A multi-national survey of experience and attitudes towards commencing home parenteral nutrition for patients with advanced cancer.

INTRODUCTION: Advanced cancer (AC) is increasingly an indication for home parenteral nutrition (HPN) but an area with possible variation in practice between geographical locations. The aims of this study are to explore the views and experiences of international multi-disciplinary teams to determine opinions and practices. METHODS: An online questionnaire was developed with members of the Home Artificial Nutrition and Chronic Intestinal Failure interest group of the European Society for Clinical Nutrition and Metabolism (ESPEN) and distributed to colleagues involved in managing patients with AC on HPN. RESULTS: A total of 220 responses were included from 5 continents including 36 countries, with 90% of all responses from Europe. Predicted survival was a key factor influencing the decision to commence HPN for most respondents 152/220 (75%), with the majority of participants reporting that patients should have a predicted survival of ≥3 months if considered for HPN (≥3 months: n = 124, 56% vs. <3 months: n = 47, 21%, p < 0.001). However, most respondents were not confident about predicting overall survival in more than 50% of cases (confident n = 40, 23% vs not confident n = 135, 77%, p < 0.001). Barriers to utilising HPN in AC included colleagues' objections (n = 91, 46%), lack of local expertise (n = 55, 28%) and funding restrictions (n = 34, 17%). CONCLUSIONS: Significant consensus was observed regarding AC as indication for HPN, while areas of variation exist. Survival prognostication is often used as an indication for commencing HPN in people with AC, although the majority of respondents were not confident in prognosticating, suggesting better clinical prognostication tools will be of assistance. Further studies are also required to better understand the obstacles faced by clinical teams to commencing HPN that may explain variations in clinical practice between countries, as well as adressing variation in funding.

Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system.

PURPOSE: In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence. METHODS: We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia. RESULTS: We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year. CONCLUSION: The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Note: Electrostatic detection of stainless steel dust particles for fusion applications.

Dust accumulation inside next-step fusion devices poses a significant safety concern and dust diagnostics will be needed to assure safe operations. An electrostatic dust detection device has been successfully demonstrated in the National Spherical Torus Experiment, Tore Supra, and the Large Helical Device, and the detector's response to carbon particles was previously characterized in laboratory experiments. This paper presents laboratory results showing that detection of stainless steel particles at levels as low as several µg/cm(2) is also possible.

Death and illness as depicted in the media.

INTRODUCTION: The media may affect how illness is perceived, in terms of its prevalence, severity and outcomes. The media also influences our perception of death and leads to an overestimation of incidence of some causes of mortality. Articles depicting medical subjects may not be in-depth and are often influenced by non-medical issues. The media has both a positive impact on the population, in providing opportunistic health information, and a negative impact, causing an overestimation of severity and incidence of certain diseases. This article aims to assess if media reporting of illness and death represents national statistics. METHOD: The 10 most common daily read UK newspapers were assessed for articles relating to the most common causes of UK mortality. The searches were performed via each newspaper's online search facility over a 12-month period. Where appropriate, media friendly terms were used as search terms. RESULTS: A total of 18,482 pertinent articles were found relating to the most common causes of death in the UK. When the reportage of illness was compared with the actual incidence cerebrovascular accidents and chronic obstructive pulmonary disease were under-represented in the media, with ratios 0.31 and 0.01 to 1, respectively. Flu/pneumonia, prostate cancer, dementia and breast cancer all have a large media profile, with ratios of 5.52, 3.06, 4.09 and 4.9 to 1, respectively. CONCLUSION: The media has a significant impact on our perceptions of illness and death. This may influence how patients seek medical attention and their concerns at consultation. Strategies to improve the educational content of the media may enhance the dissemination of health information via this resource.

Signal transduction and gene expression in cultured accessory olfactory bulb neurons.

Glutamate and norepinephrine (NE) are believed to mediate the long-lasting synaptic plasticity in the accessory olfactory bulb (AOB) that underlies pheromone recognition memory. The mechanisms by which these neurotransmitters bring about the synaptic changes are not clearly understood. In order to study signals that mediate synaptic plasticity in the AOB, we used AOB neurons in primary culture as a model system. Because induction of pheromone memory requires coincident glutamatergic and noradrenergic input to the AOB, and requires new protein synthesis, we reasoned that glutamate and NE must induce gene expression in the AOB. We used a combination of agonists that stimulate alpha1 and alpha2 adrenergic receptors in combination with N-methyl-d-aspartic acid and tested expression of the immediate-early gene (IEG) c-Fos. We found that the glutamatergic and noradrenergic stimulation caused significant induction of c-Fos mRNA and protein. Induction of c-Fos was significantly reduced in the presence of inhibitors of protein kinase C, mitogen-activated protein kinase (MAPK) and phospholipase C. These results suggest that glutamate and NE induce gene expression in the AOB through a signaling pathway mediated by protein kinase C and MAPK.

Factors associated with African Americans' enrollment in a national cancer genetics registry.

This study explored whether reactions to the Cancer Genetics Network (CGN) or CGN enrollment differed by receipt of a standard informational brochure versus a targeted version addressing factors previously associated with African Americans' health behavior decisions and research participation. The 262 participants, identified through tumor registries or clinic contacts, were mailed brochures and completed phone interviews. When asked whether - based on the brochure - they were or were not 'leaning toward' CGN enrollment, about 75% of both standard and targeted groups reported leaning toward. When given the opportunity at the end of the interview, 68% enrolled in the CGN. Trust was strongly related to enrollment. Less education, less satisfaction with cancer care, and individualistic rather than collective orientation were associated with lower trust. Education was also bivariately associated with enrollment, but mediation analysis indicated that the operational mechanism of education's influence on enrollment was through trust.

Do benefits and barriers differ by stage of adoption for colorectal cancer screening?

In 2003, over 148,300 people were expected to be diagnosed and 56,000 to die from colorectal cancer (CRC). First-degree relatives (FDRs) of people with colon cancer have a two- to eight-fold increased risk for CRC. Despite evidence that screening is effective, adherence with screening recommendations in this at-risk population is low. This study's purposes were to (1) identify perceived benefits and barriers of fecal occult blood testing (FOBT), sigmoidoscopy and colonoscopy, and (2) compare demographic characteristics and perceived benefits and barriers by stage of adoption for CRC screening. Participating FDRs (n = 257) completed a 40-min structured telephone interview. Despite high rates of agreement with the benefits of screening, most FDRs were not contemplating being screened. Of those 50 and older, most were in precontemplation for FOBT, sigmoidoscopy and colonoscopy. Older age was related to stage for FOBT and sigmoidoscopy, but not colonoscopy. Lack of provider recommendation also was related to stage. Consistent with theoretical predictions, precontemplators had (1) higher rates of endorsement of specific barriers to screening and (2) lower rates of endorsement of benefits than contemplators or actors. For morbidity and mortality reduction, participation in routine, periodic screening is imperative. These findings can guide development of screening-promoting interventions.

The effect of Helicobacter pylori infection on levels of DNA damage in gastric epithelial cells.

BACKGROUND: Helicobacter pylori infection leads to an increased risk of developing gastric cancer. The mechanism through which this occurs is not known. We aimed to determine the effect of H. pylori and gastritis on levels of DNA damage in gastric epithelial cells. METHODS: Epithelial cells were isolated from antral biopsies from 111 patients. DNA damage was determined using single cell gel electrophoresis and the proportion of cells with damage calculated before and 6 weeks after eradication of H. pylori. Cell suspensions generated by sequential digestions of the same biopsies were assayed to determine the effect of cell position within the gastric pit on DNA damage. RESULTS: DNA damage was significantly higher in normal gastric mucosa than in H. pylori gastritis [median (interquartile range) 65% (58.5-75.8), n = 18 and 21% (11.9-29.8), n = 65, respectively, p <.001]. Intermediate levels were found in reactive gastritis [55.5% (41.3-71.7), n = 13] and H. pylori negative chronic gastritis [50.5% (36.3-60.0), n = 15]. DNA damage rose 6 weeks after successful eradication of H. pylori[to 39.5% (26.3-51.0), p =.007] but was still lower than in normal mucosa. Chronic inflammation was the most important histological factor that determined DNA damage. DNA damage fell with increasing digestion times (r = -.92 and -.88 for normal mucosa and H. pylori gastritis, respectively). CONCLUSIONS: Lower levels of DNA damage in cells isolated from H. pylori infected gastric biopsies may be a reflection of increased cell turnover in H. pylori gastritis. The investigation of mature gastric epithelial cells for DNA damage is unlikely to elucidate the mechanisms underlying gastric carcinogenesis.

Examining the boundaries of tailoring: the utility of tailoring versus targeting mammography interventions for two distinct populations.

Health messages can be generic, targeted to population subsets or tailored for individual recipients. There has been little examination of which populations need tailored interventions or whether tailored and targeted interventions differ in important ways. We used data from a mammography intervention study in two distinct populations to simulate a comparison of individually tailored versus targeted interventions. Tailored intervention content was based on individual recipients' interview responses. Targeted intervention content was based on composite group responses. For more than 60% in each population group, about two-thirds of tailored message content was a good match with content of the targeted intervention generated by composite group responses; roughly one-third of the content was 'not a good' fit for their intervention needs. Tailored interventions for more than 80% of subjects in each population differed in at least some way from those generated for all other population group members. This simulation is a first step in quantifying the contribution of individual tailoring over group targeting. Future research should examine whether a targeted intervention that is mostly a 'good' match results in behavioral outcomes similar to those of individually tailored interventions and whether particular differences in tailored versus targeted interventions yield significantly more favorable intervention outcomes.

Perceptions of genetic risk assessment and education among first-degree relatives of colorectal cancer patients and implications for physicians.

BACKGROUND: Genetic risk assessment and education is a clinical service that provides an opportunity for individuals with a strong family history of cancer to understand their risk better, identify a screening regimen and discuss benefits and limitations of genetic testing. OBJECTIVES: The aim of this study was to assess knowledge of and attitudes to genetic risk assessment and education among first-degree relatives of patients with colorectal cancer. METHODS: We conducted focus groups among first-degree relatives of patients with colorectal cancer to assess perceptions of genetic risk assessment and education. In the groups, we elicited reactions using two definitions of genetic risk assessment and education-one brief and one more detailed-that might be used by a health practitioner during the referral process. RESULTS: Findings revealed a number of misconceptions and concerns including: (i) what is required to prepare for a session and a lack of desire to collect a family history; (ii) what is involved in a session (including assuming that genetic testing is always included in a session); (iii) distrust over accuracy and possible subjectivity of information provided; and (iv) fear of the effect that participation in a session might have on insurance status. CONCLUSIONS: The findings suggest that health practitioners should educate individuals about genetic risk assessment and education during the initial referral process. Further studies should explore how best to do this.

Women's interest in chemoprevention for breast cancer.

BACKGROUND: Chemoprevention is the use of pharmacologic or natural agents to inhibit the development of cancer. Tamoxifen citrate is the only approved chemopreventive agent for breast cancer. We sought to determine whether women are interested in taking a drug to prevent breast cancer and to assess the relationship between objective and subjective breast cancer risk and interest in chemoprevention. METHODS: We conducted telephone interviews (November 3, 1997, to May 6, 1998) among a community sample of women aged 40 to 45 and 50 to 55 years enrolled in a randomized controlled trial to evaluate the efficacy of a tailored mammography decision aid. Objective breast cancer risk was measured using the 5-year Gail score. Subjective breast cancer risk was measured using perceptions of absolute risk, perceptions of comparative risk, and worry about getting breast cancer. At 12-month follow-up (November 2, 1998, to July 20, 1999), we measured interest in taking a drug to prevent breast cancer. RESULTS: Among the 1273 women surveyed, 23% were interested in taking a drug to prevent breast cancer; 8% were potentially eligible for tamoxifen therapy (5-year Gail score > or = 1.66%). Eligibility for chemoprevention, based on the 5-year Gail score, was not associated with interest in taking a drug to prevent breast cancer. Women who were worried about breast cancer were 3 times more likely to be interested in taking a drug to prevent breast cancer than those who were not worried. CONCLUSION: Women's interest in chemoprevention might arise more from worries about getting breast cancer than from their objective risk factors.

Lack of association of the (AAAT)6 allele of the GXAlu tetranucleotide repeat in intron 27b of the NF1 gene with autism.

A novel allele of the GXAlu tetranucleotide repeat in intron 27b of the neurofibromatosis 1 (NF1) gene has recently been reported to be present in 4.7% of autistic patients but not in controls. We have found the novel GXAlu allele absent in 204 patients from the South Carolina Autism Project and 200 controls. The autism population studied includes a significant number of patients with hypotonia, stereotyped behaviors, or postural, gait, and motor abnormalities similar to those seen in the patients previously reported to possess the novel GXAlu allele. This suggests that the novel (AAAT)6 GXAlu allele is not associated with autism.

The short-term impact of tailored mammography decision-making interventions.

BACKGROUND: We assessed the short-term impact of decision-making interventions on knowledge about mammography, accuracy of women's breast cancer risk perceptions, attitudes toward mammography, satisfaction with decisions, and mammography use since the intervention. METHODS: The study was conducted among women who were members of Blue Cross Blue Shield of North Carolina and were in their 40s or 50s at the time the study began in 1997. Women were randomly assigned to usual care (UC), tailored print booklets (TP) alone, or TP plus telephone counseling (TP+TC ). RESULTS: 12-month interviews were completed by 1127 women to assess short-term intervention effects. Generally, women who received TP+TC were significantly more knowledgeable about mammography and breast cancer risk and were more accurate in their breast cancer risk perceptions than women in the TP and UC groups. They also were more likely to have had a mammogram since the baseline interview. In multivariable analyses, we found significant benefits of the combination of TP+TC compared to TP and to UC for knowledge, accuracy of risk perceptions, and mammography use. DISCUSSION: For complex decision-making tasks, such as women's decisions about mammography in the face of controversy, the combination of TP and TC may be more effective than TP alone, and certainly more effective than UC. It is critical that investigators determine the topics for which TP is appropriate and the situations that require additional supportive interventions.

The effects of standard care counseling or telephone/in-person counseling on beliefs, knowledge, and behavior related to mammography screening.

PURPOSE/OBJECTIVES: To determine the most effective methods of increasing mammography adherence while also considering ease of intervention delivery in evolving healthcare systems. DESIGN: Experimental. SETTING: Women from a health maintenance organization and a large general medicine practice. SAMPLE: Women 50-85 years of age who had not had breast cancer and did not have a mammogram within the last 15 months. METHODS: Once consent and baseline information were obtained, women were randomized to receive in-person, telephone, or no mammography counseling. MAIN RESEARCH VARIABLES: Mammography adherence, perception of susceptibility to breast cancer, and benefits, barriers to, and knowledge of mammography. FINDINGS: Compared to standard care, telephone counseling was more than twice as effective at increasing mammography adherence, whereas in-person counseling resulted in almost three times the mammography adherence postintervention. Both telephone and in-person counseling are successful in changing perceived susceptibility, knowledge, barriers, and benefits. CONCLUSION: Both telephone and in-person counseling interventions were successful in changing beliefs, which, in turn, increased mammography adherence. IMPLICATIONS FOR NURSING PRACTICE: Interventions based on altering beliefs are effective for increasing mammography adherence.

Additional factors for the estimation of mean glandular breast dose using the UK mammography dosimetry protocol.

The UK and European protocols for mammographic dosimetry use conversion factors that relate incident air kerma to the mean glandular dose (MGD) within the breast. The conversion factors currently used were obtained by computer simulation of a model breast with a composition of 50% adipose and 50% glandular tissues by weight (50% glandularity). Relative conversion factors have been calculated which allow the extension of the protocols to breasts of varying glandularity and for a wider range of mammographic x-ray spectra. The data have also been extended to breasts of a compressed thickness of 11 cm. To facilitate the calculation of MGD in patient surveys, typical breast glandularities are tabulated for women in the age ranges 40-49 and 50-64 years, and for breasts in the thickness range 2-11 cm. In addition, tables of equivalent thickness of polymethyl methacrylate have been provided to allow the simulation for dosimetric purposes of typical breasts of various thicknesses.

Factors associated with repeat mammography screening.

BACKGROUND: Even organizations with differing mammography recommendations agree that regular repeat screening is required for mortality reduction. However, most studies have focused on one-time screening rather than repeat adherence. We compare trends in beliefs and health-related behaviors among women screened and adherent to the National Cancer Institute's screening mammography recommendations (on schedule), those screened at least once and nonadherent (off schedule), and those never screened. METHODS: Our data are from a baseline telephone interview conducted among 1,287 female members of Blue Cross Blue Shield of North Carolina who were aged either 40 to 44 years or 50 to 54 years. RESULTS: The 3 groups differed significantly on beliefs and health-related behaviors, with the off-schedule group almost consistently falling between the on-schedule and never screened groups. Off-schedule women were more likely than on-schedule women, but less likely than those never screened, to not have a clinical breast examination within 12 months, to be ambivalent about screening mammography, to be confused about screening guidelines, and to not be advised by a physician to get a mammogram in the past 2 years. Off-schedule women perceived their breast cancer risk as lower and were less likely to be up to date with other cancer screening tests. CONCLUSIONS: Our findings suggest that women who are off schedule are in need of mammography-promoting interventions, including recommendations from and discussion with their health care providers. Because they are more positive and knowledgeable about mammography than women who have never been screened, they may benefit from brief interventions from health care providers that highlight the importance of repeat screening.

Lesbians and cervical screening.

Confusion exists in clinical practice about whether lesbians should be offered routine cervical smears. We found cervical smear abnormalities in a sample of 624 lesbians, including those who had never been sexually active with men. These findings suggest that lesbians should be routinely offered cervical cytology as part of the national screening programme. Evidence of human papilloma virus (HPV) infection in the 'exclusively lesbian' group indicates that sexual transmission of HPV may occur between women. The belief by some lesbians that they have less need for cervical smears, coupled with poor uptake of cervical screening by a significant proportion, demonstrates a need for education of lesbians and health service providers.

Outcomes of the Learn, Share & Live breast cancer education program for older urban women.

OBJECTIVES: This study assessed whether the Learn, Share & Live breast cancer education program resulted in favorable, replicable, and sustainable outcomes. METHODS: The program was implemented at index (year 1) and replication (year 2) sites. Baseline interviews (year 1; n = 240) and 2 follow-up telephone interviews (years 2 and 3; n = 337 and 323) were used to assess postintervention changes. RESULTS: From baseline to year 2, mammography adherence and stage of adoption improved at the index site relative to the replication site. Knowledge scores and percentages of respondents reporting that a friend had spoken with them about mammography improved significantly. Improvements were sustained through year 3 (2 years postintervention). In year 3, replication participants showed improvements in regard to knowledge and perceived mammography benefits, and there was a trend toward increased adherence. Site differences in postintervention adherence may have stemmed from respective choices of follow-up activities. CONCLUSIONS: The study outcomes affirm the impact of Learn, Share & Live, indicating a replicated and sustained program effect. Future studies should continue longer follow-up and explore the importance of providing mammography opportunities along with education.

In vivo DNA damage in gastric epithelial cells.

A number of risk factors have been linked epidemiologically with gastric cancer, but studies of DNA damage in gastric epithelial cells are limited. The comet assay is a simple technique for determining levels of DNA damage in individual cells. In this study, we have validated the comet assay for use in epithelial cells derived directly from human gastric biopsies, determined optimal conditions for biopsy digestion and investigated the effects of oxidative stress and digestion time on DNA damage. Biopsies taken at endoscopy were digested using combinations of pronase and collagenase, ethylenediaminetetra-acetic acid (EDTA) and vigorous shaking. The resultant cell suspension was assessed for cell concentration and epithelial cell and leukocyte content. A score for DNA damage, the comet %, was derived from the cell suspension, and the effect of various digestion conditions was studied. Cells were incubated with H(2)O(2) and DNA damage was assessed. Pronase and collagenase provided optimum digestion conditions, releasing 1. 12x10(5) cells per biopsy, predominantly epithelial. Of the 23 suspensions examined, all but three had leukocyte concentrations of less than 20%. The comet assay had high inter-observer (6.1%) and inter-assay (4.5%) reproducibility. Overnight storage of the biopsy at 4 degrees C had no significant effect on DNA migration. Comet % increased from a median of 46% in untreated cells to 88% in cells incubated for 45 min in H(2)O(2) (p=0.005). Serial 25-min digestions were performed on biopsies from 13 patients to release cells from successively deeper levels in the crypt. Levels of DNA migration were significantly lower with each digestion (r=-0.94, p<0.001), suggesting that DNA damage is lower in younger cells released from low in the gastric crypt. The comet assay is a reproducible measure of DNA damage in gastric epithelial cells. Damage accumulates in older, more superficial cells, and can be induced by oxidative stress.

Testing for hereditary breast and ovarian cancer in the southeastern United States.

OBJECTIVES: To detail characterization of mutations and uncharacterized variants in the breast cancer susceptibility genes BRCA1 and BRCA2, as observed in a population of breast cancer patients from the southeastern United States, and to examine baseline characteristics of women referred for counseling and testing and provide a preliminary look at how counseling and testing affected intentions toward prophylactic surgery. BACKGROUND: Mutations in the BRCA1 and BRCA2 genes give rise to a dramatically increased risk of developing breast or ovarian cancer or both. There are many reports about special populations in which deleterious mutations are present at a high frequency. It is useful to study these genes in more heterogeneous populations, reflecting different geographic regions. Interest in preventive surgery for gene carriers is high in women and their surgeons. METHODS: Women were recruited through a prospective clinical trial of counseling and free genetic testing. BRCA1 and BRCA2 were screened for mutations using standard techniques, and results were given to participants. Baseline questionnaires determined interest in preventive surgery at the beginning of the study. Follow-up questionnaires for those who completed testing surveyed interest in prophylactic surgery after counseling and receiving test results. RESULTS: Of 213 women who completed counseling and testing, 44 (20.6%) had 29 separate mutations; there were 11 Jewish women carrying three founder mutations. Twenty-eight women (13.1%) had uncharacterized variants in BRCA1 or BRCA2; nine were not previously reported. Women overestimated their chances of possessing a deleterious gene mutation compared to a statistical estimate of carrier risk. A number of women changed their intentions toward preventive surgery after genetic counseling and testing. CONCLUSIONS: Hereditary breast cancer due to mutations in BRCA1 and BRCA2 was a heterogeneous syndrome in the southeastern United States. Most mutations were seen just once, and uncharacterized variants were common and of uncertain clinical significance. In general, positive test results tended to reinforce intentions toward prophylactic surgery. In contrast, women not interested in surgery at the time of entry tended to remain reluctant after testing and counseling.