The role of family physicians in cancer care: perspectives of primary and specialty care providers.

BACKGROUND: Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps. METHODS: Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada. RESULTS: The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments. CONCLUSIONS: Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.

Multigene expression profile testing in breast cancer: is there a role for family physicians?

BACKGROUND: Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing. METHODS: We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing. RESULTS: The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp-patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient's comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp-oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy. CONCLUSIONS: Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed.

BLASTOCYSTIS SP. AND BLASTOCYSTIS RATTI IN A BRAZILIAN PORCUPINE (COENDOU PREHENSILIS) WITH DIARRHEA.

A hand-raised, 5-mo-old, intact male Brazilian porcupine (Coendou prehensilis) was evaluated for chronic diarrhea, failure to thrive, and anorexia. On presentation the porcupette was dull, dehydrated, and passing yellow, malodourous, watery diarrhea. Cytologic examination of feces revealed a large number of organisms, morphologically consistent with Blastocystis. Blastocystis polymerase chain reaction (PCR) performed on feces was positive. Direct sequencing on two sequential samples confirmed the presence of Blastocystis ratti and a novel Blastocystis sequence. The porcupette was treated supportively, which included a 4-wk metronidazole course. Diarrhea resolved within 2 wk of treatment, and the animal's growth rate dramatically improved. Recheck PCR was negative for Blastocystis. Although an important and controversial cause of diarrhea in immunocompromised humans, this organism is not well recognized as a potential pathogen and zoonosis in zoo animals. Clinicians should be aware of the potential for disease associated with this organism, especially in immunocompromised animals.

Do current cancer follow-up care practices meet the needs of young adult cancer survivors in Canada? A qualitative inquiry.

PURPOSE: The purpose of the present study was to assess whether current cancer follow-up care practices meet the needs of young adult cancer survivors in Canada. METHODS: This qualitative study used a constructivist grounded theory framework to analyze telephone interviews with cancer survivors from across Canada diagnosed between the ages of 18 and 39 years. The focus was specifically on cancer follow-up care (cfc). RESULTS: Interviews were conducted with 55 participants, and 53 interviews were used for the analysis. The overall theme that emerged from the data was the lack of age-specific cfc. Some of the subthemes that emerged were the absence or inadequacy of fertility and infertility treatment options; of psychological services such as family, couples, and sexuality counseling; of social supports such as assistance with entry or re-entry into the education system or workplace; of access to supplemental health insurance; and of survivorship care plans. Based on the data resulting from the interviews, we developed a conceptual model of young-adult cfc incorporating the major themes and subthemes that emerged from our study. The proposed model aims to ensure a more age-appropriate and comprehensive approach to cfc for this group of cancer patients. CONCLUSIONS: Current Canadian cfc practices are inadequate and do not provide comprehensive care for young adult cancer survivors in Canada. The conceptual model presented here aims to ensure a more comprehensive approach to cfc that meets the needs of this unique cancer population and reduces further possible physical, psychological, or social cancer sequelae.

Treatment of oromaxillary fistulae in nine standing horses (2002-2006).

REASONS FOR PERFORMING STUDY: There is minimal published information on equine oromaxillary fistulae that are unrelated to cheek teeth (CT) repulsion or on the conservative treatment of these atypical fistulae. OBJECTIVES: To report equine oromaxillary fistulae unrelated to CT extraction and describe their management in standing horses. METHODS: Case details of oromaxillary fistulae of atypical aetiology occurring at 2 referral centres between 2002-2006, including their treatment and response to treatment were examined. RESULTS: Nine cases of oromaxillary fistula were recorded, mainly in aged horses (median 22 years). Fistulae were associated with CT diastemata in 7 cases, fractured CT in one and a central defect in a worn CT in another. After removing food and exudate from the sinuses, 6 cases were treated successfully by filling the diastema or dental defect with polymethylmethacrylate (PMMA). Following dental extraction, the other 3 cases were treated successfully by use of PMMA alveolar packing. CONCLUSION: Older horses can spontaneously develop oromaxillary fistulae, usually secondary to CT diastemata. In the absence of apical infection, this disorder can usually be treated successfully in standing horses by treating the sinusitis and sealing the oral aspect of the diastema with PMMA. POTENTIAL RELEVANCE: Older horses with sinusitis should be assessed for the presence of CT diastemata and oromaxillary fistulae. If detected, these disorders can be treated successfully in the standing horse.

The economic impact on families when a child is diagnosed with cancer.

OBJECTIVE: In a study conducted in New Brunswick and Newfoundland and Labrador, we examined the economic impact on families caring for a child with cancer. METHODS: We undertook semi-structured interviews with 28 French and English families with a child diagnosed with cancer in the last 10 years. RESULTS: Families who care for a child with cancer incur considerable costs during the diagnostic, treatment, and follow-up care phases of the disease. Four major themes emerged from this qualitative study as contributing factors for these expenses: necessary travel; loss of income because of a reduction or termination of parental employment; out-of-pocket treatment expenses; and inability to draw on assistance programs to supplement or replace lost income. In addition, many of the decisions with regard to the primary caregiver were gendered. Typically, the mother is the one who terminated or reduced work hours, which affected the entire family's financial well-being. CONCLUSIONS: For families with children diagnosed with cancer, financial issues emerged as a significant concern at a time when these families were already consumed with other challenges. This economic burden can have long-term effects on the financial security, quality of life, and future well-being of the entire family, including the siblings of the affected child, but in particular the mother. Financial assistance programs for families of seriously ill children need to be revisited and expanded.

Orthodontic correction of overjet/overbite ('parrot mouth') in 73 foals (1999-2013).

REASONS FOR PERFORMING STUDY: There are limited reports on the efficacy of functional orthodontic correction of overjet or overbite in foals. OBJECTIVES: To report the outcome of using orthodontic tension bands in combination with an inclined plane biteplate in the treatment of overjet, with or without concurrent overbite, rates of correction of these 2 malocclusions and associated complications. And to examine factors associated with outcomes. STUDY DESIGN: Retrospective case series. METHODS: Clinical records for 73 foals treated at a single clinic, by the same surgeon were analysed. Overall change and rates of change in overjet and overbite were calculated. Associations between potential explanatory variables including age, severity of initial malocclusion and surgeon experience were examined using linear regression. RESULTS: Records for 73 foals (43 colts, 30 fillies) were evaluated. The median number of implant placements per animal was 2 (range 1-4). Of 61 cases with complete records, reduction in overjet and overbite dimensions were achieved in 95% and 90% of foals, respectively, with mean reductions in malocclusions of 9.9 and 8.4 mm, respectively. Complete reduction in overjet was achieved in 25% (15/61) and reduction of malocclusion dimensions to ≤5 mm (i.e. functionally corrected) was achieved in 51% (31/61). Increasing animal age was significantly associated with decreased total reduction in overjet and decreased rate of reduction in overbite. Increased original severity of overbite was significantly associated with increased rate of its correction. Short-term complications included intraoperative haemorrhage, transient facial nerve neuropraxia and irritation of the mare's udder by the brace. Longer-term complications included cheek teeth diastema formation and incisor discoloration and maleruption. CONCLUSIONS: Using this technique, correction or improvement of these malocclusions is rapid, with minimal complications. Often more than one implant is required. Animal age at the start of treatment is associated with rate and amount of correction achievable, so initiating treatment at an early age is recommended.

Twenty year experience with radiation therapy for temporal bone chemodectomas.

Between 1965 and 1984, 20 patients with chemodectomas of the temporal bone were seen at The Methodist Hospital in Houston, Texas and at the Cancer Therapy and Research Center in San Antonio, Texas, Ten patients were treated with radiation therapy alone, seven with surgery and post-operative radiation, one with pre-operative radiation, and two with radiation therapy following surgical recurrence. Most patients had advanced tumors at presentation. Radiation doses ranged from 22.5 Gy to 50.0 Gy. The most frequent dose was 45.0 Gy, given in 225 cGy fractions, 9.0 Gy per week. The most common radiation portal arrangement was oblique fields with paired wedges. There were no local failures or significant radiation induced complications among the patients with benign chemodectomas. The follow-up period ranged from 3 to 23 years (mean 11 years). Only one patient developed systemic metastases and progression of the primary temporal bone chemodectoma. These results and a review of the literature demonstrate that radiation therapy alone is a safe and effective treatment modality for chemodectomas of the temporal bone.

The treatment of advanced juvenile nasopharyngeal angiofibroma.

Fifteen patients with juvenile nasopharyngeal angiofibroma (JNA) were treated in the Department of Radiation Oncology, Baylor College of Medicine between 1973 and 1986. All patients underwent radiographic evaluation including CT scanning, selective digital subtraction angiography, tomograms, or MRI. Patients referred for definitive irradiation exhibited extensive tumor involvement. Eleven of 15 patients had middle cranial fossa involvement; cavernous sinus extension was observed in six patients. Ten patients were treated with primary radiation therapy; five patients had surgical resection initially and were referred for radiation therapy upon local recurrence. Follow-up ranges from 1 1/2-13 years. Four of the 5 patients who received 3200 cGy in 200 cGy fractions demonstrated tumor recurrence within 2 years after irradiation. All recurrences were ultimately controlled by either further irradiation and/or resection. No tumor recurrence was encountered among the patients treated at the higher tumor doses (36-46 Gy). No severe complications have been observed. Radiation therapy utilizing carefully tailored fields is an appropriate therapeutic approach to patients with extensive disease or intracranial extension. A total dose of greater than 40 Gy may allow improved local control for advanced lesions.

Effective radiotherapy in palliating mammalgia associated with gynecomastia after DES therapy.

Between 1977 and 1986, 11 patients with painful gynecomastia after DES therapy were referred for palliative radiotherapy. The treatment regimens varied from 20 Gy in 5 fractions to 40 Gy in 20 fractions. All 11 patients had satisfactory pain relief on follow-up. All 7 patients who had more than 6 months follow-up had complete relief of mammalgia. The average interval between completion of radiotherapy to complete relief of mammalgia was 3.6 months. This study revealed that radiotherapy is highly effective in palliating mammalgia associated with gynecomastia after DES therapy in prostate cancer patients.

Palliation of bronchogenic carcinoma with 198Au implantation using the fiberoptic bronchoscope.

The majority of cases of bronchogenic carcinoma remain incurable, and many of these patients require palliation of the effects of the tumor on the airway. We have developed a technique for implanting radioactive (198Au) seeds via the fiberoptic bronchoscope. We now retrospectively review the results obtained in 111 procedures in 54 patients. Response was assessed by improvement in symptoms, chest roentgenogram, or bronchoscopic appearance. Nineteen of 29 (66 percent) patients with occluding endobronchial lesions benefitted. Twenty of 22 (91 percent) with hemoptysis improved. All six patients with tracheal lesions benefitted. Two of six (33 percent) patients with nonoccluding endobronchial lesions responded. Complications directly related to the procedure were rarely of major consequence, although a single patient had an exsanguinating hemoptysis four days following the last of multiple implantations. The simplicity, relative safety, and potential wide availability coupled with low equipment costs would suggest an increasing role for this technique in the palliation of endobronchial neoplasms.

Esthesioneuroblastoma metastatic to the trachea.

Esthesioneuroblastoma is an uncommon nasal neoplasm of neural crest origin, which is recognized for its propensity for local recurrence and distant dissemination by both lymphatic and hematogenous routes. Hematogenous spread occurs most frequently to the lungs and bones, but metastases to the liver, spleen, scalp, face, breast, adrenal, aorta, and ovary have been reported. We present a patient who developed metastatic esthesioneuroblastoma of the trachea 1 year after successful craniofacial resection of his primary tumor. The patient was treated by YAG laser resection of the metastatic tumor followed by radiotherapy. He was free of tracheal disease 1 year after treatment of the metastases.

Erythrogram and red cell distribution width of Equidae with experimentally induced anemia.

The erythrogram (erythrocyte histogram) and red cell distribution width (RDW) were evaluated in 5 purebred horses and 1 pony of mixed breeding with experimentally induced anemia. Four horses were studied for 6 weeks after 20% of their estimated blood volume was removed on each of 2 consecutive days (40% total blood loss; acute blood-loss group). Two horses were given acetylphenyl hydrazine IV daily, until acute Heinz body hemolytic anemia was induced; the 2 horses were then evaluated for 6 weeks. One horse and the pony had 20% of their estimated blood volume removed via phlebotomy once each week for 8 weeks to induce iron-deficiency anemia (chronic blood-loss group); the horse had been partially depleted of iron before the study began. Weekly blood samples were examined for changes in the erythrogram, RDW, mean cell volume (MCV), and erythrocyte glucose-6-phosphate dehydrogenase activity. Fourteen days after acute blood loss, mild increases were seen in the MCV, which persisted to day 42. The RDW was increased at day 14 and remained increased until day 42; however, the percentage increase was double that of the MCV at days 14, 21, and 28. Erythrograms had mild extensions of the right slope at days 14 to 28. Mean erythrocyte glucose-6-phosphate dehydrogenase activity increased in all 3 groups, but individual concentrations were erratic. In the 2 horses with acute hemolytic anemia, modest increases of similar magnitude were seen in RDW and MCV.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo and in vitro responses of cats sensitized with viable Mycobacterium bovis (BCG).

Cats were injected subcutaneously with viable Mycobacterium bovis (BCG), and immune responses were evaluated at various times after injection. The BCG injection produced fever, leukocytosis, neutrophilia, and lymphadenopathy of regional lymph nodes. Intradermal tuberculin injection produced responses consistent with delayed type hypersensitivity reaction in the treated cats at postinoculation day 21. Skin responses to tuberculin were not significant at postinoculation day 49. The cellular infiltrate at the tuberculin injection site at 48 hours after injection was an admixture of polymorphonuclear cells and mononuclear cells. The BCG produces strong intradermal skin responses in the cat, but the response was not long-lived as in cattle and guinea pigs. The BCG injection did not produce significant changes in the absolute total lymphocyte and absolute T-lymphocyte numbers in peripheral blood. The percentage of T-lymphocytes was significantly higher in the BCG-treated group. Differences were not observed in lymphocyte blastogenesis with tuberculin and non-specific mitogens between BCG-treated and control cats.

Hematologic values and plasma and tissue folate concentrations in dogs given phenytoin on a long-term basis.

During earlier investigations of the hepatic effects in dogs of long-term administration of phenytoin alone or in combination with primidone, erythrocytic macrocytosis, neutropenia, neutrophilic hypersegmentation, and thrombocytopenia were observed. Such abnormalities were observed most often in dogs given phenytoin and resembled those known to be attributable to folate deficiency in human beings with epilepsy treated with phenytoin. To pursue the theory that these hematologic aberrations were caused by drug-induced folate deficiency, 12 dogs were given a diet specifically formulated to contain a minimally adequate concentration of folate. After 2 weeks, phenytoin was administered daily (400 mg, PO, q 8 h) to 8 of the 12 dogs for 54 weeks. A CBC, bone marrow aspiration biopsy, and measurement of plasma and RBC folate concentrations were done every 3 weeks. Bone marrow aspirates were examined by transmission electron microscopy after 24 and 36 weeks, and at the end of the treatment period. Hepatic folate concentration was also determined in all dogs before and after treatment. Excretion of formiminoglutamic acid, as a marker of folate deficiency, was measured in all dogs at the end of the study. All dogs remained healthy throughout the treatment phase. Consistent abnormalities were not observed in the blood or bone marrow of treated dogs. Plasma and RBC folate concentrations decreased in control and treated dogs as a result of dietary restriction (P less than or equal to 0.02), and remained stable until the end of the study. The RBC folate content decreased further in treated dogs (P less than or equal to 0.02), although the hepatic folate content was similar in control and treated dogs. Treated dogs did not excrete formiminoglutamic acid more rapidly than did control dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic arteriovenous fistula in two Saint Bernard pups.

Two saint bernard pups, 7 and 5 months old respectively, were examined because of anorexia, vomiting, and ascites. Exploratory laparotomy disclosed arteriovenous fistula of the right medial lobe of the liver in one dog, and in the right medial and quadrate lobes of the other one. Surgical removal of the affected lobes resulted in cessation of presenting signs. Both dogs remained healthy but had poor weight gain and vomited occasionally. After more than 2 years of apparently good health, both dogs were euthanatized and necropsied because of presumably unrelated gastrointestinal disturbances.

Effect of papain injection on mineral concentration in tissues of roosters and hens.

A study was made of the effect of injected papain on the concentration of calcium, iron, copper, zinc and selenium in tissues of roosters and laying hens. Half the males and females were injected intravenously with a papain solution and the other half with 0.9% sodium chloride. The roosters and half the laying hens were injected one-hour ante-mortem and the others injected 24 hours ante-mortem. The laying hens had less Zn, Fe, Cu and Ca in the skeletal muscle than the roosters, and less Fe and Cu, but equivalent amounts of Ca and Zn, in the kidneys. In the roosters the kidney contained approximately five times as much Se as the muscle. The liver contained equivalent concentrations of Se in the roosters and laying hens. Papain had no effect on the concentration of any of the elements in the tissues. There was no significant difference in the concentration of the minerals between one-hour and 24-hour ante-mortem injections of the papain in the laying hens.

Using a positive self-talk intervention to enhance coping skills in breast cancer survivors: lessons from a community-based group delivery model.

PURPOSE: Cancer survivorship is a distinct phase of the cancer continuum, and it can have myriad associated stresses and challenges. The purpose of the present study was to evaluate the effectiveness of a positive self-talk (pst) intervention in enhancing the coping skills and improving the psychological well-being of breast cancer survivors. METHODS: Participants (n = 38) were recruited from 5 support groups in a small eastern Canadian province. Support groups were randomly assigned to either a control (n = 18) or an intervention (n = 20) condition. Intervention participants were pre-tested, received a 2-hour pst in-person group workshop and a 10-minute "booster" session by telephone, and completed post-test questionnaires 1 month later. RESULTS: Intervention participants reviewed the workshop favourably. Nearly all participants used the intervention in everyday life, were able to accurately describe how pst works, and found that pst had a considerable impact on their ability to cope with cancer and related sequelae. However, the descriptive findings from the workshop evaluation did not translate into significant differences between the intervention and control groups on the psychometric measures. CONCLUSIONS: The pst intervention, delivered in a community group model, was positively received and effective in teaching participants about pst and how pst can be used to enhance coping skills for breast cancer patients. However, the intervention did not promote significantly greater levels of change in anxiety, depression, mood disturbance, or coping ability for intervention participants. The unique challenges of community-level psychological intervention are explored.