Knowledge, perceptions, attitudes, and barriers pertaining to genetic literacy among surgeons: a scoping review.

BACKGROUND: The rapid evolution of genetic technologies and utilization of genetic information for clinical decision-making has necessitated increased surgeon participation in genetic counselling, testing, and appropriate referral of patients for genetic services, without formal training in genetics. We performed a scoping review to describe surgeons' knowledge, perceptions, attitudes, and barriers pertaining to genetic literacy in the management of patients who had confirmed cancer or who were potentially genetically at risk. METHODS: We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist. We performed a comprehensive literature search, and 2 reviewers independently screened studies for inclusion. These studies included surgeons involved in the care of patients with confirmed gastrointestinal, breast, and endocrine and neuroendocrine cancers, or patients who were potentially genetically at risk for these cancers. RESULTS: We analyzed 17 studies, all of which used survey or interview-based formats. Many surgeons engaged in genetic counselling, testing, and referral, but reported low confidence and comfort in doing so. Knowledge assessments showed lower confidence in identifying genetic inheritance patterns and hereditary cancer syndromes, but awareness was higher among surgeons with greater clinical volume or subspecialty training in oncology. Surgeons felt responsible for facilitating these services and explicitly requested educational support in genetics. Barriers to genetic literacy were identified and catalogued at patient, surgeon, and system levels. CONCLUSION: Surgeons frequently engage in genetics-related tasks despite a lack of formal genetics training, and often report low knowledge, comfort, and confidence in providing such services. We have identified several barriers to genetic literacy that can be used to develop interventions to enhance genetic literacy among surgeons.

Influence of Alloying Elements on the Mechanical Properties of Anodized Aluminum and on the Adhesion of Copper Metallization.

The active development of the power electronics market and a constant increase in the prices of components require new materials and approaches, including a power module packaging technology. The use of aluminum instead of copper in the power module baseplate is an interesting and promising solution. The insulated metal baseplate is one of the most extensively developed technologies nowadays. The object of this study is an insulated metal substrate based on anodized aluminum. The main goal of the article is the comparison of copper topology adhesion to an anodized aluminum oxide layer formed on different aluminum alloys with aluminum content of at least 99.3 wt %. Peel test and pull-off adhesions showed a twofold difference for both aluminum alloys. The high ordered defect-free anodized alumina formed on alloys with copper content of 0.06 wt % had a mean pull-off adhesion of 27 N/mm2 and hardness of 489 HV. In the case of the alloy with copper content of around 0.15 wt %, it had hardness of 295 HV and a mean pull-off adhesion of 12 N/mm2. The results of our microstructure investigation showed that anodized alumina based on alloys with copper content of around 0.15 wt % is fragile due to spherical holes. Summing up the results, it can be concluded that not all initial impurities are critical for anodized alumina, but some, specifically copper, dramatically decreased the mechanical properties of anodized alumina.

Prophylactic Surgery in the BRCA+ Patient: Do Women Develop Breast Cancer While Waiting?

Breast cancer susceptibility gene (BRCA) mutation carriers have an increased risk of breast cancer. Mitigation of this risk can be achieved via surveillance or prophylactic mastectomy with or without breast reconstruction. Those that choose surgery expect to reduce their chance of developing cancer. The purpose of this study was to determine the incidence of patients developing breast cancer prior to surgery and to identify modifiable contributing factors within the patient journey. This is a historical cohort study of all BRCA mutation carriers identified through the British Columbia Cancer Hereditary Cancer Program between 2000 and 2012. Patients were divided into two groups: surveillance (S) and prophylactic mastectomy with immediate breast reconstruction (PM/IBR). The incidence of cancer, time to PM/IBR and patient journeys were analyzed. A total of 333 women were identified. The time to surgery from mutation disclosure was a median of 31 (5.3, 75.7) months. During this period, 6% of patients developed breast cancer compared with a 14% incidence of breast cancer in patients choosing surveillance. The majority of time to surgery was attributed to the period between mutation disclosure and the decision to proceed with surgery. Strategies to facilitate decision-making as well as wait list prioritization and dedicated operative time should be targeted to this population to decrease the number of women developing an interval cancer prior to surgery.

Management of irritable bowel syndrome in primary care: feasibility randomised controlled trial of mebeverine, methylcellulose, placebo and a patient self-management cognitive behavioural therapy website. (MIBS trial).

BACKGROUND: IBS affects 10-22% of the UK population. Abdominal pain, bloating and altered bowel habit affect quality of life, social functioning and time off work. Current GP treatment relies on a positive diagnosis, reassurance, lifestyle advice and drug therapies, but many suffer ongoing symptoms.A recent Cochrane review highlighted the lack of research evidence for IBS drugs. Neither GPs, nor patients have good evidence to inform prescribing decisions. However, IBS drugs are widely used: In 2005 the NHS costs were nearly £10 million for mebeverine and over £8 million for fibre-based bulking agents. CBT and self-management can be helpful, but poor availability in the NHS restricts their use. We have developed a web-based CBT self-management programme, Regul8, based on an existing evidence based self-management manual and in partnership with patients. This could increase access with minimal increased costs. METHODS/DESIGN: The aim is to undertake a feasibility factorial RCT to assess the effectiveness of the commonly prescribed medications in UK general practice for IBS: mebeverine (anti-spasmodic) and methylcellulose (bulking-agent) and Regul8, the CBT based self-management website.135 patients aged 16 to 60 years with IBS symptoms fulfilling Rome III criteria, recruited via GP practices, will be randomised to 1 of 3 levels of the drug condition: mebeverine, methylcellulose or placebo for 6 weeks and to 1 of 3 levels of the website condition, Regul8 with a nurse telephone session and email support, Regul8 with minimal email support, or no website, thus creating 9 groups. OUTCOMES: Irritable bowel symptom severity scale and IBS-QOL will be measured at baseline, 6 and 12 weeks as the primary outcomes. An intention to treat analysis will be undertaken by ANCOVA for a factorial trial. DISCUSSION: This pilot will provide valuable information for a larger trial. Determining the effectiveness of commonly used drug treatments will help patients and doctors make informed treatment decisions regarding drug management of IBS symptoms, enabling better targeting of treatment. A web-based self-management CBT programme for IBS developed in partnership with patients has the potential to benefit large numbers of patients with low cost to the NHS. Assessment of the amount of email or therapist support required for the website will enable economic analysis to be undertaken.

Evaluating learning and knowledge retention after a continuing medical education course on total mesorectal excision for surgeons.

The purpose of this study was to determine whether knowledge gained (as determined by a formal course test) by surgeons in a continuing education course on total mesorectal excision and rectal cancer management is retained 1 year later. A formal course test had been previously developed and validated. The test evaluated course content including pelvic anatomy, surgical techniques, imaging, pathology, adjuvant therapies, and cancer and functional outcomes. Validation was determined by the absence of change in pre- and posttest scores of the "expert" course instructors (n = 8, P = .6) and by a linear correlation in test scores with increasing level of general-surgery resident training (n = 16, P = .001). Significant learning by the 58 surgeons taking the course had been shown by improvement in test scores from before the course (mean score 19) to after the course (mean score 25.3, P = .001, out of a possible 33 total mark). At 1 year after the course, those course participants (n = 44, 76%) who had provided postcourse contact information were asked to complete the course test again. Responses were received from 18 surgeons (41% of those surveyed, 31% of the original course participants). The mean score on the test after 1 year was 23.8. Compared with the immediate posttest scores, there was no significant knowledge loss over the year (P = .09). We conclude that knowledge acquired during a continuing education course for surgeons on total mesorectal excision and rectal-cancer management is retained 1 year later.

Can cytology accurately predict benign follicular nodules?

BACKGROUND: The reliability of fine-needle aspiration (FNA) biopsy in differentiating benign from malignant follicular lesions of the thyroid has been the subject of renewed debate recently. Although surgical excision has been recommended for most follicular lesions identified by cytology, this approach may not be necessary in all cases. The goal of this study was to determine whether FNA could be used as a diagnostic tool to safely identify patients with follicular thyroid nodules who do not require immediate surgical intervention. METHODS: A retrospective review was performed on a sample of 24 patients diagnosed with either follicular adenoma or follicular carcinoma after surgical excision of a thyroid nodule. The initial FNA biopsies were independently reviewed by two experienced cytopathologists in a blinded fashion and subsequently compared with final histologic diagnoses. RESULTS: For pathologist A, overall accuracy was 58%. The positive predictive value (PPV) of a benign diagnosis was 82%; PPV of a malignant diagnosis was 38%. For pathologist B, overall accuracy was 63%. The PPV of a benign diagnosis was 83%; PPV of a malignant diagnosis was 42%. CONCLUSIONS: This study suggests that in follicular lesions of the thyroid, a benign FNA biopsy report from an experienced cytopathologist has a high positive predictive value. The predictive value may not, however, be high enough to preclude surgery; other factors may need to be considered before recommending a nonoperative approach.

Effects of positive resection margin and tumor distance from anus on rectal cancer treatment outcomes.

PURPOSE: Rectal cancer outcome depends on stage, technical aspects of surgical excision, and use of adjuvant chemoradiation. Here, we examine effects of positive resection margin and tumor distance from the anus in stage 2 and 3 cancers on 4-year disease-specific survival and recurrence. METHODS: We reviewed all 495 rectal cancer patients registered in British Columbia in 1996. RESULTS: There were 481 cases analyzed: 29 in situ, 134 stage 1, 107 stage 2, 100 stage 3, 83 stage 4, and 28 unknown stage. Survival was significantly affected by presence of positive resection margin in stage 2 and 3 cancers, P = 0.0001. Lower tumor distance from the anus for stage 2 and 3 cancers worsened survival, P = 0.0007, and overall recurrence, P =0.016, but not local recurrence, P = 0.11. Adjuvant postoperative combined radiation and chemotherapy in stage 2 and 3 cancers significantly improved survival, P = 0.070 and local recurrence, P = 0.018, but not overall recurrence, P = 0.19. CONCLUSIONS: Presence of positive resection margin and tumor distance from the anus affect survival, local recurrence, and overall recurrence. Adjuvant postoperative combined radiation and chemotherapy improved our outcomes. Our local recurrence rates for rectal cancers are worse than currently reported standards of less than 10%. Improved surgical excision and use of adjuvant preoperative radiation and chemotherapy may improve outcome.

Spousally Bereaved Elders With Subsyndromal Depression: A Descriptive Analysis and Comparison With Major Depression.

The authors compared the frequency and severity of symptoms in subsyndromal and major depression after spousal bereavement in later life, as well as measures of social support, functional status, and grief intensity. Subsyndromal subjects (n = 25, mean age = 68.1) experienced fewer and less severe depressive symptoms and less functional impairment and anxiety than subjects with major depression (n = 25, mean age = 68.5). In a multivariate discriminant-function analysis (taking into account both symptom frequency and severity), mood, anxiety, early morning awakening, and weight loss correctly identified 92% of subsyndromal subjects and 92% of those with major depression. Further longitudinal study is under way to document the relationship of the current differences in symptomatology and clinical status to clinical outcome.

Premorbid History of Major Depression and the Depressive Syndrome of Alzheimer's Disease.

To test the hypothesis that primary degenerative dementia of the Alzheimer type (PDD-AT) may increase the likelihood of expression of a lifetime vulnerability to the development of depression, the authors compared the premorbid rates of major depression in psychiatric inpatients with dementia, with or without a concurrent syndrome of depression. A premorbid history of major depression was four times more common in patients with the depressive syndrome of PDD-AT than in PDD-AT patients without depression. The authors discuss the significance of these findings for pathophysiologic models and estimates of comorbidity of depression in PDD-AT.

The Use of the Hamilton Rating Scale for Depression in Elderly Patients With Cognitive Impairment and Physical Illness.

The authors performed a prospective study to assess the impact of cognitive impairment and medical burden on the Hamilton Ratingh Scale for Depression (Ham-D) scores in older psychiatric inpatients. Over 1 year, all patients admitted to an acute-care geriatric psychiatry unit were assessed with an instrument that includes an anchored version of the 17-uten Ham-D. Ham-D scores of 72 patients who met DSM-III-R criteria for a major depressive episode were compared with the scores of 31 patients who did not. The scores of a depressed and nondepressed patients were significantly different on admission but not at discharge. By contrast, the Ham-D scores of 11 depressed patients with a primary dementia did not differ either on admission or at discharge from the scores of 61 depressed patients without dementia. Controlling for psychiatric diagnosis, cognitive impairment had no significant effect on Ham-D scores. Medical burden accounted for less than 6% of the variance in admission Ham-D yields valid ratings of the severity of depressive symptoms in elderly patients with a broad range of cognitive impairment and physical illness.

The Symptom Profile and Two-Year Course of Subsyndromal Depression in Spousally Bereaved Elders.

The authors describe the symptom presentation and clinical course of subsyndromal depression in 20 bereaved elderly persons (mean age = 68.0 years) over a period of 2 years from spousal loss. Clinical ratings on measures of general functioning, depressive symptoms, sleep disturbance, medical burden, social support, and social rhythm stability were contrasted for bereaved subjects with subsyndromal depression, nondepressed bereaved subjects, and control subjects who were neither bereaved nor depressed. Subsyndromally depressed subjects had greater impairment in work and pleasure and more pronounced anxiety. Over follow-up, they showed persistently higher bereavement intensity and were more impaired than nondepressed, bereaved subjects on measures of general functioning, sleep quality, and social support, suggesting that subsyndromally depressed, bereaved persons experience greater functional impairment, worse sleep quality, less perceived interpersonal support, and more intense grieving than non-depressed, bereaved subjects up to 2 years after spousal loss.

A Study of Elderly Suicide Attempters Admitted to an Inpatient Psychiatric Unit.

The authors distinguish demographic and clinical characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit within 4 weeks of a suicide attempt. Of 560 patients admitted, 28 (5%) were recent attempters, 32 (6%) had a past history of suicide attempt, and 500 (89%) were nonattempters. Of the 28 recent attempters, 21 (75%) were diagnosed with a mood disorder, 4 (14%) with an organic mental disorder, and 3 (11%) with other mental disorders. Among the nonattempters, the distribution among the three diagnostic categories was 188 (38%), 251 (50%), and 61 (12%), respectively. Of 166 patients with a diagnosis of major depression, 18 (11%) were recent attempters, 14 (8%) were past attempters, and 134 (71%) were nonattempters. Recent attempts were significantly associated with alcohol abuse. This study confirms earlier reports of high rates of major depression in elderly attempters.

Phenomenology and Prevalence of Neuroleptic-Induced Akathisia in Late Life.

The authors examined 115 patients totaling 127 admissions to an acute care geriatric psychiatry inpatient unit using the Barnes Akathisia Scale. Subjective complaints of akathisia were associated with a diagnosis of major depression and correlated with Hamilton Rating Scale for Depression scores but were not associated with current neuroleptic treatment. Objective evidence of akathisia was strongly associated with current neuroleptic use. Patients from 45 admissions were receiving neuroleptics at the time of assessment. By using the presence of objective akathisia to define the syndrome, the authors identified 8 patients from these 45 (17.8%) as having neurolepticinduced akathisia (NIA). The presence of MA was associated with a lower rate of antiparkinsonian agent use. NIA contributed to the presenting complaints on admission in 7 patients, comprising 5.5% of all 127 admissions.

[General and psychopathologic aspects of sexual abuse in children]. / Aspectos generales y psicopatológicos del abuso sexual en niños.

Fifteen cases of sexually abused children, who were treated at a neuropsychiatry unit were reviewed. Age at offense ranged from 5 to 14 years and two thirds of them occurred to girls. Seven cases were rapes. Nine offenders were family members, five were acquaintances and only one was a complete stranger. There cases were those of "father attacking daughter". Two were of "father abusing son", one of which was the rape of a son. Most frequent symptoms after sexual abuse were sleeping disorders (9/15) different kinds of fears (8/15) and depression (6/15). The most common psychopathological features in the parents, were alcoholism (6 cases) and open psychopathic traits in 3 cases (two fathers and one mother). The outcome of these patients was better the greater the family support. The situation is most serious when the aggressor is a family member.

Bone scanning and radiography in the evaluation of patients with malignant lymphoma.

The diagnostic value of bone scintigraphy and radiography in the detection of lymphomatous bone involvement, and the role of bone scintigraphy in the evaluation of lymphomatous bone marrow involvement, were investigated in 41 patients with malignant lymphoma. 10 patients had lymphomatous bone involvement. Whereas scintigraphy detected all the 10 cases, radiography was false negative in 2 cases. The lytic bone lesions on radiography were in most cases not detected by scintigraphy. Scintigraphy is insensitive for the detection of early bone marrow metastases. The simultaneous use of bone scanning and x-ray, however, seems to be helpful in the detection of lymphomatous bone involvement and consequently in the clinical management of patients with malignant lymphoma.