Maintenance therapy with synthetic opioids within a multidisciplinary program – A stabilizing necessity for pregnant opioid dependent women

Summary Aims: Drug addiction in females requires special attention when the woman is pregnant. In opioid dependent pregnant addicts early intervention during the prenatal period is highly desirable for maintaining the health of the woman, the fetus, and her infant after birth. The aim of our study was to perform an analysis of different variables to determine which factors are responsible for stabilizing the mother so that she could keep the child. Design: Ninety-eight pregnant opioid dependent women who were seeking treatment in our multiprofessional treatment program were investigated. Setting: The addicts were treated during pregnancy and then after delivery for an investigational period of 36 months at the University Drug Addiction Out-patient Clinic. Participants: Pregnant women who met DSM-IV criteria for opioid dependence (DSM-IV 304.0) or polysubstance dependence (DSM-IV 304.8) were included; 82 children were born during this time-frame. Intervention: All patients received oral opioid maintenance therapy (methadone, slow-release morphine, buprenorphine) and had access to the same psychosocial and psychotherapeutical treatment. Measurements: Length of treatment period, duration of maintenance therapy, type of maintenance therapy as well as attendance of psychotherapy were used to evaluate which of these parameters are predictors of whether the child can live with its own mother or had to be placed elsewhere. Findings: At the end of our investigation period, 59% (n = 48) of the children were still raised by their mothers. Duration of involvement in a maintenance program with replacement opioids (p = 0.002), as well as early intervention (p = 0.03) had a significant influence towards retaining custody of the child. In addition to successful pharmacological treatment, psychosocial and psychotherapeutical services influenced the outcome in respect of mothers keeping the child. Conclusion: Early intervention and effective multiprofessional treatment approaches facilitated a better outcome for this population at risk with respect to mothers retaining custody of their child.     

Information and decision making: patients' needs and experiences in the course of breast cancer treatment

OBJECTIVE: This study explored breast cancer patients' preferences and experiences in receiving information and decision making in the course of the first 6 months of cancer treatment. METHODS: Participants were 135 German breast cancer patients, recruited within a week of either surgery or the beginning of neo-adjuvant chemotherapy. Women were asked to complete a self-explanatory questionnaire at baseline and 3 and 6 months later. RESULTS: There was a significant decrease in the importance of specific information needs. The quality of received information through the physician was rated significantly better at baseline than 6 months later. Nearly half of all patients changed their decision making preference at least at one assessment point. Shared decision making rarely took place in the first 6 months of treatment. CONCLUSION: Breast cancer patients' information needs and decision making preferences can change during treatment. Future research should analyse which patients change their decision making preference under which circumstances. PRACTICE IMPLICATIONS: Physicians need to investigate the decision making preferences and information needs of their patients in the course of treatment. Patient oriented communication skills might be helpful to meet patients' preferences and needs.     

Saliva secretion in patients with allergic rhinitis

BACKGROUND: Allergic rhinitis is manifested by watery discharge; however its clinical effect on the watery volume in the oral cavity is unknown. In addition, the low incidence of dry mouth due to treatment with the new generation antihistamines is based on subjective patients' reports only. This study aimed to examine the effect of loratadine and fexofenadine on the salivary gland function in patients diagnosed with allergic rhinitis compared to untreated allergic patients and healthy individuals. METHODS: A comparative observational study assessed parameters related to the patients' perception of dry mouth as well as clinically observed parameters in fexofenadine-treated patients (group A) and in loratadine-treated patients (group B). Allergic patients without pharmacological treatment (group C) and healthy individuals (group D) served as a double control in order to evaluate the effect of allergy itself on dry mouth. A total of 36 patients were enrolled. RESULTS: Patients in groups A and C reported the highest intensity of xerostomia. Sialometry values were significantly lower in these 2 groups compared to the healthy controls (p = 0.02 and 0.03, respectively). Average sialometry was over 0.2 ml/min in all groups and subjective dry mouth sensation ranged in the lower quarter of the visual analogue scale. CONCLUSIONS: In this pilot study, patients diagnosed with allergy presented a significant difference in salivary flow rate compared to healthy controls. Unlike the effect of loratadine, fexofenadine-treated patients showed significantly lower salivary flow rates compared to healthy individuals. In all cases the intensity of dry mouth was low.     

A pilot study exploring the effect of discharging cancer survivors from hospital follow-up on the workload of general practitioners.

BACKGROUND: The tradition of routine, long-term follow-up of cancer patients in the outpatient clinic has led to busy clinics and long waiting times. Many cancer patients are anxious and have become dependent on the specialist clinic for reassurance. General practitioners (GPs) have been shown to be willing to assume greater responsibility for the routine follow-up of breast cancer patients, but patients have demonstrated a preference for hospital follow-up. If patients are discharged unwillingly, their rehabilitation may be at the cost of an increased demand on GP practices. AIM: To determine the consequences for GPs of discharging long-term cancer patients from a hospital outpatient follow-up clinic. METHOD: A consecutive sample of 65 patients under annual review in a hospital oncology clinic were offered a planned discharge in which their return to the clinic, if necessary, was guaranteed. The 41 patients who accepted discharge were monitored. Anxiety and depression rates were assessed using the Hospital Anxiety and Depression Scale (HADS) at the time of discharge and four months later at a home interview. The GPs of all patients who were discharged were sent questionnaires four and twelve months after discharge to evaluate consultation rates and change in psychological morbidity. RESULTS: The results showed no significant increase in the consultation rates during the 12 months after discharge compared with the previous 12 months. There was no significant change in the level of patients' anxiety or depression at four months after discharge. The great majority of GPs (71%) reported no change in their perception of patients' levels of anxiety or depression. GPs thought there was a need for more specialist Macmillan nurses working in the community and highlighted the importance of fast-track specialist referral. CONCLUSION: Discharging this group of long-term cancer survivors did not increase the workload of GPs. However, GPs' concern over the lack of availability of Macmillan nurses in the community suggests that primary care services may find it difficult to cope adequately with the special requirements involved in cancer patient care. Finally, there is a need to address the further training requirements of GPs in the routine follow-up of cancer patients.     

Adherence and perception of medication in patients with chronic heart failure during a five-year randomised trial

OBJECTIVE: Many patients with chronic heart failure (CHF) are thought to be non-adherent to their prescribed medications. The objective was to describe perceptions about and adherence to regular medicines and study medication at baseline and study end in CHF patients participating in a clinical trial. METHODS: In the carvedilol or metoprolol European trial (COMET), patients (N = 3029) with CHF were randomised and followed during a 58-month period. Patients at some Swedish centres answered a questionnaire at baseline and study end concerning their perception of their regular heart medication and study medication. Adherence was established through estimation of drug usage. RESULTS: In the Swedish sub-study, 302 patients responded once to the questionnaire while 107 patients responded both at baseline and at follow-up. At baseline, 94% of the patients stated that they believed that the study medication would make them feel better and 82% believed that their regular heart medication would do so. During the study, patients' belief in their regular cardiac medication significantly increased. Lack of belief in medication at the start of the study was a strong predictor of withdrawal from the trial (64% versus 6.8%; p < 0.0001). Those patients with very poor well-being and limited functional ability (classified as NYHA III-IV) at baseline significantly (p = 0.01) increased their belief in the regular cardiac medication but not in their study medication. CONCLUSION: Belief in medication may be related to how the patient experiences the medication's impact on functional ability, symptoms and well-being. PRACTICE IMPLICATIONS: Early identification of patients' beliefs about medication seem to be an important factor in counselling and information to patients with CHF.     

Management of Total Cancer Pain: A Case of Young Adult

Pain due to cancer is one of the most distressing symptoms experienced by the patients at some or the other time during the course of treatment or disease progression. The multidimensional nature of cancer pain is characterized by various dimensions including physical, social, psychological, and spiritual; which together constitute the term “total pain”. Young cancer patients illustrate their unique psychological and developmental needs. This case report highlights the concept of “total cancer pain” in a young adult and demonstrates his distinctive social, spiritual, and psychological sufferings. The report emphasizes that addressing all these concerns is considerably significant in order to provide optimal pain relief to the patient. In the present scenario, it has been done by a skillful multiprofessional team communicating effectively with both the patient and the carer.     

左旋18-甲基炔诺酮对大鼠下丘脑GnRH神经元的影响

目的：观察孕激素类避孕药—左旋18-甲基炔诺酮(LNG)对大鼠下丘脑GnRH神经元的影响。方法：正常雌性大鼠分为长期给药组(灌服LNG90d)和停药组(停药后正常喂养20d)。免疫组织化学方法显示下丘脑GnRH阳性神经元。结果：长期给药组与对照组相比斜角带(db)、视前区(MPA)内GnRH阳性神经元构成比发生改变,棘型神经元减少,阳性神经元光密度减低,阳性纤维膨体密度降低,正中隆起(ME)处阳性纤维密度增加。停药后基本恢复正常。结论：从形态学上证实LNG作用于下丘脑水平;停药后GnRH阳性神经元形态学变化可恢复正常,表明LNG具有高效安全性。     

Thyroxin binding globulin (TBG) radioimmunoassay. Normal patients results according to age, and sex, and in the cases of dysthyroidisms (author's transl)

The value of TBG serum concentration for the exploration of thyroid function was studied by radioimmunoassay in 203 patients (133 normals, 62 dysthyroidism, 8 women taking oral contraceptives). The results of the normal patients show important and as of yet unexplained variations of TBG levels, depending on age and sex. In hyperthyroidism, serum TBG was reduced significantly in women and no significantly in men. In hypothyroidism, the levels are significantly high in both sexes. Like the TRH test, the TBG serum concentration determination may be helpful for the diagnosis of a slight hypothyroidism. Moreover, as the serum levels return to normal values with substitutive therapy, TBG assay may be used as a follow-up test during the treatment of hypothyroid patients.     

Exploring the black box of a decision aid: What information do patients select from an interactive Cd-Rom on treatment options in breast cancer?

OBJECTIVE: It is thought that patients fare better when they participate in treatment decision-making, and when they have more control over the amount and type of information they receive. To facilitate informed decision-making, interactive decision aids have been introduced in health care. This article describes how much, and which information patients select from an interactive decision aid on breast cancer. To explore whether the interactive system facilitates that different patients receive different information, associations between patients' characteristics and information selection are inspected. METHODS: The interactive decision aid was provided to 106 patients after an initial discussion with their surgeon about their diagnosis and treatment options. Information regarding patients' age, completed education, treatment preference, psychological functioning, decision uncertainty and decision style was collected with a written, structured questionnaire. The questionnaire was completed before patients used the interactive decision aid. To create categories, a median-split procedure was employed on the scores of the continuous background variables. The information patients selected from the interactive decision aid were registered into logfiles. Associations between patients' background variables and information selection were investigated by means of univariate statistics. RESULTS: Patients (n=97; 92%) used the interactive decision aid intensively. On average, patients spent almost 70min searching for information and selected 21 information topics. Overall, treatment related information was clearly more selected than other types of information. Age, education, and decision style factors were associated with information selection. CONCLUSION: The interactive breast cancer decision aid was utilized intensively. The interactive system was found to facilitate that different patients received different amounts and types of information. PRACTICE IMPLICATIONS: Interactive decision aids may improve information giving to patients, and as a result, the quality of care. To safeguard informed-choice, decision aids should be used in conjunction with other communication strategies. Decision aids should be available continuously and throughout the patients' disease journey. The Internet may help to achieve broad dissemination and enduring access.     

Information needs and sources of information among cancer patients: a systematic review of research (1980-2003)

Understanding what cancer patients need to know and from whom they receive information during the course of care is essential to ensuring quality care. We reviewed 112 articles published from 1980 to 2003 and developed a typology summarizing cancer patients' information needs and the sources from which they receive information. The majority of articles focused on information needs and sources during the diagnosis and treatment phase. Thus, the most frequent information need was treatment-related (38.1%). The most frequent information source was health professionals (27.3%). We examined patients' information needs and sources along the continuum of care and found that during diagnosis and treatment, information needs about the stage of disease, treatment options, and side-effects of treatment were prominent; during post-treatment, patients continued to need information about treatment, and information about recovery was also important. Future research should examine cancer patients' information needs and sources throughout their cancer journey.     

Congenital Insensitivity to Pain with Anhidrosis (CIPA): A Case Report

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare disorder characterized by episodes of fever and the inability to sense of pain despite the fact that all other sensory modalities remain intact or minimally impaired. The patient also may exhibit the signs of self-mutilation, mental retardation and little or no perspiration. We present a 10 years old Iranian patient diagnosed with CIPA with the above-mentioned clinical characteristics. The prosthetic treatment and the subsequent six month follow-up are discussed. Follow-up of the patient revealed that, with the use of this prosthesis, the patient's oral function and esthetics were established and the mouth lesions improved. Therefore especial dental management of CIPA patients according to their mental status, age, oral and dental condition is essential for solving the specific problems each case may present and the full mouth teeth extraction should be considered as the last treatment.     

Correction of a suppressor cell deficiency in familial Mediterranean fever by colchicine.

We have previously reported a suppressor cell deficiency in four patients with familial Mediterranean fever (FMF). Since colchicine prevents FMF attacks, we tested the effect of colchicine (1 mg twice daily) on the suppressor cell function in three of these FMF patients. Proliferation of phytohaemagglutinin-stimulated responder cells co-cultured with concanavalin A-induced suppressor cells was measured. The three FMF patients' means (+/- s.e.m.) percentage suppression of normal responder cells was markedly low before treatment (6 +/- 2) but significantly (P less than 0.001) increased during colchicine treatment (41 +/- 5) to levels similar to normal volunteers' mean percentage suppression (44 +/- 3). Colchicine corrected their suppressor cell deficiency and prevented FMF attacks during the 15 months of treatment. These findings support the hypothesis that there may be an association between these three patients' suppressor cell deficiency and the pathogenesis of their disease. Furthermore, colchicine may be potentially useful in treating patients with other diseases associated with a suppressor cell deficiency.     

Treatment decision making in prostate cancer: patients' participation in complex decisions

OBJECTIVE: (1) To explore to what degree prostate cancer (PC) patients felt they had participated in treatment decision making (TDM). (2) To determine whether perceived roles during TDM were associated with medical and sociodemographic variables. (3) To examine to what extent satisfaction with TDM was related to perceived role or medical and sociodemographic variables. METHODS: Patients (n=126) were recruited in hospitals and from the Dutch PC patient organization. The relationship between patients' role and stage of disease, treatment modality, age, social status and education was determined, as well as patients' satisfaction with TDM. RESULTS: Most patients felt they had participated in TDM (autonomous 18%, collaborative 60%). Older patients and those with advanced disease more frequently reported not having been involved in decision making. Satisfaction with TDM was related to age and role in TDM but not to stage of disease or treatment modality. Younger men were least content when they had not been involved in decision making. CONCLUSION: Patients' level of participation and satisfaction with TDM appears to be related to medical and sociodemographic variables. PRACTICE IMPLICATIONS: Satisfaction with TDM may be related to patients' age and assumed role. It is recommended to take this into account when planning treatment for prostate cancer patients.     

Physician-older patient communication about cancer

Cancer is frequently a disease of older individuals. Communication between physicians and older patients about cancer prevention, screening, diagnosis, treatment and care is complicated by a variety of factors including patients' beliefs, perceptions, and knowledge about cancer. In addition, other older patient factors such as possible sensory deficits, cognitive impairment, functional limitations and accompaniment by significant others to the medical encounter influence communication. Physicians' attitudes about aging may also affect recommendations for cancer screening, treatment regiments and care of older cancer patients. To understand communication as a complex, multidimensional human enterprise requires knowledge of older patients' lived experience of cancer and their need for honest and compassionate care. Research findings on physician-older patient communication about cancer need to be translated into medical education, training and practice to improve the care of the older cancer patient.     

Immunoperoxidase detection of polycyclic aromatic hydrocarbon-DNA adducts in mouth floor and buccal mucosa cells of smokers and nonsmokers

Tobacco smoking is a major risk factor for oral cancer; mouth floor and buccal mucosa are among the most and least cancer-prone subsites, respectively, in the oral cavity. We investigated the applicability of immunohistochemistry of smoking-induced DNA adducts in oral cells for assessing the exposure to carcinogens, and estimating the risk for oral cancer. Polycyclic aromatic hydrocarbon (PAH)-DNA adducts were measured in mouth floor and buccal mucosa cells of smokers (n = 26) and nonsmokers (n = 22) by means of a semiquantitative immunoperoxidase assay. Smokers had elevated levels of PAH-DNA adducts compared to nonsmokers in their mouth floor cells (0.045 +/- 0.022 versus 0.022 +/- 0.016, P = 0.0008 arbitrary units of immunohistochemistry) as well as in their buccal mucosa cells (0.058 +/- 0.028 versus 0.028 +/- 0.012, P = 0.001). Also, there was a correlation between the levels of PAH-DNA adducts in mouth floor cells and those in buccal mucosa cells (r = 0.4, P = 0.01). Furthermore, PAH-DNA adduct levels in both mouth floor and buccal mucosa cells were significantly related to current smoking indices (amount of tar and number of cigarettes consumed per day). Expectedly, the levels of PAH-DNA adducts neither in mouth floor cells nor in buccal mucosa cells, both being short-lived cells, were related to smoking history index (pack years). The levels of PAH-DNA adducts, however, in mouth floor cells as the cancer prone cells were lower than those in buccal mucosa cells (0.037 +/- 0.023 versus 0.044 +/- 0.026, P = 0.04). We conclude that immunohistochemistry of PAH-DNA adducts in oral cells can be used for exposure assessment of tobacco-related carcinogens, however, it cannot be used for oral cancer risk estimation.     

Oral tegafur-uracil plus folinic acid versus intravenous 5-fluorouracil plus folinic acid as adjuvant chemotherapy of colon cancer

To compare, in terms of compliance, toxicity, quality of life (QOL) and efficacy, intravenous 5-fluorouracil plus folinic acid with oral tegafur-uracil plus folinic acid as postoperative adjuvant chemotherapy after curative resection in patients with Dukes' stage B2 and C2 colon cancer. Among all patients with adenocarcinoma of the colon operated on between July 1997 and June 1999, 122 with Dukes' stage B2 or C2 colon cancer were enrolled in this study. Fifty-three patients were treated with intravenous 5-fluorouracil plus folinic acid (5-FU group) and 69 with oral tegafur-uracil plus folinic acid (UFT group). Compliance, toxicity, QOL and efficacy were evaluated. Compared with the 5-FU group, patients in the UFT group experienced a lower incidence of grade 1 toxicity. The incidences of grade 2-4 toxicity were similar in the two treatment groups. However, severe toxicity (grade 3 or 4) was rare in both groups. A steady and significant increase of the QOL score, both during and after therapy, was evident in both groups suggesting that chemotherapy is quite tolerable and does not deteriorate the patients' QOL. At the median follow-up duration of 28 months, the survival rate and disease free survival rate for the UFT and 5-FU groups were 94.9% vs. 92.5% and 87.5% vs. 84.1%, respectively (p > 0.05). These data suggest that oral tegafur-uracil modulated with oral folinic acid as an adjuvant chemotherapy in patients with Dukes' stage B2 and C2 colon cancer may be a good alternative to infusional 5- fluorouracil.     

An approach to measuring the quality of breast cancer decisions

OBJECTIVE: To explore an approach to measuring the quality of decisions made in the treatment of early stage breast cancer, focusing on patients' decision-specific knowledge and the concordance between patients' stated preferences for treatment outcomes and treatment received. METHODS: Candidate knowledge and value items were identified after an extensive review of the published literature as well as reports on 27 focus groups and 46 individual interviews with breast cancer survivors. Items were subjected to cognitive interviews with six additional patients. A preliminary decision quality measure consisting of five knowledge items and four value items was pilot tested with 35 breast cancer survivors who also completed the control preferences scale and the decisional conflict scale (DCS). RESULTS: Preference for control and knowledge did not vary by treatment. The mean of the participants' knowledge scores was 54%. There was no correlation between the knowledge scores and the informed subscale of the DCS (Pearson r = .152, n = 32, p = 0.408). Patients who preferred to keep their breast were over five times as likely to have breast-conserving surgery than those who did not (OR 5.33, 95% CI (1.2, 24.5), p = 0.06). Patients who wanted to avoid radiation were six times as likely to choose mastectomy than those who did not (OR 6.4, 95% CI (1.34, 30.61), p = 0.04). CONCLUSION: Measuring decision quality by assessing patients' decision-specific knowledge and concordance between their values and treatment received, is feasible and important. Further work is necessary to overcome the methodological challenges identified in this pilot work. PRACTICE IMPLICATIONS: Guidelines for early stage breast cancer emphasize the importance of including patients' preferences in decisions about treatment. The ability of doctors and patients to make decisions that reflect the considered preferences of well-informed patients can and should be measured.     

Are otolaryngologists specialist for pollinosis?]

It is approved that ENT doctors are specialist for pollinosis. Is it true from the point of view of patients' medical care-seeking behavior? 214 patients with Japanese cedar pollinosis who had visited medical doctors in 2003 pollen-season were randomly sampled from 603 pollinosis patients registered at a disease survey company and we mailed self-evaluation questionnaire on patients' medical care-seeking behavior on the end of pollen season in 2004. Response rate was 65.3%. Patients visited clinics in approximately 90% more than hospitals. They selected ENT in 43.9% and general physicians in 31.1%. Their selections were based on others than their specialty such as easy access and previous experience of visit, because pollinosis is not serious disease like cancer. ENT doctors treated the patients by combination of two kinds of tablet or topical steroid with tablet, while general physicians did with single kind of tablet. The patient satisfaction, and its related questions including preference, wish to revisit in next year and recommendation to their friend were not different in treatment between ENT and general physician. Doctors' attitude, and communication with patients were the most important factor for patient satisfaction as well as treatment out-come. In conclusion, patients prefer agreeable and convenient treatment. If ENT doctors still want to be specialist for pollinosis, they should take care patients well and develop their own specific treatment methodology to cure this disease.     

Dental Expression and Role in Palliative Treatment

World Health Organization defines palliative care as the active total care of patients whose disease is not responding to curative treatment. Palliative care for the terminally ill is based on a multidimensional approach to provide whole-person comfort care while maintaining optimal function; dental care plays an important role in this multidisciplinary approach. The aim of the present study is to review significance of dentist''s role to determine whether mouth care was effectively assessed and implemented in the palliative care setting. The oral problems experienced by the hospice head and neck patient clearly affect the quality of his or her remaining life. Dentist plays an essential role in palliative care by the maintenance of oral hygiene; dental examination may identify and cure opportunistic infections and dental disease like caries, periodontal disease, oral mucosal problems or prosthetic requirement. Oral care may reduce not only the microbial load of the mouth but the risk for pain and oral infection as well. This multidisciplinary approach to palliative care, including a dentist, may reduce the oral debilities that influence the patient''s ability to speak, eat or swallow. This review highlighted that without effective assessment of the mouth, the appropriate implementation of care will not be delivered. Palliative dental care has been fundamental in management of patients with active, progressive, far-advanced disease in which the oral cavity has been compromised either by the disease directly or by its treatment; the focus of care is quality of life.     

The role of illness beliefs, treatment beliefs, and perceived severity of symptoms in explaining distress in cancer patients during chemotherapy treatment

The authors investigated cancer patients' interpretations of their physical symptoms and their illness beliefs with the objective of establishing the importance of these variables in predicting distress during chemotherapy treatment. Past researchers have suggested that causal attributions of physical symptoms and beliefs about illness progression and its consequences may serve as important mediators between number and perceived severity of symptoms and psychological adjustment in cancer patients during the treatment phase. Our aim in this study was to further these findings using the Self-Regulation Model as a theoretical framework. The study was cross-sectional in design, testing 72 patients with cancer receiving intravenous chemotherapy as outpatients in the United Kingdom. The participants completed questionnaires measuring number and perceived severity of symptoms, the causal attributions of these, illness and treatment beliefs, anxiety, and depression. The results showed that consequence beliefs serve as important mediators between number of symptoms and distress, explaining 15% of the variance in anxious mood and 5% of the variance in depressed mood. The authors found perceived severity of symptoms to be an independent predictor of anxious mood, explaining 7% of the variance. Its role in predicting depressed mood was not significant.