What do nurses want from social workers?

This study is based on a series of interviews with 45 senior nurses and outlines their perceptions about, and expectations of, social workers. The study found that nurses want social workers to provide a range of practical services for patients and to act as a bridge with the community, making use of their unique position to move between health and social services. They want a mutually satisfying professional working relationship with social workers based on trust, confidence and reliability. And they want them to fulfill their statutory responsibilities with expertise.

Altered in vivo and in vitro behavior of butanol-modified bone marrow cells

Cell-surface molecules, particularly glycoconjugates, appear to be involved in the in vivo homing of hematopoietic stem and progenitor cells and in their interactions with hematopoietic stromal cells. To study the role of cell-surface molecules of hematopoietic stem cells, the expression of some surface molecules was altered using n-butanol treatment. We examined the in vivo and in vitro colony-forming abilities, in vivo homing patterns, and cell-surface lectin receptor expression of butanol-treated bone marrow cells (BMC) from BDF1 mice. The butanol-treated/-modified BMC formed an increased number of significantly larger spleen colonies (CFU-S) in lethally irradiated (1050 rad) mice. The butanol-treated BM formed significantly larger in vitro granulocyte-macrophage progenitor cell colonies (CFU-C) and in vitro fibroblastic colonies (CFU-F), although the number of such colonies was not significantly altered. The homing pattern of butanol-treated BMC was studied by comparing the distribution in lethally irradiated mice of intravenously injected 51Cr-labeled butanol-treated BMC with that of untreated cells. The butanol treatment altered the in vivo homing pattern of these cells, with increased homing to liver, spleen, and bone marrow and decreased homing to thymus, lung, and mesenteric lymph nodes. Flow-cytometric analyses of butanol-treated BMC showed an increased expression of receptors for the lectins concanavalin A (conA) and wheat germ agglutinin (WGA), indicating an increased expression of mannosyl and galactosyl residues, which are known sugar moieties in hematopoietic stem/progenitor cell homing. These results indicate that cell surface modifications can influence homing and growth of transplanted BMC and that butanol treatment is a useful tool for studying the mechanisms of hematopoietic stem/progenitor cell homing in vivo and for further characterizing the molecules involved in this process.

Familial aggregation of adolescent personality disorders

OBJECTIVE

A family study of DSM-III-R personality disorders was conducted in the families of 66 clinically referred adolescents to examine the validity of personality disorder diagnoses in adolescents.

METHOD

Semistructured interviews of Axis I and II disorders, including the Structured Clinical Interview for DSM-III-R Personality Disorders, were used to directly interview 66 clinically referred adolescents and their adult first-degree family members, combining family study and family history data.

RESULTS

The relatives of adolescents with avoidant personality disorder had an increased prevalence of avoidant and cluster A (schizoid, schizotypal, and paranoid) personality disorders. The relatives of adolescents with borderline personality disorder demonstrated increased rates of borderline and avoidant personality disorders, even after adjusting for comorbidity.

CONCLUSIONS

The results of this study support the validity of Axis II diagnoses, particularly avoidant and borderline disorders, in adolescents.

Anti-CD45 monoclonal antibody perfusion of human renal allografts prior to transplantation. A safety and immunohistological study. CD45 Study Group

The perfusion of kidneys with anti-CD45 monoclonal antibodies prior to transplantation offers a means of targeting passenger antigen-presenting cells with the aim of reducing the subsequent incidence of rejection episodes. A safety study was performed in humans of such pretreatment in 40 unsensitized recipients of first cadaveric renal grafts, who were followed for 3 months after transplantation. A 50-ml solution containing 2 mg of each of the rat anti-CD45 mAbs YTH 24.5 and YTH 54.12 was injected into the allograft renal artery ex vivo and just before transplantation while the renal vein was kept clamped. No patients died, but 4 grafts were lost. Two were lost due to primary nonfunction, 1 was lost because of late renal artery thrombosis, and 1 was lost to rejection. There were no cases of renal vein thrombosis and 1 trivial renal artery stenosis, and only 2 patients produced human anti-rat antibodies. Between 63.5% and 100% (median 96.4%) of CD45+ cells in the postperfusion biopsies were coated with anti-CD45 as determined by double-immunolabeling. The number of patients experiencing rejection episodes was inversely associated with this "antibody uptake": 75% of the low uptake group (< 95%) had at least 1 rejection episode, compared with 22% of the high uptake group (> or = 95%) (P = 0.001). The complement components C3 and C5b-9 colocalized with perfused anti-CD45 in 32/33 (97.0%) and 11/33 (33.3%) of the biopsy specimens, respectively. We conclude that: (1) this technique appears free of adverse effects, (2) high antibody uptake within the kidney is associated with a lower incidence of rejection, and (3) the antibodies used fix and activate complement in vivo.

Local recurrence after conservative surgery and radiation therapy for ductal carcinoma in situ: Possible importance of family history

PURPOSE

The optimal treatment of ductal carcinoma in situ is controversial. Traditionally, women with this disease have been treated with mastectomy with excellent results, but recently the need for such extensive surgery has been questioned. Long-term data on the use of conservative surgery and radiation therapy for treatment are limited. A retrospective analysis was performed to assess treatment outcome and prognostic factors for patients with ductal carcinoma in situ treated with conservative surgery and radiotherapy.

PATIENTS AND METHODS

From 1976 to 1990, 76 women with ductal carcinoma in situ were treated with conservative surgery followed by radiation therapy. The median age at diagnosis was 48 years. Seventeen patients had a positive family history of breast cancer in a first-degree (n=8) or second-degree (n=9) relative. Median follow-up interval was 74 months for the 71 survivors. In 54 patients, the carcinoma was detected by mammography alone; in 13 patients, by mammography and physical examination; and in 4 patients, by physical examination with a normal mammogram; and in 5 patients, by physical examination alone without mammography. Fifty patients had re-excision after initial biopsy. Final margins were positive in 11, close in 11, negative in 34, and unknown in 20. The median volume of excised tissue was 60 cm3. The axilla was surgically staged in 30 patients (39%) and all were negative. The whole breast was irradiated to a dose of 45 to 50 Gy in all patients. Seventy-two patients also received a boost to the primary site. The median total radiation dose to the primary site was 61 Gy (range, 46 to 71).

RESULTS

Seven patients had a recurrence in the treated breast at 16, 18, 41, 63, 72, 83, and 104 months after treatment. The 5- and 10-year actuarial rates of local recurrence were 4% and 15%, respectively. Six of seven recurrences occurred in the vicinity of the original lesion. Four local recurrences were invasive, and three were ductal carcinoma in situ. Two patients developed a contralateral invasive carcinoma. The 5- and 10-year cause-specific survival rates were 100% and 96%, respectively. The 10-year actuarial rate of local recurrence was 25% in the group with a total excision volume less than 60 cm3, as compared with 0% in those with 60 cm3 or more excised (P=0.04). In patients with a positive family history, the 10-year actuarial rate of local recurrence was 37%, as compared with 9% in patients with a negative family history (P=0.008). Of the 17 patients with a positive family history, four developed either an ipsilateral or contralateral invasive breast cancer, whereas 1 of the 58 patients without a family history developed a subsequent invasive breast cancer (P=0.008).

CONCLUSION

These results suggest that patients with ductal carcinoma in situ treated with conservative surgery and radiotherapy (including a boost to the primary site) appear to benefit from wide, rather than limited, resection. These results also suggest that family history may be an important prognostic factor for progression of disease.

Expression of vascular permeability factor (vascular endothelial growth factor) and its receptors in breast cancer

Solid tumors must induce a vascular stroma to grow beyond a minimal size, and the intensity of the angiogenic response has been correlated with prognosis in breast cancer patients. Vascular permeability factor (VPF), also known as vascular endothelial growth factor (VEGF), is a secreted protein that has been implicated in tumor-associated angiogenesis. Vascular permeability factor directly stimulates endothelial cell growth and also increases microvascular permeability, leading to the extravasation of plasma proteins, which alter the extracellular matrix in a manner that promotes angiogenesis. To determine whether VPF has a role in breast cancer, we used in situ hybridization to study VPF mRNA expression in normal breast tissue (13 specimens), comedo-type ductal carcinoma in situ (DCIS) (four specimens), infiltrating ductal carcinoma (12 specimens), infiltrating lobular carcinoma (two specimens), metastatic ductal carcinoma (three specimens) and metastatic lobular carcinoma (one specimen). Vascular permeability factor mRNA was expressed at a low level by normal duct epithelium but was expressed at high levels in tumor cells in all cases of comedo-type DCIS, infiltrating ductal carcinoma, and metastatic ductal carcinoma. In contrast, VPF mRNA was not expressed at high levels in infiltrating lobular carcinoma. We also used in situ hybridization to study the expression of two recently described endothelial cell surface VPF receptors, flt-1 and kdr. Vascular permeability factor receptor mRNA was strongly expressed in endothelial cells of small vessels adjacent to malignant tumor cells in DCIS, infiltrating ductal carcinoma, and metastatic ductal carcinoma. In contrast, no definite labeling for receptor mRNA was detected in infiltrating lobular carcinoma or nonmalignant breast tissue. The intense expression of VPF mRNA by breast carcinoma cells and of VPF receptor mRNA by endothelial cells of adjacent small blood vessels provides strong evidence linking VPF expression to the angiogenesis associated with comedo-type DCIS, infiltrating ductal, and metastatic ductal breast carcinoma.

Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents

OBJECTIVE

This study was designed to assess the association between personality disorders, personality traits, impulsive violence, and suicide.

METHOD

Personality disorders and traits in 43 adolescent suicide victims and 43 community controls were assessed from the parents, using semistructured interviews and self-report forms.

RESULTS

Probable or definite personality disorders were more common in suicide victims than in controls, particularly Cluster B (impulsive-dramatic) and C type (avoidant-dependent) disorders. Suicide victims also showed greater scores on lifetime aggression, even after controlling for differences in psychopathology between suicides and controls.

CONCLUSIONS

Personality disorders and the tendency to engage in impulsive violence are critical risk factors for completed suicide.

The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy

BACKGROUND

The relationships among the involvement of tumor at the final margins of resection, the presence of an extensive intraductal component (EIC), and the risk of local recurrence are important considerations in patients treated with conservative surgery and radiation therapy for early stage breast cancer but have not been defined adequately.

METHODS

Between 1982 and 1985, 885 patients were treated for clinical Stage I or II invasive breast cancer. The study population was limited to 181 patients with an infiltrating ductal carcinoma who received a radiation dose to the surgical site of 60 Gy or greater, whose final microscopic margins of resection were evaluable, and who had at least 5 years of follow-up. A positive margin was defined as tumor present at the inked margin of resection, a close margin as tumor within 1 mm of the inked margin, and a negative margin as no tumor within 1 mm of the inked margin. A focally positive margin was defined as tumor at the margin in three or fewer low-power fields. In 157 patients (87%), the tumor was evaluable for the presence or absence of an EIC. The median follow-up was 86 months.

RESULTS

In 12 of 181 patients (7%), a recurrence developed at or near the primary site (true recurrence/marginal miss [TR/MM]) within 5 years. The 5-year rate of TR/MM (with 95% confidence intervals) among patients with negative, close, focally positive, and more than focally positive margins was 0% (0-4%), 4% (0-20%), 6% (1-17%) and 21% (10-37%), respectively. Patients with positive margins also were more likely to have a distant failure within 5 years (14%, 8%, 25%, and 32% in the four groups, respectively). However, patients with positive margins more often had positive axillary lymph nodes than patients with negative or close margins (59% vs. 38%, P < 0.02). The 5-year rate of TR/MM was 20% for patients with an EIC-positive tumor and 7% for patients with an EIC-negative tumor. However, among the 127 patients with an EIC-negative tumor, the 5-year rate of TR/MM was less than 10% in all margin groups. Among the 30 patients with an EIC-positive tumor, the 5-year rate of TR/MM was 0% when margins were negative or close but 50% when margins were more than focally positive.

CONCLUSIONS

These results provide support for the use of breast-conserving surgery and breast irradiation in all patients with uninvolved margins, whether the tumor is EIC-positive or EIC-negative. This study suggests that breast-conserving therapy (including a radiation boost to the primary site) also may be a reasonable option for some patients with an EIC-negative tumor and margin involvement.

The relation between the surgery-radiotherapy interval and treatment outcome in patients treated with breast-conserving surgery and radiation therapy without systemic therapy

PURPOSE

This analysis was performed to clarify the relationship between the surgery-radiotherapy interval and the risk of recurrence in patients treated with breast-conserving therapy for early stage invasive cancers.

METHODS AND MATERIALS

We retrospectively analyzed data from 653 patients with American Joint Commission on Cancer Stage I or II, pathologically node-negative breast cancer treated by breast-conserving therapy without adjuvant systemic therapy between 1968 and 1985. All patients received a dose of at least 60 Gy to the tumor bed. Two hundred and eighty-three patients started radiotherapy within 4 weeks of surgery, 308 started 5-8 weeks after surgery, and 54 started 9-12 weeks after surgery. Median follow-up in the 531 survivors was 100 months.

RESULTS

Pathologic features and treatment characteristics were well balanced between the groups with surgery-radiotherapy intervals of 0-4 weeks and 5-8 weeks. There was no statistically difference in the risk of overall recurrence among patients starting radiotherapy 5-8 weeks after surgery compared with those treated within 4 weeks. Analysis of the 5-year crude rates of failure further demonstrated no difference in the distribution of sites of failure in the 5-8 week group compared with the 0-4 week group. A multivariate model controlling for known risk factors, as well as potential treatment-related confounders, also failed to demonstrate an increased risk of recurrence with the longer surgery-radiotherapy interval (risk ratio = 0.89, p = 0.44).

CONCLUSION

This retrospective analysis suggests that a delay of up to 8 weeks in the interval between the last breast surgery and the start of radiotherapy is not associated with an increased risk of recurrence in patients with early stage breast cancer treated with breast irradiation to at least 60 Gy without systemic therapy.

Home-based versus hospital-based care for people with serious mental illness

BACKGROUND

A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London.

METHOD

Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

RESULTS

Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.)

CONCLUSIONS

It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

Home-based versus out-patient/in-patient care for people with serious mental illness. Phase II of a controlled study

BACKGROUND

The effect of a randomised controlled withdrawal of home-based care was studied for half of a sample of seriously mentally ill (SMI) patients from an inner London catchment area, compared with the effects of continuing home-based care.

METHOD

Patients, aged 18-64, had entered the trial at month 0 when facing emergency admission for SMI. After at least 20 months home-based care (Phase I), patients were randomised at month 30 into Phase II (months 30-45) to have either further home-based care (DLPII, n = 33) or be transferred to out-/in-patient care (DLP-control, n = 33). They were assessed at 30, 34, and 45 months. Phase I control patients (n = 70) were assessed again at month 45. Measures used were number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.

RESULTS

The slim clinical and social gains from home-based v. out-/in-patient care during Phase I were largely lost in Phase II. Duration of crisis admissions increased from Phase I to Phase II in both DLPII and DLP-control patients. During Phase II, patients' and relatives' satisfaction remained greater for home-based than out-/in-patient care patients. At 45 months, compared with the Phase I controls, DLPII patients and relatives were more satisfied with care. Such satisfaction was independent of clinical/social gains.

CONCLUSIONS

The loss of Phase I gains were perhaps due to attenuation of home-based care quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls. The Phase II home-based care team suffered from low morale.

Service use and costs of home-based versus hospital-based care for people with serious mental illness

BACKGROUND

The Daily Living Programme (DLP) offered problem-oriented, home-based care for people aged 17-64 with severe mental illness facing emergency admission to the Bethlem-Maudsley Hospital. The multidisciplinary DLP team acted as direct provider and link with other services. Each patient had a key worker. Cost-effectiveness was assessed.

METHOD

The comprehensive costs of DLP and standard in-patient care were compared within a randomised controlled trial. Cost measures ranged over all service inputs and living expenses. The costs of informal care and lost employment were also considered. Assessments of service use, costs and outcomes were conducted at referral, 4, 11 and 20 months.

RESULTS

The DLP was significantly less costly than standard treatment in both short and medium term (P = 0.000). Cost savings accrued almost exclusively to the NHS, with no other agency's costs being higher.

CONCLUSIONS

Coupled with mildly encouraging outcome results over the 20 month period, the DLP was clearly cost-effective in this medium term.

Relationship of patient age to pathologic features of the tumor and prognosis for patients with stage I or II breast cancer

PURPOSE

This analysis was performed to clarify the relationship of young age at diagnosis to the pathologic features of the tumor and prognosis in patients with early-stage breast cancer.

PATIENTS AND METHODS

We retrospectively analyzed data from 1,398 patients with American Joint Committee on Cancer Staging stage I or II breast cancer treated by breast-conserving therapy between 1968 and 1985. One hundred seven patients were younger than 35 years at the time of diagnosis. The median follow-up duration for the 1,032 survivors was 99 months.

RESULTS

Patients younger than 35 years had a significantly higher overall recurrence rate (P = .002), as well as a greater risk for developing distant metastases (P = .03), when compared with older patients. The cancers in younger patients more commonly showed factors associated with a worse prognosis (including grade 3 histology, lymphatic vessel invasion [LVI], necrosis, and estrogen receptor [ER] negativity) as compared with older patients. In a proportional hazards model that included clinical and treatment-related variables, as well as these pathologic features, age younger than 35 years remained a significant predictor for time to recurrence (relative risk [RR], 1.70), time to distant failure (RR, 1.60), and overall mortality (RR, 1.50).

CONCLUSION

Breast cancer patients younger than 35 years have a worse prognosis than older patients. This difference is only partially explained by a higher frequency of adverse pathologic factors seen in younger patients.

Genetic mapping of the BRCA1 region on chromosome 17q21

Chromosome 17q21 harbors a gene (BRCA1) associated with a hereditary form of breast cancer. As a step toward identification of this gene itself we developed a number of simple-sequence-repeat (SSR) markers for chromosome 17 and constructed a high-resolution genetic map of a 40-cM region around 17q21. As part of this effort we captured genotypes from five of the markers by using an ABI sequencing instrument and stored them in a locally developed database, as a step toward automated genotyping. In addition, YACs that physically link some of the SSR markers were identified. The results provided by this study should facilitate physical mapping of the BRCA1 region and isolation of the BRCA1 gene.

Assessment of functional vision performance: a new test for low vision patients

Measures of functional vision are needed to assess elderly low vision patients, their success in using devices, and their ability to manage outside the treatment setting. A new test devised to measure functional ability through the performance of everyday tasks was administered to 94 patients who had acuities of 20/100 or worse in their better eye. Consisting of three versions and four subtests: spot reading, short-term text reading, identifying paper currency and clock reading, the test used standardized items and was timed. In a multiple regression model predicting test performance higher scores were associated with better near acuity (P = .002), higher education (P = .022) and higher levels of self-reported visual skills (P = .072). These predictors plus distance acuity, age and sex only accounted for 35 percent of the variance in test scores. Repeated administration of the test to a different group of 21 patients showed the test to be reliable (intraclass correlation = .85, P < .01) and to have no practice or version effects or differences between raters. This new test may be useful for natural history studies and clinical trials involving low vision patients but further evaluation of its sensitivity to change over time is required.

Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces

This is the second of 2 articles on a 3-year investigation of medial collateral ligament sprains of the knee to assess the effectiveness of prophylactic knee braces in NCAA Division I college football players. Position, string, type of session, and daily brace wear were recorded. The injury rates for braced and unbraced knees were used to create an incidence density ratio. The data were stratified and simultaneously controlled for position, string, and session and evaluated for their statistical significance. The 987 Big Ten players generated 155,772 knee exposures over the study period (50% braced). Noticeable differences existed in the rates of injury for the braced and unbraced knees in almost every position during practices, depending on player or nonplayer status. When the influential factors of position, string, and session are considered, there is a consistent but not statistically significant tendency for the players wearing preventive knee braces to experience a lower injury rate than for their unbraced counterparts. For starters and substitutes in the line positions, as well as the linebackers and tight ends, there was a consistent trend toward a lower injury rate in both practices and games. The braced players in the skill positions (backs/kickers), at least during games, exhibited a higher injury rate.

Medial collateral ligament knee sprains in college football. Brace wear preferences and injury risk

In this prospective, multiinstitutional analysis of medial collateral ligament sprains in college football players, we categorized 987 previously uninjured study subjects according to frequency of wearing preventive knee braces, studied the patterns by which 47 of 100 injuries occurred to unbraced knees, and identified several extrinsic, sport-specific risk factors shared for both braced and unbraced knees. The attendance, brace wear choice, position, string, and session of each participant were recorded daily; medial collateral ligament sprains were reported whenever tissue damage was confirmed. Both the likelihood of wearing braces and risk of injury without them was highly dependent on session (games/practices), position group (line, linebacker/tight end, skill), and string group (players/nonplayers). Subjects wearing braces often faced a high injury risk to their unbraced knees, a finding compatible with the opinion that braces were a necessary evil, best worn when concern over danger of injury outweighed desire for speed and agility. It is concluded that to avoid misinterpretations due to the confounding influence of brace wear selection bias, accurate investigation of daily brace wear patterns is required. Then, before considing the impact of preventive knee braces, a repartitioning of the data base is essential to assure that only similar groups will be compared.

The association between a positive T and B cell flow cytometry crossmatch and renal transplant failure

Between January 1989 and June 1991 329 consecutive cadaveric renal transplants were carried out at this centre and, of those, 36 (10.9%) have failed. In order to assess whether the use of flow cytometry crossmatching (FCXM) would have predicted these failures, we carried out a retrospective T and B cell FCXM study comparing the failure group with a control group of 30 recipients carefully selected from patients transplanted during the same period. The number of first and second transplants in the control and failure groups was 25,5 and 23,8 respectively with six of the controls and three of the failures having panel reactive lymphocytotoxic antibodies > 50%. Stored donor material was available for 31 of the 36 failures. Two colour FCXM was performed using R-phycoerythrin-conjugated antihuman CD3 and antihuman CD19 to identify T and B cells respectively. For each recipient, three pretransplant and one post-transplant sera were tested against lymphocytes from the recipient's kidney donor. A fluorescein isothiocyanate conjugated F(ab')2 rabbit antihuman IgG was used to detect recipient IgG alloantibodies bound to donor T and/or B cells. There were no T or B cell FCXM positive (+) results in the control group whereas 11 of the 31 (35%) failures overall and nine of the 23 (39%) who failed within three months were T and B cell FCXM+ pretransplant (p = 0.0002). Seven of the nine FCXM+ results in the early failure group were with historic sera and two with historic and current sera.(ABSTRACT TRUNCATED AT 250 WORDS)