The concept of social care and the analysis of contemporary welfare states

Care is now a widely-used concept in welfare state research, firmly established in the literature by feminist analysis. We believe that the concept as it has been used and developed to date has limitations that have hampered its development as a general category of welfare state analysis. In essence we argue that the political economy aspects of the concept have remained underdeveloped. The main purpose of this article is to elaborate a care-centered concept--which we name social care--that countenances and develops care as an activity and set of relations lying at the intersection of state, market and family (and voluntary sector) relations. We are especially concerned to examine what the concept of social care can tell us about welfare state variation and welfare state change and development. The article works systematically through these themes, beginning with a brief historical sketch of the concept of care and then moving on to elaborate the analytic potential of the concept of social care. In the latter regard we make the case that it can lead to a more encompassing analysis, helping to overcome especially the fragmentation in existing scholarship between the cash and service dimensions of the welfare state and the relative neglect of the latter. The concept of social care serves to shift the centre of analysis from specific policy domains so that instead of focusing on cash benefits or services in isolation it becomes possible to consider them as part of a broader set of inter-relating elements. In this and other regards, the concept has the potential to say something new about welfare states.

Molecular characterization of Irish Salmonella enterica serotype typhimurium: detection of class I integrons and assessment of genetic relationships by DNA amplification fingerprinting

Salmonella enterica is among the principal etiological agents of food-borne illness in humans. Increasing antimicrobial resistance in S. enterica is a cause for worldwide concern. There is concern at present in relation to the increasing incidence of human infection with antimicrobial agent-resistant strains of S. enterica serotype Typhimurium, in particular of phage type DT104. Integrons appear to play an important role in the dissemination of antimicrobial resistance genes in many Enterobacteriaceae including S. enterica. In this study the antimicrobial susceptibilities and phage types of 74 randomly collected strains of S. enterica serotype Typhimurium from the Cork region of southern Ireland, obtained from human, animal (clinical), and food sources, were determined. Each strain was examined for integrons and typed by DNA amplification fingerprinting (DAF). Phage type DT104 predominated (n = 48). Phage types DT104b (n = 3), -193 (n = 9), -195 (n = 6), -208 (n = 3), -204a (n = 2), PT U302 (n = 1), and two nontypeable strains accounted for the remainder. All S. enterica serotype Typhimurium DT104 strains were resistant to ampicillin, chloramphenicol, streptomycin, Sulfonamide Duplex, and tetracycline, and one strain was additionally resistant to trimethoprim. All DT104 strains but one were of a uniform DAF type (designated DAF-I) and showed a uniform pattern of integrons (designated IP-I). The DT104b and PT U302 strains also exhibited the same resistance phenotype, and both had the DAF-I and IP-I patterns. The DAF-I pattern was also observed in a single DT193 strain in which no integrons were detectable. Greater diversity of antibiograms and DAF and IP patterns among non-DT104 phage types was observed. These data indicate a remarkable degree of homogeneity at a molecular level among contemporary isolates of S. enterica serotype Typhimurium DT104 from animal, human, and food sources in this region.

Integronlike structures in Campylobacter spp. of human and animal origin

Resistance to antimicrobial agents used to treat severe Campylobacter spp. gastroenteritis is increasing worldwide. We assessed the antimicrobial resistance patterns of Campylobacter spp. isolates of human and animal origin. More than half (n = 32) were resistant to sulphonamide, a feature known to be associated with the presence of integrons. Analysis of these integrons will further our understanding of Campylobacter spp. epidemiology.

Biological markers of risk in nipple aspirate fluid are associated with residual cancer and tumour size

We previously demonstrated that nipple aspirate fluid (NAF) can be obtained from virtually all non-Asian women between the ages of 30 and 72. The focus of this report is to (1) determine the association of candidate markers of breast cancer risk in NAF obtained from fresh mastectomy specimens with residual breast carcinoma, and (2) evaluate the association of the markers with breast tumour progression. Nipple aspiration was performed on 97 specimens. Cytology, DNA index (including % hypertetraploid cells), cell cycle parameters (S phase fraction, % cells in G2/M), prostate-specific antigen (PSA), epidermal growth factor (EGF), testosterone, carcinoembryonic antigen (CEA) and prostaglandin D synthase (PGDS) were evaluated in NAF for their association with (1) residual ductal carcinoma in situ (DCIS) or invasive cancer, and (2) pathologic tumour size. NAF was obtained from 99% (96/97) of specimens. Atypical and malignant NAF cytology were significantly associated with residual DCIS or invasive cancer (P = 0.001) and with larger tumours (P = 0.004). One hundred per cent and 88% of subjects with malignant and atypical NAF cytology, respectively, had residual carcinoma. The percentage of cells in G2/M and DNA index were associated both with risk of residual carcinoma (P = 0.01 for each) and larger tumour size (DNA index, P = 0.03; G2/M, P = 0.05), although neither biomarker improved the ability of NAF cytology, to predict residual breast cancer. Higher DNA index was associated with atypical cytology (P = 0.0001). In summary, atypical and malignant NAF cytology are associated with larger tumour size, and are highly predictive of residual carcinoma after needle or excisional biopsy of the breast.

Risky behaviors among Louisiana youth

The main threats to adolescents' health are the risky behaviors they engage in and the choices they make. There are six health-risk behaviors that adolescents engage in that account for the majority of morbidity and mortality in this age group: alcohol and drug use; tobacco use; risky sexual behaviors; behaviors leading to intentional and unintentional injury; physical inactivity; and unhealthy dietary behaviors. These behaviors also greatly impact academic achievement. Using morbidity and mortality data obtained from the Office of Public Health and survey data, risk behaviors among adolescents in Louisiana are considered. School-based health centers are one successful strategy for comprehensively addressing these behaviors.

Pregnancy and risk of early breast cancer in carriers of BRCA1 and BRCA2

BACKGROUND

Early age at first full-term pregnancy and increasing parity are associated with a reduced risk of breast cancer. However, whether pregnancy decreases the risk of early-onset hereditary breast cancer is unknown. There is concern that pregnancy may increase breast-cancer risk in carriers of BRCA1 and BRCA2 germline mutations. We aimed to establish whether pregnancy is a risk factor for hereditary breast cancer.

METHODS

We did a matched case-control study of breast cancer in women who carry deleterious BRCA1 or BRCA2 mutations. Cases were carriers who developed breast cancer by age 40 years, and controls were carriers of the same age without breast cancer, or who were diagnosed with breast cancer after age 40 years. Women who had undergone preventive mastectomy, hysterectomy, or oophorectomy, or who were diagnosed with ovarian cancer before the age at which breast cancer was diagnosed in the matched case were excluded. Information about pregnancies and pregnancy outcome was derived from a questionnaire completed by women in the course of genetic counselling.

FINDINGS

A higher proportion of cases than controls had had a full term pregnancy (173/236 vs 146/236; odds ratio 1.71 [95% CI 1.13-2.62], p=0.01). The mean number of births was also greater for cases than for controls (1.62 vs 1.38, p=0.04). The risk increased with the number of births and did not diminish with time since last pregnancy. There were no significant differences in age at first birth or age at last birth between cases and controls.

INTERPRETATION

Carriers of the BRCA1 and BRCA2 mutations who have children are significantly more likely to develop breast cancer by age 40 than carriers who are nulliparous. Each pregnancy is associated with an increased cancer risk. An early first pregnancy does not confer protection for carriers of BRCA1 or BRCA2 mutations.

Does postoperative irradiation play a role in the adjuvant therapy of stage T4 colon cancer?

PURPOSE

This study analyzes the long-term outcome of patients with stage T4 colon cancer who receive postoperative irradiation. The purpose of the study is to define the potential role of this modality with current systemic therapies.

PATIENTS AND METHODS

A retrospective analysis was performed of 152 patients undergoing resection of T4 colon cancer followed by moderate- to high-dose postoperative tumor bed irradiation with and without 5-fluorouracil-based chemotherapy. Of the 152 patients, 110 patients (T4N0 or T4N+) were treated adjuvantly, whereas 42 patients received irradiation for the control of gross or microscopic residual local tumor.

RESULTS

For 79 adjuvantly treated patients with stage T4N0 or T4N+ cancer with one lymph node metastasis, the 10-year actuarial rates of local control and recurrence-free survival were 88% and 58%, respectively. Results were less satisfactory for patients with more extensive nodal involvement. The 10-year actuarial rates of local control and recurrence-free survival of 39 patients with T4 tumors complicated by perforation or fistulas were 81% and 53%, respectively. For 42 patients with incompletely resected tumors, the 10-year actuarial recurrence-free survival was 19%.

CONCLUSIONS

In comparison with historical controls, postoperative tumor bed irradiation improves local control for some subsets of patients. In addition to standard 5-fluorouracil-based chemotherapy, adjuvant tumor bed irradiation should be considered when colon cancers invade adjoining structures, when they are complicated by perforation or fistulas, or when they are incompletely excised at the primary site.

A randomized trial of breast cancer risk counseling: the impact on self-reported mammography use

OBJECTIVES

We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer.

METHODS

Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up.

RESULTS

In multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants.

CONCLUSIONS

These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.

Molecular analysis of Pseudomonas aeruginosa: epidemiological investigation of mastitis outbreaks in Irish dairy herds

Pseudomonas aeruginosa is a pathogen in both humans and animals. This bacterium, most often associated with respiratory infections in cystic fibrosis patients, was found to be the causative agent in bovine mastitis outbreaks among 11 Irish dairy herds. Epidemiological findings suggested that the infection was spread to all herds by teat wipes that had been contaminated with this organism. Two molecular-typing strategies were used in an attempt to determine the genomic relationship(s), if any, of the P. aeruginosa strains isolated from the various herds and to verify whether the same strain was responsible for each outbreak. Thirty-six isolates from the mastitis outbreaks were tested and compared to fourteen clinical isolates from Cork University Hospital. With one exception, all outbreak-linked strains produced identical patterns when ribotyped with ClaI and PvuII enzymes. Eight of the clinical isolates gave the same ClaI ribotype pattern as the mastitis-causing strains. However, PvuII proved more discriminatory, with only the outbreak isolates producing identical patterns. Similar results were obtained with RW3A-primed DNA amplification fingerprinting, with all outbreak isolates except one displaying the same fingerprint array. The clinical strains produced several fingerprint patterns, all of which were different from those of the mastitis-causing isolates. Fine-resolution DNA fingerprinting with a fluorescence-labelled RW3A primer also identified a number of low-molecular-weight polymorphisms that would have remained undetected by conventional methods. These data support the view that the same P. aeruginosa strain was responsible for the mastitis outbreaks in all 11 herds.

Salmonella tel-el-kebir and terrapins

OBJECTIVES

An outbreak of Salmonella tel-el-kebir occurring over a 6-month period is described in this report. This is the first outbreak of S. tel-el-kebir in the reported literature.

METHODS

S. tel-el-kebir was isolated from human faecal samples using conventional laboratory methods.

RESULTS

Eight patients had S. tel-el-kebir isolated from faeces. All patients were owners of, or in close contact with, pet terrapins. The terrapins were purchased in the same pet shop, where they were imported from America. The epidemiological link with these pets was confirmed, as S. tel-el-kebir was isolated from cloacal swabs from the terrapins, and from terrapin water. Molecular biology studies using DNA amplification fingerprinting (DAF) gave identical fingerprint patterns for all human and terrapin isolates.

CONCLUSIONS

Salmonellosis associated with exotic pets is a re-emerging disease in the 1990s, and measures to reduce this are discussed.

Exploring family relationships in cancer risk counseling using the genogram

OBJECTIVES

The genogram is a tool that has facilitated counseling in family therapy and social work for many years. It is hypothesized that genograms may also be useful in genetic counseling, because they help the counselor to acquire more objective and consistent information from the client, as well as to incorporate family dynamics and psychosocial issues into the counseling approach.

MATERIALS AND METHODS

A pilot study of genograms used as an adjunct to genetic counseling was performed at Fox Chase Cancer Center's Family Risk Assessment Program. A questionnaire was developed to elicit genograms from 38 women at risk for familial breast and/or ovarian cancer. After standard pedigree expansion, a series of questions was asked about the consultand's relationship with other family members, communication patterns within the family, attitudes toward genetic testing, family reactions to cancer, roles individuals play in the family, and significant historical or anniversary events. Relationships were defined by the consultand as close, very close, conflictual, fused and conflictual, distant, or estranged.

RESULTS

The majority of relationship types reported by 38 individuals was "very close" or "close." Eighty-one % reported having close/very close relationships with their spouses, 83% reported close/very close relationships with their mothers, and 70% reported close/very close relationships with their fathers. The degree of familial cohesion as depicted by the genogram correlates positively with scores obtained on the standardized Social Adjustment Scale Self-Report (P = 0.01).

CONCLUSIONS

Given the family-wide implications of genetic testing, the genogram may offer important guidance in family-targeted interventions.

Human evolutionary psychology and animal behaviour

Homo sapiens is increasingly being studied within the evolutionary (adaptationist, selectionist) framework favoured by animal behaviour researchers. There are various labels for such work, including evolutionary psychology, human behavioural ecology and human sociobiology. Collectively, we call these areas 'human evolutionary psychology' (HEP) because their shared objective is an evolutionary understanding of human information processing and decision making. Sexual selection and sex differences have been especially prominent in recent HEP research, but many other topics have been addressed, including parent-offspring relations, reciprocity and exploitation, foraging strategies and spatial cognition. Many HEP researchers began their scientific careers in animal behaviour, and in many ways, HEP research is scarcely distinguishable from other animal behaviour research. Currently controversial issues in HEP, such as the explanation(s) for observed levels of heritable diversity, the kinds of data needed to test adaptationist hypotheses, and the characterization of a species-typical 'environment of evolutionary adaptedness', are issues in animal behaviour as well. What gives HEP a distinct methodological flavour is that the research animal can talk, an ability that has both advantages and pitfalls for researchers. The proper use of self-reports and other verbal data in HEP might usefully become a subject of future research in its own right. Copyright 1999 The Association for the Study of Animal Behaviour.

Prostate cancer risk assessment program. A model for the early detection of prostate cancer

Prostate cancer is the most common form of cancer (except skin cancer) in men. Several factors have been associated with an increased risk for prostate cancer, including age, ethnicity, family history, lifestyle, and environmental exposures. Recognition of the importance of the interaction of these factors in prostate cancer has led to an interest in their evaluation as a model both for studying genetic susceptibility patterns and for studying and providing educational tools and preventive interventions. One such model has been developed at Fox Chase Cancer Center. Critical to the implementation of the model has been the establishment of the Prostate Cancer Risk Registry (PCRR) and Prostate Cancer Risk Assessment Program (PRAP). Together, they serve as a unique resource for investigating the interaction between environmental factors and genetic susceptibility patterns; exploring the early, premalignant biological markers of prostate cancer; and prospectively assessing the quality of life (QOL) of men at risk. In addition, PRAP facilitates the evaluation of models for prostate cancer risk counseling and screening in the community. This paper describes this model for early detection and risk reduction, along with preliminary data from its first two study aims. The program is particularly relevant in view of the wealth of genetic information emerging from the Human Genome Project.

Isoelectric focusing and immunodetection of plasma antithrombin

The first studies of plasma protein variation relied predominantly on conventional electrophoretic methods in media such as starch, agar, or cellulose acetate, which separated molecules on the basis of their relative differences in net charge and size. The introduction of isoelectric focusing in polyacrylamide gels (IEF/PA) led to the discovery of additional variability previously undetected by conventional electrophoretic techniques. IEF/PA separates molecules on the basis of their isoelectric points (pI) in a pH gradient generated by the application of an electric field to a mixture of buffer components, known as carrier ampholytes, which are present within a polyacrylamide matrix. Thus, it is possible to discriminate between molecules having a difference in pI as little as 0.01 pH units. The exact composition of isolectric focusing gels may be varied depending on the protein under investigation. In particular, alternative pH gradients may be generated by mixing ampholytes in the appropriate pH range. When used in combination with a simple "native" blotting procedure (1), the basic IEF/PA protocol described below has proven successful in our hands for studying microheterogeneity of plasma antithrombin and, with minor modifications to optimize results, it may be used to analyze any acidic protein of interest, provided a specific antiserum is available.

Characterization of heparin binding variants of antithrombin by crossed immunoelectrophoresis in the presence of heparin

The first update of the antithrombin mutation database published in 1993 used a revised classification for antithrombin variants (1). Currently, two deficiency states are recognized: type 1 deficiency is characterized by a parallel reduction in immunological and functional plasma antithrombin levels, whereas type 2 is characterized by the presence of a dysfunctional protein and a discrepancy between normal antigenic and reduced functional activity levels of antithrombin. Type 2 variants are further subtyped into three categories depending on whether the mutation has its effect on the reactive site (RS), the heparin binding site (HBS) or has multiple or pleiotropic effects (PE). Thus, the last update of the antithrombin database listed 11 distinct molecular defects causing heparin binding abnormalities and nine defects having pleiotropic effects interfering with both thrombin inhibitory activity and heparin binding. The majority of PE variants are also associated with reduced immunological concentrations of plasma antithrombin and have mutations affecting amino acid residues belonging to the C-terminal strand 1C (e.g., antithrombin Utah, 407 Pro to Leu) a finding which has led to the suggestion that the integrity of the carboxy-terminal 30 amino acids of antithrombin is essential for maintaining normal circulating antithrombin levels (2).

Domestic violence and sexually transmitted diseases: the experience of prenatal care patients

OBJECTIVES

The authors analyzed interview responses of patients at a prenatal care clinic to explore whether women who had been victims of sexual and physical abuse were more likely than non-victimized women to have experienced a sexually transmitted disease (STD).

METHODS

A consecutive sample of 774 prenatal patients of a large health department in North Carolina were interviewed concerning a variety of health issues, including violence and STDs. Logistic regression analysis was used to model the women's STD status as a function of their experiences of sexual and physical abuse, controlling for several potentially confounding factors.

RESULTS

Thirty percent of the women reported having experienced at least one STD, with the most common infections being chlamydia and gonorrhea. Twenty-eight percent of the women reported having been victims of abuse; 16% reported physical abuse only, while 12% reported both physical and sexual abuse. The majority of violence was domestic in nature, perpetrated by the victims' husbands, boyfriends, male friends, and relatives. After controlling for confounding variables, the authors found that women who reported both physical and sexual abuse were significantly more likely to have experienced STDs than non-victims (odds ratio [OR] = 2.25; 95% confidence interval [CI] 1.37, 3.69). The logistic regression analysis also showed a relationship of borderline statistical significance between non-sexual physical abuse and STDs.

CONCLUSIONS

Health care providers should routinely screen patients for both abuse and STDs, and they should assist identified women in accessing appropriate health, social, and legal services.

Antithrombins Wibble and Wobble (T85M/K): archetypal conformational diseases with in vivo latent-transition, thrombosis, and heparin activation

The inherent variability of conformational diseases is demonstrated by two families with different mutations of the same conserved aminoacid in antithrombin. Threonine 85 underlies the opening of the main beta-sheet of the molecule and its replacement, by the polar lysine, in antithrombin Wobble, resulted in a plasma deficiency of antithrombin with an uncharacteristically severe onset of thrombosis at 10 years of age, whereas the replacement of the same residue by a nonpolar methionine, antithrombin Wibble, gave near-normal levels of plasma antithrombin and more typical adult thromboembolic disease. Isolated antithrombin Wibble had a decreased thermal stability (Tm 56.2, normal 57.6 degreesC) but was fully stabilized by the heparin pentasaccharide (Tm 71.8, normal 71.0 degreesC), indicating that the prime abnormality is a laxity in the transition of the main sheet of the molecule from the 5- to 6-stranded form, as was confirmed by the ready conversion of antithrombin Wibble to the 6-stranded latent form on incubation. That this transition can occur in vivo was shown by the finding of nearly 10% of the proband's plasma antithrombin in the latent form and also, surprisingly, of small but definitive amounts of latent antithrombin in normal plasma. The latent transition will be predictably accelerated not only by gross mutations, as with antithrombin Wobble, to give severe episodic thrombosis, but also by milder mutations, as with antithrombin Wibble, to trigger thrombosis in the presence of other predisposing factors, including the conformational stress imposed by the raised body temperatures of fevers. Both antithrombin variants had an exceptional (25-fold) increase in heparin affinity and this, together with an increased inhibitory activity against factor Xa, provides evidence of the direct linkage of A-sheet opening to the conformational basis of heparin binding and activation.

Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study

BACKGROUND

The finding of a decrease in contralateral breast cancer incidence following tamoxifen administration for adjuvant therapy led to the concept that the drug might play a role in breast cancer prevention. To test this hypothesis, the National Surgical Adjuvant Breast and Bowel Project initiated the Breast Cancer Prevention Trial (P-1) in 1992.

METHODS

Women (N=13388) at increased risk for breast cancer because they 1) were 60 years of age or older, 2) were 35-59 years of age with a 5-year predicted risk for breast cancer of at least 1.66%, or 3) had a history of lobular carcinoma in situ were randomly assigned to receive placebo (n=6707) or 20 mg/day tamoxifen (n=6681) for 5 years. Gail's algorithm, based on a multivariate logistic regression model using combinations of risk factors, was used to estimate the probability (risk) of occurrence of breast cancer over time.

RESULTS

Tamoxifen reduced the risk of invasive breast cancer by 49% (two-sided P<.00001), with cumulative incidence through 69 months of follow-up of 43.4 versus 22.0 per 1000 women in the placebo and tamoxifen groups, respectively. The decreased risk occurred in women aged 49 years or younger (44%), 50-59 years (51%), and 60 years or older (55%); risk was also reduced in women with a history of lobular carcinoma in situ (56%) or atypical hyperplasia (86%) and in those with any category of predicted 5-year risk. Tamoxifen reduced the risk of noninvasive breast cancer by 50% (two-sided P<.002). Tamoxifen reduced the occurrence of estrogen receptor-positive tumors by 69%, but no difference in the occurrence of estrogen receptor-negative tumors was seen. Tamoxifen administration did not alter the average annual rate of ischemic heart disease; however, a reduction in hip, radius (Colles'), and spine fractures was observed. The rate of endometrial cancer was increased in the tamoxifen group (risk ratio = 2.53; 95% confidence interval = 1.35-4.97); this increased risk occurred predominantly in women aged 50 years or older. All endometrial cancers in the tamoxifen group were stage I (localized disease); no endometrial cancer deaths have occurred in this group. No liver cancers or increase in colon, rectal, ovarian, or other tumors was observed in the tamoxifen group. The rates of stroke, pulmonary embolism, and deep-vein thrombosis were elevated in the tamoxifen group; these events occurred more frequently in women aged 50 years or older.

CONCLUSIONS

Tamoxifen decreases the incidence of invasive and noninvasive breast cancer. Despite side effects resulting from administration of tamoxifen, its use as a breast cancer preventive agent is appropriate in many women at increased risk for the disease.

Epidemiology and risk assessment for ovarian cancer

The incidence of ovarian cancer varies internationally with higher rates among women of North America and northern Europe. In the United States, there has been relatively little change in the incidence of ovarian cancer in recent decades. The incidence rate of ovarian cancer is highest among white and Hawaiian women, intermediate among African-American, Hispanic and Asian-American women, and lowest among Native American women. The most intensively studied risk factors have been family history, pregnancy history, and oral contraceptive use. Multiparity, lactation, oral contraceptive use, and tubal ligation/hysterectomy all decrease a woman's risk of ovarian cancer. One exposure that has been consistently associated with increased ovarian cancer risk is cosmetic talc applied to the perineum.