Radiation-induced osteosarcoma of the chest wall

A case of radiation-induced sarcoma of the chest wall is reported. Twenty-seven years 11 months after orthovoltage radiotherapy of the right breast a 69-year-old woman developed a radiation-induced osteosarcoma of the right thoracic wall. Initial diagnosis has been T-cell lymphoma of the skin. The right breast was irradiated with tangential fields and a total dose of 40 Gy, 2 Gy/day, 5 days a week. Orthovoltage treatment was performed in two courses of 20 Gy, 3 months apart. The clinical appearance of the secondary sarcoma was a diffuse infiltrated area in the irradiated breast which seemed to be fixed to the chest wall. Magnetic resonance imaging (MRI) demonstrated a mass in the right anterior thoracic wall which destroyed the fourth to the sixth rib. The tumor infiltrated the thoracic wall, including subcutaneous tissue and pericardium, as well as extending into the subphrenic space. Biopsy of the lesion revealed a poorly differentiated osteosarcoma. The patient's general condition precluded surgical or chemotherapeutic intervention; she died due to a cerebral stroke 6 months later. This case fulfilled all criteria for radiation-induced sarcoma, as there was a prior history of radiotherapy, latency period of several years, development of sarcoma within the irradiated field, and histologic confirmation of sarcoma.     

Dental fluorosis in schoolchildren in a county in the mountainous region of Rio Grande do Sul State, Brazil

The aim of the present study was to determine the prevalence and severity of dental fluorosis in all schoolchildren (ages 4 to 18 years, n = 259) from the town of Santa Tereza, Rio Grande do Sul, Brazil, and to investigate associated factors. Data were obtained through a questionnaire and by means of clinical tests. Dean's index was used to determine fluorosis occurrence. Prevalence of fluorosis was 63.7%. The predominant category was very mild (43.6%), followed by mild (12.0%), moderate (7.7%), borderline (7.3%), and severe (0.4%). Approximately 85.0% of the schoolchildren currently have, or have had, access to other topical sources of fluoride. Significant associations were found between place of residence and previous or ongoing fluoride mouth rinsing and prevalence and severity of fluorosis (p < 0.05). There was also a significant association between dental fluorosis and parents' level of schooling, frequency of brushing teeth, fluoride rinsing, and use of fluoride gel (p < 0.05).     

Chronic osteomyelitis in children: Shriners Hospital Honolulu experience

Chronic osteomyelitis incidence and severity in 55 hospitalized Pacific Island children between 1990 and 2002 were compared with the expected incidence and reports in the literature. Of these 55 cases, 87% were from Polynesia/Micronesia. The average length of hospital stay was 104 days. Staphylococcus aureus was cultured in 64% of the cases with 43% of those being methicillin resistant S. aureus. A total of 111 bones were involved. Average antibiotic treatment was 135 days. Each case required an average of 1.3 irrigations/debridements and 45% required a sequestrectomy. Ninety-two percent had elevated erythrocyte sedimentation rate on admission. Sixty-nine percent of the cases involved metaphyseal, diaphyseal and epiphyseal segments of the bone and 29% were multifocal. Results indicate that Pacific Island children have a higher incidence and increased severity of osteomyelitis when compared with non-Pacific Island children in the literature, requiring a high suspicion for multifocal osteomyelitis, extensive bone involvement, S. aureus positive cultures and a longer period of antibiotic treatment.     

Psychometric evaluation of the cultural competence assessment instrument among healthcare providers

BACKGROUND: The relevance of healthcare provider cultural competency to the achievement of goals for reduction in extant health disparities has been demonstrated; however, there are deficits with regard to cultural competency measurement. OBJECTIVES: To examine the test-retest reliability of the cultural competence assessment instrument (CCA) among hospice providers, and to examine the reliability and validity of the CCA among healthcare providers in nonhospice settings. METHOD: Test-retest reliability of the CCA was assessed using a sample of 51 hospice respondents who completed the CCA at two time points. The internal consistency reliability and construct validity of the CCA for healthcare providers in nonhospice settings were evaluated using a convenience sample of 405 healthcare providers. RESULTS: The CCA demonstrated adequate test-retest reliability (r = .85, p = .002) in hospice providers over 4 months. Among healthcare providers in nonhospice settings, the CCA had an internal consistency reliability of .89 overall (.91 and .75 for the two subscales). Construct validity was supported by principal axis factor analysis, which showed two factors with item loadings above .40, explaining 56% of the variance. Mean scores of the CCA were significantly higher for providers who reported previous diversity training compared to those who had not. DISCUSSION: Findings for the psychometric properties of the CCA supported its potential as an instrument for measuring provider cultural competence. Knowledge gained will be useful for developing future research studies and specific cultural competence intervention approaches for healthcare providers that may decrease health disparities.     

Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) has a high mortality and is associated with significant morbidity. Prior outcome studies have focused predominant on short-term outcomes (6-12 months). We assessed longitudinal neurocognitive, emotional, and quality of life in ARDS survivors at hospital discharge, and 1 and 2 years after hospital discharge using neuropsychologic tests and emotional and quality-of-life questionnaires. Neurocognitive sequelae occurred in 73% (54 of 74) of ARDS survivors at hospital discharge, 46% (30 of 66) at 1 year, and 47% (29 of 62) at 2 years. ARDS survivors report moderate to severe depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. The ARDS survivors had decreased quality of life, with the physical domains improving at 1 year, with no additional change at 2 years. Role emotional, pain, and general health did not change from hospital discharge to 2 years. Mental health improved during the first year and declined at 2 years. ARDS results in significant neurocognitive and emotional morbidity and decreased quality of life that persists at least 2 years after hospital discharge. ARDS can cause significant long-term, brain-related morbidity manifest by neurocognitive impairments and decreased quality of life.     

Anoxic versus traumatic brain injury: amount of tissue loss, not etiology, alters cognitive and emotional function

Research in neuropsychology suggests that the etiology of a neurologic injury determines the neuropathological and neuropsychological changes. This study compared neuropsychological outcome in subjects who had traumatic brain injury (TBI) with subjects who had anoxic brain injury (ABI), who were matched for age, gender, and ventricle-to-brain ratio. There were no group differences for morphologic or neuropsychological measures. Both groups exhibited impaired memory, attention, and executive function, as well as slowed mental processing speed. Intelligence correlated with whole brain volume, and measures of memory correlated with hippocampal atrophy. There was no unique contribution of hippocampal atrophy on neuropsychological outcome between the groups. In the absence of localized lesions, the amount of neural tissue loss, rather than etiology, may be the critical factor in neuropsychological outcome.     

Increased thrombin inhibition in experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) and its animal model, experimental autoimmune encephalomyelitis (EAE), are inflammatory diseases of the central nervous system (CNS). Activated coagulation factors are associated with inflammation and are elevated in the plasma of animals with EAE. Thrombin is a key coagulation factor and its major endogenous inhibitors are antithrombin III (ATIII) in the plasma and protease nexin 1 (PN-1) in the brain. We measured the capacity of brain homogenates to inhibit exogenous thrombin and the CNS levels of ATIII and PN-1 during the course of EAE. Acute EAE was induced in SJL/J mice by immunization with mouse spinal cord homogenates. On Days 8, 13, and 22 post-immunization, inhibition of exogenous thrombin activity was measured by a recently developed fluorimetric assay. PN-1 and ATIII were assayed both by immunohistochemistry and by immunoblots in the brain and spinal cord. Total brain thrombin inhibitory activity increased (32%) in EAE mice at the peak of clinical disease (Day 13, P=0.04 compared to controls). Brain ATIII also increased at the peak of disease (2.5-fold higher than controls, P=0.0001), and correlated significantly with clinical scores at all stages of disease (r=0.72, P=0.0068). In contrast, PN-1 elevations were more pronounced at the preclinical stage on Day 8 (3-fold higher than controls, P=0.01) than on Day 13 (1.4-fold higher, P=0.005). Increased brain thrombin inhibition at the clinical peak of EAE probably reflects increased influx of plasma thrombin inhibitors. Early PN-1 changes represent a potential target for thrombin modulating drugs in EAE and MS.     

Hyperbaric Oxygen and Radiotherapy

BACKGROUND: Hyperbaric oxygen (HBO) therapy is the inhalation of 100% oxygen at a pressure of at least 1.5 atmospheres absolute (150 kPa). It uses oxygen as a drug by dissolving it in the plasma and delivering it to the tissues independent of hemoglobin. For a variety of organ systems, HBO is known to promote new vessel growth into areas with reduced oxygen tension due to poor vascularity, and therewith promotes wound healing and recovery of radiation-injured tissue. Furthermore, tumors may be sensitized to irradiation by raising intratumoral oxygen tensions. METHOD: A network of hyperbaric facilities exists in Europe, and a number of clinical studies are ongoing. The intergovernmental framework COST B14 action "Hyperbaric Oxygen Therapy" started in 1999. The main goal of the Working Group Oncology is preparation and actual implementation of prospective study protocols in the field of HBO and radiation oncology in Europe. RESULTS: In this paper a short overview on HBO is given and the following randomized clinical studies are presented: a) reirradiation of recurrent squamous cell carcinoma of the head and neck after HBO sensitization; b) role of HBO in enhancing radiosensitivity on glioblastoma multiforme; c) osseointegration in irradiated patients; adjunctive HBO to prevent implant failures; d) the role of HBO in the treatment of late irradiation sequelae in the pelvic region. The two radiosensitization protocols (a, b) allow a time interval between HBO and subsequent irradiation of 10-20 min. CONCLUSION: Recruitment of centers and patients is being strongly encouraged, detailed information is given on www.oxynet.org.     

Perceptions of child maltreatment by parents from the Indian subcontinent: challenging myths about culturally based abusive parenting practices

Clinicians and researchers emphasize the importance of recognizing differential cross-cultural definitions of child maltreatment, cautioning awareness that some ethnic groups may use harsher methods to discipline their children. Using a mixed-method research approach, based on questionnaire and focus group data, 29 parents of South Asian descent provided input on their attitudes toward child discipline, maltreatment, and neglect. Study findings suggest that South Asian parents do not differ significantly from other populations in their judgment of appropriate parenting approaches; that is, persistent and excessive use of physical discipline was considered to be inappropriate, behaviors of parents that may have negative emotional consequences for children were recognized as inappropriate, and lack of proper supervision of children was seen as a concern. Notably, though, participants voiced their reluctance to contact child protective services should they encounter families struggling with abuse. Implications for practice and directions for future research are suggested.