A protocol for stakeholder engagement in deliver-EE: A pragmatic randomized comparative effectiveness trial evaluating effects of meal delivery on the ability of homebound older adults to remain in the community

BACKGROUND

Few clinical trials include a detailed protocol for stakeholder engagement in the design and execution of the clinical trial. Deliver-EE is a pragmatic clinical trial to assess how different types of home-delivered meals can affect older adults' health and well-being. We present the protocol for stakeholder engagement in this national, multi-site trial and initial findings from our efforts.

METHODS

Twenty-nine participants were recruited to two stakeholder advisory panels. The "Lived Experience Perspectives" panel is defined as the clients, caregivers, and meal delivery drivers with first-hand knowledge and lived experiences with meal delivery. The "System Perspectives" panel is defined as representatives from the larger financial, clinical, regulatory, and operational environments in which meal delivery to homebound older adults operate. Together, these two groups holistically represent interested parties that coordinate the interdependent elements of meal delivery to homebound older adults in order to: 1) inform our understanding of what matters most to older adults, their families, and the larger health and social care systems; 2) provide strategies to overcome challenges conducting the study; 3) enhance dissemination and uptake of study findings; and 4) identify opportunities for future research.

RESULTS

Although stakeholder partners share a common goal of using home-delivered meals as a method to improve outcomes for homebound older adults, individuals have different goals for participating as advisors in this research.

CONCLUSIONS

Understanding what individual stakeholders hope to gain from their participation is critical in designing an effective engagement protocol and critical for meaningful and rigorous stakeholder engagement in clinical trials.

Breast cancer subtypes can be a predictor of pathologic complete response and survival in the neoadjuvant setting for T4 noninflammatory breast cancer

BACKGROUND

The aim of this study is to identify whether the breast cancer subtypes are predictors of pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) and survival in patients with T4 noninflammatory breast cancer.

METHODS

The records of 181 patients treated with anthracycline +/- taxane based NAC followed by mastectomy and radiation therapy +/- hormonotherapy were evaluated. The role of intrinsic subtypes of the tumor including luminal A, luminal B, HER2, and triple-negative on pCR and survival were analyzed.

RESULTS

The median follow-up was 44 months (range: 16-82 months). All patients received a median four cycles of NAC. Twenty-three patients (12.7%) were found to have pCR. In the univariate analysis, the intrinsic subtypes of the tumor had significant effect on pCR (p < 0.01). Also, intrinsic subtypes were significant predictors of pCR to NAC in the multivariate analysis (p < 0.01; hazard ratio, 2.4; 95% confidence interval, 1.1-6.8). While patients with triple-negative tumors had the highest rate of pCR (29%), this rate was the lowest in patients with HER2 tumors (4.2%). Five-year DFS was also significantly lower in patients with triple-negative (24%) and HER2 (21%) tumors compared to luminal A (61%) subtype (p < 0.0001). Likewise, 5-year OS was poorer in patients with triple-negative tumors (30%) and HER2 tumors (%31) compared to both luminal A (70%) and luminal B (68%) subtypes (p < 0.0001).

CONCLUSIONS

It can be concluded that breast cancer subtyping defines the extent of response to NAC and has a significant effect on survival in patients with T4 noninflammatory breast cancer.

Family planning practices of migrant farm-workers: a methodological approach

"This is a methodological study concerning the family planning practices of the migrant farm-workers in the Dogankent region [of Turkey]. The workers were given health services and education about family planning methods during off-work hours. Out of the 3,022 subjects starting the study, 304 of whom were already benefiting from some kind of (traditional or modern) family planning methods: 1,393 ended up...with using effective methods...." (SUMMARY IN TUR)

Oromandibular limb hypogenesis and gastroschisis

The oromandibular limb hypogenesis syndromes (OLHS), which are congenital malformations involving the tongue, mandible, and the limbs are extremely rare with a few sporadic cases reported in the literature. In this report, the authors report a case of OLHS with gastroschisis, that has not been described previously according to the medline search.

Urodynamic findings in the tethered spinal cord: the effect of tethered cord division on lower urinary tract functions

PURPOSE

The aim of this study is to evaluate the effect of division of the tethered spinal cord urodynamically in spinal dysraphic cases.

METHODS

Between 1995-1997, 20 cases (11 males, 9 females) aged from 5 months to 13 years with TSC were investigated. 13 cases (65%) were classed as belonging to the myelomeningocele group and 5 cases (35%) to the spina bifida occulta group. We used a computerized urodynamic system to evaluate the functions of the lower urinary tracts pre- and postoperatively. The definitive diagnosis of cord tethering was made using magnetic resonance imaging (MRI) in 19 cases (95%) and spinal ultrasound in 1 case (5%). Division of filum terminale and laminectomy were carried out in all cases by the Neurosurgery Department, and 2 cases with retethering were operated on twice.

RESULTS

All of these cases were assessed urodynamically in the preoperative and postoperative period. Significant improvements were noted in detrusor functions (35%); electromyography recordings (45%); high leak point pressures (55%) and anal and urinary continence (70%).

CONCLUSION

Lower urinary tract dysfunctions secondary to tethered cord syndrome are very common in spinal dysraphic cases and significant improvements can be achieved with a judiciously timed division of the spinal tethered cord.

Biochemical evidence of crossed cerebellar diaschisis in terms of nitric oxide indicators and lipid peroxidation products in rats during focal cerebral ischemia

OBJECTIVES

Cerebral hypoperfusion in the contralateral cerebellar hemisphere after stroke is interpreted as a functional and metabolic depression, possibly caused by a loss of excitatory afferent inputs on the corticopontocerebellar pathway terminating in the cerebellar gray matter. This phenomenon is defined as crossed cerebellar diaschisis and can be diagnosed clinically by positron emission tomography, single-photon emission computed tomography, brain magnetic resonance imaging and electroencephalography in terms of regional cerebral blood flow or metabolic rate of oxygen measurements.

MATERIALS AND METHODS

In the present study, nitric oxide indicators (nitrite and cyclic guanosine monophosphate) and lipid peroxidation products (malondialdehyde and conjugated dienes) were measured in rat cerebral cortices and cerebella after permanent right middle cerebral artery occlusion in order to assess the crossed cerebellar diaschisis.

RESULTS

Nitrite values in ipsilateral cortex were significantly higher than those in contralateral cortex at 10 (P < 0.001) and 60 (P < 0.05) min of ischemia but no significant changes were observed in both cerebellum compared to the 0 min values. In both cerebral cortex and cerebellum cGMP levels at 10 and 60 min were significantly increased (P < 0.001). This increase was marked in ipsilateral cortex and contralateral cerebellum when compared with opposite cortex and cerebellum (P < 0.001). MDA values in ipsilateral cortex were significantly higher than those in contralateral cortex at 60 min of ischemia (P < 0.05). Contralateral cerebellar MDA values were found significantly higher than those in ipsilateral cerebellum at 0 (P<0.001) and 60 (P < 0.05) min of ischemia. In ipsilateral cortex, conjugated diene values at 0, 10, 60 min of ischemia were higher than those in contralateral cortex. On the other hand 0, 10, 60 min conjugated diene levels in contralateral cerebellum were significantly higher than those in ipsilateral cerebellum (P < 0.001).

CONCLUSION

These findings support the interruption of the corticopontocerebellar tract as the mechanism of the crossed cerebellar diaschisis.

Does maternal drug ingestion cause megacystis microcolon intestinal hypoperistalsis syndrome? II. Bromide trial

PURPOSE

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a congenital disease, and the etiology of the disease is unclear. It is speculated that maternal ingestion of some drugs during pregnancy and degeneration of smooth muscle cells in the fetus may be an etiologic factor. In this study we aimed to investigate the effect of maternal ingestion of bromide on the fetal bladder and colon in pregnant rats.

METHOD

We separated animals into a bromide group including 30 rats and a control group with 14 rats. Nothing was given to the control group during pregnancy. Intraperitoneally 8 mg/kg/day bromide was given to the study group from the 6th to 12th day of pregnancy. All of the rats were sacrificed on the 20th day of pregnancy. Histopathological examination of fetal colons and bladders was performed.

RESULTS

In the bromide group, an increase in the colon and bladder diameter, an increase in muscle atrophy in the colon and bladder wall, an increase in vacuolar degeneration in the muscles of the bladder and colon wall, and a significant decrease in ganglion cell numbers in the myenteric plexus of the colon and bladder were determined.

CONCLUSION

In our rat model, we found histological structural changes in the rats' colon and bladder walls as a result of using bromide on the 6-12th days of pregnancy similar to pathological findings found in some of MMIHS patients' bowels and bladders.

Does maternal drug ingestion cause megacystis microcolon intestinal hypoperistalsis syndrome? III. Ethanol trial

PURPOSE

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a congenital disease, and the etiology of the disease is unclear. It is speculated that maternal ingestion of some drugs during pregnancy may be an etiologic factor. In this study we aimed to investigate the effect of maternal ingestion of ethanol on the fetal bladder and colon in pregnant rats.

METHODS

We separated animals into an ethanol group including 30 rats and a control group with 14 rats. Nothing was given to the control group during pregnancy. Orogastrically 2 cc/day 30% ethanol was given to the study group from the 6th to 12th day of pregnancy. All of them were sacrificed on the 20th day of pregnancy. Histopathological examination of the fetal colon and bladder was performed.

RESULTS

In the ethanol group a significant decrease in the colon and bladder diameter, a significant decrease in the thickness of the colon and bladder wall, an increase in vacuolar degeneration in the muscles of the bladder wall, an increase in connective tissue proliferation among the muscles of the bladder, a significant decrease in the number of ganglion cells in the myenteric plexus of the colon and a significant decrease in the thickness of the bladder tunica muscularis were determined.

CONCLUSION

In our rat model we found histological structural changes in the rats' colon and bladder wall similar to a pathological finding found in some of the MMIHS patients' bowel and bladder as a result of using ethanol on the 6th-12th days of pregnancy.

Solitary rectal ulcer syndrome in children

The solitary rectal ulcer syndrome (SRUS) is an unusual disorder in childhood. Although well recognized in adult literature, the pediatric experience with this condition is limited, so SRUS often goes unrecognized or misdiagnosed. There are very few pediatric case reports in the English literature. This report describes four patients who presented with rectal bleeding, constipation, mucous discharge, and lower abdominal pain, with a diagnosis of SRUS. The diagnosis was made by rectoscopy, defecogram, anorectal manometry and histopathological evaluation. In two patients, defecogram showed a rectocele with both, the sphincter failed to relax to voluntary squeeze pressure on anorectal manometric examination. The histopathological finding in all patients was fibrous obliteration of the lamina propria with disorientation of muscle fibers. All of the patients responded well to conservative therapy, which included defecation training, laxatives, sulfasalazine, and application of rectal sucralfate enema, and remained asymptomatic on the follow-up. Although rare in the pediatric population, SRUS should be relatively easy to recognize in the child with rectal bleeding, after elimination of other causes. If suspected, the diagnosis of SRUS may be made at endoscopy and confirmed by rectal biopsy.

Does maternal drug ingestion cause megacystis microcolon intestinal hypoperistalsis syndrome? I. Clomiphene trial

PURPOSE

Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS) is a congenital and lethal disease, and the etiology of the disease is not clear. It is speculated that maternal ingestion of some drugs during pregnancy may be an etiologic factor. In this study we aimed to investigate the effect of maternal ingestion of clomiphene on fetal bladder and colon in pregnant rats.

METHODS

We separated animals into a control group including 14 rats and a clomiphene group with 30 rats. Nothing was given to the control group during pregnancy. Two mg/kg/day clomiphene intraperitoneally was given to the study group from the 6th to 12th day of pregnancy. All of them were sacrificed on the 20th day of pregnancy. Histopathological examination of the fetal colon and bladder was performed.

RESULTS

In the clomiphene group a significant decrease in the thickness of the bladder wall, an increase in bladder epithelium, an increase in muscle atrophy of the colon and bladder wall, an increase in vacuoler degeneration of the muscles of the bladder and colon wall, a decrease in ganglion cell numbers in the myenteric plexus of the bladder and a decrease in the thickness of the bladder tunica muscularis were determined.

CONCLUSION

In our rat model we found histological structural changes in the rats' colon and bladder walls as a result of using clomiphene on days 6-12 of pregnancy; a similar pathological finding to those found in some of the MMIHS patients' colons and bladders.

Ruptured spleen due to blunt trauma in children: analysis of blood transfusion requirements

Selective non-operative management of splenic injury in children is generally considered to be safe, and the majority of those with isolated injuries do not require blood transfusion. Eighty-four children were treated for blunt splenic trauma from 1988 to 1997 in the Department of Paediatric Surgery, The Medical Faculty of Uludag University, Bursa, Turkey. Management involved non-operative care in 56 cases (66.7%), splenectomy in 20 (23.8%) and splenorraphy in eight (9.5%) cases. There were no later complications related to splenic injury. The overall mortality was 9.5% (8/84) and the factors effecting mortality were additional intra-abdominal and/or other system injuries. Twenty-two children were not transfused during non-operative treatment. In our study, only 57.1% of the children in the non-operative group received blood transfusions. Some of the patients in this group received only small amounts of blood and probably would have recovered without it. It is concluded that, based on a very strict protocol in conservative management, the total amount of transfused blood could be reduced in children with splenic injuries due to blunt abdominal trauma.

Rabdomyosarcoma of the biliary tree

Rabdomyosarcoma of the biliary tree is one of the rare causes of biliary tract obstruction in childhood. Nevertheless it is the most common cause of obstructive jaundice due to neoplastic biliary obstruction. We present a two-year-old child with obstructive jaundice secondary to an embryonal rhabdomyosarcoma of the biliary tree. She underwent surgery and, after total excision of the mass, a hepaticojejunostomy and Roux-en-Y anastomosis were performed. She was referred to the Pediatric Oncology Group for follow-up. Rhabdomyosarcoma of the bilary tree, although rare, must be considered in the etiology of obstructive jaundice in children.

Surgical correction of muscular torticollis in older children with Peter G. Jones technique

In the Department of Pediatric Surgery, Uludağ University Medical Faculty in Bursa, during the last 11 years, the Peter G. Jones technique for the surgical correction of muscular torticollis in older children has been introduced. Twenty children between 4 and 13 years of age were treated for muscular torticollis. They were followed up from 3 months to 10 years after surgery. All patients had a middle-third open transection of the sternocleidomastoid muscle. Preoperative and postoperative assessment by a rigid scoring system showed that all patients improved in terms of function as well as cosmesis. Children younger than 10 years showed the most improvement, with 90% excellent and good results. Late middle-third open transection of the sternomastoid in muscular torticollis may give acceptable results.

Sigmoidoscopy in minor lower gastrointestinal bleeding

The role of sigmoidoscopic examination in the diagnosis, evaluation, and treatment of minor lower gastrointestinal bleeding was investigated. A hundred patients with minor rectal bleeding were examined by rigid sigmoidoscopy under general anaesthesia between January 1989 and July 1996. Patients who had bleeding secondary to infections, anal fissure, or haemorrhoids were excluded from study. Patients were reviewed retrospectively according to their diagnosis and endoscopic and histopathological findings. Twenty nine of these patients were girls and 71 boys; their ages ranged between 8 month and 14 years (mean 7.2 years). Endoscopic pathological findings were established in 60 patients; 32 had rectal polyps, 16 non-specific proctitis, four solitary rectal ulcers, three internal haemorrhoids, two ulcerative colitis, two Hirschsprung's enterocolitis, and one haemangioma. It is concluded that sigmoidoscopic examination should be performed for the diagnosis, prognosis, and choice of treatment in patients with minor rectal bleeding and the diagnosis should be confirmed histopathologically.

Inhibitory role of N omega-nitro-L-arginine methyl ester (L-NAME), a potent nitric oxide synthase inhibitor, on brain malondialdehyde and conjugated diene levels during focal cerebral ischemia in rats

The effect of N omega-nitro-L-arginine methyl ester (L-NAME) on ischemic neuronal damage was studied in a rat model of permanent focal cerebral ischemia in terms of ipsilateral and contralateral cortical and cerebellar tissue lipid peroxides. Forty-five male Swiss Albino rats were assigned to one of four groups; sham operated as control, subjected to right middle cerebral artery occlusion or injection of L-NAME (10 mg/kg i.p.) either 30 min before or just after right middle cerebral artery occlusion. Changes in lipid peroxides were expressed as nanomoles of malondialdehyde and conjugated diene per milligram of protein. Malondialdehyde values following 60 min of ischemia relative to contralateral cortex and conjugated diene levels in 0, 10 and 60 min of ischemia were found to be higher in ipsilateral cortex than in contralateral cortex. On the other hand, contralateral cerebellar malondialdehyde levels after 0 and 60 min of ischemia and conjugated diene levels after 0, 10 and 60 min of ischemia were higher than those in ipsilateral cerebellum. Pharmacological inhibition of nitric oxide synthase by L-NAME before or just after permanent middle cerebral artery occlusion significantly decreased the malondialdehyde and conjugated diene levels in both the cortex and the cerebellum. No significant differences were found in malondialdehyde values between rats that had been pre- and post-treated with L-NAME, but conjugated diene levels in the post-treated group seemed to be significantly lower than those in the pretreated group. On the whole, these results suggest that malondialdehyde and conjugated diene represent early biochemical markers of lipid peroxidation in ischemic tissues, reflecting the radical-mediated tissue damage.

The effects of a fluoroquinolone on the growth and development of infants

Growth and development were monitored for up to 42 months in nine neonates to whom ciprofloxacin, a fluoroquinolone, was given in the neonatal period at a dosage of 20 mg/kg/day. Ciprofloxacin was used only as a ¿life-saving' therapy in cases of sepsis produced by bacterial agents resistant to other antibiotics. Two other groups of nine neonates, matched by birth weight and gestational age, were studied as controls: one group with sepsis, which was effectively treated with cefotaxime and a group of healthy neonates. No statistically significant differences in growth and development between the groups were found during follow-up for 42 months. No osteoarticular problems or joint deformities were observed in the ciprofloxacin group. Ciprofloxacin appears to provide a therapeutic option as a ¿life-saving' therapy for newborns with sepsis produced by multiply resistant organisms.

Mediastinal cystic lymphangioma: report of two cases

Cystic lymphangioma is an extremely rare mediastinal benign tumor characterized by congenitally enlarged lymphatic vessels. It is often diagnosed incidentally because it is only symptomatic when it grows to be very large. We present two cases of mediastinal cystic lymphangioma and review the literature.

Fluconazole treatment of neonates and infants with severe fungal infections

A total of 24 neonates and infants, aged from 2 days to 10 months, received treatment with intravenous fluconazole for microbiologically documented or presumed fungal infection. The mean fluconazole dosage was 6 mg/kg/day (range 2-16 mg/kg/day) and the mean duration of therapy was 25 days (range 5-72 days). Efficacy was evaluated in neonates with proven fungal infections, as documented by the presence of pathogen at baseline. A positive clinical response was achieved in 23 of the 24 clinically evaluable patients (96%); eradication of the fungal organism was also achieved in 23 of the 24 evaluable patients (96%). Adverse events occurred in two patients (8%) but therapy was not discontinued in either patient. The present results confirm the efficacy and safety of fluconazole in the treatment of neonates and infants with severe fungal infections.

Effects of Lamotrigine on brain nitrite and cGMP levels during focal cerebral ischemia in rats

Glutamate receptor antagonists are protective in animal models of focal cerebral ischemia. Lamotrigine (3,5-diamino-6-[2,3-dichlorophenyl]-1,2, 4-triazine) is an anticonvulsant drug that blocks voltage-gated sodium channels and inhibits the ischemia-induced release of glutamate. Experiments in primary neuronal cultures implicate nitric oxide (NO) as a mediator of glutamatergic neurotoxicity acting via N-Methyl-D-Aspartate (NMDA) receptors. The effect of glutamate release inhibitor, Lamotrigine upon NO and cGMP production has been examined in focal cerebral ischemia in rats. Focal cerebral ischemia was produced by the permanent occlusion of right middle cerebral artery (MCA) in urethane anesthetized rats. A number of indicators of brain NO production (nitrite, cGMP) were determined in ipsilateral and contralateral cerebral cortex and cerebellum after 0, 10, 60 min of focal cerebral ischemia. The same parameters were measured in rats treated with Lamotrigine (20 mg/kg, i.p.) 30 min before or just after the occlusion of the right MCA.

Thoracoabdominal duplication cyst: US, CT and MR findings

A rare case of thoracoabdominal duplication is reported. Radiological workup including US, CT and MR provided the correct diagnosis. The US revealed the cystic nature of the lesions, whereas CT and MR showed their relationship with the diaphragm and each other. Coronal- and sagittal-plane MR images were helpful in demonstrating the extension of the lesions. The patient was discharged after an uneventful surgery and recovery. The histological evaluation revealed the cyst lined with single-layered columnar epithelium and the cyst wall contained submucosal mucous glands with underlying smooth muscle and also some mature chondroid elements with bronchogenic origin. Radiological findings and differential diagnosis are discussed.

The effects of nitric oxide synthase inhibitor, L-NAME on NO production during focal cerebral ischemia in rats: could L-NAME be the future treatment of sudden deafness?

Recent evidence in primary neuronal cell culture implicates NO as a mediator of glutamatergic neurotoxicity acting via N-methyl-D-aspartate (NMDA) receptors. In this study, we investigated the effects of inhibition of NOsynthase activity in focal cerebral ischemia in rats. Focal cerebral ischemia was produced by permanent occlusion of right MCA in urethane anesthetized rats. A number of indicators of brain NO production, nitrite and cGMP were determined in ipsilateral and contralateral cerebral cortex and cerebellum after 0, 10 and 60 minutes of focal cerebral ischemia. The same parameters were measured in rats pre- and posttreated with the potent Nitric oxide synthase (NOS) inhibitor, NW-nitro-L-arginine methyl ester (L-NAME).