Follow-up care of patients treated for breast cancer: a structured review

Breast cancer follow-up services vary, with little evidence to support which practice is best. A systematic review methodology was employed to identify and integrate primary research on the effectiveness of follow-up services. From 4418 articles identified by searches, 38 were eligible for review inclusion. Data were not sufficiently homogenous to integrate statistically, however the following patterns of findings were observed: patient survival and quality of life were not affected by intensity of follow-up or location of care; patients held positive attitudes towards follow-up but psychological distress was consistently high regardless of location of services; few studies assessed patient involvement in treatment choices; studies' research quality was poor with inadequate measures of effectiveness or research designs. There is insufficient primary empirical evidence to draw broad conclusions regarding best practice for breast cancer follow-up care in terms of (a) patient involvement in care, (b) reductions in morbidity, and (c) cost effectiveness of service provision.     

A clinical trial to compare double-arch and complete-arch impression techniques in the provision of indirect restorations

STATEMENT OF PROBLEM: Anecdotal reports of use of double-arch impressions for indirect restorations suggest time and materials savings, but there is little clinical evidence to support their use. PURPOSE: To establish whether a double-arch impression technique could produce restorations comparable with those produced by use of the complete-arch technique and to investigate reported time and material savings. MATERIAL AND METHODS: Five practitioners each recruited 10 adult patients requiring a single complete veneer crown into the study. Two sets of impressions, 1 complete-arch in a stock metal tray, and 1 double-arch in a plastic double-arch tray were made for each patient in addition-polymerized silicones in a random order. The time taken for each impression was recorded along with patient's assessment of comfort, taste, and overall acceptability. One technician, who selected the impressions for the fabrication of each crown according to a predetermined scheme of randomization, fabricated all crowns. Equal numbers of crowns were made from the complete and double-arch impressions. At the time of crown placement, the accuracy of fit, occlusal harmony, and the time taken for try-in were also recorded. The weight of impression material used was measured for each impression. Data were analyzed by use of computerized statistical software (t test for equality of means) at a significance level of 95%. RESULTS: The double-arch technique was faster (222 seconds [SD, 57 seconds] vs 445 seconds [SD, 87 seconds], P=.000), more comfortable (P=.025), better tasting (P=.001), and preferred by 80% of the patients (P=.000). No significant differences were found between the 2 groups for accuracy of fit, occlusion, or time taken for try-in of the restorations. The mean weight of impression material used was 39 g (SD, 10 g) for complete-arch and 20 g (SD, 7 g) for double-arch impressions, a mean difference of 19 g (P=.000). CONCLUSION: Within the limitations of this study, double-arch impressions were found to take less time, to use less material, and to be preferred by patients. Under the conditions of this study, the resulting restorations were no less accurate than those made from complete-arch impressions.     

Age and birth cohort effects on rates of alcohol dependence

BACKGROUND: Epidemiological studies of traits such as alcohol dependence and depression have often found lifetime rates in younger individuals exceeding those found in older individuals. This suggests additional influences of birth cohort or period effects so that individuals in later-born cohorts have an increased lifetime risk. METHODS: Data from the Collaborative Study on the Genetics of Alcoholism were used to investigate secular trends for alcoholism and related conditions and to examine risk predictors while taking the cohort effect into account. We used data on 4099 interviewed parents and siblings of alcohol-dependent subjects and 1054 members of control families. We used survival analysis techniques and the Cox proportional hazards regression model to estimate the relative risk for demographic covariates. We used the relative sample to predict risk in the sibling of the proband and family history information to determine whether there was a bias when deceased individuals were excluded from analysis. RESULTS: In the control sample, we observed a 1.8% lifetime rate of DSM-III-R alcohol dependence in women born before 1940, as contrasted to a 13% rate in women born after 1960, and a 15% lifetime rate in men born before 1940, contrasted with a 28% rate in men born after 1960. As expected, lifetime rates in relatives were increased when compared with controls. Highly significant risk ratios (RR) were observed for gender (RR, 2.3), cohort of birth (RR, 1.5 over a decade), daily smoking (RR, 2.0), heavy smoking (RR, 3.0), and comorbid diagnoses of antisocial personality (RR, 2.2) and depression (RR, 1.6). Analysis of the family history data indicated higher rates of alcohol dependence in relatives who were deceased compared to those who were living. CONCLUSIONS: Marked cohort differences were observed and may reflect real changes over time, or artifacts of memory recall, differential mortality, or public awareness. The analysis of all relatives (living or deceased) indicates that associated mortality may, in part, explain the secular trends seen when analyses are restricted to living, personally interviewed individuals.     

Regulation of matrix metalloproteinases in a model of colonic wound healing in a rabbit

PURPOSE: Matrix metalloproteinases occur in the colon at an anastomosis but not in the normal colon. Matrix metalloproteinase synthesis can be regulated by cytokines, for example interleukin-1 beta and growth factors, such as transforming growth factor beta and basic fibroblast growth factor. The aim of this study was to investigate the regulation of matrix metalloproteinases at an anastomosis by identifying the cell types that synthesize matrix metalloproteinases, examining factors that might regulate their synthesis, determining whether they occur in an active form, and assessing the effect of suture type on these parameters. METHODS: An anastomosis was formed in the distal colon of rabbits using either polyglactin or polydioxanone and the animals were killed six hours or seven days later. The distribution of matrix metalloproteinases and cytokines and the cell types were assessed by immunohistochemistry. Matrix metalloproteinase-2, matrix metalloproteinase-3, and matrix metalloproteinase-9 were detected also by zymography. RESULTS: Immunohistochemistry showed that matrix metalloproteinases were restricted to the suture line. Although zymography demonstrated that matrix metalloproteinase-2 was present mainly in an active form, matrix metalloproteinase-9 and matrix metalloproteinase-3 were present in the pro-form. The active form of matrix metalloproteinase-3 occurred more often in the polydioxanone-sutured rabbits. With the exception of matrix metalloproteinase-9, the matrix metalloproteinases were synthesized by fibroblasts. Interleukin-1 beta and transforming growth factor beta were more widespread than in the normal colon and were localized adjacent to the matrix metalloproteinases. Basic fibroblast growth factor was also more widespread postoperatively but occurred deeper in the anastomosis than the matrix metalloproteinases. CONCLUSIONS: This study has shown that interleukin-1 beta and transforming growth factor beta may regulate the synthesis of the matrix metalloproteinases by fibroblasts and that minor differences that occur in the matrix metalloproteinase profile are dependent on the suture type.Supported in part by University College London Hospitals, London, Basildon Health Authority, Essex, and The Medical Research Council, London, United Kingdom.Presented at the meeting of The Surgical Research Society, London, United Kingdom, January 2 to 3, 1997.     

Does zinc deficiency play a role in stunting among primary school children in NE Thailand?

Stunting in school-age years may result in a decrease in adult size, and thus reduced work capacity and adverse reproductive outcomes. We have compared the mean intakes of energy, protein and selected growth-limiting nutrients in fifty-eight stunted children and 172 non-stunted controls drawn from 567 children aged 6-13 years attending ten rural schools in NE Thailand. Control children were selected randomly after stratifying children by age in each school. Dietary data were calculated from 24-h recalls using nutrient values from Thai food composition data and chemical analysis. Inter-relationships between stunting and sociodemographic, anthropometric and biochemical variables were also examined. Biochemical variables investigated were serum albumin, zinc, ferritin, transferrin receptor and retinol, and iodine in casual urine samples. Significantly more males than females were stunted (males, n 38, 65.5% v. females, n 20. 34.5%: P=0.025). Stunted males had lower mean intakes of energy, protein, calcium, phosphorus and zinc, and a lower mean (95% CI) serum zinc (9.19 (8.53, 9.84) v. 9.70 (8.53, 9.29) micromol/1) than non-stunted males; no other biochemical differences were noted. Stunted males also had a lower mean arm muscle area (P= 0.015), after adjusting for age, than non-stunted males. In conclusion, the lower dietary intakes of the stunted males compared to their non-stunted counterparts may be associated with anorexia and hypogeusia induced by zinc deficiency. Hence, zinc deficiency may be a factor limiting linear growth, especially among boys in NE Thailand, but more research is needed to establish whether other factors also play a role.     

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

Two decades after the Safe Motherhood campaigns 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries.     

Managing side effects of childhood cancer treatment

This article focuses on the nurse's role as a member of the supportive care team for the child diagnosed with cancer and the family. The most common side effects of the cancer treatment are discussed in depth in this article. The adequate management of the side effects experienced by the child receiving cancer therapy may greatly influence the child's quality of life.     

Health care worker vaccination against Ebola: Vaccine acceptance and employment duration in Sierra Leone

Health care workers (HCW) are at high risk of Ebola virus disease (EVD) infection during epidemics and may contribute to onward transmission, and therefore HCW-targeted prophylactic vaccination strategies are being considered as interventions. To assess the feasibility of preventive HCW vaccination, we conducted a pilot survey on staff turnover and vaccine acceptance amongst 305 HCW in Freetown and Kambia districts of Sierra Leone.Multivariable logistic regression demonstrated which demographic and behavioural factors were associated with acceptance of a hypothetical new vaccine. We quantified the duration of employment of HCW, and used multivariable gamma regression to detect associations with duration of employment in current or any health care position. Finally, we simulated populations of HCW, to determine the likely future immunisation coverage amongst HCW based on our estimates of vaccine acceptance and employment duration.Most HCW we surveyed had a positive opinion of EVD vaccination (76.3%). We found that being a volunteer HCW (vs being on the government payroll) was associated with increased vaccine acceptance. We found that HCW have stable employment, with a mean duration of employment in the health sector of 10.9?years (median 8.0?years). Older age and being on the government payroll (vs volunteer HCW) were associated with a longer duration of employment in the health sector. Assuming a single vaccine campaign, with 76.3% vaccine acceptance, 100% vaccine efficacy and no waning of vaccine-induced protection, immunisation coverage was sustained over 50% until 6?years after a vaccination campaign. If vaccine-induced immunity wanes at 10% per year, then the immunisation coverage among HCW would fall below 50% after 3?years.Vaccinating HCW against EVD could be feasible as employment appeared stable and vaccine acceptance high. However, even with high vaccine efficacy and long-lasting immunity, repeated campaigns or vaccination at employment start may be necessary to maintain high coverage.