Prostate cancer presenting with normal serum PSA levels and boney metastases treated with zoledronic acid

Prostate specific antigen (PSA) is currently the most widely used tumor marker for diagnosing and monitoring prostate cancer. Serum PSA level greater than 10 ng/mL is considered a negative predictor for the presence of bone metastases and routine use of bone scans is therefore avoided. This report describes two cases of patients presenting with normal PSA levels (0-4 ng/ mL) and positive bone scans. The value of routine use of bone scintigraphy in the follow up of these cases is therefore questioned here. Moreover the addition of bisphosphonates to the androgen deprivation treatment, achieved not only pain relief and improvement in aspects of quality of life, but also provided radiographic evidence of management of metastatic bone disease.     

A Greek perspective on concepts of death and expression of grief, with implications for practice

Death has been conceptualised in different ways by different cultures and civilizations. It is increasingly entering into the public consciousness and society is now more ready to discuss and lessen the fear of dying and grief than it has been in the past few decades. In Greece, by Classical times there was an increase in burial rituals and commemorative practices compared to earlier periods. When Christianity was introduced into Greece it attempted to change the way the dead were mourned, preaching immortality of the soul and resurrection of the dead. Nevertheless, the way people grieve and bury their dead in Greece has not changed greatly since before the introduction of Christianity, except for the difficulty experienced in witnessing burial procedures observed in the large cities. Burial and bereavement traditions were introduced to help Greeks cope with death and bereavement. In Greece today beliefs about grief and death are based both on the ancient and the Christian Orthodox traditions. Healthcare professionals need to develop cultural competence to improve nursing and future health care. If care is culturally informed and tailored its quality is improved.     

Survival of vascular access during daily and three times a week hemodialysis

AIM: A major cause of morbidity for hemodialysis patients is vascular access failure and/or occlusion. It is commonly believed that an increased frequency of dialysis sessions, among other factors, might lead to a higher rate of fistula complications. MATERIALS AND METHODS: To evaluate if patients on daily hemodialysis carry a higher risk of vascular access occlusion, we examined the incidence rate of access occlusion and the survival function of native vascular accesses in patients undergoing daily dialysis (DD; n = 24) as compared to patients on standard three times a week hemodialysis (TWD; n = 124). RESULTS: The mean follow-up time was 3.6 years. In the TWD group 42 patients had a first-access closure, whereas only 2 patients out 24 had a similar event in the DD group. The proportion of first-access closure was 33.9% for TWD and 8.3% for DD (p < 0.01). The incidence rate was 9.8 (95% CI: 7.2 -13.2) and 2.2 (95% CI: 0.4 - 7.1) events per 100 patient-years for TWD and DD, respectively. The rate difference was 7.6 (95% CI 3.4 - 11.9) events per 100 patient-years, and the unadjusted risk ratio was 4.5 (95% CI: 1.2 - 16.9; p < 0.01). The mean vascular access survival before closure was 3.3 years in TWD and 3.7 years in DD. Survival curves, obtained considering the first-access closure as the endpoint, showed a significant difference between DD and TWD (log-rank 5.16; p < 0.05). In a Cox-proportional hazard model the relative risk (RR) of vascular-access closure in TWD remained significant (RR = 4.3; 95% CI 1.1 - 18.2) after adjustment for age. CONCLUSION: The results of this observational study, conducted on a limited number of DD patients, suggest that daily dialysis might not have an adverse prognostic significance for access closure.     

The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya

Introduction

Understanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient- and facility-level determinants of time to ART initiation among patients who initiated ART in Kenya.

Methods

We collected facility-level information and conducted a retrospective chart review of adults initiating ART between 2007 and 2012 at 51 health facilities in Kenya. We evaluated the association between patient- and facility-level covariates at the time of ART eligibility and time to ART initiation. We also explored the determinants associated with timeliness of ART initiation.

Results

The analysis included 11,942 patients. The median age at the time eligibility was first determined was 37 years (interquartile range [IQR] 31–45). Overall, 75% of patients initiated ART within two months of eligibility. The median CD4 cell count at the time eligibility was first determined rose from 132 (IQR 51–217) in 2007 to 195 (IQR 91–286) in 2011 to 2012 (p<0.001). The cumulative probability of ART initiation among treatment-eligible patients increased over time: 87.1% (95% confidence interval [CI] 85.1–89.0%) in 2007; 96.8% (96.0–97.5%) in 2008; 97.1% (96.3–97.7%) in 2009; 98.5% (98.0 −98.9%) in 2010; and 99.7% (95% CI 99.4 −99.8%) in 2011 to 2012 (p<0.0001). In multivariate analyses, attending a health facility with high ART patient volumes within two months of eligibility was considered the key facility-level determinant of ART initiation (adjusted odds ratio 0.57, 95% CI 0.45–0.72, p<0.001). Patient-level determinants included being eligible for ART in the years subsequent to 2007, advanced World Health Organization clinical stage and low CD4 cell count at the time eligibility was first determined.

Conclusions

Overall, the time between treatment eligibility and ART initiation decreased substantially in Kenya between 2007 and 2012, with uniform gains across different types of health facilities. Our findings highlight the slow increase in CD4 cell counts at the time of ART eligibility over time, indicating that a large number of patients are still beginning ART with advanced HIV disease. Our findings also support the decentralisation of ART services at all health facilities that have the capacity to initiate treatment. Continued evaluation of programme- and country-level data is needed to monitor timeliness of ART initiation as countries continue to expand treatment access.     

Silicone rubber fossa implant removal via partial arthrotomy followed by arthroscopic examination of the internal surface of the fibrous capsule

Thirteen temporomandibular joints were examined arthroscopically for evaluation for fibrous encapsulation of silicone elastomer disk replacement implants. Partial arthrotomies were performed with removal of silicone rubber implants, followed by arthroscopic examination of the internal surfaces of the fibrous capsule as a pseudodisk and to verify the continuity of the fibrous barrier between the condyle and the fossa.     

Prognostic value of 24-hour ambulatory blood pressure monitoring and of night/day ratio in nondiabetic, cardiovascular events-free hemodialysis patients

BACKGROUND: The use of 24-hour ambulatory blood pressure monitoring is increasing in end-stage renal disease (ESRD) patients but the prediction power for cardiovascular complications of time-averaged ambulatory blood pressure components has been little investigated in these patients. METHODS: We analyzed the prognostic power of 24-hour ambulatory blood pressure monitoring for all-cause and cardiovascular mortality in 168 nondiabetic, events-free hemodialysis patients selected from a total dialysis population of about 450 patients. RESULTS: During the follow-up period (38 +/- 22 months), 48 patients died, 29 of them of cardiovascular causes. On univariate Cox regression analyses, the night/day systolic ratio resulted to be the sole blood pressure indicator to be associated with all-cause and cardiovascular mortality while left ventricular hypertrophy (LVH) was a strong predictor of these outcomes. In multivariable Cox models not including LVH, the night/day systolic ratio maintained an independent prognostic value for incident outcomes. However, when both risk factors, LVH and night/day systolic ratio, were introduced into Cox models, LVH was no longer a significant predictor while the night/day systolic ratio became a predictor of marginal statistical significance. CONCLUSION: The night/day ratio emerges as the sole ambulatory blood pressure monitoring-derived indicator providing significant prognostic information in patients with ESRD. However, this indicator as well as LVH loses substantial prediction power in statistical models including both risk factors. The results suggest that the night/day systolic ratio and LVH provide overlapping prognostic information, a phenomenon in keeping with the hypothesis that they represent a common pathway leading to adverse outcomes in ESRD.     

Cancer information disclosure in different cultural contexts

The relationship between truth telling and culture has been the subject of increasing attention in the literature. The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached differently depending on country and culture. The majority of physicians tell the truth more often today than in the past, in both developed and developing countries, but most of them prefer to disclose the truth to the next of kin. Nurses in Anglo-Saxon countries are considered to be the most suitable health-care professionals for the patients to share their thoughts and feelings with. Nevertheless, in most other cultures the final decision on information disclosure lies with the treating physician. Regardless of cultural origin, the diagnosis of cancer affects both family structure and family dynamics. In most cases patients families, in an effort to protect them from despair and a feeling of hopelessness, exclude the patient from the process of information exchange. The health-care team–patient relationship is a triangle consisting of the health-care professional, the patient and the family. Each part supports the other two and is affected by the cultural background of each of the others as well as the changes that occur within the triangle.     

Pentazocine with rectal diclofenac versus pentazocine alone for pain relief following caesarean delivery in Enugu,Nigeria: A randomized controlled trial

ObjectiveTo measure postoperative pain relief following the use of rectal diclofenac combined with intramuscular pentazocine compared with intramuscular pentazocine alone in patients undergoing a caesarean delivery.MethodsThis single-blind randomized controlled trial enrolled pregnant women that had a caesarean section at the Enugu State University of Science and Technology Teaching Hospital, Enugu, Nigeria. Study participants were randomized to receive either 100 mg of rectal diclofenac given every 12 h plus 30 mg of intramuscular pentazocine given every 6 h (group A) or 60 mg of intramuscular pentazocine given every 6 h (group B). The primary outcome was the level of pain as measured using a visual analogue scale. The secondary outcomes were the level of satisfaction with pain relief and need for rescue analgesia.ResultsA total of 200 participants were randomized equally into the two groups. Participants in group A had significantly better pain control and satisfaction over the 48 h after surgery compared with group B. Significantly more of group B required rescue analgesia for breakthrough pain compared with group A.ConclusionRectal diclofenac combined with intramuscular pentazocine was significantly better at controlling pain compared with pentazocine alone in the first 48 h following caesarean section.Trial registration number: PACTR202107706925314 at www.pactr.org on 28 July 2021.