What happens when peer support workers are introduced as members of community-based clinical mental health service delivery teams: a qualitative study.

The insights of people who have experienced mental health issues are at the core of recovery frameworks. The inclusion of peer support workers in clinical care teams is crucial to a recovery-supportive focus. Peer support workers facilitate egalitarian spaces for non-peer staff and consumers to frankly discuss the lived experience of mental illness. This study was part of a larger evaluation study which aimed to explore the implementation of a newly formed community-based mental health team in South-East Queensland, Australia. The paper reports the role of peer support workers and answers two research questions: "How is peer support work constructed in an interprofessional clinical care team?" and (2) "How do interprofessional mental health clinical care teams respond to the inclusion of peer support workers as team members?" Three themes were identified: peer support worker' ability to navigate a legitimate place within care teams, their value to the team once they established legitimacy and their ability to traverse the care landscape. Ultimately, successful integration in interprofessional teams was dependent upon the ability of clinical staff to focus on unique strengths that peer support workers bring, in addition to lived experience with mental illness as a carer or consumer.

The nutrition care needs of patients newly diagnosed with type 2 diabetes: informing dietetic practice.

BACKGROUND: Understanding patients' experiences and preferences for health care is important with respect to informing how to provide best-practice, patient-centred care. The present study aimed to explore the perceptions of patients who have been recently diagnosed with type 2 diabetes regarding nutrition care received from dietitians. METHODS: Ten individuals recently diagnosed with type 2 diabetes participated in three individual semi-structured qualitative telephone interviews: at baseline, then at 3 and 6 months after recruitment. Data were analysed using content analysis at each time point and meta-synthesis of findings over time. RESULTS: Participants' initial interactions with dietitians were challenging and overwhelming as a result of the instructional nature of consultations. Many participants questioned the use of dietary guidelines to inform nutrition care because this was not adapted to the individual. Some participants valued receiving education on topics such as label reading and serving sizes; however, others considered that the nutrition care was rushed and overly directive. Very few participants perceived that an ongoing relationship with a dietitian would be useful, and limited interaction was planned beyond 6 months after diagnosis. CONCLUSIONS: These findings suggest that there is considerable opportunity for dietitians to enhance the nutrition care provided to patients with type 2 diabetes. Tailoring of dietary guidelines to individuals, utilising supportive counselling styles, and focusing on open communication in consultations that facilitate ongoing, useful care for patients, may help patients with type 2 diabetes achieve and maintain healthy dietary behaviours.

A randomized clinical trial of adjuvant adriamycin in uterine sarcomas: a Gynecologic Oncology Group Study.

After hysterectomy, 156 evaluable patients with stage I (limited to the corpus) or stage II (limited to the corpus and cervix) uterine sarcomas were randomly assigned to adjuvant chemotherapy with Adriamycin (Adria Laboratories, Columbus, Ohio) for six months or to no further treatment. Pelvic irradiation (external or intracavitary) was optional before randomization. Of 75 patients receiving Adriamycin, 31 have suffered recurrences compared with 43 of 81 receiving no adjuvant chemotherapy. This difference is not statistically significant. Moreover, there is no difference in progression-free interval or survival. The optional radiotherapy did not influence the outcome although there was a suggestion that vaginal recurrence was decreased by pelvic radiotherapy. The recurrence rates in specific cell types (leiomyosarcoma, homologous mixed mesodermal sarcoma, or heterologous mixed mesodermal sarcoma) were not significantly different although the pattern of recurrence differed, with pulmonary metastases being more common in leiomyosarcoma and extrapulmonary recurrence being more common in mixed mesodermal sarcoma. The outcome with respect to chemotherapy was not altered even after adjusting for maldistribution of cases. Thus, we could not show a benefit for this dose schedule of Adriamycin as adjuvant treatment for uterine sarcomas.

Ten-year follow-up of patients receiving cisplatin, doxorubicin, and cyclophosphamide chemotherapy for advanced epithelial ovarian carcinoma.

Fifty-six patients were randomly assigned to receive either one-day cisplatin, doxorubicin, and cyclophosphamide (PAC) chemotherapy (PAC-I) or five-day PAC (PAC-V) for advanced epithelial ovarian carcinoma. Follow-up has been 120+ months or to death. Ninety-one percent had either suboptimal stage III or stage IV disease and 55% had grade 2 or 3 lesions. Two patients died of toxicity and were free of disease at autopsy. A third patient died of congestive heart failure with no disease at 103 months. Additionally, eight patients had a negative second-look laparotomy, and three (37.5%) are alive with no evidence of disease (NED) 133 to 144 months after diagnosis. Five patients (62.5%) died of disease 2 to 123 months after negative second-look. Patients with optimal stage III disease had a longer median progression-free interval (PFI) and survival (33.3 and 44.5 months, respectively) than those with suboptimal or stage IV disease (16.4 and 22.5 months, respectively), and the difference in median PFI is significant (P less than .02). Patients with ascites at diagnosis had a shorter median PFI and survival (14.7 and 18 months) than those without ascites (30.0 and 33.0 months). Both differences were significant (PFI, P less than .04; survival, P = .005). PAC produces response rates that are superior to those obtained historically with single-agent alkylating therapy. Late recurrences after negative second-look laparotomy suggest that 5-year survival data may be inadequate in ovarian carcinoma.

Intravenous leiomyomatosis of the uterus with extension into the heart.

A 42 year old woman presented with impaired filling of the right atrium and right ventricle two years after removal of uterine leiomyomas. At the time of hysterectomy, intravenous leiomyomatosis was noted, with extension of the tumor into the inferior vena cava. The tumor subsequently extended into the right atrium and coronary sinus, and protruded through the tricuspid orifice. It was successfully removed from the heart, and proved to be histologically benign.

Adenocarcinoma corpus et colli: analysis of diagnostic variables.

Between January 1973 and December 1983, 469 patients with carcinoma of the endometrium were seen at this institution. Eighty-one patients were identified with adenocarcinoma involving both the uterine body and the cervix. Patients were divided into three groups for evaluation. Group A (n = 58) had a positive cervical biopsy or endocervical curettage, but a normal-appearing cervix at clinical examination. Group B (n = 18) had gross tumor involving the cervix which was confirmed by biopsy. Group C (n = 5) had unsuspected cervical involvement revealed at hysterectomy. Fourteen Group A patients received preoperative radiation therapy. Thirty of the 44 Group A patients (68.2%) who did not receive preoperative radiation, had no involvement of the cervix by tumor in the hysterectomy specimen. Seventy-six patients were eligible for follow-up of at least 18 months. There were 24 recurrences among these 76 patients. Recurrence was more common with advancing grade and with increasing myometrial invasion. Pelvic failures occurred with comparable frequency in both Groups A and B. Only 4 of 11 patients who were found to have extrauterine disease at surgery are still alive. In this study, we found that endocervical curettage has a significant false-positive rate, both histologic grade and volume of cervical involvement should be considered in treatment planning, primary operation should be considered in the management of selected patients with Stage II endometrial carcinoma, and extrauterine disease is a grave prognostic factor.

Paget's disease of the vulva. A histogenetic study of five cases including ultrastructural observations and review of the literature.

Five cases of extramammary Paget's disease of the vulva were studied by histologic, ultrastructural, and immunologic methods. In one of these cases, the associated invasive adnexal carcinoma was studied in a similar fashion. In all five cases, carcinoma-in situ of the sweat glands was observed. In two cases, the glands were identified as aporcrine. In the other three it could not be determined whether they were apocrine or eccrine. In one case tumor cells were seen extending from a focus of underlying carcinoma-in-situ of sweat glands through the excretory duct into the surface epithelium. The ultrastructural findings indicated that the Paget's cells as well as the cells of the invasive carcinoma were adenocarcinoma cells, but the findings were not conclusive as to whether the cells were apocrine or eccrine. There was no evidence of origin of the Paget's cells from keratinocytes. We believe that the bulk of evidence favors an extraepidermal origin for extramammary Paget's disease. The tumor is most commonly derived from the secretory portion of sweat glands, probably either of apocrine or eccrine types, or the dermal or poral portion of the sweat duct. Some cases of Paget's disease are derived from other types of glands.

Splenic scintigraphy using Tc-99m-labeled heat-denatured red blood cells in pediatric patients: concise communication.

Ten children underwent splenic imaging with heat-denatured red blood cells labeled with technetium-99m (Tc-99m DRBC). The presenting problems included the heterotaxia syndrome, recurrent idiopathic thrombocytopenic purpura following splenectomy, mass in the left posterior hemithorax, and blunt abdominal trauma. In nine patients, the presence or absence of splenic tissue was established. A splenic hematoma was identified in the tenth patient. All patients were initially scanned with Tc-99m sulfur colloid (Tc-99m SC), and were selected for Tc-99m DRBC scintigraphy only after the results of the SC scans failed to establish the clinical problem beyond doubt. The availability of kits containing stannous ions, essential for efficient and stable labeling of red blood cells with Tc-99m and requiring only a small volume of blood, make splenic scintigraphy in children a relatively simple and definitive diagnostic procedure, when identification of splenic tissue is of clinical importance.

Ovarian strumal carcinoid. An immunocytochemical and ultrastructural study of two cases.

Examination by immunoperoxidase methods showed that two strumal carcinoids contained thyroxine in the follicular epithelium and colloid. Ultrastructure showed features of thyroid epithelia. Granule-containing cells replaced some follicular epithelial cells at the colloid interface. The morphology of the granules of these cells resembled those of C-cells and foregut-hindgut carcinoids. Transition between thyroid and carcinoid occurred by proliferation of interfollicular cells which subtly formed trabecular structures. Immunoperoxidase for calcitonin was positive both in the interfollicular cells of one tumor and in cells near the transition from thyroid to carcinoid pattern of the other. We conclude that thyroid tissue is a proven component of strumal carcinoid but that follicular epithelial cells may be replaced by granule-containing parafollicular cells. We suggest that the transition from thyroid to carcinoid is accomplished through an intermediate stage of calcitonin-positive cell proliferation. We emphasize, however, that these neoplasms are types of teratomas which may show several forms of differentiation. The tumor of one patient had mid-gut carcinoid elements and represents the first described strumal carcinoid with the carcinoid syndrome.

An evaluation of the usefulness of amylase isozyme differentiation in patients with hyperamylasemia.

Amylase assays measure total activity without differentiating the relative contributions of pancreatic- and salivary-type amylase isozymes. Since polyacrylamide electrophoresis allows identification of salivary-and pancreatic-type isoxymes and their respective variants, serum and urine specimens from patients with the clinical diagnoses of mumps (4), pancreatitis (16), or undiagnosed hyperamylasemias (5) were compared with specimens from control subjects. Patients with mumps had elevations of salivary-type isozymes, while those with pancreatitis had elevations of pancreatic-type isozymes. Elevation of salivary-type isozymes was identified in the five patients who had undiagnosed hyperamylasemias; among these, the isozymes of two originated in neoplastic ovarian tissue and those of three, probably in the salivary glands. Amylase isozyme differentiation cannot unamibiguously identify the tissue source of hyperamylasemia. However, in patients whose hyperamylasemia is of unknown etiology or who respond atypically to therapy, amylase electrophoresis provides identification of the elevated isozyme type, thus providing the basis for the rational selection of further diagnostic procedures.

Mucinous cystadenocarcinoma of the retroperitoneum.

A case of a primary retroperitoneal mucinous cystadenocarcinoma of ovarian type found at laparotomy in the presence of two normal ovaries is described. Careful examination of the tumor showed no evidence of ovarian tissue in the wall. The appearance of this tumor could be traced from areas of benign mucinous cystadenoma, through a mucinous tumor of borderline malignancy to a highly malignant anaplastic tumor containing only occasional mucicarmine positive cells. In areas, the connective tissue of the neoplasm, resembled ovarian stroma in appearance. At autopsy, the retroperitoneum was free of neoplasm, but widespread metastases, consisting of poorly differentiated adenocarcinoma were observed. This neoplasm may have arisen from displaced coelomic epithelium or from a supernumerary ovary.

Eaton-Lambert syndrome as a harbinger of recurrent small-cell carcinoma of the cervix with improvement after combination chemotherapy.

Eaton-Lambert or myasthenic syndrome was diagnosed in a young woman with recurrent small-cell carcinoma of the cervix. Therapy with vincristine, doxorubicin, and cyclophosphamide resulted in a partial response of the tumor and marked improvement in neurologic symptoms. Diagnosis and treatment of this paraneoplastic syndrome are discussed.

Human papillomavirus deoxyribonucleic acid in lesions of the female genital tract: evidence for type 6/11 in squamous carcinoma of the vulva.

Tissue specimens from 51 patients with genital condyloma acuminata or invasive cervical or vulvar carcinomas were analyzed for the presence of human papillomavirus deoxyribonucleic acid (DNA) using the dot blot technique. Of ten condylomas, 80% contained DNA related to human papillomavirus 6 or 11. Sixty percent had evidence of DNA related to human papillomavirus 16, and 30% contained DNA related to human papillomavirus 18. Of 24 squamous cervical carcinomas, 58% had human papillomavirus type 16-related DNA, 33% had type 6- or 11-related DNA, and 4% had type 18-related DNA. Nine primary or recurrent vulvar carcinomas were analyzed. Seventy-eight percent contained human papillomavirus type 6- or 11-related DNA, 33% type 16-related DNA, and 22% type 18-related DNA. Whereas invasive cervical carcinomas predominantly contained DNA related to human papillomavirus 16 or 18, invasive vulvar carcinomas predominantly contained DNA related to types 6 or 11. Thus, human papillomavirus type alone cannot distinguish benign from malignant epithelial disease in the female genital tract.

Estrogen and progesterone receptors in uterine sarcomas.

Estrogen and progesterone receptors were measured in tissues from 43 patients with various uterine sarcomas using the dextran-coated charcoal assay. Estrogen receptor was present in 55.5% and progesterone receptor in 55.8% of samples, at median estrogen and progesterone receptor concentrations of 10.7 and 15.8 fmol/mg cytosol protein, respectively. These median values are much lower than those in 30 consecutive endometrial adenocarcinomas and 50 breast carcinomas assayed in our laboratory. Progesterone receptor status correlated strongly with estrogen receptor status in uterine sarcomas (P = .001). Estrogen and progesterone receptor levels were not influenced by stage, grade, or mitotic count. Patients 50 years of age or less had significantly higher progesterone receptor than those over 50. No such age effect was seen for estrogen receptor. Endometrial stromal sarcoma had higher estrogen and progesterone receptor levels than other histologic types. Low-grade endometrial stromal sarcomas had higher median estrogen receptors (238.9 fmol/mg) and better survival (all patients alive at 6-12 months) than did high grade (N = 7) endometrial stromal sarcomas (median ER = 6.6 fmol/mg, all dead of disease at 8-27 months). For all histologic types, evaluable patients with stage I or II disease (N = 16) were more likely to survive longer than one year than those with stage III or IV disease (N = 13, P = .003). Evaluable patients with estrogen receptor-positive sarcomas were more likely to survive longer than one year than those with estrogen receptor-negative tumors (P = .006). With one exception, an endometrial stromal sarcoma, hormonal therapy exerted no beneficial effect.(ABSTRACT TRUNCATED AT 250 WORDS)

The importance of peritoneal cytology in endometrial carcinoma.

From 1971-1986, peritoneal washings were obtained for cytologic examination at the time of primary exploratory laparotomy in 340 patients with endometrial adenocarcinoma. Seventy-two samples (21.2%) contained malignant cells. The finding of malignant cytology increased with stage of disease: stage I, 17%; stage II, 19.5%; stage III, 68.7%; and stage IV, 85.7% (P less than .001). In 248 patients with clinical stage I disease for whom uterine evaluation was complete, there was an increasing incidence of malignant cytology with increasing grade (P = .002), depth of myometrial invasion (P = .003), and adnexal spread (P less than .001). Twelve of 41 patients (29.3%) with clinical stage I and positive cytology developed recurrent disease, compared with six of 207 (2.9%) with negative cytology (P less than .001). Survival for all stages together was poorer in patients with positive washings than in those with negative washings (P less than .001). This difference in survival was also observed in patients with clinical stage I disease (P less than .001). Among patients with surgical stage I disease, disease-free survival was also superior in the group with negative cytology. In both clinical and surgical stage I, intra-abdominal recurrences were more common among patients with malignant peritoneal cytology.

Gender in medical encounters: an analysis of physician and patient communication in a primary care setting.

The relation of physician and patient gender to verbal and nonverbal communication was examined in 100 routine medical visits. Female physicians conducted longer visits, made more positive statements, made more partnership statements, asked more questions, made more back-channel responses, and smiled and nodded more. Patients made more partnership statements and gave more medical information to female physicians. The combinations of female physician-female patient and female physician-male patient received special attention in planned contrasts. These combinations showed distinctive patterns of physician and patient behavior, especially in nonverbal communication. We discuss the relation of the results to gender differences in nonclinical settings, role strains in medical visits, and current trends in medical education.

Orientation of medical residents to the psychosocial aspects of primary care: influence of training program.

PURPOSE: To describe the attitudes of residents in general medicine to the psychosocial dimensions of primary care and to evaluate the influences of selected variables. METHOD: A cross-sectional analysis-of-variance design (two training programs involving residents in all three residency years) was used in the analysis of 21 psychosocial attitude items from a survey questionnaire completed by general medicine residents. In 1991-92, 77 general medicine residents in ambulatory care group practices associated with the Massachusetts General Hospital were surveyed. Eighteen of the residents were in a primary care program (PCP), and 59 were in a traditional medicine program (TMP). RESULTS: The overall response rate was 82% (63 of 77 residents), with slightly lower rates for four items. The residents' attitudes to the psychosocial role of the primary care physician were positive but with reservations: 55 (87%) endorsed asking psychosocial questions, while only 28 (44%) indicated that most internists felt competent to diagnose and treat. Most residents did not feel defensive about enacting the role (neither uncomfortable asking questions in ambulatory care settings, 58, 92%; nor nosey, 56, 89%; nor personally interfering, 47, 76%). Fifty-two residents (83%) perceived patients to be receptive to psychosocial questions, yet 31 (49%) indicated that patients were resistant to psychosocial attributions, and 48 (76%) indicated that patients need to be prompted to talk about life problems. The clearest and strongest influence on attitudes was setting: ambulatory care over inpatient (p < .0001). Overall, the responses of the residents from the PCP and TMP were more similar than different. CONCLUSION: The residents accepted the psychosocial role of the primary care physician, found it most appropriate in ambulatory care settings, felt ambivalent about their ability to carry it out, and assigned it a secondary priority in patient care. To interest residents in primary care, more training should be based in ambulatory care settings and more emphasis should be placed on improving residents' competency in psychosocial skills.

Phase II study of maytansine in the treatment of advanced or recurrent squamous cell carcinoma of the cervix. A Gynecologic Oncology Group study.

Twenty-nine patients with advanced or recurrent squamous cell carcinoma of the cervix who had failed standard therapy were treated with maytansine 1.2 mg/m2 intravenously once every 3 weeks. Only one partial remission was observed among the 29 patients (3%). There were no complete remissions. Stable disease was observed in 18 (62%) and progressive disease in 10 (35%). Adverse effects were infrequent and mild to moderate and consisted primarily of myelosuppression, weakness, and nausea and vomiting. This study shows that maytansine at the dose and schedule tested is essentially inactive in the treatment of advanced or recurrent squamous cell carcinoma of the cervix.

Phase II study of maytansine in the treatment of advanced or recurrent adenocarcinoma of the ovary. A Gynecologic Oncology Group study.

Twenty-nine patients with advanced or recurrent adenocarcinoma of the ovary no longer responsive to standard treatment measures were given maytansine 1.2 mg/m2 I.V. every 3 weeks. None of the 29 patients demonstrated an objective regression of disease. Eighteen (62%) demonstrated stable disease for 1 or more months, while 11 (38%) developed rapid progression of disease. Adverse effects consisted primarily of leukopenia (7/29), thrombocytopenia (9/29), and nausea and vomiting (14/29). Only one patient developed life-threatening toxicity (platelets less than 25,000 microliters), and no drug-related deaths were observed. Maytansine thus appears inactive in the treatment of adenocarcinoma of the ovary at the dose and schedule tested.

Cisplatin, vinblastine, and bleomycin as second-trial therapy in ovarian carcinoma. A pilot study of the Gynecologic Oncology Group.

Ten patients with ovarian carcinoma whose tumors had progressed on first-trial chemotherapy were treated with cisplatin, vinblastine, and bleomycin (PVB) to determine the efficacy, dose range, and toxicity of this combination. Two dose levels of vinblastine were used. Objective responses occurred in 5/10 patients (3 CR, 2 PR), with a median response duration of 17.0 weeks. Toxicity was appreciable. One patient expired of bleomycin-induced pulmonary fibrosis. With the higher dose of vinblastine, four patients had grade III and three patients had grade IV hematologic toxicity. At the lower dose, two patients had grade II and one patient had grade III hematologic toxicity. PVB has activity in second-trial therapy of ovarian carcinoma at the dose and schedule tested, but the role of this regimen in the future treatment of this disease remains to be determined.