Exploring reasons for overuse of contralateral prophylactic mastectomy in Canada.

Background: Contralateral prophylactic mastectomy (cpm) in women with known unilateral breast cancer (bca) has been increasing despite the lack of supportive evidence. The purpose of the present study was to identify the determinants of cpm in women with unilateral bca. Methods: This qualitative descriptive study used semi-structured interviews informed by the Theoretical Domains Framework. We interviewed 74 key informants (surgical oncologists, plastic surgeons, medical oncologists, radiation oncologists, nurses, women with bca) across Canada. Interviews were analyzed using thematic analysis and an analysis for shared and discipline-specific beliefs. Results: In total, 58 factors influencing the use of cpm were identified: 26 factors shared by various health care professional groups, 15 discipline-specific factors (identified by a single health care professional group), and 17 factors shared by women with unilateral bca. Health care professionals identified more factors discouraging the use of cpm (n = 26) than encouraging its use (n = 15); women with bca identified more factors encouraging use of cpm (n = 12) than discouraging its use (n = 5). The factor most commonly identified by health care professionals that encouraged cpm was lack of awareness of existing evidence or guidelines for the appropriate use of cpm (n = 44, 75%). For women with bca, the factor most likely influencing their decision for cpm was wanting a better esthetic outcome (n = 14, 93%). Conclusions: Multiple factors discouraging and encouraging the use of cpm in unilateral bca were identified. Those factors identify potential individual, team, organization, and system targets for behaviour change interventions to reduce cpm.

Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study.

Background: Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm. Methods: A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions. Results: The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da. Conclusions: The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.

Implications of the Kidd blood group system in renal transplantation.

The association of the Kidd blood group system with hemolytic transfusion reactions and hemolytic disease of the newborn is well known. The Kidd antigens, which are localized to the HUT/UT-B urea transport protein, are found on red blood cells and the endothelial cells of the blood vessels of the medulla of the kidney. Recently it has been suggested that these antigens might play a role as minor histocompatibility antigens in renal transplantation. In the current case, the appearance of an anti-Jk(b) 10 years after renal transplantation associated with early renal allograft rejection further supports the potential importance of these antigens in renal transplantation and allograft rejection.

Effects of shift length on quality of patient care and health provider outcomes: systematic review.

BACKGROUND: Healthcare providers work increasingly under a variety of shift work systems to cover the continuous care required by patients. However, the effects of shift work on patient and provider outcomes in healthcare settings has not been systematically evaluated. OBJECTIVE: To identify and analyse the available evidence on the effect of shift length (8-h vs 12-h shifts) on quality of patient care and healthcare provider outcomes. METHODS: Systematic searching of eight online databases, key governmental/organisational websites and academic journals with ancestry search of relevant articles (limited to articles published in English and Spanish). RESULTS: Of 562 articles that were retrieved from 20 446 titles identified through database and manual searches, 27 satisfied the inclusion criteria, of which 15 were rejected because of low methodological quality. The 12 final studies included cross-sectional/survey (7), before-after (3) and prospective cohort (2) designs. The main primary outcomes evaluated were: (1) quality of patient care and (2) healthcare provider outcomes. The results were equivocal. With respect to the effect of shift length on quality of patient care, two studies found that errors and near errors were associated with working longer shifts, and another study reported decreased patient complications and length of stay with longer shifts. Specific healthcare provider outcomes such as health complaints, well-being, drug and alcohol consumption, stress and job satisfaction were mostly evaluated by single studies and therefore there was insufficient evidence from which to draw conclusions. CONCLUSIONS: Methodological quality of the studies generally was low and results equivocal with insufficient evidence to determine the effects of shift length on quality of patient care and healthcare provider outcomes. Clearly, robust well-designed studies are needed to examine the effect of shift length on patient and healthcare provider outcomes.

Mother-to-child transmission of the human immunodeficiency virus in Texas.

BACKGROUND: The Pediatric Spectrum of HIV Diseases (PSD) project has been collecting data on HIV-exposed children in Texas since 1989. These data have now been analyzed to describe mother-to-child transmission in Texas and to provide much needed information on the magnitude of the pediatric HIV epidemic in the state. METHODS: We examined trends in the numbers of perinatally exposed children and perinatally acquired cases of HIV in the Texas PSD cohort. We calculated transmission rates and relative risks for 656 children born from January, 1995, to July, 1998, that received all or part of the ACTG 076 regimen. RESULTS: Only a small proportion (38%) of pairs of an HIV-infected mother and her HIV-exposed child received the full AIDS Clinical Trial Group 076 (ACTG 076) regimen; only 73% of the mothers received at least some prenatal care. In recent years, however, the numbers of perinatally exposed children and perinatally acquired cases of HIV have decreased in Texas. Univariate analyses showed that a reduction in the vertical transmission of HIV was associated with receipt of a full ACTG 076 regimen, receipt of a partial ACTG 076 regimen and residence in Dallas County. CONCLUSIONS: Findings identify a gap in meeting the health care needs of pregnant HIV-infected women and suggest missed opportunities to prevent mother-to-child transmission of HIV. At the same time this study confirms progress in prevention efforts to reduce mother-to-child transmission of HIV in Texas.

Immunization status of children born to human immunodeficiency virus (HIV)-infected mothers in two Texas cities.

BACKGROUND: Because HIV-infected and HIV-exposed children are at risk of acquiring infectious diseases, they should be immunized. METHODS: We abstracted charts at pediatric HIV clinics in Dallas and San Antonio, matched the children to birth certificates and assessed up-to-date immunization status. RESULTS: Of the 178 children, 108 (61%) were up to date for the diphtheria-tetanus-pertussis (DTP), polio, and measles-mumps-rubella (MMR) series. In multivariate analysis, predictors of delayed immunization included maternal high-risk sexual partners and infant antiretroviral therapy. CONCLUSION: In this population of children born to HIV-infected mothers, immunizations were up to date in 61%, a figure that exceeds or equals immunization levels for other Texas children. Texas falls short of the recommended goal of 90% immunization for children of HIV-infected mothers and healthy children.

Plateletpheresis in 90- to 110-pound donors using the CS-3000 blood cell separator.

BACKGROUND: Increases in the use of single-donor apheresis components have increased the need for platelet donors. In the United States, persons must weigh 110 pounds or more to qualify as blood donors, and the same weight limitation has been placed on apheresis donors. Because automated plateletpheresis with some instruments differs considerably from whole-blood donation with respect to the volume of blood removed from the donor, the feasibility of using persons weighing between 90 and 110 pounds as platelet donors was evaluated by the use of the CS-3000 blood cell separator. STUDY DESIGN AND METHODS: The study was performed using female subjects who met all usual donor requirements except for minimum weight. The standard platelet collection procedure of the instrument was used, except that the blood processing rate was manually selected so as to optimize the blood withdrawal and return rate in individuals. Vital signs were recorded before and after donation as were signs or symptoms of any type of donor reaction. RESULTS: Twenty-six of 28 women completed the donation procedure; in two instances, collection was terminated prematurely because of an inability to maintain adequate venous access. An average of 4.5 x 10(11) platelets were collected during a mean donation time of 110 minutes. All donors tolerated the procedure well, and no serious adverse reactions were seen. Because of the administration of priming solution and anticoagulant during apheresis, there was a net positive fluid balance following the procedure, in spite of the removal of approximately 220 mL of platelet concentrate. CONCLUSION: These preliminary studies suggest that 90- to 110-pound persons may serve as plateletpheresis donors. Additional studies are needed to more fully document the safety and efficacy of this approach. The use of lower-weight donors may significantly increase the number of persons available to provide single-donor platelet components.

Use of Foley catheter to examine estrogenized hymens for evidence of sexual abuse.

An examination technique for the collection of evidence to document physical findings of sexual abuse of children uses a Foley catheter in older girls with estrogenized hymens. The inflated balloon in the distal vaginal vault puts pressure on the hymen, effectively stretching it out and allowing for a more accurate view of the hymen edges. This report demonstrates the results in 2 of 17 adolescent girls who underwent the Foley catheter stretch technique. Patient 1 was a 13-year-old girl who gave a statement of repeated sexual abuse, including penile penetration by an adult male. Patient 2 was a 12-year-old girl who disclosed a single episode of sexual assault 1 year previously. After careful examination, a Foley catheter (14 Fr) was inserted through the hymen orifice and inflated using 40 ml of air. Gentle pulling toward the orifice resulted in stretching of the hymenal tissues over the balloon surface of the catheter. After photodocumentation of the anatomy of the hymen edges, the balloon was deflated and removed.

T cell activation and human immunodeficiency virus replication after influenza immunization of infected children.

BACKGROUND: T cell activation plays a major role in the ability of HIV to remain latent or to establish a productive infection. It has been hypothesized that vaccination-mediated immune stimulation can activate T cells and enhance HIV replication. Our study was designed to determine whether influenza immunization would induce T cell activation and increase HIV burdens in HIV-infected children. METHODS: Blood samples from 16 HIV-infected children ages 6 months to 14 years were obtained immediately before and 2 and 6 to 8 weeks after the administration of influenza vaccine. The percentage of activated (CD25+) T cells was determined by flow cytometry, and HIV viral load was measured by quantitative cultures of peripheral blood mononuclear cells and plasma HIV RNA. RESULTS: The administration of influenza vaccine was associated with significant increases in HIV viral load in 5 of 16 children evaluated. These increases in HIV burden were transient, and in four of five patients the plasma HIV RNA copy number returned to baseline 6 to 8 weeks after immunization. There was no correlation between the patient's immunologic or clinical category according to the CDC classification and either the initial viral load or the likelihood of having a significant increase after immunization. Four of the five patients who experienced increases in viral load after influenza immunization were not receiving antiretroviral therapy. CONCLUSIONS: Our results emphasize the need for additional studies that examine the effect of routine immunizations on T cell activation and HIV replication in HIV-infected children.

Lactate dehydrogenase isoenzyme-1 in serum for detection of peri-operative myocardial infarction after cardiac surgery.

We prospectively studied changes in serum lactate dehydrogenase isoenzyme-1 (LD-1, EC 1.1.1.27) in 99 consecutive patients after either coronary artery bypass grafting (CABG, n = 61), isolated cardiac-valve replacement (n = 24), or the two procedures combined (n = 14); 86 of these had no clinical evidence of peri-operative myocardial infarction (MI). Blood was sampled immediately after surgery and at 6-h intervals for up to 42 h thereafter. LD-1 was isolated by using the LD M-subunit antiserum. Samples from the non-MI patients were used to establish the reference intervals for LD-1. By 24 h after surgery, mean serum LD-1 values were higher (P less than 0.001) in non-MI patients who underwent isolated valve replacement (222 +/- 74 U/L) or combined CABG and valve replacement (266 +/- 58 U/L) than in 50 non-MI patients who underwent CABG alone (134 +/- 42 U/L). Separate reference intervals were determined for CABG and other patients at each sampling time. By 24 h after operation, LD-1 exceeded these reference intervals in the 10 CABG and two combined-procedure patients in whom other evidence of MI was present. Measurement of LD-1 24 to 42 h after cardiac surgery appears to be a useful test for the diagnosis of perioperative MI.

Prolonged relief of intractable pruritus in primary sclerosing cholangitis by plasmapheresis.

We report a patient with intense pruritus in primary sclerosing cholangitis (PSC) who had long symptomatic remissions of pruritus after plasmapheresis therapy. The successful therapy may be related to removal of immune complexes as there was no lasting effect on the patient's liver function tests.

Posttransfusion crises in sickle cell anemia: role of delayed hemolytic reactions to transfusion.

We describe ten patients with sickle cell anemia who became acutely ill within a few days after a blood transfusion. Two patients died. In eight cases the posttransfusion detection of alloantibodies suggested that delayed hemolytic reactions to transfusion were involved in precipitating the acute illness. In some cases the illnesses mimicked vaso-occlusive crises, with bone marrow infarction, while in other cases transient biliary obstruction or transient renal insufficiency was documented. Profound anemia mimicked aplastic crises, but we observed a remarkable capacity of the bone marrow to restore the hemoglobin level without further transfusion. In view of the prevalence of delayed hemolytic transfusion reactions in these patients receiving frequent transfusions and whose red cell antigens differ from those of the white population, we suggest that efforts to more closely match recipient and donor red cell antigens would be clinically, technically, and financially advantageous. Moreover, criteria for transfusion in sickle cell anemia should be strictly scrutinized. Quantitation of transfused hemoglobin A has proved useful in confirming delayed hemolytic reactions in sickle cell disease.

Tolmetin-induced hemolysis.

A case of drug-associated immune hemolysis in a patient taking tolmetin for arthritic pain is described. Serologic tests showed that in the absence of tolmetin, the patient had a negative antibody screening test but a strongly positive direct antiglobulin test. An eluate prepared from the patient's red cells caused agglutination of all cells tested. However, addition of tolmetin revealed a high-titered tolmetin-dependent antibody in the patient's serum; the addition of tolmetin did not affect the results obtained with the eluate. within 3 months after the patient discontinued tolmetin, his hematocrit had increased to 45 percent, and his jaundice and bilirubinuria had disappeared. These results are similar to those described for zomepirac, another of the group of nonsteroidal anti-inflammatory medications.

A delayed hemolytic transfusion reaction due to anti-Cob.

A delayed hemolytic transfusion reaction precipitated by anti-Cob is described in a multiple transfused primigravida woman with sickle-cell disease. Sixteen days after the prophylactic transfusion of the first of 4 units of red cells, she experienced a fall in hemoglobin concentration accompanied by a newly positive antibody screen and direct antiglobulin test. Anti-Cob was identified both in the patient's serum and in an eluate prepared from her red cells.

Histocompatibility leukocyte antigen and erythrocyte MNSs specificities in patients with meningitis or epiglottitis due to Haemophilus influenzae type b.

The frequencies of erythrocyte MNSs antigens and certain histocompatibility leukocyte antigen (HLA) specificities (HLA-A, HLA-B, and HLA-DR) were determined in white patients with meningitis or epiglottitis due to Haemophilus influenzae type b and in controls. The frequency of the erythrocyte MNSs genotype was significantly lower among patients with meningitis than among those with epiglottitis (P = 0.03); this observation confirms a trend observed previously. However, the frequencies of the HLA specificities did not differ significantly in the three groups studied; this result fails to confirm previous reports of disease associations with several HLA-A and HLA-B specificities. Although susceptibility to different clinical manifestations of haemophilus disease may be influenced by genetic factors, our studies indicate that the major loci conferring susceptibility are not in linkage disequilibrium with specificities in the major histocompatibility complex.

Siblings of patients with Haemophilus meningitis have impaired anticapsular antibody responses to Haemophilus vaccine.

Siblings of patients with type b Haemophilus influenzae meningitis are at increased risk of developing Haemophilus disease. We immunized 26 healthy siblings and 25 control subjects using a vaccine containing the type b polysaccharide capsule (10 micrograms PRP) and pertussis vaccine (4 opacity units) (Lederle Laboratories) to determine whether siblings of patients with Haemophilus meningitis had an impaired antibody response to PRP. Using two intramuscular injections one month apart, we found that the siblings had a lower response to PRP. One month after the second injection, 12 of 24 of the siblings had serum concentrations of anticapsular (PRP) antibody thought to be sufficient to confer protection against Haemophilus disease (greater than or equal to 300 ng/ml), compared with 19 of 24 of the control children tested (50% vs 79%, P = 0.035 by chi-square analysis). In comparison with the normal controls, the siblings produced significantly less IgG anti-PRP antibody but similar amounts of IgM. The impaired responsiveness to PRP was most evident among the 16 children born after their sibling had meningitis and who were not known to have been exposed to type b Haemophilus infection previously. These data indicate that siblings of some patients with type b Haemophilus meningitis have reduced ability to form IgG anti-PRP antibody, which may be associated with increased susceptibility to Haemophilus disease.

Vitamin and mineral provision during enteral nutrition.

The adequacy of vitamin and mineral provision during enteral nutrition for a period of at least two weeks was studied in 20 patients. Significant increases were observed in plasma levels of vitamins C and E, and in B2, B6 and folate status. No significant changes were observed in vitamins A, B1, B12 or in plasma magnesium, zinc or copper. The requirements for vitamins and minerals during enteral nutrition are discussed.