'BREAKS' Protocol for Breaking Bad News

Information that drastically alters the life world of the patient is termed as bad news. Conveying bad news is a skilled communication, and not at all easy. The amount of truth to be disclosed is subjective. A properly structured and well-orchestrated communication has a positive therapeutic effect. This is a process of negotiation between patient and physician, but physicians often find it difficult due to many reasons. They feel incompetent and are afraid of unleashing a negative reaction from the patient or their relatives. The physician is reminded of his or her own vulnerability to terminal illness, and find themselves powerless over emotional distress. Lack of sufficient training in breaking bad news is a handicap to most physicians and health care workers. Adherence to the principles of client-centered counseling is helpful in attaining this skill. Fundamental insight of the patient is exploited and the bad news is delivered in a structured manner, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward. Six-step SPIKES protocol is widely used for breaking bad news. In this paper, we put forward another six-step protocol, the BREAKS protocol as a systematic and easy communication strategy for breaking bad news. Development of competence in dealing with difficult situations has positive therapeutic outcome and is a professionally satisfying one.     

An ecosystem service perspective on urban nature,physical activity,and health

Nature underpins human well-being in critical ways, especially in health. Nature provides pollination of nutritious crops, purification of drinking water, protection from floods, and climate security, among other well-studied health benefits. A crucial, yet challenging, research frontier is clarifying how nature promotes physical activity for its many mental and physical health benefits, particularly in densely populated cities with scarce and dwindling access to nature. Here we frame this frontier by conceptually developing a spatial decision-support tool that shows where, how, and for whom urban nature promotes physical activity, to inform urban greening efforts and broader health assessments. We synthesize what is known, present a model framework, and detail the model steps and data needs that can yield generalizable spatial models and an effective tool for assessing the urban nature–physical activity relationship. Current knowledge supports an initial model that can distinguish broad trends and enrich urban planning, spatial policy, and public health decisions. New, iterative research and application will reveal the importance of different types of urban nature, the different subpopulations who will benefit from it, and nature’s potential contribution to creating more equitable, green, livable cities with active inhabitants.     

Profile of hypopituitarism in a tertiary care hospital of eastern India--is quality of life different in patients with growth hormone deficiency?

Hypopituitarism is of diverse aetiology. Apart from pituitary adenoma and Sheehan's syndrome, snakebite is a common aetiology of hypopituitarism. A total of 82 patients of hypopituitarism were studied. Biochemical and radiological investigations were done in all the cases. A quality of life questionnaire was put among the patients. Scores were calculated from the answers of the questionnaire and they were assessed about quality of life. Though growth hormone deficiency is associated with poor quality of life there were no significant differences with patients with hypopituitarism without any growth hormone deficiency.     

Prevalence and associated risk factors of Giardia duodenalis infection among school-going children in Nepal

Parasitology Research - This study aimed to determine the prevalence of intestinal parasites and its associated risk factors among school-going children in Kathmandu, Nepal. Between August and...     

Mature cystic teratoma of the temporal lobe: A rare tumor with an unusual location

Intracranial mature cystic teratoma is rare. The temporal lobe is a very unusual location and can pose a considerable diagnostic challenge. Proper histological diagnosis and long‐term follow‐up are imperative.     

Effect of intraocular lens asphericity on posterior capsule opacification between two intraocular lenses with same acrylic material: a fellow‐eye study

Purpose: To evaluate intra‐individual differences in posterior capsule opacification (PCO) and visual performance between spherical AcrySof SN60AT and an aspheric AcrySof SN60WF intraocular lens (IOL) with a posterior aspheric surface, both of which are made of same hydrophobic acrylic material. Setting: Ophthalmology Department, St Thomas’ Hospital, London, UK. Methods: In this prospective randomized, fellow‐eye comparison, an aspheric IOL, which is 9% thinner in comparison with the spherical IOL, was randomized to the first eye of 47 patients and fellow‐eye surgery was performed within 3 weeks. Follow‐up was at 1, 3, 6, 12 and 24 months. Corrected logMAR visual acuity (CDVA) was measured at 100% and 9% contrast. After pupil dilation, digital retroillumination photographs were taken and the mean PCO percentage was calculated using poco software at each follow‐up visit. Results: At 1, 3, 6, 12 and 24 months, 47 (94 eyes), 44 (88 eyes), 42 (84 eyes) and 41 (82 eyes) patients were followed‐up respectively. Hundred per cent and 9% of LogMAR CDVA was not significantly different between the two IOLs (p = NS at all time‐points). Percentage area PCO scores (mean ± SD) at 1, 3, 6, 12 and 24 months with the spherical IOL was 5.82 ± 9.89, 7.76 ± 16.83, 7.21 ± 12.46, 9.29 ± 18.25 and 14.39 ± 25.42, respectively, and with an aspheric IOL was 8.91 ± 12.79, 5.97 ± 10.32, 5.15 ± 7.92, 7.68 ± 11.18 and 12.18 ± 20.10, respectively (p = NS at all time‐points). Conclusions: Posterior capsule opacification was not significantly different between the spheric and aspheric IOLs in this fellow‐eye, randomized comparison. Additional asphericity on the existing model of IOL does not influence PCO performance.     

First jejunal artery,an alternative graft for right hepatic artery reconstruction

Common bile duct cancer invading right hepatic artery is sometimes diagnosed intraoperatively. Excision andsafe reconstruction of the artery with suitable graft is essential. Arterial reconstruction with autologous saphenous vein graft is the preferred method practiced routinely. However the right hepatic artery reconstruction has also been carried out with several other vessels like gastroduodenal artery, right gastroepiploic artery or the splenic artery. We report a case of 63-year-old man presenting with history of progressive jaundice, pruritus and impaired appetite. Following various imaging modalities including computed tomography, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, intraductal ultrasound extrahepatic bile duct cancer was diagnosed; however, none of those detected vessel invasion. Intraoperatively, right hepatic artery invasion was revealed. Right hepatic artery was resected and reconstructed with a graft harvested from the first jejunal artery(JA). Postoperative outcome was satisfactory with a long-term graft patency. First JA can be a reliable graft option for right hepatic artery reconstruction.     

Midterm results of the Ross procedure

Objective: The lack of durable bioprosthetic valves and the inherent risks associated with anticoagulation for mechanical valves have led to the continued use of the Ross procedure, particularly in the pediatric population. Methods: We have reviewed our mid-term results retrospectively, following the Ross operation in both pediatric and adult groups. Results: Over a 11-year period from August 1991 to August 2002, 60 patients underwent the Ross procedure. The median age was 15 years (6–804 months), of which 63% were males and 55% were under the age of 20 years. The main indications were: aortic stenosis in 47 patients; aortic insufficiency in 6 patients; and mixed aortic valve disease in 28 patients. Fifteen patients had previously undergone balloon dilatation of the aortic valve, 4 had open valvotomy and 3 had both valvuloplasty procedures. The pulmonary autograft was implanted as a sub-coronary implant until 1995 (30%) after which time it was implanted using a partial inclusion cylinder technique (70%). There have been no deaths reported in this series. Over a median follow-up period of 59 months (2–122 months), there have been four re-operations for repair of autograft leak, and 2 adult patients have had autograft replacements. Conclusions: Despite the increased technical complexity, the Ross procedure can be performed safely in both paediatric and adult populations with satisfactory medium term results.     

Adenovirus-mediated expression of p33ING1b induces apoptosis and inhibits proliferation in gastric adenocarcinoma cells in vitro

Background

Inhibitor of growth 1b (ING1b) is considered to be a class II tumor suppressor gene. Although reduced expression of p33^ING1b has been reported in many human malignancies, including gastric cancers, the effect of p33^ING1b on gastric cancer cells has yet to be investigated.

Methods

Expression of p33^ING1b in gastric adenocarcinoma tissues and their adjacent non-malignant gastric mucosa, as well as in gastric adenocarcinoma cell lines and normal gastric epithelial cells, was detected by using Western blotting. Recombinant adenoviruses were prepared to mediate the ectopic expression of p33^ING1b (Ad-ING1b) and green fluorescent protein (GFP)(Ad-GFP) in the gastric adenocarcinoma cell lines, SGC-7901, MKN28, and MKN45 and the normal gastric epithelial cell line GES-1. Alterations in the proliferation and apoptosis of the cells after adenoviral infection were determined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry, respectively, and cell cycle distribution was analyzed in a fluorescence-activated cell sorter.

Results

Western blotting confirmed the reduced expression of p33^ING1b in gastric adenocarcinoma tissues and gastric adenocarcinoma cell lines. The ectopic expression of p33^ING1b mediated by Ad-ING1b resulted in decreased growth, increased apoptosis, and cell cycle arrest at the G1 phase in both benign and malignant gastric epithelial cells regardless of their p53 status. Addition of a p53 inhibitor, pifithrin-α, did not abolish the pro-apoptotic and cell cycle-arresting effects of p33^ING1b in p53 wild-type cells.

Conclusions

Down-regulation of p33^ING1b might play an important role in the development of gastric adenocarcinoma. Targeted local expression of p33^ING1b may offer a promising alternative therapeutic measure for gastric cancer.