and disorder. Our findings suggest the need to re-examine the value of the fundamental bandgap of pyrite presently in use in the literature. If the contribution from the p-band has so far been overlooked, the substantially lowered bandgap would partly explain the discrepancy with the OCV. Furthermore, we show that more states appear on the surface within the low energy sulfur p-band, which suggests a mechanism of thermalization into those states that would further prevent extracting electrons at higher energy levels through the surface. Finally, we speculate on whether misidentified states at the conduction band onset may be present in other materials.

High sensitive C-reactive protein: a new marker for urinary tract infection, VUR and renal scar

BACKGROUND

Accurate diagnosis and early treatment of urinary tract infections (UTI) are important because of its association with renal scarring (RS).

AIMS

To investigate the serum levels of fibronectin, high sensitive CRP (Hs-CRP), urinary fibronectin, and beta-2 microglobulin (beta2MG) levels in patients with UTI and relationship of these parameters with VUR (vesicoureteral reflex) and RS.

PATIENTS AND METHODS

72 patients were included in study and divided into three groups: Group I (20 patients with first UTI); Group II (16 patients with recurrent UTI with VUR); Group III (16 patients without UTI with VUR).

RESULTS

Serum and urine fibronectin levels were similar in all study groups and controls. Urinary beta2MG levels were higher in Group II (302±179 ng/ml) than in the Group I (134±90 ng/ml) (p < 0.001). Moreover, beta2MG levels were similar in Group II (302±179 ng/ml) and group III (218±147 ng/ml). By contrast, beta2MG levels were higher in Group III (218±147 ng/ml) than in the controls (64±32 ng/ml) (p < 0.001). Hs-CRP levels were higher in Group I (1.8±2.7 mg/L), Group II (23.1±32 mg/L), and III (0.4±0.1 mg/L) than the controls (0.2±0.08 mg/L) (p < 0.001). Hs-CRP levels were higher in Group II (23.1±31.9 mg/L) than in the Group I (1.8±2.7 mg/L) (p < 0.001). Hs-CRP levels were higher in Group I (1.8±2.7 mg/L) and Group II (23.1±31.9 mg/L) than in the Group III (0.4±0.1 mg/L) (p < 0.001). Hs-CRP levels were higher in group III (0.37±0.17 mg/L) than in the controls (0.2±0.08 mg/L) (p < 0.001). Hs-CRP (18.8±25 mg/L) and beta2MG levels (349.4±128.5 ng/ml) were different in UTI with RS from the controls (0.2±0.08 mg/L and 64±32 ng/ml respectively, p < 0.001). Fibronectin levels were similar in patients with and without RS.

CONCLUSIONS

Increased urinary beta2MG and Hs-CRP were observed in initial UTI and recurrent UTI with VUR. Fibronectin levels were not useful for detection of first and recurrent UTI with VUR and RS. Elevated Hs-CRP levels can help us predetermine the patients with VUR prone to proceed to clinical chronic renal failure.

Bolus fluorouracil induced syncope and pulseless ventricular tachycardia: a case report

5-fluorouracil is an anti-cancer drug commonly used in oncology practice. Typical side effects are myelosupression, nausea, vomiting, diarrhea and stomatitis. Cardiotoxicity is the other toxicity. Cardiac side effects are ST segment changes, rhythm abnormalities, supraventricular and ventricular dysrhytmias. Pulseless ventricular tachycardia and ventricular fibrillation releated with bolus fluorouracil were not detected in the literature. Here we discussed a 46 year-old male patient that has no known cardiac history. After bolus fluorouracil administration, syncope and pulseless ventricular tachycardia developed in this patient. There are a few explanations about the cardiotoxicity of fluorouracil. One of these is the effect on nitric oxide. It causes a reduction in the levels of endothelial NO and this leads coronary vasospasm. Another explanation is protein kinase C mediated vasospasm. In animal studies toxic myocarditis like lesions were detected with fluorouracil infusions. Finally both myocardit and vasospasm may lead cardiac problems like sudden cardiac deaths. Bolus 5-fluorouracil is as cardiotoxic as 5-fluorouracil infusion and we must be careful about the arrhytmia after the bolus administration.

Bilateral breast cancer: a male patient

Bilateral breast cancer represents less than 2% of male patients with breast cancer. A 63-year old male presented with a mass at right breast and modified radical mastectomy was performed. Pathology was reported as invasive ductal carcinoma. Radiotherapy and tamoxifen was administered following chemotherapy. At the 5th month, a mass was detected at left breast and modified radical mastectomy was performed. Chemotherapy was started postoperatively. BRCA1 and BRCA2 were reported negative. Although male breast cancer is rare, male patients with breast cancer may have cancer at the other breast (Fig. 1, Ref. 5).

The effect of prenatal factors on the development of colon cancer

BACKGROUND

There is some evidence that prenatal factors can play a role in the development of colon cancer. Children with an old parent age at the time of birth were observed to develop certain childhood cancers more frequently.

OBJECTIVE

This trial was designed to investigate the effects of some prenatal factors on colon cancer risk. Particularly, investigation of the effect of advanced parent age on colon cancer development risk was targeted.

MATERIALS AND METHODS

In this study 117 in or out patients diagnosed with colon cancer and 234 control subjects were included. Definitive diagnostic results and dates of diagnosis were determined from pathological reports. Groups were asked for the parent age, smoking habits, sociodemographic, environmental, familial and reproductive traits. The results were compared between the patients and the control group.

RESULTS

It was determined that children may have higher risk if mother and father are more than 30 at birth (p = 0.018, p = 0.020). While the mean mother age at birth was 25.6 +/- 5.72 in patients, it was 24.7 +/- 6.90 in the controls. The difference was not statistically significant (p < 0.056). The mean father age at birth was 29.4 +/- 6.58 in patients and 27.4 +/- 7.47 in the controls. The difference was statistically significant (p < 0.001). Smoking of mother was one of the important risk factors of colon cancer (p = 0.044).

CONCLUSION

Our data supports that some prenatal factors such as high parental age at birth and mother -smoker may be risk factors for some cancers in children. This is the first study to report that high parental age at birth and exposure to smoke prenatally increase the risk or colon cancer (Tab. 7, Ref. 28).

Clinicopathologic characteristics and BRCA-1/BRCA-2 mutations of Turkish patients with breast cancer

BACKGROUND

BRCA-1 and BRCA-2 are two major susceptibility genes for breast cancer. Between 30-70 % of hereditary breast cancers are thought to be attributed to mutations in BRCA-1 or BRCA-2. The aim of our study was to investigate the clinicopathologic characteristics and BRCA mutations of patients with breast cancer living in the northeast region of Turkey.

MATERIALS AND METHODS

Two hundred eleven patients diagnosed with breast cancer were enrolled in the present study. All patients provided their demographic, environmental, family, and reproductive traits. Patients were screened for mutations of BRCA-1 and BRCA-2 with multiple ligation-dependent probe amplification (MLPA) test.

RESULTS

In the present study, the mean age of breast cancer patients was 50.7 years and the mean age at first delivery was 21.8 years. Large genomic rearrangements in BRCA-1 were detected in 4 (1.9 %) patients; 2 of them had exon 21 deletions and the remaining 2 patients had exon 18 and 19 deletions. No BRCA-2 rearrangements were detected in the study population.

CONCLUSIONS

Different mutation analyses results were detected in different countries by using different testing techniques. The characteristics and sensitivities of patients as determined by all methods were different in these studies. Due to these factors, BRCA mutation rates were different. This is the first study where MLPA was used to screen BRCA-1 and BRCA-2 mutations in Turkish population (Tab. 1, Ref. 10).

The effects of E-cadherin and bcl-2 on prognosis in patients with breast cancer

BACKGROUND

Breast cancer is the most common malignancy in women. Axillary lymph node involvement and tumor size are the most significant prognostic factors in breast cancer. However, more factors are needed for evaluating the prognosis and individualizing the treatment in these patients. Intracellular adhesion molecule E-cadherin, antiapopitotic protein bcl-2, and p53 might have predictive and prognostic properties in breast cancer.

OBJECTIVE

We have investigated the effects of E-cadherin, bcl-2, and p53 on disease free survival and overall survival in patients with breast cancer.

METHODS

Positivity of aforementioned genes was detected with immunohistochemistry staining. Seventy-six women patients with invasive ductal and lobular breast cancer who had received adjuvant therapy were included in the study.

RESULTS

Bcl-2, E-cadherin, and p53 expression in tumor tissue specimens were found in 26.31%, 35.52%, and 9.21%, respectively. Mean duration of follow-up was 93.58 +/- 3.40 months. In multivariate analyses, axillary lymph node presence and C-erb-B2 overexpression were a strong negative prognostic factor of disease free survival and overall survival. E-cadherin and bcl-2 failed to have an effect on disease free survival and overall survival in our study. In addition, p53 overexpression was determined in a limited number of patients.

CONCLUSIONS

The results of this study showed that E-cadherin, bcl-2, and p53 did not have any significant prognostic value for our patients. In order to arrive at a decision, we need studies, which include more patients and long follow-up periods (Tab. 2, Fig. 2, Ref. 24).

Late-onset pulmonary edema due to propofol

Pulmonary edema after the administration of propofol has rarely been reported. In this case report, we describe pulmonary edema due to the administration of propofol during a Cesarean section and while in the intensive care unit. The skin tests demonstrated strong positive weal and flare reactions to propofol. The patient was treated successfully with mechanical ventilatory support. This report emphasizes that this fatal complication may be seen with propofol and underlying mechanisms and therapeutic approach are discussed.

A patient with rubella encephalitis and status epilepticus

Rubella is an important childhood disease that was historically widespread but is now very infrequent. It is an acute viral infection ordinarily characterized by mild constitutional symptoms. Complications are relatively uncommon in childhood. Encephalitis similar to that seen with measles occurs in about 1 in 6,000 cases. The severity is highly variable, and there is an overall mortality rate of 20%. Symptoms in survivors usually resolve within 1-3 week without neurologic sequelae. An 8.5-year-old boy presented with rubella encephalitis and status epilepticus. Five days before admission the patient had erythematous maculopapular rash on the face, spreading to the trunk and extremities. On the admission day, he had a generalized tonic-clonic seizure with loss of consciousness. Microscopic and cytologic examinations of cerebrospinal fluid showed nonspecific. Electro-encephalography (EEG) showed diffuse slowing. An enzyme linked immunosorbent assay (ELISA) revealed that rubella IgM antibody titer was positive in serum and in cerebrospinal fluid. One day later, the patient became conscious with normal physical condition. As a conclusion, it is possible to prevent the complications of rubella infection, especially the congenital rubella syndrome and encephalitis with a rapid and efficient vaccination program.

A mathematical model of the ascending colon of the horse

In this study we present a geometric model of the ascending colon of the horse, especially the left ventral colon and the right ventral colon, the left dorsal colon and the right dorsal colon and the pelvic flexure. We also present a mathematical model of the cross sections of these ascending colon parts with the exceptions of the pelvic flexure. We show that these cross-sections correspond to the closed algebraic curves known as epitrochoid.

A geometric description of the ascending colon of some domestic animals

In this study, a geometric recognition of the ascending colons of some domestic animals such as pig, ruminants (only the ansa spiralis coli) and dog is presented. The ascending colon of these animals can be considered a tubular shape along a special curve.

A fluid level in an acute extradural haematoma

We report a fluid level in an acute extradural haematoma developing after placement of a ventriculo-peritoneal shunt for hydrocephalus. This fluid level was thought to be due to a mixture of blood and cerebrospinal fluid.