Through the looking glass: an exploratory study of the lived experiences and unmet needs of families affected by Von Hippel-Lindau disease

Despite well-established protocols for the medical management of Von Hippel-Lindau disease (VHL), families affected by this rare tumour syndrome continue to face numerous psychological, social, and practical challenges. To our knowledge, this is one of the first qualitative studies to explore the psychosocial difficulties experienced by families affected by VHL. A semi-structured interview was developed to explore patients' and carers' experiences of VHL along several life domains, including: self-identity and self-esteem, interpersonal relationships, education and career opportunities, family communication, physical health and emotional well-being, and supportive care needs. Quantitative measures were also used to examine the prevalence of anxiety, depression, and disease-specific distress in this sample. Participants were recruited via the Hereditary Cancer Clinic at the Prince of Wales Hospital in Sydney, Australia. A total of 23 individual telephone interviews were conducted (15 patients, 8 carers), yielding a response rate of 75%. A diverse range of experiences were reported, including: sustained uncertainty about future tumour development, frustration regarding the need for lifelong medical screening, strained family relationships, difficulties communicating with others about VHL, perceived social isolation and limited career opportunities, financial and care-giving burdens, complex decisions in relation to childbearing, and difficulties accessing expert medical and psychosocial care. Participants also provided examples of psychological growth and resilience, and voiced support for continued efforts to improve supportive care services. More sophisticated systems for connecting VHL patients and their families with holistic, empathic, and person-centred medical and psychosocial care are urgently needed.

How should we discuss genetic testing with women newly diagnosed with breast cancer? Design and implementation of a randomized controlled trial of two models of delivering education about treatment-focused genetic testing to younger women newly diagnosed with breast cancer

Background

Germline BRCA1 and BRCA2 mutation testing offered shortly after a breast cancer diagnosis to inform women’s treatment choices - treatment-focused genetic testing ‘TFGT’ - has entered clinical practice in specialist centers and is likely to be soon commonplace in acute breast cancer management, especially for younger women. Yet the optimal way to deliver information about TFGT to younger women newly diagnosed with breast cancer is not known, particularly for those who were not suspected of having a hereditary breast cancer syndrome prior to their cancer diagnosis. Also, little is known about the behavioral and psychosocial impact or cost effectiveness of educating patients about TFGT. This trial aims to examine the impact and efficiency of two models of educating younger women newly diagnosed with breast cancer about genetic testing in order to provide evidence for a safe and effective future clinical pathway for this service.

Design/methods

In this non-inferiority randomized controlled trial, 140 women newly diagnosed with breast cancer (aged less than 50 years) are being recruited from nine cancer centers in Australia. Eligible women with either a significant family history of breast and/or ovarian cancer or with other high risk features suggestive of a mutation detection rate of > 10% are invited by their surgeon prior to mastectomy or radiotherapy. After completing the first questionnaire, participants are randomized to receive either: (a) an educational pamphlet about genetic testing (intervention) or (b) a genetic counseling appointment at a family cancer center (standard care). Each participant is offered genetic testing for germline BRCA mutations. Decision-related and psychosocial outcomes are assessed over 12 months and include decisional conflict (primary outcome);uptake of bilateral mastectomy and/or risk-reducing salpingo-oophorectomy; cancer-specific- and general distress; family involvement in decision making; and decision regret. A process-oriented retrospective online survey will examine health professionals’ attitudes toward TFGT; a health economic analysis will determine the cost effectiveness of the intervention.

Discussion

This trial will provide crucial information about the impact, efficiency and cost effectiveness of an educational pamphlet designed to inform younger women newly diagnosed with breast cancer about genetic testing. Issues regarding implementation of the trial are discussed.

Trial registration

The study is registered with the Australian and New Zealand Clinical Trials Group (Registration no: ACTRN12610000502033)

Pediatric health-related quality of life after intestinal transplantation

As outcomes after ITx improve, greater emphasis is needed on HRQOL. The primary aims of this study were to (i) assess the feasibility of measuring HRQOL in pediatric ITx recipients, (ii) measure HRQOL using validated instruments, and (iii) compare HRQOL in ITx recipients to healthy normal (NL) children. The CHQ and Pediatric Quality of Life (PedsQL4.0) instruments were administered to both patients and parents at outpatient visits. All 24 eligible patients were enrolled. The median age at study enrollment was 6.0 yr (range: 2-18 yr), and the median time from transplant to study enrollment was 2.8 yr (range: 0.5-11.8 yr). The majority of subjects were male (58%), Latino (58%), and liver-inclusive (92%) recipients. For CHQ and PedsQL4.0, parental responses were significantly lower in multiple categories including physical health and social functioning compared to healthy norms. Patient responses were not different from NL using CHQ but using PedsQL4.0 were significantly lower in the school functioning subcategory and psychosocial health summary score. HRQOL as reported by children and families after ITx is significantly lower in multiple categories compared to NL.

Prevalence of genital chlamydial infection among a community sample of young international backpackers in Sydney, Australia

We conducted a chlamydia prevalence study from January to June 2009 among a community sample of young international backpackers by recruiting at hostels in Sydney, Australia. Participants completed a questionnaire; men provided a urine sample and women provided a self-collected vaginal swab, which were tested for Chlamydia trachomatis DNA by strand displacement amplification. We recruited 225 men (median age 24 years) and 207 women (median age 23 years). Most (87%) of the travellers came from Europe. A new sexual partner during travel was reported by 67%, and 51% had more than one new sexual partner. Of those reporting a new sexual partner, 40% always used condoms. Prevalence of chlamydia was 3.5% (3.1% in men, 3.9% in women). Previous testing for chlamydia was reported by 40%. Drinking alcohol at hazardous levels was reported by 58% of men and 29% of women. Despite the reporting of new sexual partners and inconsistent condom use, the prevalence of chlamydia in these backpackers was not higher than that found in more general populations, and may relate to good health-care seeking behaviour. Young travellers need education about sexual risks and promotion of condom use prior to travel, and access to public sexual health services.

An exploration of the communication preferences regarding genetic testing in individuals from families with identified breast/ovarian cancer mutations

The responsibility for informing at-risk relatives of the availability of genetic testing for breast/ovarian cancer gene (BRCA1 or BRCA2) mutations currently falls on the probands. This study explored the support needs of individuals from families with identified BRCA1 or BRCA2 mutations when communicating about genetic risk and genetic testing with at-risk family members. Thirty-nine semi-structured telephone interviews were conducted with individuals from families with identified BRCA mutations. Interview responses were cross-tabulated by sample characteristics using the qualitative research analysis software NVivo8. The development of educational materials, which individuals could use when communicating the risks of carrying a BRCA gene mutation with their relatives, was identified as a specific need. Many participants expressed a preference for a staged approach, where relatives are notified of their increased risk and the availability of genetic testing risk either face-to-face or via a letter, with additional educational sources, including brief written information or access to a website, made available for those wishing to access more in-depth information. This research identified a need for the development of educational/informational resources to support individuals with identified breast/ovarian cancer mutations to communicate with their at-risk relatives about genetic risk and genetic testing availability.

"For all my family's sake, I should go and find out": an Australian report on genetic counseling and testing uptake in individuals at high risk of breast and/or ovarian cancer

CONTEXT

Despite proven benefits, the uptake of genetic counseling and testing by at-risk family members of BRCA1 and BRCA2 mutation carriers remains low.

AIMS

This study aimed to examine at-risk individuals' reported reasons for and against familial cancer clinic (FCC) attendance and genetic testing.

METHODS

Thirty-nine telephone interviews were conducted with relatives of high-risk mutation carriers, 23% (n = 9) of whom had not previously attended an FCC. Interview responses were analyzed using the frameworks of Miles and Huberman.

RESULTS

The reasons most commonly reported for FCC attendance were for clarification of risk status and to gain access to testing. While disinterest in testing was one reason for FCC nonattendance, several individuals were unaware of their risk (n = 3) or their eligibility to attend an FCC (n = 2), despite being notified of their risk status through their participation in a large-scale research project. Individuals' reasons for undergoing testing were in line with that reported elsewhere; however, concerns about discrimination and insurance were not reported in nontestees.

CONCLUSIONS

Current guidelines regarding notifying individuals discovered to be at increased risk in a research, rather than clinical setting, take a largely nondirective approach. However, this study demonstrates that individuals who receive a single letter notifying them of their risk may not understand/value the information they receive.

Extended criteria donor and severe intraoperative glucose variability: association with reoperation for hemorrhage in liver transplantation

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006.

SELECTION CRITERIA

All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals.

MAIN RESULTS

The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91).

AUTHORS' CONCLUSIONS

There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

Effects of elevated temperature and nickel pollution on the immune status of Japanese medaka

Changes in a host's environment (i.e. physical or chemical) can alter normal immune function. In aquatic organisms, exposure to stress can result in significant changes in innate immunity. In the natural environment, fish are exposed to multiple stressors simultaneously. Temperature change and/or chemical exposure as individual environmental stressors have been shown in various fish species to alter all aspects of the immune response. These same stressors have also been shown to alter plasma steroid levels in exposed fish. For this study, the effects of elevated temperature and nickel pollution on specific immune parameters of Japanese medaka (Oryzias latipes) were determined. Fish were exposed for 1, 7 or 14d to either: waterborne nickel (Ni) at the nominal concentration of 125ppb; a 5 degrees C (+/-0.5 degrees C) rapid increase in water temperature; or, both potential stressors in combination. Medaka maintained at room temperature (25 degrees C+/-1 degrees C) served as the controls. Altered function of the innate and adaptive arms of the immune response was evaluated by assessing kidney macrophage-mediated superoxide (O(2)(-)) production and splenic T-cell proliferation, respectively. Plasma cortisol levels were analysed in the same fish as a marker of the physiological stress response. While kidney cell number was unaffected by exposure of fish to either stressor alone or both factors in combination, spleen cellularity was decreased (compared to control fish) in medaka exposed for 1d to thermal stress in combination with Ni, and to a lesser extent to thermal stress alone. T-lymphocyte proliferation by medaka splenocytes was not affected by any exposure paradigm. Unstimulated intracellular O(2)(-) production by kidney phagocytes was significantly elevated (compared to control) in medaka exposed for 1d to either thermal stress alone or temperature change in combination with Ni; by 7d, only the stressor combination significantly increased baseline O(2)(-) production. Resting levels of extracellular O(2)(-) production was significantly reduced in fish maintained for 1d at the elevated temperature. Effects on phorbol 12-myristate 13 acetate (PMA)-stimulated intracellular and extracellular O(2)(-) production were less dramatic than those observed for resting phagocytes. Exposure of medaka to elevated temperature for 14d tended (p<0.06) to reduce PMA-stimulated intracellular O(2)(-) production (compared to the time-matched control). Although exposure of fish for 14d to elevated temperature only slightly reduced stimulated extracellular O(2)(-) production, exposure for the same duration to Ni alone significantly depressed oxyradical production by kidney phagocytes (compared to the time-matched controls). Decreased plasma cortisol levels were observed in fish exposed for 7d to either an elevated water temperature or Ni (compared to the time-matched control); by 14d of exposure, no significant treatment-induced effects on cortisol levels were observed. These findings add to the growing body of literature seeking to determine what effects, if any, exposure to multiple aquatic pollution-induced effects have upon fish health and the health of impacted ecosystems.

Severe pulmonary disease due to multisystemic eosinophilic epitheliotropic disease in a horse

Multisystemic eosinophilic epitheliotropic disease was diagnosed histologically in a 17-year-old Quarter Horse intact mare that was presented with a chronic history of respiratory distress. At necropsy, the lungs were poorly collapsed and the pulmonary parenchyma contained innumerable, discrete, spherical nodules in a miliary pattern. A few similar nodules were scattered in the liver and the renal lymph nodes. Histologically, these nodules consisted of fibrosing eosinophilic granulomas. Based on histologic findings and the absence of an etiologic agent, a diagnosis of multisystemic eosinophilic epitheliotropic disease was made.

Predictors of operative death after oesophagectomy for carcinoma

BACKGROUND

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease.

METHODS

Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis.

RESULTS

The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death.

CONCLUSION

Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.

New approaches to enhance the accuracy of the diagnosis of reflux disease

The accuracy of symptoms in diagnosing gastro-oesophageal reflux disease (GORD) is complicated by the lack of a gold standard test. Statistical techniques such as latent class and Bayesian analyses can estimate accuracy of symptoms without a gold standard. Both techniques require three independent diagnostic tests. Latent class analysis makes no assumptions about the performance of the tests. Bayesian analysis is useful when the accuracy of the other tests is known. These statistical techniques should be used in the future to validate GORD symptom questionnaires comparing them with endoscopy, oesophageal pH monitoring, and response to proton pump inhibitor therapy. Studies that evaluate GORD symptoms are usually done in secondary care. The prevalence of GORD in primary care will be lower and this reduces the positive predictive value of symptoms. There will be some bias in the type of patient referred for diagnosis and this usually decreases the specificity of symptom diagnosis.