Cancer treatment decisions for people living with dementia: Experiences of family carers, a qualitative interview study.

BACKGROUND: As the UK population ages, the prevalence of both dementia and cancer will increase. Family carers of people with dementia who are subsequently diagnosed with cancer are often involved in treatment decisions about cancer. These decisions are uniquely challenging. OBJECTIVES: To explore the experience of carers involved in cancer treatment decisions for people with dementia. DESIGN: A cross-sectional qualitative interview study with inductive thematic analysis. SETTING AND PARTICIPANTS: Sixteen carers of people with dementia were identified via Primary Care Research Networks and the Join Dementia Research database. RESULTS: Three main themes were derived: 'already at breaking point', which describes the extreme strain that carers were already under when the cancer diagnosis was made; 'maintaining the status quo', which describes how despite the gravity of a cancer diagnosis, avoiding further dementia-related deterioration was of prime importance; and 'LPA', which explores the benefits and frustrations of the use of lasting powers of attorney. DISCUSSION: Current services are ill-equipped to deal with people who have a combination of dementia and cancer. Proxy decisions about cancer care are made in the context of carer stress and exhaustion, which is exacerbated by shortcomings in service provision. CONCLUSIONS: As the prevalence of comorbid cancer and dementia rises, there is an urgent need to improve services that support carers with proxy health care decision-making. PATIENT OR PUBLIC CONTRIBUTION: The study design was codeveloped with a local dementia-specific patient and public involvement (PPI) group. A project-specific PPI group was formed with support from the Alzheimer's Society Research Partnership scheme to provide further bespoke input.

Mast Cell Concentrations in Pancreatic Disease Processes.

Mast cells enumeration has been performed using various histologic staining techniques with the goal of elucidating the influence mast cells exert on pathologic processes. In this study, 77 human pancreatic tissues evidencing morphologically normal pancreas, benign fibrotic changes, endocrine tumors, and adenocarcinoma were evaluated using Wright stain and immunohistochemistry markers for tryptase and CD117. Mast cell counts were similar with tryptase and CD117 but were both significantly higher than counts obtained with the Wright stain. Furthermore, all analyses demonstrated that endocrine tumors and morphologically normal pancreatic tissues had significantly lower mast cell counts as compared with benign fibrosis and adenocarcinoma suggesting that the highly fibrotic nature of both pancreatitis and adenocarcinoma are related to increased mast cell concentrations.

Understanding barriers to using long-acting reversible contraceptives (LARCs) in primary care: a qualitative evidence synthesis.

BACKGROUND: Long-acting reversible contraceptives (LARCs) are highly effective. In primary care, LARCs are prescribed less frequently than user-dependent contraceptives despite higher efficacy rates. Unplanned pregnancies are rising in the UK, and LARCs may have a role in reducing these through and redressing inequitable contraceptive access. To provide contraceptive services that offer maximal choice and patient benefit, we must understand what contraception users and healthcare professionals (HCPs) think about LARCs and uncover barriers to their use. METHODS: A systematic search using CINAHL, MEDLINE via Ovid, PsycINFO, Web of Science and EMBASE identified research about LARC use for pregnancy prevention in primary care. The approach adhered to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' methodology, critically appraised the literature, and used NVivo software to organise data and perform thematic analysis to determine key themes. RESULTS: Sixteen studies met our inclusion criteria. Three themes were identified: (1) trustworthiness (where and from whom participants obtained information regarding LARCs), (2) control (whether LARCs detract from personal autonomy) and (3) systems (how HCPs influenced LARC access). Misgivings about LARCs frequently arose from social networks and fears of surrendering control over fertility were prominent. HCPs perceived access issues and lack of familiarity or training as the main barriers to prescribing LARCs. CONCLUSIONS: Primary care plays a key role in improving access to LARC but barriers need to be addressed especially those involving misconception and misinformation. Access to LARC removal services are key to empower choice and prevent coercion. Facilitating trust within patient-centred contraceptive consult is essential.

A systematic review of long-term complications of mechanical tubal occlusion.

OBJECTIVES: To collate the available evidence of the rare but identified late complications of mechanical tubal occlusion. The primary objective is to describe the nature of these longer-term acute presentations. Secondary objectives are: 1) to delineate their aetiology, 2) characterise imaging findings and 3) identify successful management options. STUDY DESIGN: Literature search using National Institute of Clinical Excellence Healthcare Databases Advanced Search and terms (complicat* OR torsion OR infect* OR migrat* OR extru*) AND (tubal occlusion OR sterili*). Results reviewed by CM and JH for eligibility. RESULTS: 33 published case reports of long-term complications of mechanical tubal occlusion. 30 demonstrated migration of the device. 16 had infective pathology. Multiple modalities of imaging used with no clear evidence that one was superior. Medical and surgical management was used with removal of device proving definitive treatment. CONCLUSIONS: Long-term complications of mechanical tubal occlusion are rare and show a varied clinical course. Clinicians should be mindful of this when evaluating patients in the acute setting, as there is no identified timeline as to when complications may occur. Imaging is almost always essential for diagnosis and the modality should be directed by the clinical presentation. Definitive management is by removal of the occlusive device, but this carries its own risks.

Support needs of carers making proxy healthcare decisions for people with dementia: a systematic review based on the Noblit and Hare meta-ethnographic synthesis of qualitative studies.

BACKGROUND: There are 50 million dementia sufferers worldwide. Decisions about healthcare often need to be made when the person with dementia lacks capacity to do so.Understanding the support needs of carers acting as proxy healthcare decision-makers will be vital in improving the decision-making process for people with dementia and addressing the holistic needs of carers. OBJECTIVE: The objective of this study was to review the existing literature on the support needs of carers acting as proxy healthcare decision-makers for people with dementia. DESIGN: A qualitative systematic review protocol was published on PROSPERO. The Critical Appraisal Skills Programme checklist was used to appraise study quality. A meta-ethnographic synthesis was performed to develop third-order constructs. DATA SOURCES: A search was conducted using three online databases (MEDLINE, CINAHL and PsycINFO). ELIGIBILITY CRITERIA: Fifteen studies met the inclusion criteria: primary qualitative research involving carers of people with dementia who had been involved in making proxy healthcare decisions. DATA EXTRACTION AND SYNTHESIS: Two independent researchers conducted validity assessments for each paper selected for inclusion, and discrepancies were resolved by discussions with a third reviewer. Nvivo software was used and conceptual findings from study papers lead to interpretations of findings by the team. RESULTS: From the 15 papers included in the study, three main domains arose from the meta-ethnography; informational, practical and emotional. Informational support needs included information about dementia itself and the anticipated disease trajectory. Practical needs included continuity of care, person-centred care and the use of legal frameworks.Emotional support included recognising the guilt that healthcare decisions can provoke and the importance of providing guidance in an empathic manner. CONCLUSIONS: This meta-ethnography highlights opportunities for healthcare professionals and policymakers to improve experiences of carers making proxy healthcare decisions for people with dementia. PROSPERO REGISTRATION NUMBER: CRD42020124485.

Response to diagnosis of pre-diabetes in socioeconomically deprived areas: a qualitative study.

BACKGROUND: Diabetes prevention is a key priority for the NHS, with a particular focus on populations at highest risk. The NHS Diabetes Prevention Programme (NHS DPP) has been introduced, offering a course of dietary and lifestyle education to individuals with pre-diabetes. However, concerns about the NHS DPP include: (1) the possible unintended consequences of labelling more people with a 'pre-condition'; (2) the possibility of worsening health inequalities as people in socioeconomically deprived areas tend to access behaviour-change programmes less readily; (3) the appropriateness of an intervention focused on individuals versus population-wide public health policy interventions. AIM: To explore the experience of diagnosis of pre-diabetes, and understand the barriers and facilitators to uptake of the NHS DPP for people living in socioeconomically deprived areas. DESIGN & SETTING: A qualitative study was undertaken. Participants with pre-diabetes were recruited from practices serving socioeconomically deprived areas of Sheffield, UK. METHOD: Semi-structured interviews were conducted and continued until data saturation (23 participants). Thematic analysis of data was undertaken. RESULTS: Both healthcare context and an individual's personal and community context shaped response to diagnosis and likelihood of engaging with the NHS DPP. Patient activation was a useful concept in understanding response. Whether or not people participated in the NHS DPP, being diagnosed with pre-diabetes tended to provoke some degree of dietary change and did not cause significant anxiety for most. However, there were multiple barriers to engaging with the NHS DPP for this patient group. CONCLUSION: Diagnosing pre-diabetes can provoke an individual positive response, but the sociocultural environment often limits an individual's ability to engage with the NHS DPP or make lifestyle change.

The Effects of Metformin and EGCG On PANC-1 Cell Survival.

There is less than a thirty percent survival rate for patients with a localized pancreatic tumor, and less than a ten percent survival rate for patients with metastases. Patients with pancreatic cancer often have altered glucose metabolism and are prescribed metformin which has been shown to reduce cancer cell proliferation. Metformin administered at doses ranging between 10-20 mM has been reported in the literature to induce AMPK signaling pathways which increase cellular apoptosis. Epigallacto-catechan (EGCG) is a polyphenolic antioxidant that has also been shown to increase the AMPK pathway that increases cellular apoptosis. The objective of this study was to investigate the effectiveness of EGCG with a clinical dose of metformin (10µM) in reducing the survival of a pancreatic like cell line in culture. PANC-1 cells were plated onto three 24 well plates at a density of 1 x 106 cells per well. The experimental design consisted of four equal groups: Group 1 served as the control and groups 2-4 were treated with metformin, (EGCG) or metformin and EGCG, respectively. Biochemical and morphological evaluations were conducted following standard lab protocols. Results of this study show 10µM of metformin was unable to alter cell growth or proliferation over a 72 hour period, while 50µM of EGCG alone or in combination with metformin were capable of reducing cell density and cellular protein levels at 48 and 72 hours following treatment. The results show EGCG induced changes in cellular morphology which are characteristic of apoptosis. Overall, additional studies are needed to determine the effects of EGCG on AMPK and ATM pathways that are responsible in normal cellular apoptotic processes.