Parents’ Assessment of Quality of Care and Grief Following a Child’s Death
Background: Deaths among children are rare, but the effect on family members is profound. Compared with adult deaths, information about grief, recovery, and quality of care is sparse.
Objectives: To describe aspects of bereavement for parents who had experienced the death of a child and to compare these aspects by parent sex, type of death, and overall experience.
Design: In-person interviews with families, primarily parents, a mean of 21.8 months after the child's death.
Setting: Academic, tertiary care, faith-based children’s hospital.
Participants: Fifty-nine child deaths and 79 parents or guardians.
Main Outcome Measures: In-person interviews, including standard instruments for bereavement and quality of care: the Texas Revised Inventory of Grief and the Comprehensive Assessment of Satisfaction With Care–Short Form.
Results: Fathers and mothers had similar levels of grief. Mothers who experienced the sudden death of their child had somewhat more intense grief reactions than those whose child died of a chronic condition. Grief scores did not vary according to satisfaction with treatment. Comprehensive Assessment of Satisfaction With Care–Short Form scores were high for parents and similar between mothers and fathers and between sudden and unexpected deaths.
Conclusions: Although there were some differences in grief responses among parents, satisfaction-with-care scores were high. Further studies should examine the role of satisfaction with care in parental grief response and incorporate the reporting of experiences rather than simple ratings to measure satisfaction with care.
Seecharan GA, Andresen EM, Norris K, Toce SS
Mohs Micrographic Surgery vs Traditional Surgical Excision: A Cost Comparison Analysis
Objective: To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC).
Design: Prospective cost analysis with each patient serving as his or her own control.
Setting: Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center.
Patients: A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears.
Main Outcome Measures: The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure (because this outcome affects overall cost).
Results: Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs ($937 vs $1029; P = .16) or a subsequent TSE ($937 vs $944; P = .53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly ($956 vs $1399; P<.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen.
Conclusions: If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.
Bialy TL, Whalen J, Veledar E, et al
Effect of a 1-Week Treatment With 0.5% Topical Fluorouracil on Occurrence of Actinic Keratosis After Cryosurgery: A Randomized, Vehicle-Controlled Clinical Trial
Background: No long-term randomized controlled clinical trial has compared the efficacy of cryosurgery alone vs cryosurgery following fluorouracil applications for the treatment of actinic keratosis.
Objective: To determine the 6-month outcome of a 1-week course of 0.5% fluorouracil followed by cryosurgery.
Design: Prospective, multicenter, randomized, double-blind, vehicle-controlled clinical trial performed in community and academic outpatient clinics.
Patients: A total of 144 patients with 5 or more visible or palpable actinic keratoses on the face.
Interventions: Topical 0.5% fluorouracil or vehicle once daily for 7 days. At the 4-week follow-up visit, residual lesions were treated with cryosurgery.
Main Outcome Measure: Reduction in facial actinic keratoses from baseline to 4 weeks and 6 months.
Results: At 4 weeks, mean actinic keratosis lesion count was reduced by 62.4% in the 0.5% fluorouracil group vs 28.8% in the vehicle group (P<.001), and complete clearance was achieved in 16.7% of patients in the 0.5% fluorouracil group vs 0% of those in the vehicle group (P<.001). At 6 months, mean lesion count was reduced by 67.0% in the 0.5% fluorouracil plus cryosurgery group vs 45.6% in the vehicle plus cryosurgery group (P = .01), and significantly more patients in the 0.5% fluorouracil plus cryosurgery group than in the vehicle plus cryosurgery group had complete clearance (30% vs 7.7%; P<.001).
Conclusions: A 1-week course of topical 0.5% fluorouracil before cryosurgery is significantly more effective in reducing patients' numbers of actinic keratosis lesions 6 months after treatment than cryosurgery alone. The high occurrence rate of actinic keratosis lesions at 6 months suggests a need for follow-up.
JorizzoJ, Weiss J, Furst K, VandePol C, Levy SF
Effects of a Superpotent Melanotropic Peptide in Combination With Solar UV Radiation on Tanning of the Skin in Human Volunteers
Objective: Three phase 1 clinical trials of a superpotent melanotropic peptide, melanotan-1 (MT-1, or [Nle(4)-D-Phe(7)]alpha-melanocyte-stimulating hormone) were performed to demonstrate safety for MT-1 therapy combined with UV-B light or sunlight.
Design: Open-label studies at 2 dose levels of MT-1 combined with small doses of UV-B to the neck or buttock or full sunlight to half of the back.
Setting: Dermatology clinics at the Arizona Health Sciences Center, Tucson.
Interventions: The first study randomized 4 subjects to MT-1 (0.08 mg/kg per day subcutaneously) and 4 subjects to injections of isotonic sodium chloride (9%) solution for 10 days, followed by neck irradiation with 3 times the minimal erythema dose (MED) of UV-B light. In the next study (n = 12), the MT-1 dosage was increased to 0.16 mg/kg per day for 10 days, with UV-B radiation (0.25-0.75 MED) given to a buttock site for 5 days during (n = 7) or after (n = 5) MT-1 administration. A final study randomized 8 subjects to 3 to 5 days of sunlight to half of the back or to sunlight plus 0.16 mg/kg of MT-1 for 5 days per week for 4 weeks.
Results: Tanning in the first study was achieved in 3 of 4 subjects receiving MT-1, and these subjects also had 47% fewer sunburn cells at the irradiated neck site. More skin sites darkened with the higher dose of MT-1 in the second study. In the third study, there was significantly enhanced tanning of the back in the MT-1 group, and this was maintained at least 3 weeks longer than the tanning in the sunlight-only controls, who required 50% more sun-exposure time for equivalent tanning.
Main Outcome Measure: There were no pathologic findings at any UV-B or sun-exposed sites in any subject. Toxic effects due to MT-1 were minor, consisting of nausea and transient facial flushing.
Conclusion: Melanotan-1 can be safely combined with UV-B light or sunlight and appears to act synergistically in the tanning response to light.
Dorr RT, Ertl G, Levine N, Brooks C, et al
Abstracts: In Other AMA Journals. Arch Facial Plast Surg. 2004;6(6):415-416. doi: