Respite care innovations for carers of people with dementia

The importance of family carers to making a reality of community care policy is now widely recognized. The central role of carers was recently confirmed by the launch of 'The Carers' National Strategy' (Department of Health (DoH), 1999). In his foreword to this document, the Prime Minister, Tony Blair, acknowledged carers as the 'unsung' heros of British life' and pledged to raise the level and quality of the support that carers receive. Although the primary responsibility for meeting carers' needs still rests with local authorities the strategy charges everyone involved in the caring services with paying greater attention to supporting family members. In allocating monies to move the strategy forward the Government identified the provision of short breaks as one of the major priorities. This article describes the development of an innovative service for people with dementia and their carers in Sheffield. The service evolved following a research study on the views of carers and of people with dementia which identified the need for the provision of short breaks which were flexible, responsive and person-centred.     

The pulmonary neuroendocrine system and drainage of the fetal lung: effects of serotonin

The neuroendocrine system of the lungs is maximally developed and activated at birth, but has no clear function. Here, one of its products, serotonin, was tested for an ability to stop lung fluid production or activate reabsorption. Lungs from fetal guinea pigs (61 +/- 2 days of gestation) were supported in vitro for 3 h; lung liquid production was monitored by a dye dilution method. Initial studies on 36 young fetuses (61 +/- 1 days of gestation) showed that untreated controls produced fluid at 1.17 +/- 0.23 ml.kg-1.h-1, with no significant change over 3 h (ANOVA; regression analysis); those given 10(-8) M serotonin during the middle hour showed no significant changes, but those given 5 x 10(-8), 10(-7), 10(-6), or 10(-5) M serotonin reduced production significantly (P < 0.01 to P < 0.0005). Responses were linear up to 10(-7) M (threshold, 10(-9) M) and then become maximal at 50% reduction. However, responses increased with age. Comparison of 40 fetuses divided into groups of 60-61 or 65-67 days of gestation showed a large and significant increase in responses in the older fetuses (P < 0.01), where half the preparations reabsorbed fluid. Serotonin receptors were involved, since 10(-6) M cyproheptadine abolished responses (based on 24 preparations). Amiloride-sensitive Na+ channels were involved, since 10(-6) M amiloride abolished responses (based on 24 preparations). These results, in combination with earlier results from somatostatin and dopamine, together with histochemical and clinical observations, strongly suggest that the neuroendocrine system of the lungs may find a function in clearing fluid from the lungs at time of birth.     

Role of the IGF axis in prostate cancer

The major issue currently being faced in the management of prostate cancer is the inability to distinguish between indolent prostate tumors that will not present clinically from more aggressive and metastatic prostate cancers that will impact on men's lives. Only a small proportion of prostate cancers can be accounted for by unmistakable hereditary cancer syndromes and the predominant contribution to the progression of most sporadic cancers is thought to be environmental, with nutrition having the greatest influence. Population studies have clearly implicated metabolic factors as contributors to disease progression and poor response to therapy. It is well established that the IGF system is key in regulating growth and metabolism and mediates the effects of nutrition on these processes. It consists of two ligands (IGF-I and IGF-II), two receptors [type 1 IGF-IR and IGF-II/mannose 6-phosphate receptor], and six high affinity IGF-binding proteins (IGFBP-1 to -6). This review provides evidence from in vitro, in vivo, clinical and epidemiology studies that indicates an important role for the IGF axis in the development of prostate cancer and the likely role that it plays in mediating the effects of nutrition on disease progression. We suggest that the IGF axis is central to understanding how lifestyle impacts on prostate cancer and we highlight this by describing numerous strategies being developed to target this axis.     

Finger injuries to children involving exercise bicycles

OBJECTIVE: A previously unreported source of injuries to children, the exercise bicycle, is identified and the associated injuries and their treatment are described. DESIGN: A retrospective review of clinical records and the records of the Victorian Injury Surveillance System. SETTING: The Plastic Surgery Unit of the Royal Children's Hospital, Parkville, Victoria. PATIENTS: Seventeen children with finger injuries from exercise bicycles presented to the Emergency Department of the hospital and one presented to one of us (K L M) at his private practice. Sixteen of the 18 children were under five years of age; 10 were less than two years of age. Five times as many boys as girls were injured. INTERVENTIONS: Fourteen children required surgical treatment of their injuries. RESULTS: Four children had superficial injuries not in need of surgical repair. Eleven children had single digit injuries--five had injuries that were repaired by suture; five had complete avulsion of the tip of the digit that required flap graft repair; and one child underwent amputation of the index finger. Three boys had multiple digit injuries, each one requiring the amputation of a digit and repair of other digits. Two of these boys underwent replantation of a digit; only one replantation was successful. CONCLUSIONS: The most dangerous parts of the exercise bike were the wheel, the chain and the sprocketwheel. Design modifications and education of parents about the risks for children playing near exercise bikes are warranted.     

Changes in position and volume of lung cancer target volumes during stereotactic body radiotherapy (SBRT): is image guidance necessary?

The purpose of this study was to analyze inter- and intra-fractional changes in tumor volume with respect to both spatial and volumetric parameters among patients treated by SBRT for lung cancer. Twelve patients (13 tumors) were treated by SBRT with abdominal compression in 3-5 fractions over a 2 week period to a median dose of 60 Gy (range, 48 to 60 Gy). Kilovoltage cone-beam CT (CBCT) was obtained prior to the delivery of each fraction as well as intra-fractionally yielding a total of 55 CBCT scans. All CBCT scans were registered with the planning CT for target alignment and shifts were recorded and analyzed. Retrospectively, gross tumor volume (GTV) was contoured on all CBCT images and compared to initial planning volumes; positional differences were evaluated utilizing directional and vector analysis. Shifts greater than 5 mm were applied inter-fractionally in 6.8% (lateral), 29.5% (longitudinal), and 6.8% (vertical) of all delivered treatments. Using a 10 mm threshold, the corresponding percentages were 2.3%, 13.6%, and 2.3%, respectively. Across all fractions, the calculated inter-fractional shift vectors ranged from 0 to 31.2 mm, with 40.9%, 15.9%, and 11.4% of all fractions having shift vectors≥5 mm, ≥10 mm, and ≥20 mm, respectively. Intra-fractional shifts were also evaluated and found negligible in a small portion of patients evaluated. The mean overall reduction in GTV was 21.1% during SBRT. Significant changes in both position and volume occur during SBRT for lung cancer. Shifts (particularly in the superior-inferior axis) may exceed applied margins and compromise target coverage. Due to the extreme hypofractionation associated with SBRT, inter-fractional image guidance is necessary.     

Endoscopic assisted harvest of the pedicled pectoralis major muscle flap.

The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring.