Working With Parents Through a Devastating Experience-The Birth of a Mongoloid Child

The author believes that professional advice given the parents of a mongoloid infant determines their initial decision on institutionalization. Multidisciplinary counseling by the health team can help parents decide on a course of action that will prove satisfactory in the long run. Consultation should include health t e r n efforts to help parents work through the mourning process and presentation of a) an objective, comprehensive view of the child's condition, b) information on integrating a mongoloid into the family unit, and c) outside resources available to the parents. Deliberation with the parents to help them reach their own decision is essential.     

What survival benefits do premenopausal patients with early breast cancer need to make endocrine therapy worthwhile?

BACKGROUND: Adjuvant endocrine therapies such as tamoxifen, goserelin, and oophorectomy improve survival for premenopausal women diagnosed with early-stage breast cancer. However, these treatments often result in menopausal symptoms, sexual dysfunction, permanent infertility, or the need to delay pregnancy. We aimed to quantify the survival gains that premenopausal patients with early-stage breast cancer require to justify the side-effects and inconvenience of adjuvant endocrine treatments. METHODS: Participants consisted of 102 women who had been diagnosed with early-stage (stage I-II) breast cancer 6-60 months previously, who were aged 40 years or younger at diagnosis, and who had been treated for a minimum of 3 months with endocrine therapy (67 with tamoxifen alone, seven with goserelin alone, and 28 with tamoxifen and goserelin or oophorectomy). 76 patients also received chemotherapy, and 75 received radiotherapy. Participants attended a face-to-face patient-preference interview, in which they were presented with four hypothetical clinical scenarios that were used to quantify the gains in survival rate and life expectancy that women judged necessary to make their endocrine therapy worthwhile. They also completed a questionnaire on standard psychological measures. FINDINGS: About half of participants thought that adjuvant endocrine therapy was worthwhile for an absolute gain in survival of 2% from a baseline of either 65% or 85%, and for a gain in life expectancy of 3 months from a baseline of 5 years and of 6 months for a baseline of 15 years. Women who had had more severe endocrine side-effects required larger gains to make endocrine therapy worthwhile (univariate p=0.02, multivariate p=0.04). INTERPRETATION: Modest gains in survival are sufficient to make adjuvant endocrine treatment worthwhile for premenopausal women with early-stage breast cancer. Knowing and incorporating what women think should enhance shared decision-making.     

Population pharmacokinetic estimation of tacrolimus apparent clearance in adult liver transplant recipients

The goal was to study the factors affecting tacrolimus apparent clearance (CL/F) in adult liver transplant recipients. Tacrolimus dose and concentration data (n = 694) were obtained from 67 liver transplant recipients (22 female and 45 male), and the data were analyzed using a nonlinear mixed-effect modeling (NONMEM) method. A 1-compartment pharmacokinetic model with first-order elimination, an absorption rate constant fixed at 4.5 hours, and first-order conditional estimation was used to describe tacrolimus disposition. The predictive performance of the final model was evaluated using data splitting and assessing bias and precision of the estimates. The population estimate of tacrolimus CL/F and apparent volume of distribution (V/F) were found to be 21.3 L/h (95% confidence interval, CI, 18.0-24.6 L/h) and 316.1 L (95% CI 133-495 L), respectively. Neither patient's age, weight, gender, nor markers of liver function influenced tacrolimus CL/F. The final model was TVCL = 21.3 + 9.8 x (1 - HEM) + 3.4 x (1 - ALB) - 2.1 x (1 - DIL) - 7.4 x (1 - FLU), where TVCL, typical estimate of apparent clearance, HEM = 0 if hematocrit <35%, otherwise 1; ALB = 0 if albumin <3.5 g/dL, otherwise 1; DIL = 0 if diltiazem is coadministered, otherwise 1; FLU = 0 if fluconazole is coadministered, otherwise 1. This study identified the factors that significantly affect tacrolimus disposition in adult liver transplant recipients during the early posttransplantation period. This information will be helpful to clinicians for dose individualization of tacrolimus in liver transplant recipients with different clinical conditions including anemia or hypoalbuminemia or in those patients receiving diltiazem or fluconazole.     

Difficulties in Immunohaematology : The Weak D Antigen

Background

The Rh blood system is one of the most polymorphic and immunogenic systems known to humans. The expression of Rh blood group antigen is complex. The Rh D antigen is the most important of the antigens that constitute the Rh antigen system. In most cases, D antigen can easily be detected. However, due to variability of expression, weak forms antigen are encountered. The reactivity of weak D with antisera is variable and presents as a problem in blood banking.

Methods

A retrospective analysis for a five-year period was done. Blood samples that were negative for Rh D by immediate spin tube method were tested for weak D antigen by additional lab tests.

Result

Of 34932 serial Rh grouping tests done in our Blood Bank, the incidence of weak D Rh antigen was 0.189%. All these were confirmed by the antiglobulin test.

Conclusion

These patients present as a problem for the blood banker and a curiosity to the clinician. Although uncommon, all health care workers should be aware of this entity to avoid anti D alloimmunisation.Key Words: Weak D, Rh Blood Group     

Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617]

Background  

Acute low back pain is a common condition resulting in pain and disability. Current national and international guidelines advocate general practitioner care including advice and paracetamol (4 g daily in otherwise well adults) as the first line of care for people with acute low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulative therapy (SMT) are advocated in many guidelines as second line management options for patients with acute low back pain who are not recovering. No studies have explored the role of NSAIDs and/or SMT in addition to first line management for acute low back pain. The primary aim of this study is to investigate if NSAIDs and/or SMT in addition to general practitioner advice and paracetamol results in shorter recovery times for patients with acute low back pain. The secondary aims of the study are to evaluate whether the addition of SMT and/or NSAIDs influences pain, disability and global perceived effect at 1, 2, 4 and 12 weeks after onset of therapy for patients with significant acute low back pain.     

The effect of selenium on thyroid status in a population with marginal selenium and iodine status

The effects of Se on thyroid metabolism in a New Zealand population are investigated, including (a) the relationship between Se and thyroid status, and (b) the effect of Se supplementation on thyroid status. The data used come from two cross-sectional studies of Se, I, thyroid hormones and thyroid volume (studies 1 and 4), and three Se intervention studies in which thyroid hormones, Se and glutathione peroxidase (GPx) activities were measured (studies 2, 3 and 5). There were no significant correlations between Se status and measures of thyroid status after controlling for sex at baseline or after supplementation in any of the studies. When data from study 4 were divided into two groups according to plasma Se, plasma thyroxine (T4) was lower in males with higher plasma Se levels (P=0.009). Se supplementation increased plasma Se and GPx activity, but produced only small changes in plasma T4 and triiodothyronine (T3):T4 ratio. In study 2, there was a significant reduction in plasma T4 (P=0.0045). In studies 3 and 5 there were small decreases in plasma T4 and a small increase in the T3:T4 ratio, which were not significantly different from placebo groups. Lack of significant associations between plasma Se and thyroid status, and only small changes in T4 suggest that Se status in New Zealand is close to adequate for the optimal function of deiodinases. Adequate plasma Se may be approximately 0.82-0.90 micromol/l, compared with 1.00-1.14 micromol/l for maximal GPx activities.     

Exploring medical students' attitudes towards peer physical examination

With opportunities for dissection and examination of sick patients decreasing, the role of peer physical examination (PPE) is increasing. This study explores students' attitudes towards PPE and the relationship between attitudes and demographics. A total of 129 first-year medical students from the Peninsula Medical School completed the Examining Fellow Students (EFS) questionnaire. At least 97% of students were comfortable participating in PPE of all body parts except breast and inguinal regions. Over 20% of students were unwilling to participate in PPE of the breast and inguinal regions. Students were more comfortable with PPE within gender than across gender. Females were more likely to be uncomfortable with PPE. Further research with larger sample sizes is required to determine whether attitudes are related to age and religious faith.