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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dental care and instrumentation.

Equine dentistry is not just carpentry work that involves floating the sharp enamel points off cheek teeth. Although floating is the most common and essential part of equine dentistry, every horse deserves a complete veterinary dental examination on a regular basis. Without such an examination, the equine practitioner can not determine the corrective procedures needed inside the horse's mouth. Dentistry for all ages is covered. Necessary instruments for a complete oral examination are also discussed.

Dental corrective procedures.

This article explains what is needed for successful extraction of diseased cheek teeth and how to realign the occlusal surface. Incisor teeth procedures and correcting abnormalities of cheek tooth crown wear are also discussed along with wolf and floating teeth.

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

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

Effects of screws and a sleeve on initial fixation in uncemented total knee tibial components.

Aseptic loosening of tibial components remains a serious problem in uncemented total knee arthroplasties. Achieving rigid initial fixation of porous-coated components is one of the most important factors in promoting bone ingrowth. The results of a biomechanical study for micromovement of the tibial component under posteroanterior shear and axial compressive loading are presented. Forty anatomic specimen tibiae were stress tested on a servohydraulic mechanical test machine to evaluate the effects of screws and a sleeve on initial fixation of the uncemented total knee tibial component. Twenty specimens were used for posteroanterior shear loading and 20 for anterolateral axial compressive loading. Four cancellous screws were inserted through holes of the tibial tray to pierce the cortex of the proximal tibia. The methylmethacrylate sleeve was applied to the central stem. Rigidity of fixation was significantly improved by the combination of screws and a sleeve. Bone strength was also an important factor affecting the quality of fixation.

Interstitial radiogold implantation for the treatment of recurrent high-grade gliomas.

Thirty-three patients were treated at the Methodist Hospital, Baylor College of Medicine (Houston) between 1983 and 1987, for high-grade gliomas which had recurred after conventional external-beam radiation therapy. The mean dose to the tumor volume from the external-beam therapy was 5800 cGy. Thirteen patients had recurrent astrocytoma Grade 4 (glioblastoma), whereas 20 had recurrent astrocytoma Grade 3 (anaplastic astrocytoma). All patients were treated for their recurrence by the combination of reexcision of as much of the tumor mass as was technically feasible and intraoperative radiogold (198Au) seed implantation of the residual tumor and/or tumor bed. The mean dose to the tumor volume from the implant was 4000 cGy. For the 13 patients treated for recurrent glioblastoma the 1-year, 2-year, and 3-year survival rates were 46%, 15%, and 8%, respectively. For the 20 patients treated for recurrent anaplastic astrocytoma the 1-year, 2-year, and 3-year survival rates were 75%, 50%, and 15%, respectively. Survival was measured from the time of implant. The median survival for patients with glioblastoma was 9 months. The median survival for patients with anaplastic astrocytoma was 17 months. One patient died in the immediate postoperative period from a gastrointestinal bleed. No patient required reoperation for radiation necrosis. The authors believe that this technique is an effective treatment for patients with high-grade gliomas recurring after external-beam radiation therapy, and are now including interstitial irradiation in the initial management of selected patients with high-grade gliomas.

Twenty year experience with radiation therapy for temporal bone chemodectomas.

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

The treatment of advanced juvenile nasopharyngeal angiofibroma.

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

The risk of distant metastases after transurethral resection of the prostate versus needle biopsy in patients with localized prostate cancer.

Although transurethral resection of the prostate provides an effective treatment for obstructive voiding symptoms associated with prostate cancer, there is growing concern about the possible role of transurethral resection in the dissemination of this malignancy. To determine the effect of transurethral resection on the rate of development of distant metastasis, we analyzed a large series of patients (379) treated at our institution with definitive radiotherapy for localized prostate cancer that was diagnosed by either needle biopsy or transurethral prostatic resection. In our series the presence of lymph node metastasis was documented by pelvic lymph node dissection in all patients. An initial univariate analysis suggested that patients diagnosed by transurethral resection had distant metastases significantly more rapidly than patients diagnosed by needle biopsy. However, transurethral resection usually was performed because of the presence of obstructive voiding symptoms and such patients were much more likely to have positive lymph node dissections than patients without obstructive voiding symptoms. A proportional hazards regression analysis showed that nodal status and the degree of obstructive voiding symptoms at diagnosis were independent and powerful predictors of the interval to distant metastases, along with stage and grade. The type of initial biopsy (transurethral prostatic resection versus needle biopsy) had no independent prognostic significance in this analysis. Among patients who had substantial obstructive voiding symptoms there was no significant difference in interval to distant metastases between the transurethral prostatic resection and needle biopsy groups. We conclude that the apparent adverse effect of transurethral prostatic resection results from the poor prognosis of tumors causing obstructive voiding symptoms rather than as a direct result of the resection itself.

Prognostic significance of lymph nodal metastases in prostate cancer.

Pelvic lymph node metastases indicate a poor prognosis for patients with clinically localized prostate cancer but the significance of minimal nodal metastases still is debated. We determined the progression and cancer specific survival rates based on the extent of nodal metastases in 511 patients followed for a mean of 8.6 years (range 2.5 to 17.5 years) after bilateral pelvic lymph node dissection and irradiation therapy. The patients were divided into 4 groups based on the extent of nodal metastases: NO--negative nodes (359 patients), N1--a single microscopic positive node (37), N2--multiple microscopic positive nodes (86) and N3--grossly positive or juxtaregional nodes (29). The risks of distant metastases and of dying of prostate cancer were much greater in the 152 patients with positive nodes (N+) than in those with negative nodes (p less than 0.00005). The risk of metastatic disease at 10 years was only 31 +/- 7 per cent for the NO patients compared to 83 +/- 7 per cent for the N+ patients, and the risk of dying of prostate cancer was only 17 +/- 6 per cent at 10 years for the NO group and 57 +/- 11 per cent for the N+ patients. Patients with a single microscopic node (N1) had a pattern of progression and cancer specific mortality rate similar to patients with more extensive nodal metastases and markedly worse than patients with negative nodes. The risk of distant metastases was 80 +/- 15 per cent at 10 years for the N1 group, 84 +/- 11 per cent for the N2 group and 88 +/- 13 per cent for the N3 group, while the risk of dying of prostate cancer at 10 years was 40 +/- 19, 66 +/- 15 and 58 +/- 24 per cent, respectively. The finding of a single pelvic lymph node containing microscopic metastatic disease markedly worsened the prognosis of our patients with prostate cancer. Once prostate cancer is found within the pelvic lymph nodes the patient has systemic disease unlikely to be controlled by pelvic lymph node dissection and radiotherapy.

The effect of collar and distal stem fixation on micromotion of the femoral stem in uncemented total hip arthroplasty.

Collar seating and tight distal stem fit were evaluated for their effects on micromotion of the implant in the proximal femur. Collared and collarless implants were inserted with a cementless technique in 42 preserved femoral specimens from adult cadavers and cyclically axially loaded in a 9 degree valgus position. Micromotion was registered with dial indicators. Micromotion was minimized distally and proximally by achieving tight distal fixation. Collar seating prevented distal migration and failure of fixation, but it did not have a detectable effect on mediolateral or anteroposterior proximal micromotion. Toggle appears to be controlled primarily by the distal portion of the stem. Axial load transfer appears to be primarily controlled by collar seating. The least micromotion was achieved with a tight fit distally.

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

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