Meaningful lives: elders in treatment for depression

This study used a qualitative approach and was conducted to gain insights into the lives of elders with depression that could eventually lead to improvements in treatment strategies for this population. Twenty elders described a typical day in their lives. Using a multistep analysis of the interviews, six themes emerged: independence, spirituality, family relationships, depression, medical comorbidities, and motivation. A perspective of the process of elders finding meaning in their lives was explicated such that characteristics of independence, motivation, and spirituality enabled these elders to identify their need for treatment and to cope with their comorbidities. During treatment, these elders began to appreciate their experiences of social and family relationships and began to be able to appreciate the meaning inherent in their lived experience. Developing the role of the clinician as coordinator of health care and the appropriateness of MI as a treatment strategy were presented as possible avenues to improving treatment for elders with depression.     

Receiving healthcare for drug-resistant TB: a cross-sectional survey from Pakistan

OBJECTIVE:To describe and quantify patients’ self-reported experiences of receiving healthcare from Pakistan’s Programmatic Management of Drug-Resistant Tuberculosis (PMDT) model of care, and to understand these experiences within the broader context of Pakistan’s health system.METHOD:This was a cross-sectional survey of patients attending three PMDT clinics in Khyber-Pakhtunkhwa Province in Pakistan.RESULTS:The median consultation time at the PMDT clinics was 10 minutes. In their most recent visit to the PMDT clinic, 34.9% of patients spent >40% of their monthly income to access treatment. To specify, 71% of patients reported spending out-of-pocket for ancillary medicines and 44.7% for laboratory tests. In 10.5% of cases, medicines for drug-resistant TB (DR-TB) were dispensed without the patient attending the clinic. Only 43.7% of treatment supporters regularly accompanied patients to the clinic, and 6% supervised the patient’s intake of medicines. Disbursement of financial support was irregular in 98.6% of cases. Only 6.2% of patients received their daily injections from a public facility, the rest went elsewhere.CONCLUSION:Several shortcomings in PMDT services, including hurried consultations, irregularities in financial support, and gaps in Pakistan’s broader health system undermined healthcare experience of patients with DR-TB. To improve health outcomes and patients’ care experience these service gaps need to be addressed.     

Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery.     

Human glioma cells transformed by IGF-I triple helix technology show immune and apoptotic characteristics determining cell selection for gene therapy of glioblastoma.

AIMS: Insulin-like growth factor type I (IGF-I) antisense cellular gene therapy of tumours is based on the following data: rat glioma or hepatoma cells transfected with the vector encoding IGF-I antisense cDNA lose their tumorigenicity and induce a tumour specific immune response involving CD8(+) T cells. Recently, using the IGF-I triple helix approach in studies of tumorigenicity, major histocompatibility complex class I (MHC-I) antigens were demonstrated in rat glioma transfected cells. This study used comparative IGF-I antisense and triple helix technologies in human primary glioma cells to determine the triple helix strategy that would be most appropriate for the treatment of glioblastoma. METHODS: The cells were transfected using the IGF-I triple helix expression vector, pMT-AG, derived from the pMT-EP vector. pMT-AG contains a cassette comprising a 23 bp DNA fragment transcribing a third RNA strand, which forms a triple helix structure within a target region of the human IGF-I gene. Using pMT-EP, vectors encoding MHC-I or B7 antisense cDNA were also constructed. RESULTS: IGF-I triple helix transfected glioma cells are characterised by immune and apoptotic phenomena that appear to be related. The expression of MHC-I and B7 in transfected cells (analysed by flow cytometry) was accompanied by programmed cell death (detected by dUTP fluorescein terminal transferase labelling of nicked DNA and electron microscopic techniques). Cotransfection of these cells with MHC-I and B7 antisense vectors suppressed the expression of MHC-I and B7, and was associated with a pronounced decrease in apoptosis. CONCLUSION: When designing an IGF-I triple helix strategy for the treatment of human glioblastoma, the transfected tumour cells should have the following characteristics: the absence of IGF-I, the presence of both MHC-I and B7 molecules, and signs of apoptosis.     

Screening for subclinical stenosis in native vessel arteriovenous fistulae.

Guidelines recommend the use of ultrasound dilution techniques (UDT), including measurement of access recirculation (AR) and access blood flow (Q(a)), to screen for subclinical vascular access dysfunction. Although these techniques are efficacious in polytetrafluoroethylene grafts, data in native vessel arteriovenous fistulae (AVF) are lacking. A prospective observational study was conducted to evaluate the utility of UDT screening in AVF. Q(a) and AR were measured bimonthly. Positive studies required fistulograms and were defined by Q(a) < 500 ml/min, DeltaQ(a) > 20% from baseline or AR > 5%. Accesses with stenosis underwent percutaneous angioplasty. After 1 yr, there were 1355 mo of follow-up in 177 patients. There were 44 positive studies in 40 patients. Q(a) was <500 ml/min in 36 (82%), DeltaQ(a) was >20% in 5 (11%), and AR was >5% in 6 (14%). Of patients with Q(a) < 500 ml/min, 29 (81%) had stenosis. Only two patients (40%) with DeltaQ(a) > 20% but Q(a) > 500 ml/min had stenosis. No patient with AR > 5% had stenosis unless Q(a) was also <500 ml/min. Immediate patency rate was 93% post-PTA. Mean Q(a) increased from 303 +/- 154 ml/min to 602 +/- 220 ml/min (P < 0.0001), and mean urea reduction ratio increased from 70.4 +/- 8.4% to 74.6 +/- 6.5% (P = 0.003) post-PTA. The results demonstrate that UDT could detect subclinical stenoses in AVF, and most lesions were amenable to angioplasty. AVF that underwent PTA delivered higher Q(a) and urea reduction ratio, and immediate patency rates were acceptable. Access failure after negative UDT was unusual. Measuring AR increases the time required to perform UDT but does not improve utility. Serial measurements of Q(a) alone may be the best strategy for screening AVF.     

Verrucous carcinoma of the oral cavity: A clinical and pathological study of 101 cases

This paper studies the clinical and pathological predictors of local recurrence and disease-free survival (DFS) in patients with oral verrucous carcinoma (OVC) treated surgically, through a retrospective chart review. Three hundred and two patients with OVC were identified from January 1990 to December 2000, of which, 101 surgically treated patients who fulfilled our inclusion criteria were analyzed. A univariate analysis (UVA) of important prognostic factors, patterns of recurrence, and DFS is reported. Seventy-nine patients were male (M:F ratio, 3.6:1) and the mean age at presentation was 53.9 years (range, 23-90 years). The median follow up was 4.61 years (range, 0.51-14.3 years). The incidence of tobacco chewing, smoking, and alcohol intake was 77%, 42%, and 10%, respectively. Thirty-four patients (33.7%) had either leukoplakia or submucous fibrosis (SMF) on oral cavity examination. Early-stage tumors accounted for 39.7%; while 60.4% were late-stage tumors. On UVA, tumor location, presence of a premalignant lesion, smoking, and positive margins were statistically significant. Sixty-eight percent (19/28) recurred locally. The salvage rate for recurrent tumors was 66.7% (16/28) with a median post-recurrence survival of 16 months (range, 10-83 months). The five year DFS with surgical therapy was 77.6%. OVC has an excellent prognosis with surgical treatment. The significance of positive margins emphasizes the need for adequate surgical resection. Additionally, the presence of either leukoplakia or SMF and tumor location in the upper alveolar-palatal complex is associated with worse outcomes. Neck dissection, if considered, may be limited to a supra-omohyoid neck dissection (SOHND).     

Imaging in bronchopulmonary sequestration

Bronchopulmonary sequestration is an uncommon pulmonary disorder characterized by an area of non‐functioning abnormal lung tissue, which receives its blood supply from a systemic artery and characteristically has no connection with the tracheobronchial tree. The abnormal lung tissue is located within the visceral pleura of a pulmonary lobe in the intralobar variety, whereas the extralobar form has its own visceral pleura. The venous drainage of the extralobar type is usually into the systemic veins, whereas the intralobar type drains into the pulmonary veins. Radiological imaging plays a vital role in establishing the diagnosis, and even more importantly, in providing to the clinician a vascular roadmap essential for surgical planning. We present here a review of bronchopulmonary sequestration and also discuss the role of various imaging methods in the early diagnosis and management of these cases.