Informal carers of cancer patients: what are their unmet psychosocial needs?

This paper considers the significant unmet psychosocial needs of the informal carers of cancer patients, drawing on data generated in a 3-year UK study (1997-2000) on the psychosocial needs of cancer patients and their main carers. While the needs of the carers of cancer patients are increasingly being recognised in healthcare policy documents, there is relatively little published literature on these needs. A "significant unmet need" is defined here as a need deemed important by the carer, but which has not been met. A descriptive cross-sectional survey of carers was conducted and the responses of 195 carers relating to 48 psychosocial need items were analysed. A subset of these carers (n = 32) were interviewed. Forty-three per cent of carers had significant unmet needs. They were more likely to be those where the relationship to the patient was not that of a partner or spouse, more likely to have other caring responsibilities, and less likely to have friends or relations to call upon for help. Carers with unmet needs were also more likely to be in poor health themselves or to be caring for a patient who had reached the palliation-only phase in their cancer journey. The majority of carers expressed the importance of needs such as having good relationships with healthcare professionals and receiving honest information, but few expressed dissatisfaction with these aspects of need. Items of significant unmet need clustered around aspects of managing daily life, emotions, and also social identity for a sizeable minority of carers. These are the same areas of significant unmet need that concern patients. However, carers have more of these concerns, reflecting their comparative neglect. The paper also considers how these widespread concerns can be addressed.

The significant unmet needs of cancer patients: probing psychosocial concerns

'Significant unmet needs' are those needs that patients identify as both important and unsatisfied. In this article we ask whether the overall needs of cancer patients are actually being met. We believe that the range of unmet need, and the kinds of patients who are more likely to claim unmet need, should be carefully identified. The needs responses of a series of 295 cancer patients in a cross-sectional survey were analysed. The majority expressed the opinion that information and good relationships with health care professionals were important, and few expressed dissatisfaction with these aspects of need. Similarly, needs items about support from family and friends were largely rated as important and satisfied. For a sizeable minority of patients, items of significant unmet need cluster around aspects of managing daily life, emotions, and social identity. The distribution of significant unmet needs is not random but is more likely to be experienced by patients who are younger, have a long-standing illness or disability, do not own/have use of a car, and/or have no religious faith. Furthermore, significant unmet needs relate to patients' ability to talk freely to a carer about the cancer, the degree to which the cancer interferes with social activities, and whether financial difficulties are experienced. Most of the significant unmet need is beyond the remit of services primarily designed for the treatment of disease. We consider whether multidisciplinary cancer teams can be expected to deal with all aspects of the cancer experience.

A study of occlusal variation in the primary dentition of Australian twins and singletons

In this study, we quantified the extent of variation in different occlusal features of Australian children of European descent with complete primary dentitions, but no permanent teeth present in the mouth. The study group consisted of 412 individuals, aged between 3 and 7 years, including 70 monozygous (MZ) twin pairs, 68 same-sexed dizygous (DZ) twin pairs, 11 opposite-sexed DZ twin pairs, and 114 singletons. Occlusal traits, including inter-dental spacing, incisal overbite and overjet, arch breadth and arch depth, were obtained directly from dental casts or indirectly from photocopies or impressions of the casts. Descriptive statistics summarised the data and indicated that distributions were similar to those published for other populations. Univariate genetic analysis, using the structural equation modelling package Mx, was carried out on the quantitative data using the normal assumptions of the twin model. Genetic modelling indicated that a model incorporating additive genetic (A) and unique environmental variation (E) was the most parsimonious for interdental spacing, overbite, overjet and arch dimensions. Estimates of heritability for interdental spacing ranged from 0.62 to 0.81. Estimates for overbite and overjet were 0.53 and 0.28, respectively, and estimates for arch dimensions ranged from 0.69 to 0.89. These results indicated a moderate to relatively high genetic contribution to observed variation.

Radio-prevention of micrometastases

In developed countries, the cancer incidence is about 150,000 cases per year and half of people with cancer may die from the extension of the primary tumour in secondary deposits. This disaster costs more than 2 billion euro per year. People with cancer are often treated with surgery and/or radiotherapy of localized primary tumour and chemo-prevention of occult disseminated micrometastases. Since chemotherapy essentially targets cycling tumour cells, quiescent micrometastases which may contain only one cell may escape. We previously reported that human melanoma clones with high metastatic potential and low gangliosides content appeared very radiosensitive to low-dose ionizing radiation both in culture and in immunosuppressed animals. This exquisite radiosensitivity was observed with the highly metastatic single cells which were resting at the time of irradiation. These data are consistent with the dose-response relationship for the radiotherapy of secondary deposits which appears linear with no threshold. Highly metastatic cells at an early stage of growth also appear very sensitive to chemicals and activated immune cells. We propose the medical hypothesis according to which the spread of resting micrometastases should be prevented by a single fraction of total-body irradiation delivered at a dose sufficiently low (below 0.2 Gy) to avoid normal tissue radiotoxicity. Radio-prevention may complement standard treatments for patients with metastases and may be delivered even for patients in whom no distant metastases were detected on tumour diagnosis (M0 stage).

The prevalence of mental illness in prison

Over the last decade state prisons have experienced unprecedented growth and many demographic changes. At the same time, courts are requiring states to provide mental health screening and treatment to prisoners. Findings from recent studies indicate that the prevalence of mental illness is higher in prisons than in the community, and comorbidity is common. Our ability to generalize from these studies is limited, however, because of major shifts in the demographic mix in prisons during the past decade. New studies on the prevalence of mental illness in prisons, which consider these recent changes would help planners allocate funds and staff to more effectively meet the needs of these individuals.

Mutations in the sterol-sensing domain of Patched suggest a role for vesicular trafficking in Smoothened regulation

The tumor suppressor gene patched (ptc) encodes an approximately 140 kDa polytopic transmembrane protein [1-3] [corrected] that binds members of the Hedgehog (Hh) family of signaling proteins [4-6] [corrected] and regulates the activity of Smoothened (Smo), a G protein-coupled receptor-like protein essential for Hh signal transduction [7-9] [corrected]. Ptc contains a sterol-sensing domain (SSD) [10, 11] [corrected], a motif found in proteins implicated in the intracellular trafficking of cholesterol [12] [corrected], and/or other cargoes [13-15] [corrected]. Cholesterol plays a critical role in Hedgehog (Hh) signaling by facilitating the regulated secretion and sequestration of the Hh protein [16] [corrected], to which it is covalently coupled. In addition, cholesterol synthesis inhibitors block the ability of cells to respond to Hh [18, 19] [corrected], and this finding points to an additional requirement for the lipid in regulating downstream components of the Hh signaling pathway. Although the SSD of Ptc has been linked to both the sequestration of, and the cellular response to Hh [16, 20, 21] [corrected], definitive evidence for its function has so far been lacking. Here we describe the identification and characterization of two missense mutations in the SSD of Drosophila Ptc; strikingly, while both mutations abolish Smo repression, neither affects the ability of Ptc to interact with Hh. We speculate that Ptc may control Smo activity by regulating an intracellular trafficking process dependent upon the integrity of the SSD.

Effect of intravenous platelet-activating factor on bovine pulmonary mast cells

The effect of platelet-activating factor (PAF) on bovine pulmonary mast cells (MCs) was investigated in calves aged 1-4 months. PAF was administered over a 5-min period at a rate of 50 ng/kg/min to six animals, which were killed approximately 10 min later. No macroscopical lesions were observed in the lung tissue of five control calves. On semi-thin toluidine-blue stained sections, MC cytoplasm showed profuse deep-blue granulation. In the lung tissues of PAF-treated calves, striking interstitial, alveolar and interlobular oedema and emphysema were observed. MC granules occurred at the periphery of the cytoplasm and MC nuclei were easily detectable. Moreover, the number of granules in the MC cytoplasm was remarkably low. A few granules with some metachromatic material were sometimes detected outside the cell limits. Ultrastructurally, the matrix pattern of the MC granules in lung tissues of control calves was either amorphous or granular. In lung tissues of the PAF-treated calves, the granular matrix pattern was pronounced, varying from fine- to coarse-grained, and the MCs were of reduced size, with many filiform processes and exocytotic vesicles. These findings indicate that pulmonary MC degranulation was induced by PAF in healthy calves.

Craniofacial surgery in Oman: a preliminary study of 10 cases

Craniofacial surgery requires a highly specialized surgical team, appropriate precision delicate instruments, dedicated anesthetist, and upgraded intensive care unit facilities. This type of surgery is undertaken in a large number of congenital problems such as encephalocele, craniosynostosis, hypertelorism, tumors of the craniofacial region, and for craniofacial injuries. We present our experience with craniofacial surgery in 10 patients during a 15-month period at Khoula Hospital, Muscat, Sultanate of Oman. These operations were the first of this kind to be done in this part of the world. This article highlights the need for developing craniofacial units in the Gulf region.

Glioblastoma-related gene mutations and over-expression of functional epidermal growth factor receptors in SKMG-3 glioma cells

Amplification of the epidermal growth factor receptor (EGFR) gene is found in about 40% of glioblastomas (GBMs) but is rarely detected in GBM cell lines. We confirmed that the exceptional SKMG-3 GBM cell line retained amplified EGFR genes in vitro, and found that these sequences were concentrated on extra-chromosomal DNA particles similar to double-minute chromosomes. The cells contained two other gene mutations that are associated with high-grade astrocytic tumors: extra-chromosomal amplification of the cyclin-dependent kinase-4 (CDK4) gene and a homozygous mutation within the PTEN tumor suppressor gene. Immunoblots revealed very high levels of EGFR, moderately increased expression of CDK4, and no detectable PTEN protein. The overexpressed SKMG-3 EGFRs responded to exogenous ligand and resembled normal rather than mutant receptors. A heterozygous mutation of the p53 gene (p53R282W) correlated with failure of radiation to induce the expression of cyclin-dependent kinase inhibitor p21waf1 or an early G1 cell cycle arrest. Although each of these gene mutations occurs in GBMs, SKMG-3 cells had an unusual genotype in that a p53 gene mutation co-existed with amplified EGFR genes. Nonetheless, the SKMG-3 cell line can be exploited as a model to study how oncogenic EGFR signals in GBM cells interact with over-expressed CDK4 and loss of PTEN to confer the malignant phenotype.

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

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

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

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

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

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

Minimizing discomfort with surface neuromuscular stimulation

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

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

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

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

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

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

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

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

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