Surgical treatment of thymoma. Personal experience

Introduction. Thymomas (THs) are rare epithelial tumors of the thymus gland. In this study we report our personal experience in the management and surgical treatment of THs. Case reports. We report two clinical cases treated with combined therapy (surgery followed by adjuvant therapy). Results. Total transternal thymectomy was performed in both patients. The post-operative course was uneventful. The patients received adjuvant radiotherapy and chemotherapy. No relapse has been observed during follow-up. Discussion. THs are usually slowly growing tumors with similar incidence in both sexes. They occur through a wide age range, with a peak in the fifth and sixth decades. Distinctive features reminiscent of the normal thymus make the pathologic diagnosis of THs easy in most cases. Malignant behaviour is indicated by microscopic or macroscopic invasion of the tumor capsule or surrounding organs or by the presence of metastases. Although there is no standardized staging system for thymoma, the one proposed by Masaoka is commonly employed. Total thymectomy is the procedure of choice, even for encapsulated tumors, with carefully exploration of the mediastinum for evidence of ectopic thymic tissue or local invasion. Conclusions. Despite an indolent course and a cytologically bland appearance, all thymic tumors can manifest a malignant behavior. Surgery continues to be the mainstay of treatment, and the ability to achieve complete resection seems to be the most important prognostic factor. Multimodality treatment involving postoperative chemotherapy and radiotherapy appears to increase the rate of complete resection and improves survival in advanced THs.

Surgical strategy for the treatment of sporadic medullary thyroid carcinoma: our experience

Background. Medullary thyroid carcinoma (MTC) is a rare disease which accounts for approximately 5-9% of all thyroid cancers and originates from the calcitonin-secerning parafollicular C cells. MTC can be divided into two subgroups: sporadic (75%) or inherited (25%). The majority of patients with invasive MTC have metastasis to regional lymph nodes at the time of diagnosis, as evidenced by the frequent finding of persistently elevated calcitonin levels after thyroidectomy and the high rates of recurrence in the cervical lymph nodes reported in retrospective studies. Objectives. The purpose of the study is to review our single institution's experience with MTC since 1998 and to evaluate surgical strategy, patterns of lymph node metastases and calcitonin response to compartment-oriented lymphadenectomy in patients with primary or recurrent sporadic medullary thyroid carcinoma. Methods. A retrospective review of 26 patients treated for MTC at the “Antonio Cardarelli” Hospital referral center, in Naples, between 1998 and 2012. There were 18 female and 8 male patients, median age at presentation was 55 years, and median follow-up for survivors was 5 years. Total thyroidectomy was performed in all 26 patients; central compartment (CC) node dissection (level VI) in 12 (46%) patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 7 (27%) patients. 4 patients (15%) underwent reoperation for loco-regional recurrent/persistent MTC. Results. After a median post-surgical follow-up of 5 years (range 1-10 years), 63 % of patients were living disease-free, 15% were living with disease and/or persistently elevated calcitonin levels after surgery, 11% were deceased due to MTC and 11 % were lost to follow-up. Conclusions. We agree with most authors advocating for a total thyroidectomy and prophylactic central neck dissection in the setting of clinically detected MTC. Lateral neck dissection may be best reserved for patients with positive preoperative imaging. Nevertheless MTC has a high rate of lymph node metastases that are sub optimally detected preoperatively in the central compartment by neck ultrasound or intra-operatively by the surgeon, and reoperation is associated with a higher rate of surgical complications. In our limited experience, patients with thyroid confined nodular pathology, without nodal disease and unknown preoperative diagnosis of MTC, underwent only total thyroidectomy with a good prognosis.

Ultrasound-assisted electrochemical treatment of wastewaters containing organic pollutants by using novel Ti/Ta2O5-SnO2 electrodes

Advanced oxidation processes (AOPs) are modern methods using reactive hydroxyl radicals for the mineralization of organic pollutants into simple inorganic compounds, such as CO2 and H2O. Among AOPs electrochemical oxidation (EO) is a method suitable for coloured and turbid wastewaters. The degradation of pollutants occurs on electrocatalytic electrodes. The majority of electrodes contain in their structure either expensive materials (diamond and Pt-group metals) or are toxic for the environment compounds (Sb or Pb). One of the main disadvantages of electrochemical method is the polarization and contamination of electrodes due to the deposition of reaction products on their surface, which results in diminishing of the process efficiency. Ultrasound combined with the electrochemical degradation process eliminates electrode contamination because of the continuous mechanical cleaning effect produced by the formation and collapse of acoustic cavitation bubbles near to the electrode surface. Moreover, high frequency ultrasound generates hydroxyl radicals at water sonolysis. Ultrasound-assisted EO is a non-selective method for oxidation of different organic compounds with high degradation efficiencies. The aim of this research was to develop novel sustainable and cost-effective electrodes working as electrocatalysts and test their activity in electrocatalytic oxidation of organic compounds such as dyes and organic acids. Moreover, the goal of the research was to enhance the efficiency of electrocatalytic degradation processes by assisting it with ultrasound in order to eliminate the main drawbacks of a single electrochemical oxidation such as electrodes polarization and passivation. Novel Ti/Ta2O5-SnO2 electrodes were developed and found to be electrocatalytically active towards water (with 5% Ta content, 10 oxide film layers) and organic compounds oxidation (with 7.5% Ta content, 8 oxide film layers) and therefore these electrodes can be applicable in both environmental and energy fields. The synergetic effect of combined electrolysis and sonication was shown while conducting sonoelectrochemical (EO/US) degradation of methylene blue (MB) and formic acid (FA). Complete degradation of MB and FA was achieved after 45 and 120 min of EO/US process respectively in neutral media. Mineralization efficiency of FA over 95% was obtained after 2 h of degradation using high frequency ultrasound (381, 863, 1176 kHz) combined with 9.1 mA/cm2 current density. EO/US degradation of MB provided over 75% mineralization in 8 h. High degradation kinetic rates and mineralization efficiencies of model pollutants obtained in EO/US experiments provide the preconditions for further extrapolation of this treatment method to pilot scale studies with industrial wastewaters.

Synthesis, characterization and chemical vapor deposition of transition metal di(tert-butyl)amido compounds

Although the transition metal chemistry of many dialkylamido ligands has been well studied, the chemistry of the bulky di(tert-butyl)amido ligand has been largely overlooked. The di(tert-butyl)amido ligand is well suited for synthesizing transition metal compounds with low coordination numbers; such compounds may exhibit interesting structural, physical, and chemical properties. Di(tert-butyl)amido complexes of transition metals are expected to exhibit high volatilities and low decomposition temperatures, thus making them well suited for the chemical vapor deposition of metals and metal nitrides. Treatment of MnBr₂(THF)₂, FeI₂, CoBr₂(DME), or NiBr₂(DME) with two equivalents of LiN(t-Bu)2 in benzene affords the two-coordinate complex M[N(t-Bu)₂]₂, where M is Mn, Fe, Co, or Ni. Crystallographic studies show that the M-N distances decrease across the series: 1.9365 (Mn), 1.8790 (Fe), 1.845 (Co), 1.798 Å (Ni). The N-M- N angles are very close to linear for Mn and Fe (179.30 and 179.45°, respectively), but bent for Co and Ni (159.2 and 160.90°, respectively). As expected, the d⁵ Mn complex has a magnetic moment of 5.53 μΒ that is very close to the spin only value. The EPR spectrum is nearly axial with a low E/D ratio of 0.014. The d⁶ Fe compound has a room temperature magnetic moment of 5.55 μΒ indicative of a large orbital angular momentum contribution. It does not exhibit a Jahn-Teller distortion despite the expected doubly degenerate ground state. Applied field Mössbauer spectroscopy shows that the effective internal hyperfine field is unusually large, Hint = 105 T. The magnetic moments of Co[N(t-Bu)₂]₂ and Ni[N(t-Bu)₂]₂ are 5.24 and 3.02 μΒ respectively. Both are EPR silent at 4.2 K. Treatment of TiCl₄ with three equivalents of LiN(t-Bu)2 in pentane affords the briding imido compound Ti₂[μ-N(t-Bu)]₂Cl₂[N(t-Bu)₂]₂ via a dealkylation reaction. Rotation around the bis(tert-butyl)amido groups is hindered, with activation parameters of ΔH‡ = 12.8 ± 0.6 kcal mol-1 and ΔS‡ = -8 ± 2 cal K-1 ·mol-1, as evidenced by variable temperature 1H NMR spectroscopy. Treatment of TiCl₄ with two equivalents of HN(t-Bu)₂ affords Ti₂Cl₆[N(t-Bu)₂]₂. This complex shows a close-contact of 2.634(3) Å between Ti and the carbon atom of one of the CH₃ substituents on the tert-butyl groups. Theoretical considerations and detailed structural comparisons suggest this interaction is not agostic in nature, but rather is a consequence of interligand repulsions. Treatment of NiI₂(PPh3)₂ and PdCl₂(PPh₃)₂ with LiN(t-Bu)₂in benzene affords Ni[N(t-Bu)₂](PPh₃)I and Pd₃(μ₂-NBut₂)2(μ₂-PPh₂)Ph(PPh₃) respectively. The compound Ni[N(t-Bu)₂](PPh₃)I has distorted T-shape in geometry, whereas Pd₃(μ₂-NBut₂)₂(μ₂-PPh₂)Ph(PPh₃) contains a triangular palladium core. Manganese nitride films were grown from Mn[N(t-Bu)₂]₂ in the presence of anhydrous ammonia. The growth rate was several nanometers per minute even at the remarkably low temperature of 80⁰C. As grown, the films are carbon- and oxygen-free, and have a columnar morphology. The spacings between the columns become smaller and the films become smoother as the growth temperature is increased. The composition of the films is consistent with a stoichiometry of Mn₅N₂.

Plasma diagnostics and ITO film deposition by RF-assisted closed-field dual magnetron system

Deposition of indium tin oxide (ITO) among various transparent conductive materials on flexible organic substrates has been intensively investigated among academics and industrials for a whole new array of imaginative optoelectronic products. One critical challenge coming with the organic materials is their poor thermal endurances, considering that the process currently used to produce industry-standard ITO usually involves relatively high substrate temperature in excess of 200°C and post-annealing. A lower processing temperature is thus demanded, among other desires of high deposition rate, large substrate area, good uniformity, and high quality of the deposited materials. For this purpose, we developed an RF-assisted closed-field dual magnetron sputtering system. The “prototype” system consists of a 3-inch unbalanced dual magnetron operated at a closed-field configuration. An RF coil was fabricated and placed between the two magnetron cathodes to initiate a secondary plasma. The concept is to increase the ionization faction with the RF enhancement and utilize the ion energy instead of thermal energy to facilitate the ITO film growth. The closed-field unbalanced magnetrons create a plasma in the intervening region rather than confine it near the target, thus achieving a large-area processing capability. An RF-compensated Langmuir probe was used to characterize and compare the plasmas in mirrored balanced and closed-field unbalanced magnetron configurations. The spatial distributions of the electron density ne and electron temperature Te were measured. The density profiles reflect the shapes of the plasma. Rather than intensively concentrated to the targets/cathodes in the balanced magnetrons, the plasma is more dispersive in the closed-field mode with a twice higher electron density in the substrate region. The RF assistance significantly enhances ne by one or two orders of magnitude higher. The effect of various other parameters, such as pressure, on the plasma was also studied. The ionization fractions of the sputtered atoms were measured using a gridded energy analyzer (GEA) combined with a quartz crystal microbalance (QCM). The presence of the RF plasma effectively increases the ITO ionization fraction to around 80% in both the balanced and closed-field unbalanced configurations. The ionization fraction also varies with pressure, maximizing at 5-10 mTorr. The study of the ionization not only facilitates understanding the plasma behaviors in the RF-assisted magnetron sputtering, but also provides a criterion for optimizing the film deposition process. ITO films were deposited on both glass and plastic (PET) substrates in the 3-inch RF-assisted closed-field magnetrons. The electrical resistivity and optical transmission transparency of the ITO films were measured. Appropriate RF assistance was shown to dramatically reduce the electrical resistivity. An ITO film with a resistivity of 1.2×10-3 Ω-cm and a visible light transmittance of 91% was obtained with a 225 W RF enhancement, while the substrate temperature was monitored as below 110°C. X-ray photoelectron spectroscopy (XPS) was employed to confirm the ITO film stoichiometry. The surface morphology of the ITO films and its effect on the film properties were studied using atomic force microscopy (AFM). The prototype of RF-assisted closed-field magnetron was further extended to a larger rectangular shaped dual magnetron in a flat panel display manufacturing system. Similar improvement of the ITO film conductivities by the auxiliary RF was observed on the large-area PET substrates. Meanwhile, significant deposition rates of 25-42 nm/min were achieved.

Increased CSF Aβ during the very early phase of cerebral Aβ deposition in mouse models

Abnormalities in brains of Alzheimer's disease (AD) patients are thought to start long before the first clinical symptoms emerge. The identification of affected individuals at this 'preclinical AD' stage relies on biomarkers such as decreased levels of the amyloid-β peptide (Aβ) in the cerebrospinal fluid (CSF) and positive amyloid positron emission tomography scans. However, there is little information on the longitudinal dynamics of CSF biomarkers, especially in the earliest disease stages when therapeutic interventions are likely most effective. To this end, we have studied CSF Aβ changes in three Aβ precursor protein transgenic mouse models, focusing our analysis on the initial Aβ deposition, which differs significantly among the models studied. Remarkably, while we confirmed the CSF Aβ decrease during the extended course of brain Aβ deposition, a 20-30% increase in CSF Aβ40 and Aβ42 was found around the time of the first Aβ plaque appearance in all models. The biphasic nature of this observed biomarker changes stresses the need for longitudinal biomarker studies in the clinical setting and the search for new 'preclinical AD' biomarkers at even earlier disease stages, by using both mice and human samples. Ultimately, our findings may open new perspectives in identifying subjects at risk for AD significantly earlier, and in improving the stratification of patients for preventive treatment strategies.

A III-V channel field effect transistor for non-classical CMOS: process optimisation for improved gate stack function

This thesis describes a collection of studies into the electrical response of a III-V MOS stack comprising metal/GaGdO/GaAs layers as a function of fabrication process variables and the findings of those studies. As a result of this work, areas of improvement in the gate process module of a III-V heterostructure MOSFET were identified. Compared to traditional bulk silicon MOSFET design, one featuring a III-V channel heterostructure with a high-dielectric-constant oxide as the gate insulator provides numerous benefits, for example: the insulator can be made thicker for the same capacitance, the operating voltage can be made lower for the same current output, and improved output characteristics can be achieved without reducing the channel length further. It is known that transistors composed of III-V materials are most susceptible to damage induced by radiation and plasma processing. These devices utilise sub-10 nm gate dielectric films, which are prone to contamination, degradation and damage. Therefore, throughout the course of this work, process damage and contamination issues, as well as various techniques to mitigate or prevent those have been investigated through comparative studies of III-V MOS capacitors and transistors comprising various forms of metal gates, various thicknesses of GaGdO dielectric, and a number of GaAs-based semiconductor layer structures. Transistors which were fabricated before this work commenced, showed problems with threshold voltage control. Specifically, MOSFETs designed for normally-off (VTH > 0) operation exhibited below-zero threshold voltages. With the results obtained during this work, it was possible to gain an understanding of why the transistor threshold voltage shifts as the gate length decreases and of what pulls the threshold voltage downwards preventing normally-off device operation. Two main culprits for the negative VTH shift were found. The first was radiation damage induced by the gate metal deposition process, which can be prevented by slowing down the deposition rate. The second was the layer of gold added on top of platinum in the gate metal stack which reduces the effective work function of the whole gate due to its electronegativity properties. Since the device was designed for a platinum-only gate, this could explain the below zero VTH. This could be prevented either by using a platinum-only gate, or by matching the layer structure design and the actual gate metal used for the future devices. Post-metallisation thermal anneal was shown to mitigate both these effects. However, if post-metallisation annealing is used, care should be taken to ensure it is performed before the ohmic contacts are formed as the thermal treatment was shown to degrade the source/drain contacts. In addition, the programme of studies this thesis describes, also found that if the gate contact is deposited before the source/drain contacts, it causes a shift in threshold voltage towards negative values as the gate length decreases, because the ohmic contact anneal process affects the properties of the underlying material differently depending on whether it is covered with the gate metal or not. In terms of surface contamination; this work found that it causes device-to-device parameter variation, and a plasma clean is therefore essential. This work also demonstrated that the parasitic capacitances in the system, namely the contact periphery dependent gate-ohmic capacitance, plays a significant role in the total gate capacitance. This is true to such an extent that reducing the distance between the gate and the source/drain ohmic contacts in the device would help with shifting the threshold voltages closely towards the designed values. The findings made available by the collection of experiments performed for this work have two major applications. Firstly, these findings provide useful data in the study of the possible phenomena taking place inside the metal/GaGdO/GaAs layers and interfaces as the result of chemical processes applied to it. In addition, these findings allow recommendations as to how to best approach fabrication of devices utilising these layers.

The development of planar high-K/III-V p-channel MOSFETs for post-silicon CMOS

Conventional Si complementary-metal-oxide-semiconductor (CMOS) scaling is fast approaching its limits. The extension of the logic device roadmap for future enhancements in transistor performance requires non-Si materials and new device architectures. III-V materials, due to their superior electron transport properties, are well poised to replace Si as the channel material beyond the 10nm technology node to mitigate the performance loss of Si transistors from further reductions in supply voltage to minimise power dissipation in logic circuits. However several key challenges, including a high quality dielectric/III-V gate stack, a low-resistance source/drain (S/D) technology, heterointegration onto a Si platform and a viable III-V p-metal-oxide-semiconductor field-effect-transistor (MOSFET), need to be addressed before III-Vs can be employed in CMOS. This Thesis specifically addressed the development and demonstration of planar III-V p-MOSFETs, to complement the n-MOSFET, thereby enabling an all III-V CMOS technology to be realised. This work explored the application of InGaAs and InGaSb material systems as the channel, in conjunction with Al2O3/metal gate stacks, for p-MOSFET development based on the buried-channel flatband device architecture. The body of work undertaken comprised material development, process module development and integration into a robust fabrication flow for the demonstration of p-channel devices. The parameter space in the design of the device layer structure, based around the III-V channel/barrier material options of In_x≥0.53Ga_1-xAs/In_0.52Al_0.48As and In_x≥0.1Ga_1-xSb/AlSb, was systematically examined to improve hole channel transport. A mobility of 433 cm²/Vs, the highest room temperature hole mobility of any InGaAs quantum-well channel reported to date, was obtained for the In_0.85Ga_0.15As (2.1% strain) structure. S/D ohmic contacts were developed based on thermally annealed Au/Zn/Au metallisation and validated using transmission line model test structures. The effects of metallisation thickness, diffusion barriers and de-oxidation conditions were examined. Contacts to InGaSb-channel structures were found to be sensitive to de-oxidation conditions. A fabrication process, based on a lithographically-aligned double ohmic patterning approach, was realised for deep submicron gate-to-source/drain gap (L_side) scaling to minimise the access resistance, thereby mitigating the effects of parasitic S/D series resistance on transistor performance. The developed process yielded gaps as small as 20nm. For high-k integration on GaSb, ex-situ ammonium sulphide ((NH₄)₂S) treatments, in the range 1%-22%, for 10min at 295K were systematically explored for improving the electrical properties of the Al₂O₃/GaSb interface. Electrical and physical characterisation indicated the 1% treatment to be most effective with interface trap densities in the range of 4 - 10×10¹²cm^-2eV^-1 in the lower half of the bandgap. An extended study, comprising additional immersion times at each sulphide concentration, was further undertaken to determine the surface roughness and the etching nature of the treatments on GaSb. A number of p-MOSFETs based on III-V-channels with the most promising hole transport and integration of the developed process modules were successfully demonstrated in this work. Although the non-inverted InGaAs-channel devices showed good current modulation and switch-off characteristics, several aspects of performance were non-ideal; depletion-mode operation, modest drive current (I_d,sat=1.14mA/mm), double peaked transconductance (g_m=1.06mS/mm), high subthreshold swing (SS=301mV/dec) and high on-resistance (R_on=845kΩ.μm). Despite demonstrating substantial improvement in the on-state metrics of I_d,sat (11×), g_m (5.5×) and R_on (5.6×), inverted devices did not switch-off. Scaling gate-to-source/drain gap (L_side) from 1μm down to 70nm improved I_d,sat (72.4mA/mm) by a factor of 3.6 and gm (25.8mS/mm) by a factor of 4.1 in inverted InGaAs-channel devices. Well-controlled current modulation and good saturation behaviour was observed for InGaSb-channel devices. In the on-state In_0.3Ga_0.7Sb-channel (I_d,sat=49.4mA/mm, g_m=12.3mS/mm, R_on=31.7kΩ.μm) and In_0.4Ga_0.6Sb-channel (I_d,sat=38mA/mm, g_m=11.9mS/mm, R_on=73.5kΩ.μm) devices outperformed the InGaAs-channel devices. However the devices could not be switched off. These findings indicate that III-V p-MOSFETs based on InGaSb as opposed to InGaAs channels are more suited as the p-channel option for post-Si CMOS.

Investigation on possibility of survival and growth enhancing by selected seaweeds from Persian Gulf in post larvae shrimp Litopenaeus vannamei

The use of antibiotics in aquaculture has been limited. Scientifics seeking for natural substitutes to prevent of aquatic animals diseases. Considering seaweeds are rich of nutritions and bioactive compounds, the purpose of this study is: investigation the potential and use possibility of native seaweeds from Persian Gulf in shrimp aquculture industry to improve growth, survival of postlarvae and to resistance against pathogens such as vibriosis. For this propose 7 macroalgae species from Bushehr province coast, inclouding: green algae (C. iyengarii), brown algae (S. angutifolium and S. ilicifolium) and red algae (L. snyderiae, K. alvarezii and G. corticata) were collected and identified. Then seaweed extracts abtained by Water, Ethanol, Methanol and Chloroform solvents by soaking method. In vitro antibacterial activity of extracts against Gr+ bacteria (S. aureus and B. subtilis) and Gr- bacteria (V. harveyi, V. alginolyticus and E. coli) was conducted by Agar diffusion, MIC and MBC methods. Antioxidant activity also by DPPH and EC50 methods was investigated. According to results of these two tests four seaweeds species (S. angutifolium, L. snyderiae, K. alvarezii and G. corticata) were selected for use in shrimp postlarvae (PL22) diets by Bio-Encapsulation (Artemia enrichment). Before of enrichment, toxicity effect of extracts to Artemia nauplii were evaluated by determination of LC50 24 h method. From results of this section Ethanol extracts were selected to bioencapsulation. After encapsulation shrimp postlarvae divided to 12 groups in triplicate, namely: C-, C+, S (200), S (400), S (600), L(200), L(400), L(600), G(300), G(600), K(300) and K(600). During 30 days of reared period C- and C+ use of basal diet and unenriched Artemia, but the other groups use of basal diet and enriched Artemia. Except C-, the shrimps in first day of culture put in 107 cfu/ml v. harveyi suspension for 30 minutes, and after water exchange 10 ml of this dose was added to reared aquaria. After 30 days survival percentage, obtained weight and SGR% were investigated. To evaluate vibrio loading, every 10 days 5 postlarvae were sampled randomly for vibrio count. Results showed that vibrio count in C- was less than the others and in C+ was more than the others. In treatments vibrio count in L(200) was the most and L(600) was the less. Survival rate in C- was the most and after that G(600) with 79.4±6.6% and then S(300) and K(600) were 73.3±7.3% and 70.6±6.6% respectively that were significantly compare the other (P < 0.01). Also the C+ was the less with 33.3±6.6% that difference was significant (P< 0.01). In this study growth parameters of all groups that fed by enriched Artemia were better than C+ (P<0.05). After cultre period 10 shrimp of every aquarium disinfected and reared for 10 days like before treatment. After 10 days the shrimps were challenged by 3×108 cfu/ml V. harveyi and mortality was recorded for 7 days. The all of animals in C- were survive but more than 90% of C+ were dead. And survival in all of treatments were better the C+ (P<0.05). The study showed the ethanol extracts of selected seaweed from Persian Gulf is a good source for growth, Survival and disease control in shrimp larviculture.

Caregivers' experiences and coping strategies relating to patient's subjective treatment-related cognitive impairment following Haematopoietic Stem Cell Transplant (HSCT)

The treatments involved in cancers of the blood and bone marrow can be physically and psychologically challenging and be associated with adverse secondary effects, including cognitive impairment. The incidence and severity of treatment-related cognitive impairment varies widely, however it can significantly impact quality of life by interfering with patients’ activities of daily living, relationships and future plans. It can also pose challenges for the patients’ caregivers, an area which has received comparatively less research attention. The aim of this study was to investigate caregivers’ experiences of treatment-related cognitive impairment in patients who have undergone Haematopoietic Stem Cell Transplant (HSCT); how they coped, both practically and emotionally, and what supports they believe could help them. Participants were caregivers to individuals who had undergone HSCT within the past 20 years and who had reported cognitive changes at the HSCT Late Effects Clinic, Beatson West of Scotland Cancer Centre. Five participants completed a single semi-structured interview. The data was then analysed using Interpretative Phenomenological Analysis (IPA). Results of this analysis illustrated four super-ordinate themes: noticing change; managing expectations, managing personal feelings and commitment. Findings from the current study highlighted the importance of caregiver education regarding post HSCT cognitive and behavioural changes and providing caregiver emotional support. Future research should explore the mutual needs of both care recipient and caregiver.

A dyadic perspective on genito-pelvic pain : trauma antecedents and treatment effectiveness

La vestibulodynie provoquée (VP) est la forme la plus répandue de douleur génito-pelvienne/trouble de la pénétration et la cause la plus fréquente de douleur vaginale chez les femmes pré-ménopausées. Les femmes qui en souffrent rapportent plus de détresse psychologique ainsi qu’un fonctionnement sexuel appauvri, une diminution de la fréquence des activités sexuelles et du plaisir, et plus d’attitudes négatives à l’égard de la sexualité. Les recherches portant sur les couples souffrant de VP ont montré le rôle prépondérant des variables relationnelles dans la modulation des conséquences sexuelles et psychologiques pour les femmes et leurs partenaires. Cependant, aucune analyse dyadique n’a été appliquée au facteur de risque étiologique le plus robuste, soit la maltraitance durant l’enfance. Par ailleurs, malgré des recommandations répétées pour inclure le partenaire dans le traitement psychologique pour la VP, aucune étude à ce jour n’a examiné l’efficacité d’une psychothérapie qui inclut systématiquement le partenaire et dont la cible est le couple. L’objectif général de cette thèse a été d’utiliser une perspective dyadique afin d’examiner les antécédents de maltraitance et l’efficacité d’une intervention conçue pour améliorer les issues des couples souffrant de VP. Le premier article vise à examiner les liens entre la maltraitance durant l’enfance des femmes souffrant de VP et leurs partenaires, et leur fonctionnement sexuel, leur ajustement psychologique, leur satisfaction conjugale et enfin avec la douleur rapportée par les femmes durant les relations sexuelles. Quarante-neuf couples souffrant de VP ont complété des questionnaires auto-rapportés. La maltraitance durant l’enfance chez les femmes était associée à un fonctionnement sexuel plus faible chez les femmes et les hommes, une augmentation de l’anxiété chez les femmes seulement, et une douleur affective accrue durant les relations sexuelles. La maltraitance durant l’enfance chez les hommes était associée à un fonctionnement sexuel plus faible, moins de satisfaction conjugale, plus d’anxiété chez les femmes et les hommes, et une douleur affective accrue durant les relations sexuelles rapportée par les femmes. En se basant sur les recommandations issues des études empiriques, une thérapie cognitive et comportementale pour les couples (TCCC) souffrant de VP a été développée. Le deuxième article présente les résultats d’une étude pilote testant son efficacité, fidélité et faisabilité potentielles. Neuf couples ont complété des questionnaires auto-rapportés pré- et post-traitement. La TCCC de 12 rencontres était manualisée. Les femmes ont rapporté une amélioration significative de la douleur, du fonctionnement et de la satisfaction sexuels, et les partenaires ont rapporté une amélioration significative de leur satisfaction sexuelle. Les couples ont rapporté des niveaux élevés de satisfaction quant à la psychothérapie, et les psychothérapeutes ont rapporté suivre le manuel de traitement de manière fidèle. Le troisième article, s’appuyant sur les résultats prometteurs de l’étude pilote, décrit le protocole de recherche pour un essai clinique randomisé mesurant l’efficacité de la TCCC comparée à une intervention médicale de première ligne, la lidocaïne topique, pour le traitement de la VP. Enfin, les implications cliniques et théoriques de la thèse sont discutées.

Post-menopausal metrorrhagia - an ovarian thecoma presentation

Os tecomas são tumores raros do ovário, do grupo dos tumores dos cordões sexuais, de natureza sólida e frequentemente unilaterais. Têm maior incidência no período pósmenopausa e normalmente são silenciosos. Quando sintomáticos traduzem-se por dor pélvica e metrorragia (condicionada pela habitual natureza produtora de estrogénios do tumor). Podem ser concomitantes a síndrome de Meigs e/ou de Golin-Goltz e associaremse a transformação benigna ou maligna do endométrio. Embora a ecografia possa ser inespecífica neste contexto, uma avaliação multiparamétrica abrangente em ressonância magnética, incluindo por estudo dinâmico e com ponderação em difusão, permite frequentemente orientar de modo favorável a marcha diagnóstica. Apresentamos um caso raro de tecoma do ovário, com espessamento associado do endométrio, avaliado por ecografia ginecológica por vias supra-púbica e transvaginal bem como tomografia computorizada e ressonância magnética, confirmado cirurgicamente. Tratou-se de uma examinada caucasiana de 61 anos de idade, apresentando-se com metrorragia pósmenopáusica, sem outros sintomas nem contexto familiar relevante. Procedeu-se, a este propósito, a uma revisão da literatura focada no diagnóstico multimodal diferencial, apresentação clínica, tratamento e prognóstico destes tumores.

Retour post-isolement en milieu psychiatrique : développement, implantation et évaluation d’une intervention en soins aigus

L’isolement avec ou sans contention (IC) en milieu psychiatrique touche près d’un patient sur quatre au Québec (Dumais, Larue, Drapeau, Ménard, & Giguère-Allard, 2011). Il est pourtant largement documenté que cette pratique porte préjudice aux patients, aux infirmières et à l’organisation (Stewart, Van der Merwe, Bowers, Simpson, & Jones, 2010). Cette mesure posant un problème éthique fait l’objet de politiques visant à la restreindre, voire à l’éliminer. Les études sur l’expérience de l’isolement du patient de même que sur la perception des infirmières identifient le besoin d'un retour sur cet évènement. Plusieurs équipes de chercheurs proposent un retour post-isolement (REPI) intégrant à la fois l’équipe traitante, plus particulièrement les infirmières, et le patient comme intervention afin de diminuer l’incidence de l’IC. Le REPI vise l’échange émotionnel, l’analyse des étapes ayant mené à la prise de décision d’IC et la projection des interventions futures. Le but de cette étude était de développer, implanter et évaluer le REPI auprès des intervenants et des patients d’une unité de soins psychiatriques aigus afin d’améliorer leur expérience de soins. Les questions de recherche étaient : 1) Quel est le contexte d’implantation du REPI? 2) Quels sont les éléments facilitants et les obstacles à l’implantation du REPI selon les patients et les intervenants? 3) Quelle est la perception des patients et des intervenants des modalités et retombées du REPI?; et 4) L’implantation du REPI est-elle associée à une diminution de la prévalence et de la durée des épisodes d’IC? Cette étude de cas instrumentale (Stake, 1995, 2008) était ancrée dans une approche participative. Le cas était celui de l’unité de soins psychiatriques aigus pour premier épisode psychotique où a été implanté le REPI. En premier lieu, le développement du REPI a d’abord fait l’objet d’une documentation du contexte par une immersion dans le milieu (n=56 heures) et des entretiens individuels avec un échantillonnage de convenance (n=3 patients, n=14 intervenants). Un comité d’experts (l’étudiante-chercheuse, six infirmières du milieu et un patient partenaire) a par la suite développé le REPI qui comporte deux volets : avec le patient et en équipe. L’évaluation des retombées a été effectuée par des entretiens individuels (n= 3 patients, n= 12 intervenants) et l’examen de la prévalence et de la durée des IC six mois avant et après l’implantation du REPI. Les données qualitatives ont été examinées selon une analyse thématique (Miles, Huberman, & Saldana, 2014), tandis que les données quantitatives ont fait l’objet de tests descriptifs et non-paramétriques. Les résultats proposent que le contexte d’implantation est défini par des normes implicites et explicites où l’utilisation de l’IC peut générer un cercle vicieux de comportements agressifs nourris par un profond sentiment d’injustice de la part des patients. Ceux-ci ont l’impression qu’ils doivent se conformer aux attentes du personnel et aux règles de l’unité. Les participants ont exprimé le besoin de créer des opportunités pour une communication authentique qui pourrait avoir lieu lors du REPI, bien que sa pratique soit variable d’un intervenant à un autre. Les résultats suggèrent que le principal élément ayant facilité l’implantation du REPI est l’approche participative de l’étude, alors que les obstacles rencontrés relèvent surtout de la complexité de la mise en œuvre du REPI en équipe. Lors du REPI avec le patient, les infirmières ont pu explorer ses sentiments et son point de vue, ce qui a favorisé la reconstruction de la relation thérapeutique. Quant au REPI avec l’équipe de soins, il a été perçu comme une opportunité d’apprentissage, ce qui a permis d’ajuster le plan d’intervention des patients. Suite à l’implantation du REPI, les résultats ont d’ailleurs montré une réduction significative de l’utilisation de l’isolement et du temps passé en isolement. Les résultats de cette thèse soulignent la possibilité d’outrepasser le malaise initial perçu tant par le patient que par l’infirmière en systématisant le REPI. De plus, cette étude met l’accent sur le besoin d’une présence authentique pour atteindre un partage significatif dans la relation thérapeutique, ce qui est la pierre d’assise de la pratique infirmière en santé mentale. Cette étude contribue aux connaissances sur la prévention des comportements agressifs en milieu psychiatrique en documentant le contexte dans lequel se situe l’IC, en proposant un REPI comportant deux volets de REPI et en explorant ses retombées. Nos résultats soutiennent le potentiel du développement d’une prévention tertiaire qui intègre à la fois la perspective des patients et des intervenants.

HBsAg seroclearance or seroconversion induced by peg-interferon alpha and lamivudine or adefovir combination therapy in chronic hepatitis B treatment: a meta-analysis and systematic review

Background and aims: Seroclearance or seroconversion of hepatitis B surface antigen (HBsAg) is generally considered as a clinical endpoint. The purpose of the present meta-analysis was to evaluate the effect of combined therapy with pegylated interferon alpha (PEG-IFNα) with or without lamivudine (LAM) or adefovir (ADV) on HBsAg seroclearance or seroconversion in subjects with chronic hepatitis B (CHB). Methods: Randomized controlled trials performed through May 30th 2015 in adults with CHB receiving PEG-IFNα and LAM or ADV combination therapy or monotherapy for 48-52 weeks were included. The Review Manager Software 5.2.0 was used for the meta-analysis. Results: No statistical differences in HBsAg seroclearance (9.9% vs. 7.1%, OR = 1.47, 95% CI: 0.75, 2.90; p = 0.26) or HBsAg seroconversion (4.2% vs. 3.7%, OR = 1.17, 95% CI: 0.57, 2.37; p = 0.67) rates were noticed between PEG-IFNα + LAM and PEG-IFN α + placebo during post-treatment follow-up for 24-26-weeks in subjects with hepatitis Be antigen (HBeAg)-positive CHB. No statistical differences in HBsAg clearance (10.5% vs. 6.4%, OR = 1.68, 95% CI: 0.75, 3.76; p = 0.21) were seen, but statistical differences in HBsAg seroconversion (6.3% vs. 0%, OR = 7.22, 95% CI: 1.23, 42.40; p = 0.03) were observed, between PEG-IFNα + ADV and PEG-IFNα for 48-52 weeks of treatment in subjects with HBeAg-positive CHB. A systematic evaluation showed no differences in HBsAg disappearance and seroconversion rates between PEG-IFNα + placebo and PEG-IFNα + LAM for 48-52 weeks in subjects with HBeAg-positive CHB. A systematic assessment found no differences in HBsAg disappearance and seroconversion rates between PEG-IFNα + placebo and PEG-IFNα + LAM during 24 weeks' to 3 years' follow-up after treatment in subjects with HBeAg-negative CHB. Conclusion: Combined therapy with PEG-IFNα and LAM or ADV was not superior to monotherapy with PEG-IFNα in terms of HBsAg seroclearance or seroconversion.

Supra-treatment threshold neonatal jaundice: Incidence in HIV-exposed compared to non-exposed neonates at Queen Elizabeth Central Hospital in Blantyre, Malawi

Introduction Jaundice is the yellowish pigmentation of the skin, sclera, and mucous membranes resulting from bilirubin deposition. Children born to mothers with HIV are more likely to be born premature, with low birth weight, and to become septic—all risk factors for neonatal jaundice. Further, there has been a change in the prevention of mother-to-child transmission (PMTCT) of HIV guidelines from single-dose nevirapine to a six-week course, all of which theoretically put HIV-exposed newborns at greater risk of developing neonatal jaundice. Aim We carried out a study to determine the incidence of severe and clinical neonatal jaundice in HIV-exposed neonates admitted to the Chatinkha Nursery (CN) neonatal unit at Queen Elizabeth Central Hospital (QECH) in Blantyre. Methods Over a period of four weeks, the incidence among non-exposed neonates was also determined for comparison between the two groups of infants. Clinical jaundice was defined as transcutaneous bilirubin levels greater than 5 mg/dL and severe jaundice as bilirubin levels above the age-specific treatment threshold according the QECH guidelines. Case notes of babies admitted were retrieved and information on birth date, gestational age, birth weight, HIV status of mother, type of feeding, mode of delivery, VDRL status of mother, serum bilirubin, duration of stay in CN, and outcome were extracted. Results Of the 149 neonates who were recruited, 17 (11.4%) were HIV-exposed. One (5.88%) of the 17 HIV-exposed and 19 (14.4%) of 132 HIVnon- exposed infants developed severe jaundice requiring therapeutic intervention (p = 0.378). Eight (47%) of the HIV-exposed and 107 (81%) of the non-exposed neonates had clinical jaundice of bilirubin levels greater than 5 mg/dL (p < 0.001). Conclusions The study showed a significant difference in the incidence of clinical jaundice between the HIV-exposed and HIV-non-exposed neonates. Contrary to our hypothesis, however, the incidence was greater in HIVnon- exposed than in HIV-exposed infants.