Is it helpful to give older people with cancer the same chance at rehabilitation as older general medical patients?

UNLABELLED: Although the complexity of age combined with a cancer diagnosis can result in unmet supportive care needs there are seldom resources to assess or address such needs for older people with cancer (OPWC). The purpose of this project was to trial a service to improve the care for OPWC through (1) an expanded supportive care screening process and (2) capacity building of subacute ambulatory care services (SACS) staff to increase referrals to community-based rehabilitation. METHODS/DESIGN: Collaboration between allied health (AH) staff at an inner city general hospital with a large cancer service, a cancer specialist hospital, and a SACS service in Melbourne, Australia, developed an AH geriatric screening assessment (GSA) tool. Parallel to this process training was provided to SACS staff in relation to working with OPWC. Although close to one half (44%) of SACS staff who participated in this program (n = 22) had over 6 years' experience, 32% had not worked with OPWC. Prior to training, 81% did not feel confident in their knowledge about working with this cohort. After their training 72% were more confident about normal aging and implications for care of OPWC. Of the 491 patients screened, 80% were older than age 65, however, only 25 resided in the SACS catchment area. More than one third of these did not have clear rehabilitation needs, and the remainder were not referred due to ongoing medical issues. Less than one half of the patients in the catchment area were discussed in a Multi-disciplinary Meeting (MDM) but all were referred to allied health and assessed using the GSA. Although this project did not result in referrals of OPWC to SACS the training program for SACS staff was a success and allied health assessments were improved to include GSA factors. The complexity of care for OPWC was further highlighted through interviews with staff involved with the study.

Early vitamin E supplementation attenuates diabetes-associated vascular dysfunction and the rise in protein kinase C-beta in mesenteric artery and ameliorates wall stiffness in femoral artery of Wistar rats.

AIMS/HYPOTHESIS: The impact of early vitamin E supplementation on vascular function in diabetes remains unresolved. Therefore, we examined the effects of vitamin E on functional and structural parameters and on chemical markers that are disturbed in diabetes in mesenteric and femoral arteries. METHODS: Segments of both arteries, taken from control and 8-week-old streptozotocin diabetic Wistar rats that were treated or not with vitamin E, were mounted on wire and pressure myographs, after which endothelium-dependent and -independent vasodilation was assessed. Passive mechanical wall properties and the localisation and levels of protein kinase C (PKC)-beta(2) and AGE were evaluated in these vessels. RESULTS: Vitamin E supplementation was associated with improved endothelium-dependent and -independent vasodilatation in mesenteric arteries from diabetic rats. Impaired endothelium-dependent vasodilatation in diabetic mesenteric vessels was associated with PKC-beta(2) up-regulation and this was prevented by vitamin E supplementation. Increased AGE accumulation and plasma isoprostane levels in diabetic rats were not changed by vitamin E. In the femoral artery, vitamin E supplementation had no effect on endothelium-dependent or -independent vasodilatation, but did prevent the wall stiffening associated with diabetes. CONCLUSIONS/INTERPRETATION: Early vitamin E supplementation has a beneficial effect on diabetes-induced endothelial dysfunction in resistance arteries. This benefit may arise from a direct effect on smooth muscle function, as a result of inhibition of the PKC-beta(2) isoform by vitamin E.

Comparison of effects of diabetes mellitus on an EDHF-dependent and an EDHF-independent artery.

The hypothesis tested in this study is that diabetes has a different impact on an artery in which endothelium-dependent responses derive from both nitric oxide (NO) and endothelium-derived hyperpolarizing factor (EDHF) compared with responses in which NO predominates and EDHF is absent. The streptozotocin-treated rat model of diabetes was used, and the arteries were mounted on a wire myograph. In mesenteric arteries depolarized and constricted with phenylephrine, acetylcholine evoked hyperpolarization (31 +/- 2 mV) and complete relaxation; these responses were attributed to EDHF and NO. In femoral arteries, acetylcholine evoked a small, NO-mediated hyperpolarization (5 +/- 1 mV) and incomplete relaxation. Bradykinin evoked NO-dependent responses in mesenteric arteries. Whereas diabetes significantly impaired the EDHF-dependent hyperpolarization and relaxation in mesenteric arteries, NO-dependent responses in femoral and mesenteric arteries were preserved. 1-Ethyl-2-benzimidazolinone evoked hyperpolarization and relaxation in mesenteric arteries, and this was impaired in diabetes. In conclusion, NO-dependent responses are preserved in diabetes, whereas endothelial responses-dependent upon EDHF appear to be impaired. The putative channels responsible for mediating the EDHF response may be altered in diabetes.

Mental health. Doing the hurdles.

A survey of senior mental health managers in London found that less than half thought they would stay in their job more than a year. The resulting turnover could create significant instability. Respondents considered the development of community mental health teams as the top priority for implementation. Financial restrictions were seen as the major obstacle to service development. Most respondents welcomed the national service framework for mental health.

Cushing's syndrome secondary to ectopic ACTH secretion from metastatic breast carcinoma.

Breast carcinoma is a rare cause of ectopic ACTH syndrome. There are only two previously reported cases in which ACTH secretion is documented. We describe the case of a 56-year-old woman who presented with clinical and biochemical features of ectopic ACTH syndrome in the setting of metastatic breast carcinoma. Despite aggressive management of her ectopic ACTH syndrome, her course was complicated by opportunistic infection, respiratory failure and death. Immunostaining of the breast metastases for ACTH was positive and in situ hybridization revealed proopiomelanocortin gene expression. This is the first reported case of ectopic ACTH syndrome associated with metastatic breast cancer in which the technique of in situ hybridization has been used to confirm the breast cancer metastases as the source of ectopic ACTH secretion.

Thyroxine abuse: an unusual case of thyrotoxicosis in pregnancy.

Eating disorders and the associated behavioural problems and drug abuse are uncommon in pregnancy. When they do occur they are often unrecognized because of denial but when significant may pose a risk to both the mother and her fetus. This case illustrates a number of problems that may be encountered in women with eating disorders in pregnancy, including prolonged and recurrent metabolic disturbances and diuretic abuse. In particular it illustrates the derangements of thyroid function seen in pregnant women with eating disorders and reminds us that when a cause for thyrotoxicosis remains obscure, thyroxine abuse should be considered and explored.