The carer's place in the cancer situation: where does the carer stand in the medical setting?

Recent thinking about policy on cancer services in the UK has highlighted the importance of recognising the needs of carers, but is unclear about the ways in which this might be done. Our recent study on the psychosocial needs of cancer patients and their main informal carers was unusual in its combined focus on patients and carers experiencing the 'cancer journey' together. One of our aims was to contribute to an understanding of what it means to be the main carer of someone with cancer. Using the qualitative data from the 79 carers and patients we interviewed, we ask how carers negotiate their place in the cancer situation, and particularly how do carers identify their role in relation to the patient and the medical setting? We posit carers as taking part in a shifting process of 'carerhood' in which competing needs vie for space. Our evidence suggests carers actively negotiate the challenges of their position in dealing with issues of identity, support, and sharing. We suggest that when the carer's involvement in the cancer scenario is recognised and legitimised by others it is easier for them to attend to their own needs alongside those of the patient.

Sensitivity of human melanoma cells to adherent leukocytes depends on the ratio between them, the activation status of adherent leukocytes and the metastatic potential of tumor cells

This study examined the interaction of the poorly metastatic human melanoma cell line M4Be and the highly metastatic clone 4 derived from M4Be, with respect to fresh adherent leukocytes (AL) isolated from 17 different healthy blood donors. These AL contained 80% (73%-93%) monocytes, 15% (6%-20%) B lymphocytes and 5% (1%-8%) T lymphocytes. The survival of these tumor cells against the stress exerted by these AL was estimated with a clonogenic assay where isolated tumor cells were co-cultured for 14 days in contact with AL and lipopolysaccharide (LPS). For a given blood donor, AL either stimulates or inhibits the colony formation of the tumor cells (T) depending on the AL/T ratio, the AL activation status and the metastatic potential of tumor cells. At low AL/T ratios (< 10/1) in the presence of low (8 ng/ml) and trace (8 pg/ml) levels of LPS, hydrogen peroxide (H2O2) release is significantly reduced, and tumor cells significantly increase their colony formation; the feeder effect of AL is suggested to be due to low concentrations of soluble tumor necrosis factor-alpha (TNF-alpha). At high AL/T ratios (> 10/1), whatever the characteristics of the blood donor, clone 4 is significantly more sensitive than M4Be to AL activated with medium containing low (8 ng/ml) or high (1,000 ng/ml) levels of LPS; this killing effect is suggested to be due to TNF-alpha, both soluble and membrane-bound, but not to be due to release of H2O2. These data suggest that the regulatory role of AL, which remove the majority of human melanoma cells and stimulate the colony formation of a small fraction of them, is partly due to TNF-alpha.

Evidence that regenerating optic axons maintain long-term growth in the lizard Ctenophorus ornatus: growth-associated protein-43 and gefiltin expression

In the lizard, Ctenophorus ornatus, the optic nerve regenerates but animals remain blind via the experimental eye, presumably as a result of axons failing to consolidate a retinotopic map in the optic tectum. Here we have examined immunohistochemically the expression of the growth-associated protein GAP-43 and the low-molecular-weight intermediate filament protein gefiltin, up to one year after optic nerve crush. Both proteins were found to be permanently up-regulated, suggesting that regenerating axons are held in a permanent state of re-growth. We speculate that, in the lizard, the continued expression of GAP-43 and the failure to switch from the expression of low- to high-molecular-weight intermediate filament proteins are associated with the inability to consolidate a retinotopic projection.

Minimizing discomfort with surface neuromuscular stimulation

The purpose of this study was to evaluate the effects of stimulus parameters, electrode types, and electrode positions on the perception of discomfort during lower extremity surface neuromuscular stimulation. Ten normal and eight neurologically impaired (four incomplete spinal cord and four stroke) subjects were enrolled. Neurologically impaired subjects had some sensation, although it was often reduced. Parameters of the stimulation were varied in a way that produced the same level of ankle dorsiflexion, as measured with a goniometer. Discomfort was assessed after each stimulation with a 0-10 verbal scale (0, no discomfort; 10, worst pain). Increasing the pulse frequency was associated with increased discomfort for subjects in both groups (p > 0.05). Increasing the pulse duration was associated with increased discomfort in the neurologically impaired subjects (p > 0.05), but not in the normal subjects (p > 0.05). The electrode size and type had no effects on discomfort (p > 0.05). Stimulation of the peroneal nerve over the fibular head was better tolerated than the direct motor point stimulation of the tibialis anterior motor point (p < 0.05). The data suggest that to minimize discomfort, surface stimulation should be applied over nerves rather than motor points, and frequency and pulse duration should be set as low as possible for a given degree of contraction.

Young adults with cancer: the effect of the illness on parents and families

This article is based on the findings from a qualitative study involving a collection of narratives written by the parents of young adults with cancer. It examines the effects of the illness on parents and family and illustrates that young people aged 18-25 years face particular difficulties when diagnosed with a life-threatening illness. The article focuses on how these difficulties are experienced by the parents of young adults who are attempting to maintain 'normality' and perhaps also manage newly established sexual relationships. The article considers the problems for parents, e.g. the ownership of medical information when the young adult is of age but dependent on his/her parents, the effect on siblings and the financial implications of the illness for the family. A gap in the knowledge of professionals and families relating to these effects may result in families believing that the acute problems they face are caused by their particular family dynamics rather than the life-stage of their young adult children.

Medicine, gender, and disability: disabled women's health care encounters

In this article I examine the intersection of gender and disability in the medical arena by considering disabled women's experiences of receiving health care in the United Kingdom. Drawing on the "social model of disability," I focus on the attitudes and practices of doctors. I use two sources of qualitative data: (i) 68 disabled women's narratives gathered in the United Kingdom in 1996-1997; (ii) interviews with 17 disabled women regarding their reproductive experiences in the United Kingdom. I suggest that disabled women health service users are at risk of experiencing oppressive medical practices because two forces of oppression appear to be frequently, and interactively, in play: patriarchy and disablism.

Functional elements of the strong psbAI promoter of Synechococcus elongatus PCC 7942

The psbAI gene of the cyanobacterium Synechococcus elongatus PCC 7942 is one of three psbA genes that encode a critical photosystem II reaction center protein, D1. Regulation of the gene family in response to changes in the light environment is complex, occurs at transcriptional and posttranscriptional levels, and results in an interchange of two different forms of D1 in the membrane. Expression of psbAI is downregulated under high-intensity light (high light) in contrast to induction of the other two family members. We show that, in addition to a known accelerated degradation of the psbAI message, promoter activity decreases upon exposure to high light. Unlike the other psbA genes, additional sequences upstream of the psbAI -35 element are required for expression. Mutagenizing the atypical psbAI -10 element from TCTCCT to TATAAT increased the magnitude of expression from both psbAI::lacZ and psbAI::luxAB fusions but did not affect downregulation under high light. Inactivation of group 2 sigma factor genes rpoD2 and sigC, in both wild-type and -10-element mutagenized backgrounds, resulted in elevated psbAI::luxAB expression but did not alter the response to high light. The results are consistent with redundancy of promoter recognition among cyanobacterial group 2 sigma factors. Electrophoretic mobility shift assays showed that the DNA sequence corresponding to the untranslated leader of the psbAI message binds one or more proteins from an S. elongatus extract. The corresponding region of psbAII efficiently competed for this binding activity, suggesting a shared regulatory factor among these disparately regulated genes.

Conjugative metabolism of 1,2-dibromoethane in mitochondria: disruption of oxidative phosphorylation and alkylation of mitochondrial DNA

1,2-Dibromoethane (DBE) is an environmental contaminant that is metabolized by glutathione S-transferases to a haloethane-glutathione conjugate. Since haloethane-glutathione conjugates are known to alkylate nuclear DNA and cytoplasmic proteins, these effects were investigated in isolated rat liver mitochondria exposed to DBE by measuring guanine adducts and several aspects of oxidative phosphorylation including respiratory control ratios, respiratory enzyme activity, and ATP levels. Mitochondrial large-amplitude swelling and glutathione status were assessed to evaluate mitochondrial membrane integrity and function. When exposed to DBE, mitochondria became uncoupled rapidly, yet no large-amplitude swelling or extramitochondrial glutathione was observed. Mitochondrial GSH was depleted to 2-53% of controls after a 60-min exposure to micromolar quantities of DBE; however, no extramitochondrial GSH or GSSG was detected. The depletion of mitochondrial glutathione corresponded to an increase of an intramitochondrial GSH-conjugate which, based on HPLC elution profiles and retention times, appeared to be S,S'-(1,2-ethanediyl)bis(glutathione). Activities of the NADH oxidase and succinate oxidase respiratory enzyme systems were inhibited 10-74% at micromolar levels of DBE, with succinate oxidase inactivation occurring at lower doses. ATP concentrations in DBE-exposed mitochondria in the presence of succinate were 5-90% lower than in the controls. The DNA adduct S-[2-(N(7)-guanyl)ethyl]glutathione was detected by HPLC in mtDNA isolated from DBE-exposed mitochondria. The results suggest that respiratory enzyme inhibition, glutathione depletion, decreased ATP levels, and DNA alkylation in DBE-exposed mitochondria occur via the formation of an S-(2-bromoethyl)glutathione conjugate, the precursor of the episulfonium ion alkylating species of DBE.

Pudendal nerve terminal motor latency: age effects and technical considerations

OBJECTIVES

The measurement of the pudendal nerve terminal motor latency (PNTML) is used to assess anal sphincter innervation. In healthy subjects, we studied the influence of age on PNTML and the advantage of a new intra-rectal stimulator.

METHODS

PNTML was determined in a first series of 40 normal subjects, aged 21-75 years, using a standard St. Mark's electrode, and in a second series of 20 normal subjects over 50 years, using a new intra-rectal monopolar stimulator that did not require finger insertion through the anal canal.

RESULTS

In the first series, PNTML ranged from 1.8 to 5.6 ms (mean+/-SD 2.94+/-0.8 ms) and correlated positively with the age of the subjects (P=0.01, Spearman test). In the second series, PNTML ranged from 2.2 to 5.4 ms (3.7+/-0.9 ms) and was similar to that of the subjects over 50 years of the first series (3.5+/-0.4 ms) (P=0.35, Mann-Whitney U test).

CONCLUSIONS

This study showed significant effects of age on PNTML. This should encourage every examiner to establish age-stratified reference values of PNTML for older age groups. In addition, we showed the advantage of using a new type of intra-rectal stimulator to reduce the patient's discomfort by avoiding finger insertion to stimulate the pudendal nerve.

Retaining the aortic fat pad during cardiac surgery decreases postoperative atrial fibrillation

BACKGROUND

Atrial arrhythmias are a common and serious complication of cardiac surgical procedures. Reports describing pericardiac neurogenic tissue led us to hypothesize that removal of the aortic fat pad could cause an autonomic imbalance and contribute to atrial arrhythmias following cardiac surgery.

METHODS

Patients (n=131) underwent either conventional cardiopulmonary bypass surgery (CPB) or off-pump coronary artery bypass (OPCAB) surgery. The aortic fat pad was either left intact or removed. The incidence of de novo atrial arrhythmias during the patient's hospital stay was tabulated. Patients with peri-operative myocardial infarction or pre-existing atrial or supraventricular arrhythmias were excluded.

RESULTS

Demographics, preoperative medications, ASA and NYHA classifications, and complication rates (other than for atrial arrhythmias) did not differ among the groups. The STS-predicted mortality was higher in the CPB/Fat-Pad-Removed group (2.23 +/- 1.89) than in either the OPCAB/Fat-Pad-Intact (1.09 +/- 0.80) or OPCAB/Fat-Pad-Removed (1.02 +/- 0.62) groups (p < 0.05). Atrial arrhythmias were present in 19 of 131 patients (14.5%). Logistic regression demonstrated a significantly elevated atrial arrhythmia rate when the fat pad was removed (odds ratio = 3.49, 95% bounds = 1.09 to 11.18, p = 0.035). Neither the pump status nor the cross product of pump status by fat pad status were significant in this pilot study.

CONCLUSIONS

Retaining the aortic fat pad during coronary artery bypass surgery is correlated with a decreased incidence of postoperative atrial arrhythmias.

Influence of gangliosides or LPS-like gangliosides on the tumoricidal activity of adherent leukocytes

We previously showed that highly metastatic clones derived from the poorly metastatic human melanoma cell line M4Be are very radiosensitive provided that they are deficient in complex gangliosides. Here, we report that the highly metastatic clone 4 appears more sensitive to activated adherent leukocytes than M4Be via a transmembrane TNF-alpha-dependent mechanism. Adherent leukocytes (AL) were freshly isolated from different blood donors and were activated with Esherichia coli lipopolysaccharide (LPS). These AL contain 80% (73-93%) monocytes, 15% (6-20%) B lymphocytes and 5% (1-8%) T lymphocytes. The tumour cell survival following contact with AL was estimated with a clonogenic assay where isolated tumour cells were plated for 14 days with AL. We show on the one hand that either exogenous bovine brain GM1 gangliosides or Campylobacter jejuni LPS with GM1-like structure (LPS-like GM1) significantly decrease the hypersensitivity of clone 4 to AL. On the other hand, the cleaving with neuraminidase of more than 50% of the sialic residues bound to endogenous gangliosides in resistant M4Be cells significantly increases their sensitivity to AL. Thus, our highly metastatic cells appear both very sensitive to activated AL when they are deficient in complex gangliosides and resistant to AL when they are transiently exposed to exogenous gangliosides or LPS-like gangliosides. These in vitro data may reflect the paradoxidal behaviour of highly metastatic cells in vivo which appear both very sensitive to physiological stresses and able to survive to form secondary tumours.

Three-dimensional quantification of color-marked occlusal paths on anatomically oriented casts

STATEMENT OF PROBLEM

The analysis of occlusal contacts on mounted diagnostic casts is an important task in prosthetic diagnostics. However, it is still restricted mainly to qualitative aspects because existing measuring techniques fail to provide 3-dimensional data for more than a few single points in acceptable time.

PURPOSE

The aim of this study was to develop a method for quantifying occlusal contacts and paths by using anatomically oriented diagnostic casts and to design the method to allow fast acquisition of digital 3-dimensional coordinates.

MATERIAL AND METHODS

Plaster casts with color-marked contacts were digitized optically with a profilometric system based on the fringe projection technique. Digital camera images taken simultaneously were used to define the contact areas by marking them either manually or automatically with the help of image-processing routines. Three-dimensional coordinates were determined by finding the corresponding points within the profilometric data set.

RESULTS

Color-marked contact areas on diagnostic casts were successfully digitized with a computer-controlled, automatic setup in approximately 30 seconds. The accuracy of the acquired 3-dimensional data was estimated to be better than 60 microm in lateral and 30 microm in height resolution. The data set was visualized and evaluated in a skull related coordinate system.

SUMMARY

This study verified the use of a new tool to quantify color-marked occlusal contacts on diagnostic casts in terms of spatial coordinates. The resulting digital data may be stored easily and analyzed numerically as well as visualized 3-dimensionally with computer graphic equipment. Because the anatomic orientation of the casts is maintained throughout the measurement process, it is possible to compare the data with electronically registered condyle paths and therefore to investigate, for example, their relation to the corresponding guidance paths of the frontal teeth and the canines in dynamic occlusion.

Factors altering the sleep of burned children

Although few studies have been conducted on burn patients, they indicate that sleep of burned children is altered. We suggest in this review, on the basis of the limited data available that factors contributing to sleep disruption in burned individuals may be broadly categorized as pathophysiological responses to the injury, the pain and discomfort experienced by the patient and medications used to treat these symptoms, and the physical environment in the Burns Intensive Care Unit. The responses to thermal injury include alterations in circulating neuropeptides, hormones, and immune-active substances, many of which are known to regulate/modulate sleep. Medications for the management of pain and for treating symptoms of various injury-induced stress and anxiety disorders may also alter sleep. Finally, frequent disruptions of the patient by medical staff is but one of the many environmental factors that may contribute to disrupted sleep. Severe burns induce a hypermetabolic response that may result in peripheral wasting, that depletes substrates necessary for tissue repair, and is associated with reduced growth hormone. Burn-induced growth hormone insufficiency is aggressively treated to counteract peripheral wasting and to aid in wound healing of skin graft donor sites. We speculate that improvement of sleep quality would result in a less severe reduction in growth hormone due to the well documented relationship between slow-wave sleep onset and growth hormone secretion. Such improvement in spontaneous growth hormone secretion patterns may aid in recovery by supporting tissue repair and by minimizing the hypermetabolic response to thermal injury. The experiments to test such hypotheses remain to be conducted, yet the results of such experiments may provide the basis for beginning to answer the question of whether or not sleep aids in recovery from injury.

[Hemorrhagic fever with renal syndrome]

Puumala hantavirus is the most common hantavirus infection in Western Europe. The causative agent, Puumala virus, is a member of the Hantavirus genus in the Bunyaviridae family. The natural hosts of hantaviruses are chronically, but asymptomatic infected rodents, which transmit the virus to human in their excretions. Puumala virus is carried by the bank vole, clethrionomys glareolus. Hemorrhagic fever with renal syndrome (HFRS) caused by Puumala virus in France or Belgium is very similar to the previously described Nephropathia epidemica in Scandinavia. In most severe cases, the disease is clinically characterized by high fever of abrupt onset, headache, loin or abdominal pains, nausea and vomiting, and occasionally acute and transient myopia. Renal involvement results in transient proteinuria and hematuria and acute renal failure. Except for interstitial hemorrhage in the outer medulla, the renal histopathologic findings are unspecific and include prominent changes in the interstitium with interstitial oedema and inflammatory infiltrates. Thrombocytopenia, mild elevation of liver enzymes, and leukocytosis are typical laboratory findings. Spontaneous complete recovery is the rule. Laboratory diagnosis is primarily based on serology such as indirect immunofluorescence or capture enzyme--linked immunosorbent assays which detect IgM antibodies and an increased level of IgG antibodies against Puumala virus. Viral antigen may be demonstrated in the cytoplasm of renal tubular epithelial cells.

The eating disorders NOS diagnostic profile among college women

The authors examined a proposed profile of eating-related behaviors, associated features, developmental issues, and help-seeking behavior among college women, using an eating disorder response program. The most common symptom scenario was a pattern of regular binge eating, together with daily exercise and occasional purging. The most common associated features were distressing or dysfunctional overconcern about body image and self-esteem, usually with day-to-day stress and intermittent depression. The women who fit this pattern also presented developmental issues of perfectionism, conflictual relationships with parents, and struggles for independence; and they tended to be ambivalent about seeking services. Implications for practice, including the need to develop a framework for eating disorder responses on campus that includes preventive programs and developmental interventions to target emerging and moderate concerns are discussed; limitations and the preliminary nature of the findings are explicated.

Consensus statement on the live organ donor

OBJECTIVE

To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor.

PARTICIPANTS

An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo.

CONSENSUS PROCESS

Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees.

CONCLUSION

The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.

Generalists and oncologists show similar care practices and outcomes for hospitalized late-stage cancer patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks for Treatment

OBJECTIVE

The objective of this work was to identify similarities and differences in primary attending physicians' (generalists' versus oncologists') care practices and outcomes for seriously ill hospitalized patients with malignancy.

DESIGN

This was a prospective cohort study (SUPPORT project).

SETTING

Subjects were recruited from 5 US teaching hospitals; data were gathered from 1989 to 1994.

SUBJECTS

Included in the study was a matched sample of 642 hospitalized patients receiving care for non-small-cell lung cancer, colon cancer metastasized to the liver, or multiorgan system failure associated with malignancy with either a generalist or an oncologist as the primary attending physician.

MEASUREMENTS

Care practices and patient outcomes were determined from hospital records. Length of survival was identified with the National Death Index. Physicians' perceptions of patient's prognosis, preference for cardiopulmonary resuscitation (CPR), and length of relationship were assessed by interview. A propensity score for receiving care from an oncologist was constructed. After propensity-based matching of patients, practices and outcomes of oncologists' and generalists' patients were assessed through group comparison techniques.

RESULTS

Generalist and oncologist attendings showed comparable care practices, including the number of therapeutic interventions, eg, "rescue care" and chemotherapy, and the number of care topics discussed with patients/ families. Length of stay, discharge to supportive care, readmission, total hospital costs, and survival rates were similar. For both physician groups, perception of patients' wish for CPR was associated with rescue care (P < 0.03), and such care was related to higher hospital costs (P < 0.000). Poorer prognostic estimates predicted aggressiveness-of-care discussions by both types of physicians. Length of the patient-doctor relationship was associated with oncologists' care practices. More documented discussion about aggressiveness of care was related to higher hospital costs and shorter survival for patients in both physician groups (P < 0.001).

CONCLUSIONS

Generalists and oncologists showed similar care practices and outcomes for comparable hospitalized late-stage cancer patients. Physicians' perceptions about patients' preferences for CPR and prognosis influenced decision making and outcomes for patients in both physician groups. Length of relationship with patients was associated only with oncologists' care practices. Rescue care increased hospital costs but had no effect on patient survival. Future studies should compare physicians' palliative care as well as acute-care practices in both inpatient and ambulatory care settings. Patients' end-of-life quality and interchange between physician groups should also be documented and compared.