Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

Genetic transformation in Lactobacillus sp. strain 100-33 of the capacity to colonize the nonsecreting gastric epithelium in mice

Lactobacillus isolates able to colonize the surfaces of the nonsecreting epithelia in the stomachs of monoassociated ex-germfree mice were derived from Lactobacillus acidophilus 100-33. Strain 100-33 was originally isolated from pig feces and is unable to colonize the murine gastric epithelium. In experiments involving attempts genetically to transform the capacity to colonize the epithelium, cells of strain 100-33 were treated with muralytic enzymes and mixed with polyethylene glycol and genomic or plasmid DNA extracted from Lactobacillus fermentum RI. Strain RI was originally isolated from a conventional mouse and has the capacity to colonize the nonsecreting gastric epithelium. The mixtures containing cells, polyethylene glycol, and DNA were plated on a regeneration medium. After overnight incubation, the cells were washed from the plates and introduced by gastric gavage into germfree mice. Only mice that received regenerated 100-33 cells previously mixed with genomic DNA from strain RI had layers of gram-positive bacteria on the keratinized epithelia of their stomachs. Six isolates cultured from the washed gastric tissues of these animals were characterized. When a culture of each or a pool of cultures of the six were orally administered to germfree mice, layers of gram-positive bacterial cells were visible on the keratinized gastric epithelia of the animals within 1 to 3 weeks. Cells of all six, but not of strain 100-33, reacted with antibody made in rabbits to L. fermentum RI cells, as determined by an enzyme-linked immunosorbent assay. Nevertheless, all six had fermentation profiles identical to that of strain 100-33.(ABSTRACT TRUNCATED AT 250 WORDS)     

Induction of anti-CD8 resistant cytotoxic T lymphocytes by anti-CD8 antibodies. Functional evidence for T cell signaling induced by multi-valent cross-linking of CD8 on precursor cells

The effector function of most MHC class I allospecific CTL is inhibited by anti-CD8 mAb. In the present study, we report the surprising observation that multi-valent cross-linking of CD8 molecules on precursor cells by specific antibody actively induces the generation of CD8+ class I allospecific CTL whose lytic function is resistant to anti-CD8 antibody inhibition, and actively induces down-modulation of cell surface CD8 expression on these cells. In marked contrast, bi-valent cross-linking of CD8 inhibits the generation of CD8+ CTL from precursor cells and fails to induce down-modulation of cell surface CD8 expression. These results demonstrate that CD8 can transduce net positive signals, but only when the molecule is extensively cross-linked.     

Bone graft survival in expanded skin

The effect of tissue expansion on iliac bone graft (onlay) survival was studied on the skulls of 35 New Zealand white rabbits. Wet bone weights at the time of grafting and at sacrifice in control animals (group I) were compared to three experimental groups. Histologic sections of the developing and resolving pseudosheath and skin envelope were performed. A self-inflating 5-mil-thick silicone expander was used for soft-tissue expansion over the rabbit snout. Bone grafts were subsequently placed in this site. Elliptical snout excision without expansion (group II) demonstrated no statistically significant difference in bone graft survival when compared to controls (group I) (p = 0.350). Full tissue expansion followed by immediate bone grafting (group III) within the pseudosheath cavity likewise demonstrated no statistically significant difference in bone graft survival when compared to controls (group I) (p = 0.500); however, when full tissue expansion was followed by delayed (2 weeks) bone grafting to allow for resolution of the giant cell inflammatory reaction of the pseudosheath (group IV), a statistically significant increased bone graft survival was achieved (p less than 0.001). The study demonstrates that the increased vascularity in the pseudosheath and in the expanded soft-tissue envelope significantly increased bone graft survival only when bone grafting was delayed.     

Nonequivalent effects of PKC activation by PMA on murine CD4 and CD8 cell-surface expression

The membrane glycoproteins CD4 (L3T4) and CD8 (Lyt2) are expressed on distinct populations of mature murine T lymphocytes, and are thought to be receptors for monomorphic determinants expressed on MHC class II and class I molecules, respectively. Although they differ in their ligand specificity, it has been presumed that CD4 and CD8 perform equivalent functions in the T cells that bear them. Since activation of protein kinase C (PKC) is known to cause rapid down-regulation of various receptors, including the T cell receptor complex (TcR complex), we treated cells with phorbol 12-myristate 13-acetate (PMA), a PKC activator, to determine whether cell-surface expression of CD4 and CD8 would be similarly affected by this intracellular mediator. Brief or relatively prolonged treatment with PMA induced mature murine T cells to reduce their surface expression of the TcR complex and of CD4, but not of CD8. Similarly, PMA rapidly induced transfected L cells to down-regulate surface CD4 expression, but had no effect on surface CD8 expression. Most significantly, PMA treatment induced CD4+CD8+ immature thymocytes to rapidly reduce their surface CD4 expression, but, again, it had no immediate effect on the surface expression of CD8. These results indicate that CD4 and TcR complex cell-surface expression are both sensitive to PKC activation by brief treatment with PMA, whereas CD8 expression is not, and suggest that CD4 and CD8 surface expression levels are regulated by distinct intracellular mechanisms.     

Studies on the immediate and delayed leucocytosis elicited by brief (30-min) strenuous exercise

Eight healthy male volunteers exercised for two 30-min sessions starting 3 h apart on an electronically braked cycle ergometer at a work load (mean 155.9 W, SD 33.4 W) which required an oxygen consumption that was 70% of their maximal rate of oxygen uptake. Venous blood samples were taken through an indwelling cannula over a period of 6 h beginning shortly before the first bout of exercise and were analysed for routine haematological parameters and for lactate, noradrenaline, adrenaline and cortisol. Both bouts of exercise induced an immediate leucocytosis due to rises in lymphocytes and neutrophils but only the first exercise bout induced a substantial delayed neutrophilia. In at least five subjects, changes in lymphocyte and platelet numbers were correlated (Spearman's rank procedure, P less than 0.05) with simultaneous changes in the plasma concentrations of lactate, noradrenaline and adrenaline over the 6-h period studied. Increases in the plasma concentration of cortisol due to exercise correlated positively with the percentage changes in neutrophil numbers at 3 h and 6 h. These results are consistent with the suggestion that the immediate and delayed leucocytosis induced by exercise are mediated respectively by catecholamine and by cortisol.     

A review of the molecular basis of hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency

Hypoxanthine-guanine phosphoribosyltransferase (HPRT, EC 2.4.2.8) is a purine salvage enzyme that catalyses the conversion of hypoxanthine and guanine to their respective mononucleotides. Partial deficiency of this enzyme can result in the overproduction of uric acid leading to a severe form of gout, whilst a virtual absence of HPRT activity causes the Lesch-Nyhan syndrome which is characterised by hyperuricaemia, mental retardation, choreoathetosis and compulsive self-mutilation. The HPRT-encoding gene is located on the X chromosome in the region q₂₆–q₂₇ and consists of nine exons and eight introns totalling 57 kb. This gene is transcribed to produce an mRNA of 1.6 kb, which contains a protein encoding region of 654 nucleotides. With the advent of increasingly refined techniques of molecular biology, it has been possible to study the HPRT gene of individuals with a deficiency in HPRT activity to determine the genetic basis of the enzyme deficiency. Many different mutations throughout the coding region have been described, but in the absence of precise information on the three-dimensional structure of the HPRT protein, it remains difficult to determine any consistent correlation between the structure and function of the enzyme.     

Group size and stability: Why do gibbons and spider monkeys differ?

Gibbons and spider monkeys have similar diets, body size, and locomotor patterns. They are therefore expected to be subject to similar socioecological rules. However their grouping patterns differ. Gibbons live in small stable groups, whereas spider monkey form unstable sub-groups that vary from small to large during different seasons. If similar principles apply to the two species, food abundance should vary more for spider monkeys than for gibbons; food density should be similar for the two species when spider monkey sub-groups are the same size as gibbon groups; and the highest level of food abundance should be higher for spider monkeys than for gibbons. These predictions are upheld for a comparison of particular populations ofHylobates muelleri andAteles geoffroyi.