Informal Caregiver Challenges for Advanced Cancer Patients During End-of-Life Care in Johannesburg, South Africa and Distinctions Based on Place of Death.

CONTEXT: In sub-Saharan Africa, late diagnosis with cancer is common. Many dying patients rely on family members for care; little is known about the challenges African informal caregivers face. OBJECTIVES: To better understand the challenges of informal caregivers at the end of life in South Africa, both at home and in inpatient facilities. METHODS: We included advanced cancer patients and caregivers from a public hospital in Johannesburg, South Africa. Study nurses interviewed patients and caregivers about their experiences. Using univariate and multivariate analyses, we determined the factors associated with greater caregiver difficulty, focusing on patients dying at home vs. in inpatient facilities. RESULTS: Among 174 informal caregivers, 62 (36%) reported "a lot" of challenges. These caregivers struggled most with keeping the patient clean (16%) and with patient interactions (34%). Symptoms associated with greater difficulty included pain (odds ratio [OR] 2.4 [95% CI 1.2-4.7]), urinary incontinence (OR 2.3 [95% CI 1.1-4.9]), fecal incontinence (OR 2.4 [95% CI 1.0-5.7]), insomnia (OR 2.9 [95% CI 1.3-6.9]), fatigue (OR 6.3 [95% CI 1.8-21.6]), extremity weakness (OR 2.9 [95% CI 1.3-6.9]), shame (OR 4.2 [95% CI 1.5-12.0]), and sadness (OR 2.3 [95% CI 1.1-4.8]). Caregivers of patients dying at home reported the greatest difficulty with patients' physical symptoms; caregivers of those dying in facilities reported the greatest difficulty with emotional symptoms. CONCLUSION: Informal caregivers of patients dying at home reported challenges with practical functional care; this effect was reduced in the inpatient setting. Skills training for these caregivers could relieve some of this burden.

Reversibility of temperature driven discrete layer-by-layer formation of dioctyl-benzothieno-benzothiophene films.

Film forming properties of semiconducting organic molecules comprising alkyl-chains combined with an aromatic unit have a decisive impact on possible applications in organic electronics. In particular, knowledge on the film formation process in terms of wetting or dewetting, and the precise control of these processes, is of high importance. In the present work, the subtle effect of temperature on the morphology and structure of dioctyl[1]benzothieno[3,2-b][1]benzothiophene (C8-BTBT) films deposited on silica surfaces by spin coating is investigated in situ via X-ray diffraction techniques and atomic force microscopy. Depending on temperature, bulk C8-BTBT exhibits a crystalline, a smectic A and an isotropic phase. Heating of thin C8-BTBT layers at temperatures below the smectic phase transition temperature leads to a strong dewetting of the films. Upon approaching the smectic phase transition, the molecules start to rewet the surface in the form of discrete monolayers with a defined number of monolayers being present at a given temperature. The wetting process and layer formation is well defined and thermally stable at a given temperature. On cooling the reverse effect is observed and dewetting occurs. This demonstrates the full reversibility of the film formation behavior and reveals that the layering process is defined by an equilibrium thermodynamic state, rather than by kinetic effects.

Temperature and layer thickness dependent in situ investigations on epindolidione organic thin-film transistors.

We report on in situ performance evaluations as a function of layer thickness and substrate temperature for bottom-gate, bottom-gold contact epindolidione organic thin-film transistors on various gate dielectrics. Experiments were carried out under ultra-high vacuum conditions, enabling quasi-simultaneous electrical and surface analysis. Auger electron spectroscopy and thermal desorption spectroscopy (TDS) were applied to characterize the quality of the substrate surface and the thermal stability of the organic films. Ex situ atomic force microscopy (AFM) was used to gain additional information on the layer formation and surface morphology of the hydrogen-bonded organic pigment. The examined gate dielectrics included SiO2, in its untreated and sputtered forms, as well as the spin-coated organic capping layers poly(vinyl-cinnamate) (PVCi) and poly((±)endo,exo-bicyclo[2.2.1]hept-5-ene-2,3-dicarboxylic acid, diphenylester) (PNDPE, from the class of polynorbornenes). TDS and AFM revealed Volmer-Weber island growth dominated film formation with no evidence of a subjacent wetting layer. This growth mode is responsible for the comparably high coverage required for transistor behavior at 90-95% of a monolayer composed of standing molecules. Surface sputtering and an increased sample temperature during epindolidione deposition augmented the surface diffusion of adsorbing molecules and therefore led to a lower number of better-ordered islands. Consequently, while the onset of charge transport was delayed, higher saturation mobility was obtained. The highest, bottom-contact configuration, mobilities of approximately 2.5 × 10-3cm2/Vs were found for high coverages (50 nm) on sputtered samples. The coverage dependence of the mobility showed very different characteristics for the different gate dielectrics, while the change of the threshold voltage with coverage was approximately the same for all systems. An apparent decrease of the mobility with increasing coverage on the less polar PNDPE was attributed to a change in molecular orientation from upright standing in the thin-film phase to tilted in the bulk phase. From temperature-dependent mobility measurements we calculated activation barriers for the charge transport between 110 meV and 160 meV, depending on the dielectric configuration.

Polymerase chain reaction amplifying mycobacterial DNA from aspirates obtained by endoscopic ultrasound allows accurate diagnosis of mycobacterial disease in HIV-positive patients with abdominal lymphadenopathy.

Abdominal lymphadenopathy in human immunodeficiency virus (HIV) infection remains a diagnostic challenge. We performed a prospective cohort study by recruiting 31 symptomatic HIV + patients with abdominal lymphadenopathy and assessing the diagnostic yield of endoscopic ultrasound fine-needle aspiration (EUS-FNA). Mean age was 38 years; 52% were female; and mean CD4 count and viral load were 124 cells/µL and 4 log, respectively. EUS confirmed additional mediastinal nodes in 26%. The porta hepatis was the most common abdominal site. Aspirates obtained by EUS-FNA were subjected to cytology, culture and polymerase chain reaction (PCR) analysis. Mycobacterial infections were confirmed in 67.7%, and 31% had reactive lymphadenopathy. Cytology and culture had low sensitivity, whereas PCR identified 90% of mycobacterial infections. By combining the appearance of aspirates obtained by EUS-FNA and cytologic specimens, we developed a diagnostic algorithm to indicate when analysis with PCR would be useful. PCR performed on material obtained by EUS-FNA was highly accurate in confirming mycobacterial disease and determining genotypic drug resistance.

Endometriosis of the inguinal region: magnetic resonance imaging (MRI) findings.

A case of endometrioma of the right inguinal canal region, diagnosed preoperatively, is presented. The diagnosis was made on the basis of cyclical symptoms relating to menstrual periods, in combination with demonstration of blood products within an enhancing focal lesion in the inguinal region with magnetic resonance imaging. The case presented here is unique, as it is the first case, to our knowledge, of an endometriotic lesion in the inguinal canal to demonstrate the characteristic 'shading sign' at magnetic resonance imaging.

Medial meniscus posterior root attachment injury and degeneration: MRI findings.

The posterior root attachment of the medial meniscus is readily identifiable on MRI. Unless specifically reviewed, injuries involving this structure may be overlooked. Significant meniscal root pathology may cause functional incompetence of the meniscus, with consequent early onset cartilage degeneration and osteoarthritis. This review article emphasizes the importance of positive identification of an intact meniscal root and illustrates the known association of meniscal root injury or tear with medial extrusion of the medial meniscus by greater than 3 mm beyond the joint margin.

Hemorrhage is uncommon in new Alzheimer family with Flemish amyloid precursor protein mutation.

BACKGROUND: Most mutations in the amyloid precursor protein (APP) gene have been associated with familial Alzheimer disease (AD); however, some mutations within the Abeta-coding sequence have been described in families with recurrent cerebral hemorrhage. The APPAla692Gly (Flemish) mutation was reported in a family in which affected members developed hemorrhagic stroke, progressive dementia, or both. OBJECTIVE: To describe clinical, neuropathologic, and genetic features of a family of British origin with the Flemish APP mutation. METHODS: Clinical features of the proband and two affected relatives were obtained by history, examination, and medical record review. Some information on deceased affected relatives was obtained by informant interview. Neuropathologic examination was carried out on one case. DNA studies were carried out on three affected and three unaffected individuals. RESULTS: Presenile dementia was present in a pattern consistent with dominant inheritance, with the APP692 mutation being found in all affecteds and no unaffecteds. The proband also had a cerebral hemorrhage, but was the only one of five affecteds to have this complication. Neuropathologic examination confirmed AD, congophilic angiopathy, and hemorrhagic infarction. CONCLUSIONS: This expands the number of families reported with mutations in the coding region of the amyloid precursor protein gene. Cerebral hemorrhage appears to be less frequent in this family than in the previously reported Flemish pedigree with the same mutation.

PHEXdb, a locus-specific database for mutations causing X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is a dominant disorder of phosphate (Pi) homeostasis characterized by growth retardation, rachitic and osteomalacic bone disease, hypophosphatemia, and renal defects in Pi reabsorption and vitamin D metabolism. The gene responsible for XLH was identified by positional cloning and designated PHEX (formerly PEX) to depict a Phosphate regulating gene with homology to Endopeptidases on the X chromosome. To date, 131 mutations in the PHEX gene have been reported. We undertook to centralize information on mutations in the PHEX gene by establishing a database search tool, PHEXdb (http://data.mch.mcgill.ca/phexdb). This site is dedicated to the collection and distribution of information on PHEX mutations, and is accessible to the scientific community. PHEXdb provides a submission form to allow the addition of newly identified mutations in the PHEX gene. Users can search the database by mutation, phenotype, and authors who have published or submitted mutations. The PHEXdb home page includes links to information pages, which refer to recent publications on PHEX, XLH, and murine Hyp and Gy homologues, and to other web pages relevant to XLH. This resource will facilitate the identification of PHEX structure-function relationships and phenotype-genotype correlations.

Magnetic resonance imaging of the supraspinatus tendon: the significance of signal intensity alterations at the 'critical zone'.

A pictorial essay of normal and abnormal appearances of the supraspinatus tendon is presented. An increased signal intensity within the supraspinatus tendon on short TE sequences is not necessarily abnormal. Increased signal seen within the tendon on modern magnetic resonance imaging (MRI) units is often due to a phenomenon known as the 'magic angle' effect. Only when supraspinatus tendon signal intensity is greater than that of muscle on long TE (T2) sequences should it be considered to be abnormal. The physical basis for the magic angle effect is outlined and a pictorial essay demonstrating the practical implications of this effect is presented. A comparison is made to signal intensity changes seen with partial and complete tears of the supraspinatus tendon. Correlation is made with important morphologic features of partial or complete tears.

Acinic cell carcinoma of the parotid in children.

The imaging findings of two children with acinic cell carcinoma of the parotid gland are presented. Ultrasonic features are emphasized. One of these children, a 6-year-old boy, suffers from the oculocerebrorenal syndrome of Lowe, a rare congenital, inherited condition manifested by defects of the nervous system (mental retardation, hypotonia), eyes (cataracts, glaucoma) and kidneys. To date, no known association exists between these two rare entities. The other child, a 10-year-old girl, was otherwise well. The ultrasound findings of both cases demonstrate features more classic for a benign intraparotid mass than for a potentially malignant lesion. The possibility of acinic cell carcinoma should be considered if a well-defined, relatively homogenously hypo-echoic intraparotid mass is encountered in a child, especially if cystic spaces are present.

Midline interhemispheric fusion associated with atypical callosal dysgenesis: a mild type of holoprosencephaly.

We report the imaging findings in a 3 year old girl with a mild form of holoprosencephaly. The malformation is of interest because it may contribute to our understanding of brain development. The relatively mild clinical features are emphasized.

Copper, iron, manganese, and zinc content of hair from two populations of rhesus monkeys.

The concentrations of the elements copper (Cu), iron (Fe), manganese (Mn), and zinc (Zn) in hair of caged (in Maryland) and free-ranging (in Puerto Rico) rhesus monkey populations were determined. Significant chronological age-related decreases were evident for the trace elements Mn and Zn in both populations (P < or = 0.01) and for Cu and Fe in free-ranging monkeys (P < or = 0.005). The only overall gender difference was higher hair Mn concentration in free-ranging males than in females (P < 0.03). There were no significant differences in hair Cu, Fe, or Mn related to pregnancy status. Hair Zn was lower in samples from pregnant than from nonpregnant monkeys from the caged monkeys (P < or = 0.05), but did not differ in the free-ranging monkeys. Comparison of the two populations revealed that hair Zn levels were significantly higher in caged vs free-ranging animals (P < 0.001). We attribute this higher hair Zn in the caged monkeys to contact and ingestion of Zn from their galvanized enclosures. Hair iron levels were significantly higher (P < 0.001) in free-ranging monkeys, possibly as a result of Fe-rich soil ingestion from their environment. These data support continued investigation of the use of hair as an indicator of the exposure of large groups or populations to potentially high levels of specific minerals, and the use of nonhuman primates as models for the study of trace element deficiency and/or toxicity in humans.

Calcium, magnesium, and phosphorus content of hair from two populations of rhesus monkeys.

The use of hair for the assessment of human mineral nutritional status is controversial, yet has potential because of the ease of collection and storage, and the high concentration of minerals in hair. This study generated baseline values for hair macromineral content in the most commonly used primate model for human nutrition and disease, the rhesus monkey. Hair digests from monkeys in Maryland (n = 98) and Puerto Rico (n = 208) were analyzed by inductively coupled plasma atomic emission spectrometry (ICP-AES). Significant differences existed between the two populations for hair calcium (Ca), magnesium (Mg), and phosphorus (P) (P < 0.01, P < 0.001, P < 0.02). Male hair had higher concentrations of Mg in specimens from the Puerto Rican population (P < 0.001), whereas hair phosphorus was higher in female hair (P < 0.02). There were no significant differences attributable to pregnancy status. Differences in hair content attributable to categorical age were found for Ca and Mg (P < 0.001, P < 0.01). Significant location differences paralleled dietary differences. These values therefore can be considered reference ranges for hair Ca, Mg, and P for free-ranging and caged rhesus monkeys.

Effects of dietary zinc, manganese, and copper on tissue accumulation of cadmium by Japanese quail.

The beneficial effects of a combined dietary supplement of Zn, Cu, and Mn in decreasing Cd absorption was previously reported. The purpose of this study was to investigate the individual and combined effects of these three elements. In the first two experiments, day-old Japanese quail were fed basal diets containing either requirement amounts of Zn (30 ppm) and Mn (12 ppm) and slightly above requirement levels of Cu (5 ppm). From Day 7 birds were fed either the basal diet or diets containing combinations at twice these concentrations; a 2 X 2 X 2 factorial design was used. 109Cd content and Cd concentration of these diets were 100 mu Ci and 145 micrograms/kg, respectively. In the third experiment, day-old birds were fed either the basal diet or a basal diet containing 109Cd and single additional supplements of either Zn, Cu, or Mn. All birds were killed at 14 days of age. The Cd concentration was determined for the duodenum, jejunum-ileum, liver, and kidney. When the experimental diets were fed for 7 days, only Zn had a protective effect against Cd. Whereas none of the elements reduced the Cd concentration of the duodenum, Zn reduced the Cd in the jejunum-ileum, liver, and kidney by approximately 66, 21, and 11%, respectively. Cu and Mn caused occasional increases of Cd in some tissues. Feeding the experimental diets for 2 weeks resulted in similar responses. Zn nutrition appears to play an important role in protecting against dietary Cd absorption.

Elemental content of predigested liquid protein products.

Eight commercially available partially digested gelatin liquid products that have been used as a source of protein in dietary regimens for weight reduction and for protein supplementation were analyzed for their elemental composition. These products were prepared either by dry ashing or wet digestion techniques that were suitable for the analysis of individual elements by their respective analytical methods. Analytical methods used to assess the elemental content included inductively coupled argon plasma emission spectrometry for Ca, Mg, P, Fe, Zn, Cu, Mn, Ni, Mo, V, Be, Co, Cr, Tl, Al, Te, Sn and Sb; atomic absorption spectrophotometry for Na and K; hybride generation with atomic absorption spectrophotometry for Se and As; anodic stripping voltammetry for Cd and Pb; and ion selective electrode for F. The content of almost all of the elements in these products was extremely low compared with the amounts supplied daily for normal individuals by usual sources of dietary protein, the adult United States Recommended Daily Allowances, and typical intakes from the Total Diet Study. The following elements were not detectable in significant amounts in these products by inductively coupled argon plasma emission spectrometry: Mo, V, Be, Co, Cr, Tl, Al, Te, Sn, and Sb. The results suggest that use of these predigested liquid protein products as a sole source of nutriment will result in an inadequate intake of all of the essential elements. These products contained insignificant amounts of Ce and Pb, nonessential toxic elements.

Effects of vitamin C and iron and cadmium metabolism.

Toxic levels of dietary cadmium (5-200 ppm) interfered with iron absorption and produced an iron deficiency. Supplements of iron (particularly the divalent form) and ascorbic acid protected against the cadmium. With very low levels of dietary cadmium (about 0.06-0.08 ppm), typical of those in the diets of humans, supplements of iron(II) and ascorbic acid markedly decreased cadmium concentrations in the liver, kidney, and small intestine. Iron deficiency changed the distribution of cadmium within the body. The effect of ascorbic acid on cadmium metabolism appears to depend primarily, if not entirely, on its influence in improving iron absorption. Maintenance of modest iron stores appears to be very important in minimizing cadmium absorption.

Effects of nutritional factors on metabolism of dietary cadmium at levels similar to those of man.

Several nutrients are known to affect cadmium toxicity, but little is known about the effect of dietary nutrient levels on absorption and tissue retention of cadmium at low dietary levels, similar to those of man. Feeding gradedlevels of zinc in a casein-gelatin diet to young Japanese quail with 109Cd (as the chloride) and 0.062 ppm added cadmium decreased the cadmium concentrations in the proventriculus-ventriculus, duodenum, jejunum-ileum, and the liver, but not in the kidney. Zinc also affected some zinc, iron, manganese, and copper tissue levels. Different tissue concentration patterns of cadmium and essential minerals were obtained with two purified control diets, one based on casein-gelatin and the other on soy isolate as the principal protein sources. The data show that relatively small dietary changes can markedly affect tissue levels of cadmium and that a low intake of zinc may increase the risk to dietary cadmium exposure. The complexity of the nutrient interrelationships and their effects on cadmium require further study to define mechanisms, which may be similar to those produced by low cadmium intakes in man.