Life before death: identifying preparatory grief through the development of a new measurement in advanced cancer patients (PGAC)

Goals of work This paper describes the development of a self-rating scale to measure preparatory grief in advanced cancer patients.Patients and methods The Preparatory Grief in Advanced Cancer patients (PGAC) instrument incorporates seven multi-items scales. The final sample consisted of 200 patients. The questionnaire was completed at baseline and 3 days later with a cross-validation sample of 100 patients.Main results The average time required to complete the questionnaire was 9 min. All scales met the minimum standards of reliability (Cronbachs alpha coefficient >0.70). The test–retest reliability in terms of Spearman-rho coefficient was also satisfactory (p<0.05). Validity was demonstrated by content validity, factor analysis, convergence and discriminative validity, inter-scales correlations, concurrent validity with the Hospital Anxiety and Depression Scale (HADS) and known-group validity with the Eastern Cooperative Oncology Group (ECOG) performance status.Conclusions The PGAC is a reliable and valid measure for the assessment of anticipatory grief in patients with advanced stage cancer.     

Dynamic loading performance of fasciocutaneous flaps and implications for gait

BACKGROUND: Recent advancements in microsurgery allow the free tissue transfer for reconstruction of soft-tissue defects on the plantar surface of the foot. Fasciocutaneous flaps are one available option to the reconstructive surgeon. However, their functional weight-bearing capabilities have never been adequately evaluated. This study investigated the dynamic loading performance of selected fasciocutaneous flaps during walking using instrumented gait analysis. METHODS: We investigated 6 feet with reconstructed heels along with their contralateral normal feet. A control group of normals was included also. Time-distance, ground reaction force parameters and plantar foot pressure distribution were evaluated. Data were normalized to account for anthropometric variations. A series of t-tests were used to investigate contrasts. FINDINGS: Walking velocity of injured subjects was decreased (P<0.0001). Step length and single limb support were the shortest for the involved feet (P<0.04). Double limb support and swing were the longest (P<0.0002). The reconstructed heels sustained high pressures (P<0.05) and vertical loadings underlining their functional weight-bearing capabilities. However, the walking patterns implemented by the injured subjects resulted in reduced anterior-posterior shear forces that could help maintain the integrity of the shear plane at the graft-recipient bed interface. INTERPRETATION: The dynamic loading capabilities of the fasciocutaneous flaps make it an effective means for restoring functional gait. Patients implement gait patterns that result in primarily decreasing shear forces. Consequently, the fasciocutaneous flaps should be included in the surgeons' armentarium as a plausible reconstructive means for soft-tissue defects on the plantar surface of the foot.     

The role of nitric oxide on endothelial function

The vascular endothelium is a monolayer of cells between the vessel lumen and the vascular smooth muscle cells. Nitric oxide (NO) is a soluble gas continuously synthesized from the amino acid L-arginine in endothelial cells by the constitutive calcium-calmodulin-dependent enzyme nitric oxide synthase (NOS). This substance has a wide range of biological properties that maintain vascular homeostasis, including modulation of vascular dilator tone, regulation of local cell growth, and protection of the vessel from injurious consequences of platelets and cells circulating in blood, playing in this way a crucial role in the normal endothelial function. A growing list of conditions, including those commonly associated as risk factors for atherosclerosis such as hypertension, hypercholesterolemia, smoking, diabetes mellitus and heart failure are associated with diminished release of nitric oxide into the arterial wall either because of impaired synthesis or excessive oxidative degradation. The decreased production of NO in these pathological states causes serious problems in endothelial equilibrium and that is the reason why numerous therapies have been investigated to assess the possibility of reversing endothelial dysfunction by enhancing the release of nitric oxide from the endothelium. In the present review we will discuss the important role of nitric oxide in physiological endothelium and we will pinpoint the significance of this molecule in pathological states altering the endothelial function.     

KIT-negative gastrointestinal stromal tumors with a long term follow-up： A new subgroup does exist

AIMTo investigate the incidence of KIT immunoho-stochemical staining in(GI)stromal tumors(GISTs),and to analyze the clinical manifestations of the tumors and prognostic indicators.METHODSWe retrospectively analyzed 50 cases of Previously diagnosed GISTs.Tissue samples were assessed with KIT(CD117 antigen),CD34,SMA,desmin,S-100,NSE,PCNA,Ki-67,and BCL-2 for immunohistochemical study and pathological characteristics were analyzed for prognostic factors.RESULTSFifteen tumors(30%)were negative in KIT staining.A significant association was observed between gender(male patients14/15)and KIT-negative staining P = 0.003).The patients's mean age was 56.6 years.Tumors developed in stomach(n = 8),small intestine (n = 5),large intestine(n = 1)and oesophagus(n = 1).The mean tumor size was 5.72 cm.The mitotic count ranged from 0-29/50 HPF(mean3.4)and 73% of tumors showed no necrosis.The majority of the tumors(67%)had dual or epithelioid differentiation.Tumors were classified as very low or low risk(n = 7),intermediate risk(n = 5),and high risk(n = 3)groups.Twelve(80%)patients were alive without evidence of residual tumor for an average period of 40.25 mo(12-82 mo);three patients developed metastatic disease to the liver and eventually died within 2-12 mo(median survival8.6 mo).CONCLUSIONA small subgroup of GISTs fulfils the clinical and morphological criteria of these tumors,and lacks KIT expression.These tumors predominantly developed in the stomach,being dual or epithelioid in morphology,which are classified as low risk tumors and presented a better survival status than KIT-positive tumors.The ability to diagnose GISTs still depends on immunohistochemical staining but the research should extend in gene mutations.     

Relation between local temperature and C-reactive protein levels in patients with coronary artery disease: effects of atorvastatin treatment

Although previous studies have shown systemic inflammatory activation the relation with the local plaque inflammatory activation has not been extensively studied. The present study investigated the relation between local and systemic inflammatory activation in patients with coronary artery disease and the impact of atorvastatin treatment. We included 215 patients undergoing percutaneous coronary intervention; of them 140 were treated with atorvastatin. Patients with stable angina (SA) and acute coronary syndromes (ACS) were included. Systemic inflammation was assessed by serum C-reactive protein (CRP), soluble adhesion molecules levels and local plaque inflammatory activation by coronary thermography. Temperature difference (DeltaT) was assigned as the difference between the proximal vessel wall temperature from the maximal temperature at the culprit plaque. Patients with ACS (n=78) had increased DeltaT compared to patients with SA (n=137) (0.16+/-0.10 degrees C versus 0.08+/-0.07 degrees C, P<0.001). Patients treated with atorvastatin had lower DeltaT compared to untreated patients (0.10+/-0.07 degrees C versus 0.15+/-0.10 degrees C, P<0.01). DeltaT was less in the treated group compared to the untreated group in patients with SA and ACS (ACS: 0.13+/-0.08 degrees C versus 0.20+/-0.11 degrees C, P<0.01, SA: 0.08+/-0.06 degrees C versus 0.13+/-0.08 degrees C, P=0.03). Although a correlation was found between CRP levels and DeltaT (R=0.29, P<0.01), in certain groups a discrepancy between CRP levels and DeltaT was observed. In 25% of patients with low DeltaT CRP levels were >1mg/dl and in 35.5% of patients with high DeltaT CRP was <2mg/dl. The correlation between soluble adhesion molecules and DeltaT did not reach statistical significance. Although there is a correlation between widespread and local inflammatory activation in patients with coronary artery disease, a discrepancy between culprit plaque and systemic inflammatory activation is observed. Atorvastatin has a parallel effect on systemic and local inflammatory process in patients with coronary artery disease.     

The incremental effect of obstructive sleep apnoea syndrome on arterial stiffness in newly diagnosed essential hypertensive subjects

OBJECTIVE: Although obstructive sleep apnoea syndrome (OSAS) is accompanied by an increased atherosclerotic cardiovascular disease burden, its relationship with arterial stiffness is not yet well determined. We investigated whether essential hypertensive individuals with OSAS are characterized by increased arterial stiffness. METHODS: Our study population consisted of 46 consecutive patients with newly diagnosed untreated stage I-II essential hypertension suffering from OSAS (35 men, aged 49 +/- 8 years) and 53 hypertensive individuals without OSAS, matched for age, sex, and smoking status. All subjects underwent polysomnography, echocardiography and aortic stiffness evaluation by means of carotid-femoral pulse wave velocity (c-fPWV) measurements. RESULTS: Hypertensive subjects with OSAS [apnoea/hypopnoea index (AHI)>or =5] compared with hypertensive subjects without OSAS (AHI < 5) demonstrated increased levels of body mass index (31.4 +/- 4 versus 29.3 +/- 4 kg/m2, P = 0.015), office systolic/diastolic blood pressure (151/99 versus 145/94 mmHg, respectively, P < 0.05, for both cases) and relative wall thickness (RWT; 0.46 +/- 0.06 versus 0.42 +/- 0.07, P=0.010). Hypertensive subjects with OSAS compared with those without OSAS had significantly increased c-fPWV by 9% (8.56 +/- 0.49 versus 7.85 +/- 0.93 m/s, P=0.001) and this difference remained significant even after adjustment for confounders (P=0.04). In the total study population, c-fPWV was correlated with age (r=0.35, P=0.015), office systolic blood pressure (r=0.30, P=0.007), RWT (r=0.30, P=0.03), logAHI (r=0.389, P=0.0001) and minimum oxygen saturation (r=-0.418, P=0.0001). CONCLUSIONS: OSAS has a significant incremental effect on aortic stiffening in the setting of middle-aged essential hypertensive subjects. This finding suggests that the presence of OSAS in a hypertensive patient accelerates vascular damage, increasing cardiovascular risk.