Clinically effective cancer care: working with families

Families of those with cancer frequently report that their information and support needs are not being met to their satisfaction. Moreover there is evidence of prolonged stress and overt psychological morbidity within this group. Family nursing is suggested as a means by which nurses can assist families adapt to the stresses of supporting others with cancer, yet this has not been tested to any great extent. This paper offers a critical review of a selection of key studies where nursing has been shown to demonstrate positive health outcomes for families when a member has cancer.

For left ventricular opacification and endocardial border definition: is it really important which contrast agent we use, or is it the imaging modality we choose?

AIMS

The purpose of this study was to prospectively compare the effect of three imaging modalities (fundamental, harmonics, and power harmonics) on left ventricular opacification and endocardial border definition with two different echo agents, Optison and Albunex.

METHODS

A total of 84 patients who had suboptimal transthoracic images were studied with echo contrast agents Albunex (n=41) and Optison (n=43). Each contrast agent was examined with three different imaging modalities, fundamental, harmonics and power harmonics, respectively. Left ventricular opacification was obtained by videodensitometric analysis. Percentage of endocardial border visualization was determined by indexing circumference of visualized endocardium to total circumference. Variables were compared with respect to three imaging modalities between two different echo agents.

RESULTS

Higher videointensities and higher percentages of endocardial visualization were achieved with Optison compared to Albunex with fundamental and harmonics. However, there was no significant difference between Optison and Albunex with respect to LV opacification and border visualization by power harmonics.

CONCLUSION

These results indicate that left ventricular opacification and endocardial border visualization is significantly improved by using power harmonic imaging as compared to harmonics or fundamental imaging following both echo contrast agents. Furthermore, although Optison is clearly superior to Albunex in opacifying left ventricle, power harmonic imaging compensates for the less robust agent.

Human glutathione transferase T2-2 discloses some evolutionary strategies for optimization of the catalytic activity of glutathione transferases

Steady state, pre-steady state kinetic experiments, and site-directed mutagenesis have been used to dissect the catalytic mechanism of human glutathione transferase T2-2 with 1-menaphthyl sulfate as co-substrate. This enzyme is close to the ancestral precursor of the more recently evolved glutathione transferases belonging to Alpha, Pi, and Mu classes. The enzyme displays a random kinetic mechanism with very low k(cat) and k(cat)/K(m)((GSH)) values and with a rate-limiting step identified as the product release. The chemical step, which is fast and causes product accumulation before the steady state catalysis, strictly depends on the deprotonation of the bound GSH. Replacement of Arg-107 with Ala dramatically affects the fast phase, indicating that this residue is crucial both in the activation and orientation of GSH in the ternary complex. All pre-steady state and steady state kinetic data were convincingly fit to a kinetic mechanism that reflects a quite primordial catalytic efficiency of this enzyme. It involves two slowly interconverting or not interconverting enzyme populations (or active sites of the dimeric enzyme) both able to bind and activate GSH and strongly inhibited by the product. Only one population or subunit is catalytically competent. The proposed mechanism accounts for the apparent half-site behavior of this enzyme and for the apparent negative cooperativity observed under steady state conditions. These findings also suggest some evolutionary strategies in the glutathione transferase family that have been adopted for the optimization of the catalytic activity, which are mainly based on an increased flexibility of critical protein segments and on an optimal orientation of the substrate.

Human glutathione transferase T2-2 discloses some evolutionary strategies for optimization of substrate binding to the active site of glutathione transferases

Rapid kinetic, spectroscopic, and potentiometric studies have been performed on human Theta class glutathione transferase T2-2 to dissect the mechanism of interaction of this enzyme with its natural substrate GSH. Theta class glutathione transferases are considered to be older than Alpha, Pi, and Mu classes in the evolutionary pathway. As in the more recently evolved GSTs, the activation of GSH in the human Theta enzyme proceeds by a forced deprotonation of the sulfhydryl group (pK(a) = 6.1). The thiol proton is released quantitatively in solution, but above pH 6.5, a protein residue acts as an internal base. Unlike Alpha, Mu, and Pi class isoenzymes, the GSH-binding mechanism occurs via a simple bimolecular reaction with k(on) and k(off) values at least hundred times lower (k(on) = (2.7 +/- 0.8) x 10(4) M(-1) s(-1), k(off) = 36 +/- 9 s(-1), at 37 degrees C). Replacement of Arg-107 by alanine, using site-directed mutagenesis, remarkably increases the pK(a) value of the bound GSH and modifies the substrate binding modality. Y107A mutant enzyme displays a mechanism and rate constants for GSH binding approaching those of Alpha, Mu, and Pi isoenzymes. Comparison of available crystallographic data for all these GSTs reveals an unexpected evolutionary trend in terms of flexibility, which provides a basis for understanding our experimental results.

How accurate are chronic wound assessments using interactive video technology?

This project examined the accuracy of chronic wound assessments made using an interactive, video telecommunications system (Teledoc 5000, NEC America, Inc., Irving, TX) by comparing a nurse expert's in-person wound assessments with wound assessments made from taped Teledoc sessions. Wound assessments determined the absence or presence of nine wound characteristics instrumental in guiding treatment (e.g., tunneling, undermining, granulation tissue, necrotic tissue, epithelial tissue, purulent exudate, erythema, edema, induration). A sample of 13 paired wound observations was analyzed. The accuracy of the Teledoc technology was examined by calculating the amount of agreement between the in-person assessments and the taped Teledoc assessments for each of the nine characteristics. Agreement for eight of the nine wound characteristic exceeded 75%, suggesting this telehealth medium does not alter wound assessment data, which are essential in guiding treatment decisions. In addition to connecting the remotely based nurse with nursing expertise to improve patient care, telehealth technology seemed to increase the remotely-based nurses' knowledge of wound assessment and treatment as well.

A nursing application of telecommunications. Measurement of satisfaction for patients and providers

Consumer and provider satisfaction is key to the continued use and expansion of telehealth technology. This pilot study compared satisfaction of providers and patients with wound consultations done in person with those done via real-time interactive video technology. Eleven telehealth consultations with a nurse expert were immediately followed by an in-person consultation with a second nurse expert. Satisfaction questionnaires were administered to patients, referring nurses, and the consultant nurse expert following both the in-person consultation and the telehealth consultation. The referring nurses (100%) were satisfied with both the telehealth and in-person consultations, noting the ability to provide better care for their patients. The patients (55%) were "very satisfied" with the telehealth consultations versus 40% satisfied with the in-person consultations. Difficulty in hearing for the patients was equal in both groups, which resulted in changes in the consultation process. The patients' difficulty in seeing the telehealth consultant was addressed through larger screens and strategic positioning to provide easier viewing for the patient and providers. The telehealth nurse consultant was satisfied overall but had some difficulty communicating. This pilot study helped provide useful information for both the telehealth and in-person consultations.

Evaluating the cost of one telehealth application connecting an acute and long-term care setting

This article describes a study of the costs of a pilot telemedicine chronic wound consultation clinic. Cost minimization analysis is the technique used to examine the costs of the clinic. The components of cost analysis include the fixed costs of personnel and equipment and the indirect costs of circuit and line charges. Cost avoidance is also examined. Cost avoidance evaluates what costs were avoided by the use of the telemedicine clinic. Additionally, the cost perspectives of the consulting agency, the referring agency, and the patient are examined. The average cost of a chronic wound consultation was $136.16 (acute care perspective). Costs of a traditional face-to-face consultation, if the residents were transported to the acute care facility would be $246.28. Fifteen telehealth consultations per month were used to determine per consultation costs for line charges and depreciation/maintenance costs. In this pilot study, a cost savings was realized and patients benefited. Increased volume will help to offset the cost of the equipment depreciation and maintenance and make telehealth chronic wound consultations more cost effective.

Social perceptions of cancer and their impacts: implications for nursing practice arising from the literature

Social perceptions of cancer and their impacts: implications for nursing practice arising from the literature At the millennium cancer still holds a special mystique and is imbued with socio-cultural meanings, which extend far beyond the rational, scientific and biological facts of the disease. Excessive fear and dread may cause family and friends to display avoidance or overprotective behaviours to the ill person, who may subsequently perceive dissatisfaction with social support. Drawing on a literature review this paper explores the impact of cancer on social relationships. Interpersonal strain in relationship is often explained in the stigmatization of the illness and this concept is explored through contemporary social theorizing. These findings have direct implications for nursing practice where the goal of care is to enhance the support relationship.

Immunolocalization of 5alpha-reductase isozymes in acne lesions and normal skin

BACKGROUND

Dihydrotestosterone mediates androgen-dependent diseases, such as acne, hirsutism, and androgenetic alopecia. This hormone is produced from testosterone by the 5alpha-reductase enzyme. There are 2 isozymes of 5alpha-reductase (types 1 and 2) that differ in their localization within the body and even within the skin. Activity of the type 1 isozyme predominates in sebaceous glands, where it may be involved in regulation of sebum production. Since specific inhibition of 5alpha-reductase type 1 may represent a novel therapeutic approach to acne, it is important to define the localization of these isozymes in normal sebaceous follicles and acne lesions.

OBSERVATIONS

Skin biopsy specimens were obtained from the backs of 11 subjects: 8 with acne and 3 without acne. Sections of normal follicles, open comedones, closed comedones, and inflammatory lesions were incubated with antibodies to types 1 and 2 5alpha-reductase. In all samples, the type 1 antibody localized specifically to sebaceous glands, and the type 2 antibody localized to the companion layer of the hair follicle (the innermost layer of the outer root sheath) and granular layer of the epidermis. Localization of the type 2 isozyme was also noted within the walls of open and closed comedones and in endothelial cells from sections of inflammatory lesions.

CONCLUSIONS

The immunolocalization of 5alpha-reductase isozymes in normal sebaceous follicles and acne follicles is similar to the pattern described in terminal hair follicles and corresponds with the findings of biochemical studies that have demonstrated predominance of type 1 activity in sebaceous glands. The function of type 2 5alpha-reductase in comedones or endothelial cells in inflammatory lesions is unknown.

Genomic structure and expression of parathyroid hormone-related protein gene (PTHrP) in a teleost, Fugu rubripes

In this study we describe the isolation and characterisation of the parathyroid hormone-related protein (PTHrP) gene from the teleost Fugu rubripes. The gene has a relatively simple structure, compared with tetrapod PTHrP genes, composed of three exons and two introns, encompassing 2.25kb of genomic DNA. The gene encodes a protein of 163 amino acids, with a putative signal peptide of 37 amino acids and a mature peptide of 126 amino acids. The overall homology with known tetrapod PTHrP proteins is low (36%), with a novel sequence inserted between positions 38 and 65, the absence of the conserved pentapeptide (TRSAW) and shortened C-terminal domain. The N-terminus shows greater conservation (62%), suggesting that it may have a hypercalcaemic function similar to that of tetrapod PTHrP. In situ localisation and RT-PCR have demonstrated the presence of PTHrP in a wide range of tissues with varying levels of expression. Sequence scanning of overlapping cosmids has identified three additional genes, TMPO, LDHB and KCNA1, which map to human chromosome 12, with the latter two mapping to 12p12-11.2. PTHrP in human also maps to this chromosome 12 sub-region, thus demonstrating conservation of synteny between human and Fugu.

Work-based learning as a means of developing and assessing nursing competence

Work-Based Learning is the bringing together of self-knowledge, expertise at work and formal knowledge. It takes a structured and learner-managed approach to maximizing opportunities for learning and professional development in the workplace. The development and assessment of nursing competence can be facilitated through Work-Based Learning, although this may require pedagogic and structural changes within nurse education. There are a number of conditions which must accompany effective participative learning, and these are discussed in the paper in relation to examples of nursing programmes. This method of learning and assessment has potential to bridge the gap between theory and practice, and as such it can only be achieved through commitment and partnership between the individual practitioner, clinical services and universities.

The genetic aspects of adult-onset glaucoma: a perspective from the Greater Toronto area

BACKGROUND

The myocilin gene is the first glaucoma gene to be associated with primary open-angle glaucoma (POAG). The hereditary subset of POAG and the role of the myocilin gene in our population are not clearly defined. Identification of cases of hereditary glaucoma and a better appreciation of the role of the myocilin gene may allow earlier diagnosis of the disease and optimize management of those at risk for glaucoma.

METHODS

Patients were recruited from university glaucoma practices in the Greater Toronto area from 1996 to 1998. Pedigree analysis and DNA banking were performed for each participant. Mutational analysis of the myocilin gene by means of single-strand conformation polymorphism analysis and direct sequencing was completed for 140 probands with POAG of diverse ethnic background.

RESULTS

A total of 103 patients (55.7%) had a family history of glaucoma. Disease-causing mutations of the myocilin gene were observed in 7 (5.0%) of the 140 probands, which accounted for 6.5% (5/77) of the familial cases. Most mutations were associated with familial disease, which implies a 50% risk of transmission of a high-risk factor for glaucoma.

INTERPRETATION

The hereditary subset of POAG is significant, and heritable glaucoma should always be suspected. In spite of the diversity of the ethnic background of our subjects, the observed prevalence of myocilin gene mutations was comparable to that previously reported, and such mutations do not appear to spare any ethnic group.

Oligonucleotide-based inhibition of embryonic gene expression

We describe a technique to define gene function using antisense oligonucleotide (AS-ODN) inhibition of gene expression in mice. A single intravenous injection of an AS-ODN targeting vascular endothelial growth factor (VEGF) into pregnant mice between E7.5-8.5 resulted in a lack of primary angiogenesis. This enabled us to define the critical window required to inhibit VEGF expression and recapitulate the primary loss of function phenotype observed in VEGF (-/-) embryos. This phenotype was sequence-specific and time- and dose-dependent. Injection of an AS-ODN targeting a second gene, E-cadherin, into pregnant mice at E10 confirmed a hypothesized secondary phenotype. This is the first report of AS-ODN inhibition of gene expression in utero and provides a new strategy for target validation in functional genomics.

Is a tight patch necessary after trabeculectomy?

AIMS

To determine if post-trabeculectomy patching reduces the prevalence of shallow/flat anterior chambers and pain.

METHODS

435 eyes were prospectively randomised to either a double patch with tape or no patch with tape group.

RESULTS

There was no statistically significant difference in flat or shallow anterior chamber rates or pain symptoms between the patch and no patch groups.

CONCLUSION

There is no benefit to patching the post-trabeculectomy eye.

Immunohistochemical localization of types 1 and 2 5alpha-reductase in human scalp

The predominant form of 5alpha-reductase (5aR) in human scalp is 5aR1. None the less, clinical studies have shown that finasteride, a selective inhibitor of 5aR2, decreases scalp dihydrotestosterone and promotes hair growth in men with androgenetic alopecia. Immunolocalization studies were thus carried out to examine 5aR isozyme distribution within scalp and, in particular, to determine whether 5aR2 might be associated with hair follicles. 5aR2 was localized using both a rabbit polyclonal and a mouse monoclonal antibody. 5aR1 was detected with a mouse monoclonal antibody. The specificity of these reagents was demonstrated both by immunofluorescence and Western blot analyses of COS cells overexpressing human 5aR1 or 5aR2. When cryosections of scalp from men with androgenetic alopecia were stained with antibody against 5aR2, using immunoperoxidase avidin-biotin complex methodology, immunostaining was observed in the inner layer of the outer root sheath and, in more proximal regions of the follicle, in the inner root sheath. Staining was also prominent in the infundibular region of the follicle, with less intense staining extending throughout the granular layer of the epidermis. Some staining was also seen in sebaceous ducts. Similar results were obtained with both the polyclonal and monoclonal 5aR2 antibodies. In contrast, in scalp cryosections stained with antibody to 5aR1, no immunostaining was observed within hair follicles. Intense staining for the type 1 isozyme was, however, detected within sebaceous glands. Our immunolocalization data suggest that the results seen in clinical trials of men with male pattern hair loss treated with finasteride may be due, at least in part, to local inhibition of 5aR2 within the hair follicle.

Public participation in the design of educational programmes for cancer nurses: a case report

Genuine involvement of the public in planning, monitoring and evaluation of health care is a prerequisite to a better quality of service. Similarly users of health services and their carers can contribute much to the planning and delivery of professional education, although this contribution has only recently been acknowledged in any strategic way by nursing educational and professional bodies. This paper provides one example of user and career involvement in the design of continuing education and higher education in cancer care nursing within the University of Leeds School of Healthcare Studies. The author reflects upon the positive aspects and some of the challenges presented in the achievement of public involvement in nurse education.

Facing the issue of dependence: some implications from the literature for the hospice and hospice nurses

Research and clinical practice suggest that dependence upon others causes distress to those with a life-threatening illness and that the hospice may serve to reinforce feelings of loss of autonomy. Hospice nurses can contribute to good care and act therapeutically to maximize an individual's potential for independent activity where this is possible and desirable. However, literature from other contexts demonstrates variability in the extent to which this is achieved. This paper outlines the problem of dependence in those with a life threatening illness. Therapeutic nursing is explored in relation to issues which may arise in a hospice context, potential relationships between therapeutic nursing and partnership are noted, particularly with regard to the possible meanings of dependence which for some individuals comes to be apprehensively associated with impending death.

Coxsackievirus and adenovirus receptor amino-terminal immunoglobulin V-related domain binds adenovirus type 2 and fiber knob from adenovirus type 12

The extracellular region of the coxsackievirus and adenovirus receptor (CAR) is predicted to consist of two immunoglobulin (Ig)-related structural domains. We expressed the isolated CAR amino-terminal domain (D1) and a CAR fragment containing both extracellular Ig domains (D1/D2) in Escherichia coli. Both D1 and D1/D2 formed complexes in vitro with the recombinant knob domain of adenovirus type 12 (Ad12) fiber, and D1 inhibited adenovirus type 2 (Ad2) infection of HeLa cells. These results indicate that the adenovirus-binding activity of CAR is localized in the amino-terminal IgV-related domain and confirm our earlier observation that Ad2 and Ad12 bind to the same cellular receptor. Preliminary crystallization studies suggest that complexes of Ad12 knob bound to D1 will be suitable for structure determination.

Parry-Romberg syndrome associated with intracranial vascular malformations

We describe a 23-year-old woman with iridocyclitis, enophthalmos, facial hemiatrophy, and transient numbness of her contralateral upper and lower extremities. The patient was found to have white matter densities in the right hemisphere in magnetic resonance T2-weighted images and vascular malformations involving right vertebral, right carotid, and right anterior cerebral arteries. Histopathologic evaluation of a biopsy specimen of anterior orbital fat and lacrimal gland revealed fibrosis and chronic inflammation. These findings were consistent with the diagnosis of progressive facial hemiatrophy (Parry-Romberg syndrome) in association with iridocyclitis and intracranial vascular malformations.

Achieving partnership: the contribution of nursing education to the production of a flexible workforce

AIM

This paper examines education's contribution to labour force reform in the nursing profession within the United Kingdom.

BACKGROUND

In a globalized society there is increasing demand for more flexible forms of working. Nursing faces radical change in its employment characteristics if it is to continue to meet the health care needs of the population in the new century. ORIGINS OF INFORMATION AND DATA ANALYSIS: Key sociological texts and contemporary analysis of nursing skill have been analysed and synthesized to identify the dynamic of change in nursing and nursing education's contribution to these changes.

KEY ISSUES

Patterns of upskilling and multiskilling are leading to the breakdown of professional role boundaries in the broader workforce. These patterns can also be seen in nursing. Upskilling is associated with increased stress and 'risk' for the individual, therefore achievement of flexibility is not without cost. Changes in the skill level in nursing lead many to conclude that the profession will become divided into a core and periphery distinction. This simplistic analysis does not account for the complexities of nursing and nursing skill although there is clearly a growing need for a 'knowledge and technical elite'.

CONCLUSIONS

The core-periphery distinction is too simplistic to analyse nursing skills and the dynamic of change in the workforce. A radical perspective of nursing characterized by workers with a range of skills and competencies is less likely to lead to rigid professional boundaries. There is a clear need for multiskilled and knowledgeable workers; the 'technical and knowledge elite'. These nurses may be recognized as advanced practice nurses. High quality education is required to prepare these practitioners. Adaptation of nursing to the postmodern world needs to be facilitated by changes in current educational policy and practice.