Caregivers in home palliative care: gender, psychological aspects, and patient's functional status as main predictors for their quality of life.

PURPOSE: This study aims to investigate the impact of possible predictors of quality of life (QoL) in a group of Italian caregivers assisting a cancer patient in home palliative care. METHODS: Data from 570 adult informal caregivers and their cancer-affected relatives were collected. A multivariate regression analysis was conducted to assess the effect of three groups of variables on Caregivers Quality of Life Index-Cancer (CQOLC) scale: (a) socio-demographic characteristics of caregivers; (b) psychological characteristics of caregivers assessed by Profile Mood of States (POMS), Caregiver Burden Inventory (CBI), and Preparedness for Caregiving Scale (PCS); (c) Socio-demographic characteristics and functional status of the patients assessed by Karnofsky Performance Status (KPS), Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). RESULTS: Regression analysis shows that some variables from each of these clusters are significantly associated with CQOLC, in particular: (a) the gender of the caregiver (st.ß = .115, t = 2.765, p = .006) and the time spent for caregiving (st.ß = - .165, t = - 3.960, p < .001); (b) the scores obtained by the caregivers in POMS,CBI (st.ß = - .523, t = - 16.984, p < .001 and st.ß = - .373, t = - 12.950, p < .001, respectively) and PCS (st.ß = .092, t = 3.672, p < .001); (c) the gender (st.ß = - .081, t = - 1.933, p = .045) and the IADL score (st.ß = .195, t = 4.643, p < .001) of the patient. CONCLUSIONS: A multidimensional evaluation is a key strategy to identify the most vulnerable caregivers. Apart from the condition of the patient, the gender of the caregivers, the time spent for caregiving and, above all, their psychological condition are strong predictors of caregivers' QoL.

A galaxy rapidly forming stars 700 million years after the Big Bang at redshift 7.51.

Of several dozen galaxies observed spectroscopically that are candidates for having a redshift (z) in excess of seven, only five have had their redshifts confirmed via Lyman α emission, at z = 7.008, 7.045, 7.109, 7.213 and 7.215 (refs 1-4). The small fraction of confirmed galaxies may indicate that the neutral fraction in the intergalactic medium rises quickly at z > 6.5, given that Lyman α is resonantly scattered by neutral gas. The small samples and limited depth of previous observations, however, makes these conclusions tentative. Here we report a deep near-infrared spectroscopic survey of 43 photometrically-selected galaxies with z > 6.5. We detect a near-infrared emission line from only a single galaxy, confirming that some process is making Lyman α difficult to detect. The detected emission line at a wavelength of 1.0343 micrometres is likely to be Lyman α emission, placing this galaxy at a redshift z = 7.51, an epoch 700 million years after the Big Bang. This galaxy's colours are consistent with significant metal content, implying that galaxies become enriched rapidly. We calculate a surprisingly high star-formation rate of about 330 solar masses per year, which is more than a factor of 100 greater than that seen in the Milky Way. Such a galaxy is unexpected in a survey of our size, suggesting that the early Universe may harbour a larger number of intense sites of star formation than expected.

Cold streams in early massive hot haloes as the main mode of galaxy formation.

Massive galaxies in the young Universe, ten billion years ago, formed stars at surprising intensities. Although this is commonly attributed to violent mergers, the properties of many of these galaxies are incompatible with such events, showing gas-rich, clumpy, extended rotating disks not dominated by spheroids. Cosmological simulations and clustering theory are used to explore how these galaxies acquired their gas. Here we report that they are 'stream-fed galaxies', formed from steady, narrow, cold gas streams that penetrate the shock-heated media of massive dark matter haloes. A comparison with the observed abundance of star-forming galaxies implies that most of the input gas must rapidly convert to stars. One-third of the stream mass is in gas clumps leading to mergers of mass ratio greater than 1:10, and the rest is in smoother flows. With a merger duty cycle of 0.1, three-quarters of the galaxies forming stars at a given rate are fed by smooth streams. The rarer, submillimetre galaxies that form stars even more intensely are largely merger-induced starbursts. Unlike destructive mergers, the streams are likely to keep the rotating disk configuration intact, although turbulent and broken into giant star-forming clumps that merge into a central spheroid. This stream-driven scenario for the formation of discs and spheroids is an alternative to the merger picture.

The role of black holes in galaxy formation and evolution.

Virtually all massive galaxies, including our own, host central black holes ranging in mass from millions to billions of solar masses. The growth of these black holes releases vast amounts of energy that powers quasars and other weaker active galactic nuclei. A tiny fraction of this energy, if absorbed by the host galaxy, could halt star formation by heating and ejecting ambient gas. A central question in galaxy evolution is the degree to which this process has caused the decline of star formation in large elliptical galaxies, which typically have little cold gas and few young stars, unlike spiral galaxies.

Lost and found dark matter in elliptical galaxies.

There is strong evidence that the mass of the Universe is dominated by dark matter, which exerts gravitational attraction but whose exact nature is unknown. In particular, all galaxies are believed to be embedded in massive haloes of dark matter. This view has recently been challenged by the observation of surprisingly low random stellar velocities in the outskirts of ordinary elliptical galaxies, which has been interpreted as indicating a lack of dark matter. Here we show that the low velocities are in fact compatible with galaxy formation in dark-matter haloes. Using numerical simulations of disk-galaxy mergers, we find that the stellar orbits in the outer regions of the resulting ellipticals are very elongated. These stars were torn by tidal forces from their original galaxies during the first close passage and put on outgoing trajectories. The elongated orbits, combined with the steeply falling density profile of the observed tracers, explain the observed low velocities even in the presence of large amounts of dark matter. Projection effects when viewing a triaxial elliptical can lead to even lower observed velocities along certain lines of sight.

Fluoroscopy-guided biodegradable spacer implantation using local anesthesia: safety and efficacy study in patients with massive rotator cuff tears.

BACKGROUND: The management of massive rotator cuff tears (MRCTs) is challenging and associated with a high failure rates. Studies have shown that advanced age, lower American Society of Anesthesiologists physical status score and concomitant comorbidities are associated with higher risks of death and postoperative complications. This study was designed to assess the safety and efficacy of fluoroscopy-guided biodegradable spacer implantation under local anesthesia, in patients with MRCT and comorbidities completely or partially contraindicating surgeries under general anesthesia. METHODS: In this open-label, single arm, prospective study, subjects with MRCTs underwent subacromial fluoroscopy-guided implantation with a biodegradable spacer (InSpace™ system) under local anesthesia. Fifteen patients were treated and assessed. Follow-up visits were scheduled according to routine clinical practice. Shoulder function was evaluated using Constant (CS) and American Shoulder and Elbow Society (ASES) scores. RESULTS: All patients demonstrated an overall improvement in the total CS and ASES beginning at 6 weeks and sustained by at least 12 months postoperatively. Of the 15 patients who reached the 1-year follow-up, 85% showed a clinically significant improvement of at least 15 points in their Constant score starting at 6 weeks postoperation and maintained throughout the entire follow-up period. CONCLUSIONS: We conclude that in this initial patient's cohort, fluoroscopy-guided implantation of InSpace™ system under local anesthesia, represented an effective alternative to the existing procedures. This procedure may be considered as a treatment option for elderly patients or for patients with multiple comorbidities complicating or contraindicating surgery under general anesthesia. Technically easy, this technique can be an effective tool in the armamentarium of most orthopedic surgeons. Level of proof: single-arm prospective study, Level II.

Galaxy evolution. Evidence for mature bulges and an inside-out quenching phase 3 billion years after the Big Bang.

Most present-day galaxies with stellar masses ≥10(11) solar masses show no ongoing star formation and are dense spheroids. Ten billion years ago, similarly massive galaxies were typically forming stars at rates of hundreds solar masses per year. It is debated how star formation ceased, on which time scales, and how this "quenching" relates to the emergence of dense spheroids. We measured stellar mass and star-formation rate surface density distributions in star-forming galaxies at redshift 2.2 with ~1-kiloparsec resolution. We find that, in the most massive galaxies, star formation is quenched from the inside out, on time scales less than 1 billion years in the inner regions, up to a few billion years in the outer disks. These galaxies sustain high star-formation activity at large radii, while hosting fully grown and already quenched bulges in their cores.

Thrombosis of the pelvic veins associated with a large myomatous uterus.

BACKGROUND: Deep vein thrombosis is a rare indication for hysterectomy. CASE: A 45-year-old woman presented with a myomatous uterus of 20 gestational weeks' size that was compressing the pelvic veins directly and causing thrombosis. After preparation of the patient with anticoagulants and installation of an umbrella device in the inferior vena cava, we performed an uneventful abdominal hysterectomy. CONCLUSION: Pelvic deep vein thrombosis is a rarely reported complication of myomatous uterus. It can be managed successfully by anticoagulants, placement of an umbrella device in the inferior vena cava, and hysterectomy, as in our case.

Severe abdominal complications after transvaginal ultrasonographically guided retrieval of oocytes for in vitro fertilization and embryo transfer.

Severe life-threatening complications as a result of ultrasonically guided ovum pick-up for IVF may rarely occur. We report 14 cases, out of 3,656 patients undergoing the procedure, presenting with a clinical picture of acute abdomen. In 9 patients tubo-ovarian and pelvic abscess were diagnosed; 3 were treated by laparotomy, whereas in the other 6, culdocentesis and drainage were performed. In 3 cases severe intra-abdominal bleeding occurred with 1 requiring laparotomy and hemostasis, whereas in the others laparoscopic drainage and hemostasis were sufficient. Ruptured endometriotic cystic masses caused acute abdomen in 2 patients; partial oophorectomy and drainage were essential operative procedures. We conclude that although severe postovum retrieval complications are rare, one has to be aware of their occurrence with the aim of accurate diagnosis and prompt intervention.

A severe case of ovarian hyperstimulation syndrome despite the prophylactic administration of intravenous albumin.

OBJECTIVE: To evaluate the role of the recently suggested IV administration of human albumin solution as an effective preventive measure of severe ovarian hyperstimulation in high-risk patients. CASE: Presented here is, to the best of our knowledge, the first case of early severe ovarian hyperstimulation necessitating early transabdominal aspiration of ascites and intensive fluid and colloid (dextran and albumin) replacement, which developed despite administration of IV human albumin solution in an attempt to prevent severe ovarian hyperstimulation. CONCLUSIONS: Because IV albumin does not prevent severe ovarian hyperstimulation in absolute terms, its use in high-risk patients should not lead one astray. Further research should be directed at investigating the fundamental cause of ovarian hyperstimulation syndrome and developing a reliable predictive test for this complication.

Polycystic ovary syndrome patients as oocyte donors: the effect of ovarian stimulation protocol on the implantation rate of the recipient.

OBJECTIVE: To evaluate the outcome of oocytes donated by women with polycystic ovarian syndrome (PCOS) compared with oocytes donated by women with mechanical infertility. DESIGN: A retrospective study. PATIENTS: The outcome of 159 oocyte donation cycles with oocyte donated by PCOS patients were compared with 69 oocyte donation cycles with oocytes donated by patients with mechanical infertility. We compared the stimulation protocols in the donors to assess if the combination of GnRH analogue (GnRH-a), FSH, and hMG has an advantage over FSH and hMG alone with respect to their effect on fertilization and implantation rates in oocyte donation cycles. RESULTS: When treated with GnRH-a, pregnancy rates in PCOS and mechanical infertility donors were higher than those treated with FSH and hMG alone. The comparison between PCOS and mechanical factor oocyte recipients revealed no significant difference in the pregnancy and abortion rates, but the oocytes of patients with PCOS that were exposed to GnRH-a had a significantly higher implantation rate than those not exposed to GnRH-a. CONCLUSIONS: Oocytes obtained from PCOS patients had a fertilization potential equal to oocytes obtained from mechanical infertility donors. Furthermore, because the oocytes of patients with PCOS exposed to GnRH-a had a significantly higher implantation rate, a detrimental role of high LH on oocyte quality seems probable. However, because PCOS has a high familial prevalence, some reservations may arise due to a possible propagation of the problem in the next generation of oocyte donation programs.

Severe pneumococcal peritonitis complicating IUD: case report and review of the literature.

A case of pneumococcal peritonitis associated with an IUD is presented and four previously reported cases of pneumococcal peritonitis with IUD are reviewed. The infection may occur in previously healthy women who were fitted with an IUD, possibly by ascending infection from the genital tract via the fallopian tubes. The condition is usually accompanied by bilateral salpingitis and may be severe, with fatal outcome. We suggest that any woman over 30 using an IUD, who presents with peritonitis without obvious cause, should be given antibiotics with activity against Streptococcus pneumoniae, following removal of the IUD.

PIP: A case of a woman with pneumococcal peritonitis 3 months after insertion of a Nova-T copper IUD is described and the 5 other cases in the literature are reviewed. The 38-year old woman was multiparous, and had no related history other than recurrent right nephrolithotomy. She had acute peritonitis of 8 hours duration when admitted, with acute abdominal pain, fever, tachycardia and hypertension. She was treated with penicillin, gentamycin and chloramphenicol, and the IUD was removed. Her blood pressure fell to 70/40 and she developed acidosis and septic shock. Laparotomy, drainage, continued antibiotics, artificial ventilation and intensive hemodynamic treatment for 3 days were necessary to reverse coma and respiratory distress. Primary pneumococcal peritonitis only occurs in girls; in women it is though to arise from IUDs, pelvic infection or perhaps from the bowel. The other cases showed no preference for any type of IUD (3 Lippes loops, 1 Dalkon shield and 1 Gravigard) or length of use (1.5-5.5 years). 1 of the women died, and another had recurrent pneumococcal peritonitis. Therapy should include surgical drainage, instillation of antibiotics, and removal of the IUD.

Primary choriocarcinoma of the fallopian tube. Report of a case with survival and postoperative delivery. Review of the literature.

A patient is presented with primary choriocarcinoma of the fallopian tube arising from a tubal pregnancy. Treatment consisted of an initial operation including adnexectomy and resection of bilateral ovarian thecalutein cysts, followed by chemotherapy. The patient delivered a healthy infant 2 years later, and is alive and well 5 years after the event.

Munchausen syndrome in obstetrics and gynecology.

Munchausen syndrome (MS) is a well-defined clinical psychiatric entity. Furthermore, it is a complicated and intriguing problem in medicine in general and in obstetrics and gynecology in particular. The proportion of MS cases in obstetrics and gynecology is rising. This review covers relevant reports from the last four decades. Emphasis is put on the clinical expression of MS cases in obstetrics and gynecology. A discussion about their validity as such is included. Awareness of attending physicians to this type of illness in the era of patient rights, on the one hand, and the existence of defensive medicine on the other, is crucial.

Hyperemesis gravidarum during Ramadan.

During Ramadan, adult Muslims fast from dawn to dusk. We frequently encounter young pregnant Muslim women with hyperemesis gravidarum who fast during this holy month. We have investigated whether there is an association between the prolonged fasting during Ramadan and excessive vomiting during pregnancy. Possible psychologic and physiologic explanations are presented and discussed.

Ovarian vascular accidents: a complication of anticoagulant therapy.

Ovarian vascular accidents are usually more severe when the patient is being kept on anticoagulant therapy following cardiac surgery or for other reasons. 4 cases of massive hemoperitoneum are reported. Rupture of the corpus luteum and corpus luteum cyst and an ovarian ectopic pregnancy were responsible for massive hemoperitoneum. All 4 patients survived and recovered.

Bilateral Sertoli-Leydig cell tumor with heterologous elements: report of an unusual case and review of the literature.

A case of bilateral ovarian Sertoli-Leydig cell tumor with heterologous elements is reported in an 18-yr-old girl with marked virilization. Panhysterectomy was performed, yet the tumor recurred shortly after the intervention. The microscopic picture was one of intermediate to poor differentiation. Despite chemotherapy, the postoperative course was rapidly malignant, and the patient died 4 wk later.

Transplacental passage of cefazolin in the first trimester of pregnancy.

The transfer of cefazolin, an antibiotic compound of the cefalosporin group, through the placental barrier was investigated in the first trimester of pregnancy. All cases were chosen from among women admitted for therapeutic abortion. The test group comprised 70 women, while there were 30 in the control group. The bacteriostatic activity was examined in the amniotic fluid, obtained by the vaginal route as well as the maternal blood, following the i.m. injection of 500 mg cefazolin. Our results indicate that the antibiotic cefazolin crosses the placental barrier, even during the first trimester of pregnancy. However, the concentrations obtained were considerably lower than those observed in the 2nd and 3rd trimesters.

Torsion of a fallopian tube following Pomeroy tubal ligation: a rare case report and review of the literature.

A case of unilateral fallopian tube torsion following Pomeroy tubal ligation, as well as a review of the literature, is presented. Although uncommon, this entity should be considered in the differential diagnosis of abdominal pain in the female patient. Early surgical intervention by means of laparoscopy is mandatory in order to correctly diagnose and treat this complication.

Femoral neuropathy subsequent to abdominal hysterectomy. A comparative study.

In a prospective study of two 5-yr periods two groups of patients undergoing pelvic operative procedures were compared. Iatrogenic femoral neuropathy occurred in 282 patients who underwent pelvic abdominal surgery in the first group of women, an overall incidence of 7.45%. The neuropathy was associated with the use of self-retaining retractors during surgery. Femoral nerve neuropathy occurred only in two patients in the second group in whom no retractors were used during operation. No other contributing factors were found. The duration of complaints ranged from 3 to 90 days. Spontaneous recovery occurred in 265 patients, while in 17 there were residual mild symptoms for up to 116 days. No serious sequelae have been observed. Prevention of this mostly mild yet annoying syndrome may be achieved if no retractors are used in gynecological operations, or, if they are necessary, due to difficult conditions at surgery or if the operation is long, they should be used with care and loosened from time to time. It is estimated that the incidence of iatrogenic femoral nerve neuropathy is higher than reported, since in very mild cases the patient fails to mention her complaints. The prognosis is usually rather good.