The politics of ageing: how to get policymakers to support lifecourse policies

Background

Given that there is not much evidence that ageing imperils the finance and provision of health care, why do so many policymakers act like it does?

Methods

We break conventional wisdom down into myths and realities, identifying the evidence against them.

Results

A first myth is that ageing produces unsustainable health care costs, which in turn, creates intergenerational conflict over public policy. A second myth is that older people behave as a single group, always pursuing policies that benefit themselves. The final myth is that decisions about policy are made by politicians who pander to that elderly block. The first reality is that most of the problems ascribed to inequality between generations (intergenerational equity) are actually problems of inequality within society as a whole that span across age groups (intragenerational equity). The second reality is that policies that address these broader inequalities are built on the life-course perspective, which focuses on identifying the policies which can make people happier and healthier at all ages by drawing on the context and circumstances under which aging occurs. The third reality is that it is possible to construct coalitions of politicians and interests that can develop and support sophisticated life-course policies that lessen the burdens of ageing and health on everybody.

Conclusions

Intergenerational inequality is not, and need not be, a significant problem for rich countries. It is substantially a product of current and past intragenerational inequality, and in fact inequality between generations often goes with inequality within generations. Intergenerational conflict is a distraction from policies that promote greater equality within and between generations, and talk of an ageing crisis is frequently just another version of longstanding arguments against public social investment from cradle to grave.

The European Union Confronts COVID-19

Issue

The politics of European Union (EU) health policy are also the politics of European integration. Debate about EU policies always entails debate about the appropriate role and powers granted to the EU.

Description

From some angles, the EU looks more like a federation (ex EUA), deeply entrenched in its citizens' lives. It has a powerful shared culture among leaders and strong, entrepreneurial, and statelike political institutions. Its legal system is entwined with member state law to such an extent that member state courts have driven legal integration and change as much as EU institutions, both in general and in health. From another angle, it still looks like an international organization (ex WHO) or a regional trade block (ex Mercosur). We ask what policy a member state might make, but, in the case of the EU, many ask if the EU should have a policy at all. Should it respond, and, if so, how and to whose benefit?

Results

Like international organizations or confederations, though, the EU responds primarily to and is shaped by the demands of its member states. They have actively maintained this dichotomous structure so as to prevent transfer of power and loss of sovereignty. Member states ultimately determine the direction of the EU, and they have supported EU expansion only when they require a “European rescue of the nation state”.

Lessons

The EU's weak public health and social policy responses to the crisis reflect this effort on the part of member states to limit its role over the decades, whereas the major expansion in its role over the summer of 2020 reflects the perceived interests of member states, which now seek another European rescue of the nation state.

Main messages

This crisis of COVID-19 leave behind a different EU. Between the redefinition in salience, resource, and law of public health, shared European actions and the development of EU debt for member states, it is likely that a step forward promoted integration in health and beyond.

The politics of public health in the United Kingdom between medical, social, and local

Background

Public health in the UK exists on a continuum from a national and medical pole to a local and social pole, with each end threatening obliteration as a distinctive field of expertise and action. The national-medical produces a subfield of medicine, with a range of highly developed skills including epidemiology. The local-social, manifested in social medicine as well as equivalent approaches in social work, education, and local government, produces health, which need not be medical, as a result of investment in integrated services that enable solidary, dignified communities. This model is more invested in local communities and local governments, and more likely to blur borders with social work, leisure, and other areas, and have an overtly social democratic ethics and set of arguments.

Methods

A comparative historical analysis (CHA) based on government documents, law, and secondary sources.

Results

Public health in the UK has changed shape many times, from the end of most formal public health between 1948 and 1974, to the creation of a public health function in the 1980s, to the moment of divergence in 2012 when England reverted to a local public health and the devolved administrations did not.

Conclusions

The scope of public health might formally be the causes of avoidable ill health. In practice, the accepted expertise and autonomy of public health is found in narrower areas related to medicine: communicable disease control, health education, a few social services such as outpatient and outreach mental and sexual health, and the search for politically acceptable policies to address NCD threats. With public health moved to local government in England, its relationship with the NHS and medicine is likely to weaken further, to the likely detriment of the formal public health function and public health.

Optimizing real time fMRI neurofeedback for therapeutic discovery and development

While reducing the burden of brain disorders remains a top priority of organizations like the World Health Organization and National Institutes of Health, the development of novel, safe and effective treatments for brain disorders has been slow. In this paper, we describe the state of the science for an emerging technology, real time functional magnetic resonance imaging (rtfMRI) neurofeedback, in clinical neurotherapeutics. We review the scientific potential of rtfMRI and outline research strategies to optimize the development and application of rtfMRI neurofeedback as a next generation therapeutic tool. We propose that rtfMRI can be used to address a broad range of clinical problems by improving our understanding of brain–behavior relationships in order to develop more specific and effective interventions for individuals with brain disorders. We focus on the use of rtfMRI neurofeedback as a clinical neurotherapeutic tool to drive plasticity in brain function, cognition, and behavior. Our overall goal is for rtfMRI to advance personalized assessment and intervention approaches to enhance resilience and reduce morbidity by correcting maladaptive patterns of brain function in those with brain disorders.

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Guidelines are proposed for studies of rtfMRI neurofeedback for clinical therapeutics.

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Evidence-based guidelines are needed for clinical trials of rtfMRI neurofeedback.

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These guidelines will shape the design of future clinical trials.

Five-chlorodeoxycytidine, a tumor-selective enzyme-driven radiosensitizer, effectively controls five advanced human tumors in nude mice

PURPOSE

The study's goals were as follows: (1) to extend our past findings with rodent tumors to human tumors in nude mice, (2) to determine if the drug protocol could be simplified so that only CldC and one modulator, tetrahydrouridine (H4U), would be sufficient to obtain efficacy, (3) to determine the levels of deoxycytidine kinase and dCMP deaminase in human tumors, compared to adjacent normal tissue, and (4) to determine the effect of CldC on normal tissue radiation damage to the cervical spinal cord of nude mice.

METHODS AND MATERIALS

The five human tumors used were as follows: prostate tumors, PC-3 and H-1579; glioblastoma, SF-295; breast tumor, GI-101; and lung tumor, H-165. The duration of treatment was 3-5 weeks, with drugs administered on Days 1-4 and radiation on Days 3-5 of each week. The biomodulators of CldC were N-(Phosphonacetyl)-L-aspartate (PALA), an inhibitor of aspartyl transcarbamoylase, 5-fluorodeoxycytidine (FdC), resulting in tumor-directed inhibition of thymidylate synthetase, and H4U, an inhibitor of cytidine deaminase. The total dose of focused irradiation of the tumors was usually 45 Gy in 12 fractions.

RESULTS

Marked radiosensitization was obtained with CldC and the three modulators. The average days in tumor regrowth delay for X-ray compared to drugs plus X-ray, respectively, were: PC-3 prostate, 42-97; H-1579 prostate, 29-115; glioblastoma, 5-51; breast, 50-80; lung, 32-123. Comparative studies with PC-3 and H-1579 using CldC coadministered with H4U, showed that both PALA and FdC are dispensable, and the protocol can be simplified with equal and possibly heightened efficacy. For example, PC-3 with X-ray and (1) no drugs, (2) CldC plus the three modulators, (3) a high dose of CldC, and (4) escalating doses of CldC resulted in 0/10, 3/9, 5/10, and 6/9 cures, respectively. The tumor regrowth delay data followed a similar pattern. After treating mice only 11/2 weeks with CldC + H4U, 92% of the PC-3 tumor cells were found to possess CldU in their DNA. The great majority of head-and-neck tumors from patient material had markedly higher levels of dC kinase and dCMP deaminase than found in adjacent normal tissue. Physiologic and histologic studies showed that CldC + H4U combined with X-ray, focused on the cervical spinal cord, did not result in damage to that tissue.

CONCLUSIONS

5-CldC coadministered with only H4U is an effective radiosensitizer of human tumors. Ninety-two percent of PC-3 tumor cells have been shown to take up ClUra derived from CldC in their DNA after only 11/2 weeks and 2 weeks of bolus i.p. injections. Enzymatic alterations that make tumors successful have been exploited for a therapeutic advantage. The great electronegativity, coupled with the relatively small Van der Waal radius of the Cl atom, may result in CldC's possessing the dual advantageous properties of FdC on one hand and BrdU and IdU on the other hand. These advantages include autoenhancing the incorporation of CldUTP into DNA by not only overrunning but also inhibiting the formation of competing TTP pools in tumors. A clinical trial is about to begin, with head-and-neck tumors as a first target of CldC radiosensitization.

Morbidity and mortality in rheumatoid arthritis patients with prolonged and profound therapy-induced lymphopenia

OBJECTIVE

Therapies that deplete lymphocytes often improve symptoms in patients with otherwise refractory autoimmune disease but may result in long-term lymphopenia, the consequences of which are uncertain. To assess the impact of prolonged lymphopenia on morbidity and mortality, we studied patients who had previously received lymphocytotoxic monoclonal antibody (mAb) therapy for rheumatoid arthritis (RA).

METHODS

Fifty-three patients who received the lymphocytotoxic mAb CAMPATH-1H between 1991 and 1994 in the United Kingdom were assessed for mortality and infectious and malignant morbidity, by interview and case-note review. In addition, patients were monitored via the National Health Service Central Registry, to verify notification of death. Peripheral blood lymphocyte subsets were analyzed by flow cytometry. A retrospective, matched-cohort study of mortality was also performed with 102 control subjects selected from the European League Against Rheumatism database, which comprises patients with rheumatic disorders who have received immunosuppressive drugs.

RESULTS

There was profound and persistent peripheral blood lymphopenia in the mAb-treated patients, affecting predominantly the CD4+ subset. Median CD4+, CD8+, and CD19+ peripheral blood lymphocyte counts at 73-84 months after therapy were 185 cells/microl, 95 cells/microl, and 115 cells/microl, respectively. At a median followup of 71 months (range 14-90), 13 patients had died (24.5%), compared with 18% of the matched controls, providing a mortality rate ratio of 1.45 (95% confidence interval 0.65-3.13). During 283 patient-years of followup, there were 36 infections classified as major (12.7 per 100 patient-years). The causes of death and the spectrum of infections documented were similar to those expected in a hospital-based RA cohort. Patients who received more than 1 course of therapy had more severe lymphopenia than did patients who received a single course, but this did not have an impact on mortality or morbidity.

CONCLUSION

Despite the occurrence of profound and long-lasting lymphopenia following treatment with antilymphocyte mAb therapy for RA, this therapy is not associated with a large excess of mortality nor with an unusual spectrum of infections, at least during a medium-term period of followup. These data are also relevant to patients receiving lymphocytotoxic mAb therapy for other indications, and to patients receiving other lymphodepleting therapies such as autologous stem cell transplantation.

What's in a name? Neuroimmunomodulation or psychoneuroimmunology?

Compelling evidence is presented to support the hypothesis that psychological processes affect immune function. Consequently, it is argued that psychological processes should be included in human immunological studies and that neuroimmunomodulation could accurately by called psychoneuroimmunology.

The mode selection trial (MOST) in sinus node dysfunction: design, rationale, and baseline characteristics of the first 1000 patients

BACKGROUND

More than 200,000 permanent pacemakers will be implanted in the United States in 2000 at a cost of more than $2 billion. Sick sinus syndrome (SSS) will likely account for approximately half of all cases necessitating implantation. Pacemaker technology permits the selection of ventricular (single-chamber) or dual-chamber devices. However, clinical and outcomes data are inadequate to support a clear recommendation that one or the other type of device be used.

METHODS

The Mode Selection Trial (MOST) is a single-blind study supported by the National Heart, Lung, and Blood Institute designed to enroll 2000 patients with SSS. All patients will receive a DDDR pacemaker programmed to VVIR or DDDR before implantation. The average time of follow-up will be 3 years. MOST has a >90% power to detect a 25% reduction in the primary end point-nonfatal stroke or total (all cause) mortality-in the DDDR-treated group. Secondary end points will include health-related quality of life and cost effectiveness, atrial fibrillation, and development of pacemaker syndrome. Prespecified subgroups for analysis will include women and the elderly. Enrollment was completed in October 1999, with a total of 2010 patients.

RESULTS

The median age of the first 1000 enrolled patients is 74 years, with 25% of patients 80 years or older. Women comprise 49%, and 17% are nonwhite, predominantly black (13%). Before pacemaker implantation, 22% of patients reported a history of congestive heart failure, 11% coronary angioplasty, and 25% coronary bypass surgery. Supraventricular tachycardia including atrial fibrillation was present in 53% of patients. A prior stroke was reported by 12%. Antiarrhythmic therapy was in use in 18% of patients.

CONCLUSIONS

MOST will fill the clinical need for carefully designed prospective studies to define the benefits of dual-chamber versus single-chamber ventricular pacing in patients with SSS. The MOST population is typical of the overall pacemaker population in the United States. Thus the final results of MOST should be clinically generalizable.

Mind-body research in psychooncology

The biomedical model of disease, though powerful, does not explain all known facts about cancer. It is argued that a broader theoretical framework which includes psychosocial factors is needed. There is empirical evidence that a hopeless/helpless coping style is associated with unfavorable disease outcome in patients with certain cancers. The converse, namely a link between an active, fighting spirit coping style and favorable disease outcome, is under-researched and less clear-cut. The delineation, measurement and psychophysiology of positive states of mind have been sorely neglected. This is a promising area for future research. Psychobiological mechanisms of possible relevance to cancer are considered in terms of psychoneuroimmunology. Despite formidable theoretical and methodological problems, some progress is being made. Recent evidence indicates that psychotherapeutic intervention can augment natural killer cell activity and lymphokine-activated killer cell activity in patients with malignant melanoma and with locally advanced, nonmetastatic breast cancer respectively. These challenging findings, if confirmed, have major implications for our understanding of mind-body interactions in patients with cancer.

Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other

This article describes the interplay among theory, research and practice regarding the maintenance of psychological well-being during serious illness. The ideas emerged from two independent lines of work, one that evolved through clinical practice within the medical model, the other that evolved through theory and field research within a behavioral science model. Each of these lines of work independently points to the importance of focusing on psychological well-being and the coping processes that support it, as a complement to the traditional focus in both the medical and behavioral sciences on psychiatric symptoms. This article describes a theoretical framework for the discussion of psychological well-being during serious illness. Then, this framework is used to define variables that research indicates contribute specifically to psychological well-being during serious illness, and finally, based on theory and research, a therapeutic program is described for patients with serious illness. The goal of this paper is to encourage researchers and clinicians to give as much attention to the development and maintenance of psychological well-being in the face of serious illness as they do to the etiology and treatment of psychiatric symptoms.

Pulsed monoclonal antibody treatment and autoimmune thyroid disease in multiple sclerosis

BACKGROUND

Multiple sclerosis results from T-cell-dependent inflammatory demyelination of the central nervous system. Our objective was long-term suppression of inflammation with short-term monoclonal antibody treatment.

METHODS

We depleted 95% of circulating lymphocytes in 27 patients with multiple sclerosis by means of a 5-day pulse of the humanised anti-CD52 monoclonal antibody, Campath-1H. Clinical and haematological consequences of T-cell depletion, and in-vitro responses of patients' peripheral-blood mononuclear cells were analysed serially for 18 months after treatment.

FINDINGS

Radiological and clinical markers of disease activity were significantly decreased for at least 18 months after treatment. However, a third of patients developed antibodies against the thyrotropin receptor and carbimazole-responsive autoimmune hyperthyroidism. The depleted peripheral lymphocyte pool was reconstituted with cells that had decreased mitogen-induced proliferation and interferon gamma secretion in vitro.

INTERPRETATION

Campath-1H causes the immune response to change from the Th1 phenotype, suppressing multiple sclerosis disease activity, but permitting the generation of antibody-mediated thyroid autoimmunity.

Influence of psychological response on survival in breast cancer: a population-based cohort study

BACKGROUND

The psychological response to breast cancer, such as a fighting spirit or an attitude of helplessness and hopelessness toward the disease, has been suggested as a prognostic factor with an influence on survival. We have investigated the effect of psychological response on disease outcome in a large cohort of women with early-stage breast cancer.

METHODS

578 women with early-stage breast cancer were enrolled in a prospective survival study. Psychological response was measured by the mental adjustment to cancer (MAC) scale, the Courtauld emotional control (CEC) scale, and the hospital anxiety and depression (HAD) scale 4-12 weeks and 12 months after diagnosis. The women were followed up for at least 5 years. Cox's proportional-hazards regression was used to obtain the hazard ratios for the measures of psychological response, with adjustment for known clinical factors associated with survival.

FINDINGS

At 5 years, 395 women were alive and without relapse, 50 were alive with relapse, and 133 had died. There was a significantly increased risk of death from all causes by 5 years in women with a high score on the HAD scale category of depression (hazard ratio 3.59 [95% CI 1.39-9.24]). There was a significantly increased risk of relapse or death at 5 years in women with high scores on the helplessness and hopelessness category of the MAC scale compared with those with a low score in this category (1.55 [1.07-2.25]). There were no significant results found for the category of "fighting spirit".

INTERPRETATION

For 5-year event-free survival a high helplessness/hopelessness score has a moderate but detrimental effect. A high score for depression is linked to a significantly reduced chance of survival; however, this result is based on a small number of patients and should be interpreted with caution.

Mechanism of bone loss after liver transplantation: A histomorphometric analysis

Organ transplantation is associated with increased bone loss and high fracture risk, but the pathophysiological mechanisms responsible have not been established. We have performed a histomorphometric analysis of bone remodeling before and 3 months after liver transplantation in 21 patients (14 male, 7 female) aged 38-68 years with chronic liver disease. Eight-micrometer undecalcified sections of trans-iliac biopsies were assessed using image analysis. Preoperatively, bone turnover was low with a tendency toward reduced wall width and erosion depth. The bone formation rate increased from 0.021 +/- 0.016 (mean +/- SD) to 0.067 +/- 0.055 microm2/microm/day after transplantation (p < 0.0002) and activation frequency from 0.24 +/- 0.21/year-1 to 0.81 +/- 0. 67/year-1 (p < 0.0001). No significant change was observed in wall width, but there was a trend toward an increase in indices of resorption cavity size. There was a small increase in osteoid seam width postoperatively (p< 0.02) and decrease in mineralization lag time (p < 0.001). No significant changes in indices of cancellous bone structure were observed in the postoperative biopsies. These results demonstrate a highly significant and quantitatively large increase in bone turnover in the first 3 months after liver transplantation. Although no significant disruption of cancellous bone structure was demonstrated during the time course of the study, the observed changes in bone remodeling predispose to trabecular penetration and may thus result in long-term adverse effects on bone strength.

Living and working with latex allergies: personal perspectives from a nurse

Living with the limitations of latex sensitivity can be devastating. Even more devastating is when the diagnosis can end a career. For a registered nurse, latex allergy can be a career ender, or it can spur the individual to become increasingly clever in coping with the allergy while maintaining a productive personal and professional life. This article describes the personal struggle an individual registered nurse has overcome to maintain her position in nursing.

A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer

This study compared the effectiveness of two psychological treatments in a group of 57 patients with various types of cancer attending the Royal Marsden Hospital. Patients referred for psychiatric assessment who met criteria for an abnormal adjustment reaction were randomly allocated to either 8 weeks of Adjuvant Psychological Therapy (APT), a problem-focused, cognitive behavioural treatment programme, or 8 weeks of a comparison treatment of supportive counselling. At 8 weeks from the baseline assessment, APT had produced a significantly greater change than the counselling intervention on fighting spirit, helplessness, coping with cancer, anxiety, and self-defined problems. At 4 months from baseline, APT had produced a significantly greater change than counselling on fighting spirit, coping with cancer, anxiety and self defined problems. It is concluded that APT produces greater change in anxiety, adjustment to cancer and use of coping strategies than a non-directive, supportive intervention over an 8 week period of treatment. This difference persists at follow up 4 months after baseline assessment.

Adjuvant psychological therapy for cancer patients

Adjuvant psychological therapy (APT), a brief, problem-focused, cognitive-behavioural treatment for patients with cancer, is described. A previously published randomized trial demonstrated a significant reduction in cancer-related emotional distress. APT is recommended for cancer patients suffering from such distress.

Early increase in plasma parathyroid hormone levels following liver transplantation

BACKGROUND/AIMS

The pathogenesis of post-transplantation bone loss is poorly understood, although glucocorticoid therapy is believed to play an important role. In the present study we have measured plasma parathyroid hormone concentrations in the first few months after orthotopic liver transplantation, in order to examine the potential contribution of hyperparathyroidism to bone disease.

PATIENTS AND METHODS

Twenty-seven patients aged 32-54 years, 12 male, undergoing liver transplantation were studied prospectively before and for 3 months after operation. Plasma parathyroid hormone and serum 25-hydroxyvitamin D concentrations were measured by radioimmunoassay.

RESULTS

Plasma parathyroid hormone levels were normal in all but two patients prior to transplantation. There was a highly significant increase in plasma parathyroid hormone concentrations at 1 and 2 months (p < 0.0005 and 0.001, respectively, versus baseline); by 3 months, values were close to those obtained preoperatively. Serum 25-hydroxyvitamin D concentrations showed no significant change over the study period. However, 74% of the patients had subnormal values at baseline.

CONCLUSIONS

An early and transient increase in plasma parathyroid hormone after liver transplantation may be responsible for the high rates of bone loss which occur during the first few post-operative months. Prevention of post-transplantation bone disease is most likely to be achieved by peri-operative intervention with an anti-resorptive agent.

Viral serology and detection

Viral detection is an important part of clinical hepatology. For many years practical clinical tests have been serological but recently newer molecular techniques have become available for virus detection, although these have yet to become routine and some, such as PCR of viral nucleic acid in blood or tissue are not yet consistently reliable. Serology remains the mainstay at present for routine diagnosis. Hepatitis A testing in clinical practice is entirely serological, the IgM response representing acute infection and the IgG response immunity, although more sophisticated molecular techniques have been applied experimentally. A second agent of epidemic enteral hepatitis, the hepatitis E virus, has recently been cloned and sequenced and serological tests for this virus are available, although experience in their use is necessarily limited and a commercial IgM assay has yet to be produced. Serological tests for the hepatitis B virus are well developed. The IgM anticore response differentiates acute infection from chronic, the latter being characterized by the persistence of hepatitis B surface antigen for over six months. Chronic carriers are at risk of liver damage and this risk is best assessed by the amount of viral DNA circulating, which can be determined using a hybridization assay. More sensitive techniques such as the branched chain DNA assay or PCR can detect lower levels of viral DNA but their clinical relevance remains to be established. The hepatitis D virus is defective and relies on hepatitis B to replicate. Serology for antibody and antigen is well established although PCR for circulating viral genome may come to supplant hepatic viral antigen as a test for hepatitis D replication. For hepatitis C serology is feasible only for antibodies, not antigens; although early tests were prone both to false positives and false negatives, current versions are more reliable. PCR has been much used for detection of hepatitis C RNA in blood and tissues and a bDNA assay is now commercially available. Cytomegalovirus detection is confounded by the problem of distinguishing asymptomatic viral replication from disease. Serology is helpful, especially in primary infections, but viral culture is a widely used method. PCR (especially quantitative modifications) or the pp65 antigenaemia assay are experimental approaches which may prove specific enough for general use.

Five-chlorodeoxycytidine and biomodulators of its metabolism result in fifty to eighty percent cures of advanced EMT-6 tumors when used with fractionated radiation

PURPOSE

To extend our findings in previous radiation and biochemical studies with five rodent tumors, in which we used one and occasionally two or three irradiations. The extent of control of the EMT-6 mammary adenocarcinoma was determined using fractionated radiation (12 irradiations) over a 3-week period using the radiosensitizer 5-chloro-2'-deoxycytidine (CldC) and biomodulators of its metabolism: N-(Phosphonacetyl)-L-aspartate (PALA), tetrahydrouridine and 5-fluoro-2'-deoxycytidine (FdC).

METHODS AND MATERIALS

Mammary adenocarcinoma EMT-6 tumors implanted 1 week prior to therapy in BALB/c mice were subjected to single daily doses of focused radiation, not exceeding a total of 60 Gy, on days 2-5 of each week. N-(Phosphonacetyl)-L-aspartate (PALA) was administered on the first day of therapy. Five-fluoro-2'-deoxycytidine and CldC were administered in the morning and afternoon, respectively, of the next 2 days, and CldC was administered on the fourth day. Tetrahydrouridine was always coadministered with FdC or CldC. Drug and radiation treatments overlapped for 3 weeks.

RESULTS

Fifty to 80% cures (usually 70%) were obtained with no apparent morbidity and the same moderate weight loss that occurs with radiation alone. Neither tumor regrowth delay nor cures were obtained with drugs or radiation alone. An apparent threefold dose increase effect was obtained with the end point: "days to reach 4 times initial tumor volume." Increasing the radiation dose threefold (without drugs) resulted in four out of five deaths; increasing the dose twofold (without drugs) resulted in extensive weight loss and hair loss in the entire ventral area and no cures. Increasing the dose of drugs or radiation 1.5-fold, in the complete protocol, did not result in increased morbidity. Comparative studies with Iododeoxyuridine demonstrate the heightened efficacy of CldC.

CONCLUSIONS

One cannot achieve the same results obtained with CldC and the modulators by merely increasing the dose of radiation. There is a significant window of safety in this approach. The evidence we have obtained with EMT-6, the fifth rodent tumor we have studied with CldC, as well as the demonstrated and proposed reasons for its superior efficacy over 5-Iododeoxyuridine (and 5-Bromodeoxyuridine), drugs in current use, indicate that CldC will allow more aggressive treatment of human tumors with radiation than is now feasible.

Improving quality of life: adjuvant psychological therapy for patients with cancer

The present paper describes a psychological treatment programme--Adjuvant Psychological Therapy (APT)--that has been developed specifically for patients with cancer-related psychosocial disorders. APT is brief (average six sessions), directed at current problems and conducted with individual patients together with their partners or spouses, if possible. Therapy focuses on the personal meaning of cancer to the patient and his or her coping strategies. An outline of APT together with a clinical illustration is given. A randomised trial has demonstrated that APT produces significant improvement in psychological distress and thus in the quality of life of patients with cancer.

The management of denial in cancer patients

Faced with a diagnosis of cancer, many patients react initially with a kind of numbed disbelief that is a form of denial. In the majority of cases, this reaction is subsequently replaced by other coping responses. Some patients, however, continue to use denial. Clinically, it is useful to categorize denial as follows: (1) complete denial, (2) denial of implications of a diagnosis of cancer, (3) denial of affect. Denial, particularly if complete, can have adverse effects in terms of delay in seeking treatment and noncompliance with treatment. But there are also certain advantages. Denial is associated with reduction in psychological distress, and there is preliminary evidence suggesting that it may be associated with prolonged duration of survival in women with nonmetastatic breast cancer. Although there are no hard and fast guidelines for the psychological management of patients who use denial, four possible management scenarios are provided.

Adjuvant psychological therapy for patients with cancer: a prospective randomised trial

OBJECTIVE

To determine the effect of adjuvant psychological therapy on the quality of life of patients with cancer.

DESIGN

Prospective randomised controlled trial comparing the quality of life of patients receiving psychological therapy with that of patients receiving no therapy, measured before therapy, at eight weeks, and at four months of follow up.

SETTING

CRC Psychological Medicine Group of Royal Marsden Hospital.

PATIENTS

174 patients aged 18-74 attending hospital with a confirmed diagnosis of malignant disease, a life expectancy of at least 12 months, or scores on various measures of psychological morbidity above previously defined cut off points.

INTERVENTION

Adjuvant psychological therapy, a brief, problem focused, cognitive-behavioural treatment programme specifically designed for the needs of individual cancer patients.

MAIN OUTCOME MEASURES

Hospital anxiety and depression scale, mental adjustment to cancer scale, Rotterdam symptom checklist, psychosocial adjustment to illness scale.

RESULTS

156 (90%) patients completed the eight week trial; follow up data at four months were obtained for 137 patients (79%). At eight weeks, patients receiving therapy had significantly higher scores than control patients on fighting spirit and significantly lower scores on helplessness, anxious preoccupation, and fatalism; anxiety; psychological symptoms; and on orientation towards health care. These differences indicated improvement in each case. At four months, patients receiving therapy had significantly lower scores than controls on anxiety; psychological symptoms; and psychological distress. Clinically, the proportion of severely anxious patients dropped from 46% at baseline to 20% at eight weeks and 20% at four months in the therapy group and from 48% to 41% and to 43% respectively among controls. The proportion of patients with depression was 40% at baseline, 13% at eight weeks, and 18% at four months in the therapy group and 30%, 29%, and 23% respectively in controls.

CONCLUSIONS

Adjuvant psychological therapy produces significant improvement in various measures of psychological distress among cancer patients. The effect of therapy observed at eight weeks persists in some but not all measures at four month follow up.

5-chlorodeoxycytidine, a radiosensitizer effective against RIF-1 and Lewis lung carcinoma, is also effective against a DMBA-induced mammary adenocarcinoma and the EMT-6 tumor in BALB/c mice

5-Chlorodeoxycytidine (CldC), coadministered with modulators of pyrimidine metabolism, is an effective radiosensitizer of murine tumors. Past studies that utilized RIF-1 tumors in C3H mice and Lewis lung carcinoma (LLC) in BDF1 mice have been extended with an emphasis on using multiple cycles of drug administration followed by irradiation of LLC and the use of two additional tumor models. Four of seven cures of BDF1 mice bearing LLC were obtained with three doses of 20 Gy irradiation, in which the first and third dose were preceded by a "Standard Protocol" that includes N-(phosphonacetyl)-L-aspartic acid (PALA), 5-fluorodeoxycytidine (FdC), tetrahydrouridine, and the radiosensitizer, 5-chlorodeoxycytidine. No cures were obtained in groups of mice receiving radiation alone or drugs alone, and there were no "no takes" in untreated control groups (six mice/group). Extensive tumor inhibition, exceeding that obtained with drugs or radiation alone, was obtained with two cycles of drugs and radiation combined when a dimethybenzanthracene-induced mammary adenocarcinoma was used in BALB/c mice. With the EMT-6 tumor in BALB/c mice, doses of 10 and 20 Gy were administered 9 and 16 days after tumor implantation, each preceded with the Standard Protocol; this resulted in a tumor growth delay of 24 days. No tumor growth delay occurred with drugs or radiation alone. The omission of PALA, FdC or CldC from the Standard Protocol resulted in loss of tumor control, which was obtained with the complete protocol. The fact that 5-chlorodeoxycytidine is an effective radiosensitizer in four rodent tumor systems is compelling evidence that it has potential as a radiosensitizer of human tumors, especially in view of its tumor selectivity and its resistance to catabolism when used with modulators of its metabolism, and in view of the high levels of the key enzymes in human tumors, which can convert 5-chlorodeoxycytidine to 5-chlorodeoxyuridine triphosphate, the proximate radiosensitizer.

Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients

The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked.

The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer

An exploratory factor analysis of the HAD was carried out in 568 cancer patients. Two distinct, but correlated, factors emerged which corresponded to the questionnaire's anxiety and depression subscales. The factor structure proved stable when subsamples of the total sample were investigated. The internal consistency of the two subscales was also high. These results provide support for the use of the separate subscales of the HAD in studies of emotional disturbance in cancer patients.

Psychological response to cancer and survival

The hypothesis is advanced that the psychological stance which patients adopt in response to cancer can, in some cases, influence the course of their disease. This hypothesis is examined in the light of the author's 15-year follow-up study of women with early breast cancer and of other pertinent studies. The available evidence supports the hypothesis in respect of certain early-stage non-metastatic cancers.

Improved carrier detection of haemophilia A using novel RFLPs at the DXS115 (767) locus

Two novel restriction fragment length polymorphisms (RFLPs) around the DXS115 (767) locus, detectable with the restriction enzymes MspI, are described. Since DXS115 is closely linked to the factor VIII gene (F8C), the MspI RFLP was employed in haemophilia A carrier detection. The utility of these RFLPs lies in the increased applicability and accuracy of diagnoses carried out in cases where available intragenic markers are uninformative.

Some consequences of market forces in US hospitals: lessons for the new look NHS

"We write", say Ann Greer and Scott Greer, "with the thought that an idea should not travel unencumbered by the experience of its implementation". They survey the arguments for a market in health care, describe the impact of competitive health policies in the USA and conclude that none of the expected benefits of the market have materialised.

Locus of control and adjustment to cancer

The English form of the Cancer Locus of Control Scale was administered to an heterogeneous sample of 68 cancer patients. A principal components analysis confirmed the three subscales described in the original Dutch form, however, with five items excluded. Correlations with other measures indicated that high internal control over the course of the illness was associated with a tendency to adopt an attitude toward cancer of 'fighting spirit' whereas high internal control over the cause of the illness was associated with an 'anxious preoccupation' about cancer. No specific relationship was found between scale scores and either depression and anxiety or the tendency to be emotionally controlled. It was concluded that the scale provides a valid measure of perceptions of control of cancer patients and is a useful method of assessing these important psychological responses.

The Denver Developmental Screening Test: how good is its predictive validity?

Five studies assessing the predictive validity of the Denver Developmental Screening Test (DDST) were evaluated and the results were pooled. Only one study demonstrated good compliance with the authors' methodological standards, but the results were similar to the over-all pooled results. The pooled data indicated that for children over three years of age: (1) the DDST is specific (94 per cent of the children with a good outcome were categorized as normal); (2) the DDST is not sensitive (it did not identify 80 per cent of the children who later had a poor outcome); and (3) a child with a poor outcome was 14 times more likely to have an abnormal or questionable DDST result than a normal one. These data suggest that a child with an abnormal DDST is likely to have a poor school outcome and that many children with school-related problems who might benefit from early intervention are not identified by the DDST.

Wernicke's encephalopathy in an 18-year-old woman

An unusually young woman (18 years old) who misused alcohol and developed Wernicke's encephalopathy is described.