"We're back in control of the story and we're not letting anyone take that away from us": patient teacher programs as means for patient emancipation.

While patient engagement in healthcare professions education (HPE) has significantly increased in the past decades, a theoretical gap remains. What are the varied reasons as to why patients get involved with HPE programs? With a focus on understanding what drives patient involvement with HPE programs, this study examined how a patient as teacher (PAT) program was experienced by medical students, patient teachers, and faculty within a medical school. Through a phenomenographic approach, this study captures and describes the different ways our study participants experienced a PAT program (the 'phenomenon'). 24 semi-structured interviews were conducted in total, comprised of interviews with patient teachers (N = 10), medical students (N = 10) and program facilitators (N = 4) who participated in a PAT program. Our focus was on participants' description of the program and was grounded in their experiences of as well as their beliefs about it. Our findings captured 4 layers representing the qualitatively different (yet interrelated) ways in which participants experienced/perceived and conceptualized the various aspects of their experience with the PAT program: (1) A productive disruption of the learning space (2) A re-humanization within healthcare (3) A means of empowerment and agency (4) A catalyst for change and emancipation. Our outcome space results can be visually illustrated by a nesting "Matryoshka" doll, representing the four layers and depicting the process of uncovering the less conscious layers of sense-making within this phenomenon. HPE programs that are co-produced with patients and actively involve patients as teachers have the potential, but not guarantee, to be emancipatory. To engage in PAT programs that exhibit an emancipatory potential, we need to consider transformative paradigms of education, which are aligned with social change, and disrupt the traditional teacher-learner hierarchy.

Imaging technologies in breast diagnosis and surgical treatment.

The diagnostic and surgical management of breast cancer has changed dramatically over the past 2 decades. All facets in the multidisciplinary management of breast cancer are rapidly evolving and being driven forward by technological advances. Conventional imaging techniques are now being augmented with advances in molecular imaging that probe biological properties of tissue to create images, and optical imaging which reflects physical properties of normal and diseased tissues. Automated computer assisted biopsy techniques are being developed to sample breast tissue with a higher degree of accuracy and patient comfort. As the trend toward minimally invasive breast surgery continues ablative techniques such as radiofrequency ablation, cryoablation, interstitial laser ablation and focused ultrasound ablation are being explored to potentially avoid the need for surgery all together. New intraoperative lesion localization techniques such as 3-dimensional ultrasonographic tumor models, magnetic resonance imaging (MRI)-guided projection and reproduction, radioguided occult lesion localization and optical imaging techniques are being developed to improve surgical guidance. Evaluation of advanced imaging and intraoperative guidance techniques requires more comprehensive histopathological examination of surgical specimens, prompting the development of techniques aimed at to improving upon the current limitations in breast pathology. This review will describe the development of new technologies in breast imaging, tumor ablation, intraoperative surgical guidance and tissue processing aimed at advancing minimally invasive diagnosis and treatment of breast cancer.

Isoflavones isolated from red clover (Trifolium pratense) inhibit smooth muscle contraction of the isolated rat prostate gland.

This study investigated whether red clover contains any bioactive constituents which may affect contractility of rat prostatic smooth muscle in an attempt to determine whether its medicinal use in the treatment of benign prostatic hyperplasia is supported by pharmacological effects. A commercially available red clover extract was chemically fractionated and various isoflavones (genistein, formononetin and biochanin A) were isolated from these fractions and their effects on contractility were examined on preparations of the isolated rat prostate gland. Contractile effects of the isolated fractions were compared with commercially available isoflavones (genistein, formononetin and biochanin A). Pharmacological tools were used to investigate the mechanism of action modifying smooth muscle contraction. Crude red clover extract (Trinovin) inhibited electrical field stimulation induced contractions of the rat prostate across a range of frequencies with an IC(50) of approximately 68 microg/ml. Contractions of the rat prostate elicited by exogenous administration of acetylcholine, noradrenaline or adenosine 5'-triphosphate (ATP) were also inhibited. Chromatographic separation, and final purification by high performance liquid chromatography (HPLC) permitted the isolation of the isoflavones: daidzein, calycosin, formononetin, prunetin, pratensin, biochanin A and genistein. Genistein, formononetin and biochanin A (100 microM) from either commercial sources or isolated from red clover extract inhibited electrical field stimulation induced contractions of the isolated rat prostate. It is concluded that isoflavones contained in red clover are able to inhibit prostatic smooth muscle contractions in addition to their antiproliferative effects. However, the high concentrations required to observe these smooth muscle relaxant effects mean that a therapeutic benefit from this mechanism is unlikely at doses used clinically.

The role of nipple discharge cytology in the diagnosis of breast disease: a study of 1948 nipple discharge smears from 1530 patients.

In this study a review of 1948 nipple discharge (ND) samples from 1530 patients in the age range of 18-83 years was undertaken to determine whether cytological findings from ND smears could provide useful diagnostic information regarding various breast lesions. The study included 1494 females and 36 males and was carried out during a period of 20 years 8 months. The clinical information in all patients was obtained from clinicians (coauthors), medical records and a review of biopsies in 205 patients who had undergone surgery following the cytodiagnosis. Of the ND samples examined, 1480 were unilateral while 468 were from 234 bilateral ND. The cytodiagnoses were: benign 624, inadequate (despite two to three repeat samples) 492, inflammatory 96, papillary lesion not otherwise specified (NOS) 229, suspicious 22 (21 females, one male) and malignant 67 (63 females, four males). A breast biopsy in the 22 suspicious cases revealed breast carcinoma in 18 cases (females n = 17, male n = 1), atypical ductal hyperplasia (female n = 1), fibroadenoma (female n = 1) and a papilloma in two females. In the 67 cases with a diagnosis of malignancy 65 revealed a breast carcinoma in the biopsy (female n = 62, male n = 3) while one female was diagnosed as fibroadenoma and one male as florid gynaecomastia. In 63 cases (females n = 61; males n = 2) with clinical lumpy areas consistent with the diagnosis of fibrocystic condition in ND, the biopsy confirmed a fibrocystic process. In 53 of 229 cases with ND findings suggestive of a papillary lesion (NOS) the biopsy revealed a papilloma in 41 cases while in 12 cases no lesion was found. In the remaining cases of all the groups only a clinical follow-up and appropriate investigations were performed with no untoward outcome. Based on our study it is felt that cytological examination of ND smears seems to be a reasonably specific method in the diagnosis of malignant and suspicious cases but may be somewhat less specific for other diagnoses.

High levels of untreated distress and fatigue in cancer patients.

The purpose of the study was to assess a large representative sample of cancer patients on distress levels, common psychosocial problems, and awareness and use of psychosocial support services. A total of 3095 patients were assessed over a 4-week period with the Brief Symptom Inventory-18 (BSI-18), a common problems checklist, and on awareness and use of psychosocial resources. Full data was available on 2776 patients. On average, patients were 60 years old, Caucasian (78.3%), and middle class. Approximately, half were attending for follow-up care. Types of cancer varied, with the largest groups being breast (23.5%), prostate (16.9%), colorectal (7.5%), and lung (5.8%) cancer patients. Overall, 37.8% of all patients met criteria for general distress in the clinical range. A higher proportion of men met case criteria for somatisation, and more women for depression. There were no gender differences in anxiety or overall distress severity. Minority patients were more likely to be distressed, as were those with lower income, cancers other than prostate, and those currently on active treatment. Lung, pancreatic, head and neck, Hodgkin's disease, and brain cancer patients were the most distressed. Almost half of all patients who met distress criteria had not sought professional psychosocial support nor did they intend to in the future. In conclusion, distress is very common in cancer patients across diagnoses and across the disease trajectory. Many patients who report high levels of distress are not taking advantage of available supportive resources. Barriers to such use, and factors predicting distress and use of psychosocial care, require further exploration.

Metabolic responses to leptin in obese db/db mice are strain dependent.

Obese, diabetic C57BL/Ks db/db mice that lack the long-form leptin receptor exhibit no decrease in body weight or food intake when treated with leptin. Here we compared responses to leptin in two strains of db/db mice: C57BL/6J mice that are hyperglycemic and hyperinsulinemic and C57BL/Ks that are hyperglycemic and normo- or hypoinsulinemic. Chronic intraperitoneal infusion of 10 microgram leptin/day partially reversed hyperglycemia in C57BL/6J male mice but exaggerated the diabetic state of female mice. Bolus intraperitoneal injections of 40 microgram leptin/day did not effect glucose in either strain of male db/db mice, whereas chronic intraperitoneal infusion of 20 microgram leptin/day significantly reduced fasting blood glucose in male mice from both strains, especially C57BL/6J mice. Food intake, body weight, rectal temperature, and body fat did not change. Chronic intraperitoneal infusion of 10 microgram leptin/day significantly reduced body fat in lean db/+ C57BL/6J but not in C57BL/Ks mice. Thus peripherally administered leptin is active in mice that have only short-form leptin receptors, and the response is dependent on the method of leptin administration and the background strain.

Effective mood stabilization with a chelated mineral supplement: an open-label trial in bipolar disorder.

BACKGROUND: To determine in open trials the therapeutic benefit of a nutritional supplement for bipolar disorder. METHOD: The sample consisted of 11 patients with DSM-IV-diagnosed bipolar disorder aged 19 to 46 years, who were taking a mean of 2.7 psychotropic medications each at study entry. Three additional patients dropped out prematurely. The intervention is a broad-based nutritional supplement of dietary nutrients, primarily chelated trace minerals and vitamins, administered in high doses. At study entry and periodically thereafter, patients were assessed with the Hamilton Rating Scale for Depression (HAM-D), the Brief Psychiatric Rating Scale (BPRS), and the Young Mania Rating Scale (YMRS). RESULTS: For those who completed the minimum 6-month open trial, symptom reduction ranged from 55% to 66% on the outcome measures; need for psychotropic medications decreased by more than 50%. Paired t tests revealed treatment benefit on all measures for patients completing the trial: HAM-D mean score at entry = 19.0, mean score at last visit = 5.4, t = 5.59, df = 9, p < 01; BPRS mean score at entry = 35.3, mean score at last visit = 7.4, t = 2.57, df = 9, p <.05; YMRS mean score at entry = 15.1, mean score at last visit = 6.0, t = 4.11, df = 9, p < .01. The effect size for the intervention was large (> .80) for each measure. The number of psychotropic medications decreased significantly to a mean +/- SD of 1.0+/-1.1 (t = 3.54, df = 10, p < .01). In some cases, the supplement replaced psychotropic medications and the patients remained well. The only reported side effect (i.e., nausea) was infrequent, minor, and transitory. CONCLUSION: Some cases of bipolar illness may be ameliorated by nutritional supplementation. A randomized, placebo-controlled trial in adults with bipolar I disorder is currently underway, as well as open trials in children.

Effect of group therapy for breast cancer on healthcare utilization.

PURPOSE: The purpose of this study was to determine whether participation in a group psychosocial intervention by patients with breast cancer would result in an improvement in psychological measures and in reduced billings in general medical expenses. DESCRIPTION OF STUDY: Eligible women who had completed treatment for stage 0, I, or II primary breast cancer were prospectively and randomly assigned to either the intervention (n=46) or control (n=43) group. Both groups received the usual psychosocial care; however, the intervention group also participated in six weekly cognitive/behavioral psychosocial meetings. All were assessed on psychiatric symptoms, mood, depression, and coping strategies at four time periods: pre-intervention, post-intervention, 1-year follow-up, and 2-year follow-up. Alberta Healthcare billing records were obtained covering the 2-year follow-up period to determine the amount billed per person over the course of the study. RESULTS: Women in the intervention group had less depression, less overall mood disturbance, better overall quality of life, and fewer psychiatric symptoms than those in the control group, beginning immediately post-intervention and remaining so at 2 years post-intervention. Billing in the intervention group was an average of $147 less than in the control group, a 23.5% reduction. CLINICAL IMPLICATIONS: This is the first study to show that a psychosocial intervention can reduce direct healthcare billings in a sample of patients with cancer. Importantly, these findings help to justify the routine availability of such programs in cancer treatment facilities worldwide.

Mycalamides C and D, cytotoxic compounds from the marine sponge Stylinos n. species.

The new cytotoxic compounds, mycalamides C (3) and D (4), have been isolated from the marine sponge Stylinos n. sp., along with the known theopederin E (1) and mycalamide A (2).

Neural tube defects along the Texas-Mexico border, 1993-1995.

In response to a 1991 anencephaly cluster in Cameron County, Texas, a surveillance and neural tube defect (NTD) recurrence prevention project for NTDs was implemented in the 14 Texas-Mexico border counties. For 1993-1995, NTD-affected pregnancies were identified at all gestational ages through active surveillance of multiple case-ascertainment sources. There were 87 cases of anencephaly, 96 cases of spina bifida, and 14 cases of encephalocele for respective rates of 6.4, 7.1, and 1.1 per 10,000 live births. Of the 197 NTD case-women, 93% were Hispanic. The overall, Hispanic, and Anglo NTD rates were, respectively, 14.6, 14.9, and 10.6 per 10,000 live births. The NTD rate for El Paso County (9.8 per 10,000), the most northwestern Texas county, was significantly lower (p = 0.001) than the aggregate rate for the rest of the Texas border (17.1 per 10,000). The overall Texas border rate was significantly higher (p < 0.001) than a recently estimated rate of 9.3 for California and minimally higher than a recently adjusted rate of 11.3 for the Metropolitan Atlanta Congenital Defects Program counties (p = 0.052), both of which now reflect all gestational ages. Of the 197 Texas border cases, 85% (168 cases) reached a gestational age of > or =20 weeks. Excluding cases of <20 weeks' gestation in the rate had a more marked effect on reducing the anencephaly rate (4.9 per 10,000) than the spina bifida rate (6.7 per 10,000). A country of birth was known for 153 (83%) of the 184 Hispanic case-women: 63% were born in Mexico; 24%, in Texas; and 11%, elsewhere in the United States. Rates for Mexico-born Hispanic women (15.1 per 10,000) were significantly higher than rates for United States-born Hispanic women (9.5 per 10,000) (p = 0.006).

Privatizing maternal and child health services in Texas: reinventing Title V programs.

In November 1994, the Texas Department of Health embarked upon a major initiative to "reinvent" maternal and child health services funded through the Title V Maternal and Child Health Block Grant and related state general revenue. This article describes the rationale, planning process, and implementation issues associated with the initiative to redefine the fundamental roles and priorities of the department and traditional public health entities in the delivery of maternal and child health services.

Fine-needle aspiration cytodiagnosis of breast masses in pregnant and lactating women and its impact on management.

We reviewed our experience with 9,726 cases of fine-needle aspiration cytology of the breast that were done from January 1983 to February 1992. During our review, we found that 214 aspirates had been submitted from pregnant and lactating women for the investigation of breast mass(es). Despite a variable clinical presentation and spectrum of cytologic findings, we considered the application of aspiration cytology in these women as useful as in the nonpregnant-nonlactating women for management decision. A team approach between the clinician and cytopathologist was always maintained; with this approach, the false-positive or -negative diagnoses were reduced to almost nil. In all cases in which the cytodiagnosis of carcinoma of breast was made, the findings corresponded with subsequent cell blocks from the aspirate and tissue examination. Benign lesions were diagnosed cytologically with minimal difficulty, and all aspirates that were less than optimal for cytodiagnosis were repeated to minimize the chance of missing an abnormality. All the benign lesions were followed throughout pregnancy, postpartum, and thereafter; if the mass persisted, the aspiration was repeated. With this protocol of follow-up, the need for a customary liberal surgical biopsy was reduced to a minimum.

Fine needle aspiration cytodiagnosis of a carcinoid tumour of the male breast.

The diagnosis of a primary carcinoid tumour of the breast in a 38-year-old male was initially made from a fine needle aspiration sample. The cytodiagnosis was supported by the histochemical demonstration of Grimelius-positive granules in tumour cells which were also found in tissue removed in a subsequent biopsy. An immunocytochemical study using markers for neuron-specific enolase and chromagranin in the aspirated sample and tissue was found to be negative. A total mastectomy with axillary node dissection was performed which showed no residual or metastatic tumour. No primary tumour was found elsewhere.

Fine needle aspiration cytodiagnosis of apocrine carcinoma of the breast.

The cytopathological appearances of 14 cases of apocrine breast carcinoma diagnosed by fine needle aspiration cytology are described and the features compared to those seen in apocrine cells aspirated from benign cystic and solid lesions. Significant atypia must be observed before a diagnosis of apocrine carcinoma can be entertained.

Coexpression of vimentin, cytokeratin and S-100 in monomorphic adenoma of salivary gland; value of marker studies in the differential diagnosis of salivary gland tumours.

An unusual coexpression of glial fibrillary acid protein (GFAP), keratin and vimentin occurs in pleomorphic adenoma of salivary gland. We designed this study to see if coexpression of the markers was also present in monomorphic adenoma of the salivary gland and whether monomorphic adenoma could be distinguished from other salivary gland tumours by marker studies. Immunocytochemical markers were used on fine needle aspiration samples from four cases of monomorphic adenoma, two cases of oncocytic adenoma, three cases of adenoid cystic carcinoma and four cases of pleomorphic adenoma. While positivity for cytokeratin, vimentin and S-100 was consistently found in all cases of monomorphic adenoma, only cytokeratin was expressed in adenoid cystic carcinoma. In pleomorphic adenoma, GFAP, cytokeratin and vimentin were coexpressed while in cases of oncocytic adenoma none of the markers was localized. Thus, it appears that by using a combination of GFAP, cytokeratin, vimentin and S-100 a distinction between these neoplasms may be possible. However, a larger study is needed to establish the usefulness of this approach.

Needle aspiration cytology, immunocytochemistry, and electron microscopy in a rare case of secretory carcinoma of the breast in an elderly woman.

Needle aspiration was performed on a breast mass in a 91-year-old woman. The cytologic features in the aspirate were a diffuse, prominent, intracytoplasmic vacuolization and secretion in malignant cells and occasional signet ring-like forms. This was confirmed in a subsequent cell block which was made from the aspirate. Immunocytochemical studies showed a positivity for mucin by alcian blue stain in the vacuolated cells which was periodic acid-Schiff positive and resistant to diastase digestion. Oil-red-O staining was negative and on Colloidal iron stain the tumour cells were positive. Immunopositivity to carcinoembryonic antigen, cytokeratin, and epithelial membrane antigen was found in the malignant cells, while on electron microscopy the tumour cells contained a significant amount of intracytoplasmic secretory material. Secretory carcinoma of the breast is a rare tumour and can be diagnosed and differentiated from other breast carcinomas in view of its characteristic cytologic features.