Emily K. Robinson

Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy.

OBJECTIVE To evaluate an entertainment-based patient decision aid for early stage breast cancer surgery in low health literacy patients. METHODS Newly diagnosed female patients with early stage breast cancer from two public hospitals were randomized to receive an entertainment-based decision aid for breast cancer treatment along with usual care (intervention arm) or to receive usual care only (control arm). Pre-decision (baseline), pre-surgery, and 1-year follow-up assessments were conducted. RESULTS Patients assigned to the intervention arm of the study were more likely than the controls to choose mastectomy rather than breast-conserving surgery; however, they appeared better informed and clearer about their surgical options than women assigned to the control group. No differences in satisfaction with the surgical decision or the decision-making process were observed between the patients who viewed the intervention and those assigned to the control group. CONCLUSIONS Entertainment education may be a desirable strategy for informing lower health literate women about breast cancer surgery options. PRACTICE IMPLICATIONS Incorporating patient decision aids, particularly computer-based decision aids, into standard clinical practice remains a challenge; however, patients may be directed to view programs at home or at public locations (e.g., libraries, community centers).

Standardized patient care guidelines reduce infectious morbidity in appendectomy patients

BACKGROUND Surgical wound infection and intra-abdominal abscess remain common infectious complications after appendectomy, especially in the setting of a perforated or gangrenous appendix. We therefore developed a clinical protocol for the management of appendicitis to decrease postoperative infectious complications. METHODS Between January 1, 1999, and December 31, 1999, 206 patients with appendicitis were treated on protocol. Retrospectively, the charts were reviewed for all protocol patients as well as for 232 patients with appendicitis treated in the year prior to protocol initiation. Data were collected on surgical wound infections and intra-abdominal abscesses. RESULTS There were significantly fewer infectious complications in the protocol group than in the nonprotocol group (20 [9%] versus 8 [4%]; P <0.05). In patients with a perforated or gangrenous appendix, the infectious complication rate was reduced from 33% to 13% (P <0.05). CONCLUSIONS The incidence of infectious complications after appendectomy can be significantly reduced with a standardized approach to antibiotic therapy and wound management.

Does upregulation of inducible nitric oxide synthase play a role in hepatic injury

Lipopolysaccharide (LPS) and gut ischemia/reperfusion (I/R) injury cause reversible liver injury. Because nitric oxide (NO) can have both beneficial and deleterious effects in the gastrointestinal tract, and because the role of NO in gut I/R-induced hepatic injury is unknown, this study examined its role in LPS and gut I/R-induced hepatic injury in the rat. Both LPS and gut I/R caused a similar increase in serum hepatocellular enzymes. LPS but not gut I/R caused a significant increase in upregulation of hepatic inducible NO synthase (iNOS) according to quantitative real-time RT-PCR and Western immunoblot analysis. Aminoguanidine, a selective iNOS inhibitor, attenuated LPS-induced hepatic injury and hypotension, but did not prevent gut I/R-induced hepatic injury. In contrast, the non-selective NOS inhibitor NG-nitro-L-arginine methyl ester aggravated liver damage from both LPS and gut I/R. These data indicate that iNOS plays a role in mediating LPS-induced hepatic injury, but not gut I/R-induced hepatic injury. The data also suggest that the constitutive isoforms of NOS play a hepatoprotective role in both models of hepatic injury.

Preliminary testing of a just-in-time, user-defined values clarification exercise to aid lower literate women in making informed breast cancer treatment decisions

Objective  To report on the initial testing of a values clarification exercise utilizing a jewellery box within a computerized patient decision aid (CPtDA) designed to assist women in making a surgical breast cancer treatment decision.

Past, present, and future: Critical analysis of use of gastric bands in obese patients

Adjustable gastric banding (AGB) is quickly becoming the most popular bariatric operation performed in the United States and Canada. Patients are particularly fond of the simplicity of the tool, the relatively low morbidity of the surgery, the quick recovery, and overall results. The gastric band has evolved over its 35-year history into a very successful adjustable tool used to restrict food consumption and limit caloric intake. The percent of excessive weight loss after banding can range from 30%–60% and depends on the time out from surgery. Along with weight loss, there is good resolution of the co-morbid conditions that are associated with excess weight and improvements in quality of life demonstrated after banding. Nutrition and follow up are extremely important after banding to ensure good compliance and adequate weight loss. Failure to follow the postoperative diet, exercise regiment, or mechanical failure of the band can lead to failure to lose adequate weight. While there are particular early and late complications associated with this surgery, the safety profile of the AGB is very appealing when compared to other bariatric operations. As we continue to reduce the morbidity of the procedure, the simple adjustable band concept has a lot of potential to remain a primary technique of maintaining long term weight loss. In conclusion, AGB has and continues to play an important role in the treatment of morbid obesity. It offers reasonably good weight loss results with very little morbidity, and the future of the adjustable band is bright.

Cell cycle regulation of human pancreatic cancer by tamoxifen

AbstractBackground: Clinical trials have suggested a survival advantage for selected patients with metastatic pancreatic cancer treated with tamoxifen. We sought to identify the molecular mechanism by which tamoxifen inhibits human pancreatic cancer cell (HPCC) growth. Methods: HPCCs were grown in tamoxifen and growth inhibition was determined by3H-thymidine uptake and by the MTT assay; changes in cell viability were determined by cell counts. Cell cycle alterations were evaluated by FACS, and the induction of apoptosis was evaluated using the TUNEL assay. Total cellular RNA was isolated after tamoxifen treatment, and Northern blot analysis was performed for p21waf1. Results: Tamoxifen inhibited HPCC growth as measured by inhibition of3H-thymidine incorporation and by the MTT assay. However, there was no decrease in the total number of viable cells after 6 days of treatment with 10 µM of tamoxifen and no evident apoptosis, confirming the absence of a cytotoxic effect. Cell cycle analysis revealed cellular arrest in the G0/G1 phase, which correlated with p21waf1 mRNA upregulation in response to tamoxifen treatment. Conclusions: Tamoxifen inhibits HPCC growth by inducing G0/G1 arrest with an associated increase in p21waf1 mRNA expression. Tamoxifen is an effective inhibitor of HPCC growth in vitro and warrants further in vivo study.

Differential effects of luminal arginine and glutamine on metalloproteinase production in the postischemic gut.

BACKGROUND Matrix metalloproteinases (MMPs) are a group of endopeptidases induced under inflammatory conditions in the intestine which possess the capacity to degrade components of the extracellular matrix. We have previously demonstrated that MMP-2 expression correlates with increased inducible nitric oxide synthase (iNOS) production in the stomach and that iNOS is upregulated in the postischemic gut by the luminal nutrient arginine and repressed by luminal glutamine. We therefore hypothesized that arginine would enhance expression of MMP-2 in the postischemic gut. METHODS Jejunal sacs were created in rats at laparotomy and filled with either 60 mM glutamine, arginine, or magnesium sulfate (osmotic control) followed by 60 minutes of superior mesenteric artery occlusion (SMAO) and 6 hours of reperfusion and compared with shams. Jejunum was harvested, and membrane type-1 matrix metalloproteinase (MT1-MMP), MMP-2, and iNOS protein expression was determined by Western analysis and MMP-9 production by gelatin zymography. RESULTS MMP-2, MT1-MMP, MMP-9, and iNOS were all increased after SMAO compared with shams. Arginine maintained while glutamine inhibited the increase in iNOS, MT1-MMP, and MMP-2 expression in the postischemic gut. Pretreatment of the arginine group with a selective iNOS inhibitor blunted the induction of MMP-2 in the postischemic gut. There was no differential modulation of MMP-9 by the luminal nutrients. CONCLUSIONS The arginine-induced upregulation of iNOS may contribute to increased activity of MT1-MMP and MMP-2. The mechanism for this differential regulation by arginine warrants further investigation.

Effect of NOS inhibition on rat gastric matrix metalloproteinase production during endotoxemia.

Matrix metalloproteinases (MMPs) degrade the extracellular matrix and contribute to LPS-induced gastric injury. MMPs are closely modulated by their activators, membrane type-MMP (MT-MMPs) and their endogenous inhibitors, the tissue inhibitors of metalloproteinases (TIMPs). As LPS-induced gastric injury is mediated in part by iNOS, and NO modulates MMP production in vitro, we hypothesized that NOS inhibition would similarly modulate LPS-induced gastric MMP production. Therefore, the purpose of these studies was to compare the effects of selective and nonselective NOS inhibition on LPS-induced gastric MMP production. Methods Sprague-Dawley rats were given either the nonselective NOS inhibitor NG-nitro-l-arginine methyl ester (l-NAME; 5 mg/kg, s.c.), a selective iNOS inhibitor, aminoguanidine (45 mg/kg, i.p.) or l-N-iminoethyl-lysine (l-NIL; 10 mg/kg, i.p.), or vehicle 15 min before saline or LPS (20 mg/kg, i.p.) and killed 24 h after LPS administration. Stomachs were assessed for macroscopic injury (computed planimetry), and gastric mucosal MMP production was assessed by gelatin zymography, in situ zymography, and Western analysis for MMP-2, MT1-MMP, and TIMP-2. (n ≥ 4/group; ANOVA). Results Aminoguanidine treatment decreased LPS-induced macroscopic gastric injury as well as MMP-2 and MT1-MMP protein production while having no effect on TIMP-2 protein levels. l-NIL similarly attenuated the induction of MMP-2 and MT1-MMP by LPS. l-NAME failed to attenuate LPS induced gastric injury or MT1-MMP protein induction and increased MMP-2 levels. l-NAME similarly had no effect on gastric TIMP-2 production. Conclusions Selective iNOS inhibition decreases gastric MMP-2 activity after LPS administration, whereas nonselective inhibition increases MMP-2 levels. The ability of selective iNOS inhibition to ameliorate LPS-induced gastric injury may be due in part to its inhibition of active MMP-2 production, whereas nonselective NOS inhibitors increase MMP-2 levels and maintain gastric injury after LPS administration.

The Neglected Topic Presentation of Cost Information in Patient Decision Aids

Costs are an important component of patients’ decision making, but a comparatively underemphasized aspect of formal shared decision making. We hypothesized that decision aids also avoid discussion of costs, despite their being tools designed to facilitate shared decision making about patient-centered outcomes. We sought to define the frequency of cost-related information and identify the common modes of presenting cost and cost-related information in the 290 decision aids catalogued in the Ottawa Hospital Research Institute’s Decision Aid Library Inventory (DALI) system. We found that 56% (n = 161) of the decision aids mentioned cost in some way, but only 13% (n = 37) gave a specific price or range of prices. We identified 9 different ways in which cost was mentioned. The most common approach was as a “pro” of one of the treatment options (e.g., “you avoid the cost of medication”). Of the 37 decision aids that gave specific prices or ranges of prices for treatment options, only 2 were about surgery decisions despite the fact that surgery decision aids were the most common. Our findings suggest that presentation of cost information in decision aids is highly variable. Evidence-based guidelines should be developed by the International Patient Decision Aid Standards (IPDAS) Collaboration.

Distant Metastatic Disease Manifestations in Infiltrating Lobular Carcinoma of the Breast

OBJECTIVE This article reviews unusual distant metastatic patterns of infiltrating lobular carcinoma (ILC) of the breast. CONCLUSION ILC of the breast tends to spread to the gastrointestinal tract, genitourinary tract, peritoneum, retroperitoneum, and leptomeninges in addition to common visceral sites such as the liver, bone, and lung. Knowledge of these unusual metastatic manifestations and disease patterns may aid in differentiating distant metastatic disease from secondary primary cancers and help plan appropriate therapy.