Accommodation needs for carers of and adults with intellectual disability in regional Australia: their hopes for and perceptions of the future.

INTRODUCTION: This article provides an in-depth investigation of the accommodation circumstances of a population of aging adults with intellectual disability living at home with parents or in supported accommodation in an Australian regional centre. Given the ageing of both the carer and adult population with intellectual disability our research explored the accommodation needs and perceptions of future lifestyle issues from the perspective of both the carers and the adults with intellectual disability. This study aimed to describe these accommodation circumstances related to a regional/rural location and did not make direct comparisons with urban/metropolitan situations. METHODS: A mixed methods approach, specifically an explanatory design, participant selection model was utilised for the overall study. This article reports on the qualitative study consisting of data from both free response open-ended survey questions and semi-structured interviews with selected adults with intellectual disability and their carers. This study explored and described participants' experiences and perceptions regarding their accommodation needs and future lifestyle issues. A purposive sampling technique was used to identify a representative sample of participants for interviews. The interview questions were guided by the results of the quantitative first study phase. Data were analysed by content analysis for major themes emerging from the interview and free response survey data. RESULTS: A total of 146 carers (mean age 61.5 years; range 40-91 years) and 156 adults with intellectual disability (mean age 37.2 years; range 18-79 years) participated in the study. Data saturation was reached after 10 interviews were undertaken with carers (mean age 60 years) and 10 with adults with intellectual disability (no age criteria applied). Six major themes were identified: ageing, family issues, living at home, living away from home, government support and funding, and future needs. The perceptions and views of both adults with intellectual disability and their carers around these major themes are reported and discussed. CONCLUSIONS: This study indicates that there is a lack of suitable, available, supported accommodation for people aged 18 years and older with intellectual disability in this Australian regional centre. Consequently, aging parents caring at home have little choice but to continue in their caring role. For those caring away from home, existing services are decreasingly seen as fitting the ideal life they want for the person with intellectual disability for whom they care. The told experiences, perceptions and views of older carers of and adults with intellectual disability have highlighted their increasing vulnerability to the 'disability system'. The findings suggest that government and disability services must acknowledge the changing needs of people with intellectual disability in connection with their advancing age and the urgency of increasing care needs due to the advancing age of their carer's. The overwhelming feeling is that the carer's voice will only be heard when the situation reaches crisis point. For many carers and their families this has already occurred.

Stimulation of V(D)J recombination by histone acetylation.

V(D)J recombination assembles functional immunoglobulin and T cell receptor genes from individual gene segments [1]. A common recombination mechanism, initiated by the proteins RAG1 and RAG2 at conserved recombination signal sequences (RSSs), operates at all rearranging loci [2] [3]. It has been proposed that the key regulator of the reaction is 'accessibility' of the RSS within chromatin [4]. Recently, the packaging of RSSs into nucleosomes was shown to inhibit initiation of V(D)J recombination [5] [6]. Nevertheless, the tight tissue specificity of regulation cannot be explained by nucleosome-mediated repression alone because a significant fraction of RSSs would be predicted to lie in linker regions between nucleosomes. Therefore, some aspect of the regulation of the recombination reaction must rely on the disruption of higher-order chromatin structure. Here, we report that histone acetylation directly stimulates the recombination reaction in vivo in the correct cell- and stage-specific manner. Neither expression of RAG genes nor activity of RAG proteins was increased by acetylation. Furthermore, histone acetylation failed to overcome nucleosome-mediated repression of RSS recognition and cleavage in vitro. Our data suggest a role for histone acetylation in stimulating recombination in vivo through disruption of higher-order chromatin structures.

Perturbation of nucleosome structure by the erythroid transcription factor GATA-1.

The ability of transcription factors to gain access to their sites in chromatin requires the disruption or displacement of nucleosomes covering the promoter, signalled by the generation of a nuclease hypersensitive site. We characterise here the alterations in nucleosome structure caused by binding of the erythroid factor GATA-1 to a nucleosome carrying GATA-1 sites. DNase I and micrococcal nuclease probes show that GATA-1 binding causes extensive, cooperative breakage of the histone/DNA contacts to generate a complex very similar to that formed by the factor with free DNA. The only region which differs is confined to about 50 bp surrounding the nucleosome dyad axis which appears to be the domain of residual contact between the DNA and histone octamer. Despite considerable breakage of the histone/DNA contacts, the complex is completely stable in solution, and disruption of the nucleosome is entirely reversible: it is regenerated quantitatively upon removal of the transcription factor. Moreover, the histone 2A/2B component of the octamer does not exchange to external competitor. We suggest that formation of this complex may be a step in the generation of a fully hypersensitive site in vivo over regulatory elements containing GATA family binding sites.

GABA(B) receptors at glutamatergic synapses in the rat striatum.

Although multiple effects of GABA(B) receptor activation on synaptic transmission in the striatum have been described, the precise locations of the receptors mediating these effects have not been determined. To address this issue, we carried out pre-embedding immunogold electron microscopy in the rat using antibodies against the GABA(B) receptor subunits, GABA(B1) and GABA(B2). In addition, to investigate the relationship between GABA(B) receptors and glutamatergic striatal afferents, we used antibodies against the vesicular glutamate transporters, vesicular glutamate transporter 1 and vesicular glutamate transporter 2, as markers for glutamatergic terminals. Immunolabeling for GABA(B1) and GABA(B2) was widely and similarly distributed in the striatum, with immunogold particles localized at both presynaptic and postsynaptic sites. The most commonly labeled structures were dendritic shafts and spines, as well as terminals forming asymmetric and symmetric synapses. In postsynaptic structures, the majority of labeling associated with the plasma membrane was localized at extrasynaptic sites, although immunogold particles were also found at the postsynaptic specialization of some symmetric, putative GABAergic synapses. Labeling in axon terminals was located within, or at the edge of, the presynaptic active zone, as well as at extrasynaptic sites. Double labeling for GABA(B) receptor subunits and vesicular glutamate transporters revealed that labeling for both GABA(B1) and GABA(B2) was localized on glutamatergic axon terminals that expressed either vesicular glutamate transporter 1 or vesicular glutamate transporter 2. The patterns of innervation of striatal neurons by the vesicular glutamate transporter 1- and vesicular glutamate transporter 2-positive terminals suggest that they are selective markers of corticostriatal and thalamostriatal afferents, respectively. These results thus provide evidence that presynaptic GABA(B) heteroreceptors are in a position to modulate the two major excitatory inputs to striatal spiny projection neurons arising in the cortex and thalamus. In addition, presynaptic GABA(B) autoreceptors are present on the terminals of spiny projection neurons and/or striatal GABAergic interneurons. Furthermore, the data indicate that GABA may also affect the excitability of striatal neurons via postsynaptic GABA(B) receptors.

A new monoclonal anti-CD7 antibody reactive on paraffin sections.

CBC.37 monoclonal antibody (mAb) was generated using balb/c mice immunized with CEM T cell line. It was selected because of its strong reactivity on T lymphocytes on paraffin tissue sections. The anti-CD7 specificity of CBC.37 mAb was assessed by immunohistochemistry, cross-blocking, and cross-immunoprecipitation experiments using CBC.37 and the anti-CD7 mAb DK24. CBC.37 mAb immunoprecipitated a 40-kDa protein. Cross-blocking and cross-immunoprecipitation experiments demonstrated that the two antibodies recognized the same molecule. Immunostaining of a large number of reactive lymph nodes and B and T cell lymphomas confirms that CBC.37 mAb was directed against T cells. As expected, on reactive lymph nodes the staining pattern was comparable to that of CD3. Among the 110 T cell lymphomas examined, all T lymphoblastic lymphomas were positive (15+/15; 100%). As a result of the frequent loss of CD7 antigen, only 25+/95 (26%) of peripheral T cell neoplasms were found to be positive for CBC.37. A marked reduction in the number of CBC.37-positive T cells was observed in 7 of the 60 cases of benign inflammatory dermatoses studied (approximately 12%). CBC.37 was unreactive with all healthy and neoplastic non-lymphoid samples examined. Because the lack of CD7 expression in T cell lymphomas is of diagnostic value, CBC.37 mAb in association with other anti-T cell antibodies working on paraffin sections could be of particular value in asserting the diagnosis of T cell lymphomas in routine histopathology.

The use of paratenon, polyethylene film, or silastic sheeting to prevent restricting adhesions to tendons in the hand.

We treated 132 patients by insertion of paratenon, polyethylene, or Silastic between a digital tendon and a bone, ligament, or fixed fascial structure to prevent adhesions. From 1950 to 1974, autogenous paratenon was used in thirty patients; from 1956 to 1965, polyethylene film was used in sixty-three patients; and from 1965 to 1974, Silastic sheeting was used in thirty-nine patients. By comparing the preoperative and postoperative measurements of joint motion and the changes in the distance separating the pulp of a finger from the palm during flexion, these patients were calssified as improved, unchanged, or worse. In some areas the material used appeared to make little difference, but in other areas one or the other was superior. Silastic sheeting (non-reinforced) proved to be the best material for most conditions, but it should not be employed when the skin is of poor quality or beneath a pedicle flap, and it should not be used adjacent to a tendon graft in an area that has recovered from an infection. Under those circumstances, paratenon is the preferred material.

Capsulodesis of the metacarpophalangeal joint of the thumb in children with cerebral palsy.

A deformity of hyperextension of the metacarpophalangeal joint of the thumb occurring in thirteen children with spastic cerebral palsy was corrected by capsulodesis of the joint. The technique involves shifting the metacarpal attachment of the volar plate more proximally in the metacarpal. When combined with selective release of the involved intrinsic muscles and selective transfer of the extrinsic motors, when indicated, the thumb is brough away from the palm and its function and appearance are improved. Moreover, there is not risk to growth of the thumb such as might follow arthrodesis in a growing child. Results were satisfactory except in two athetoid patients, in whom some of the intial correction was lost, but even their thumbs did not revert into hyperextension. In five patients, for reasons not entirely clear, the previously flexed interphalangeal joint had better extension postoperatively. This improved the function of the thumb, because the broad pulp of the thumb could then be used firmly against the side of the index finger.

Fracture of the hook of the hamate in athletes.

During an eight-year period, four tennis players, seven golfers, and nine baseball players were seen with a fracture of the hook of the hamate. Eighteen of these twenty patients were disabled by pain and after the fracture fragment was removed, all eighteen were relieved so that they returned to their athletic pursuits. Two patients were asymptomatic, their old fracture being discovered accidentally when they were treated for other injuries. Nineteen of the twenty patients had been examined before coming under our care, but the correct diagnosis had been made in only two. Conservative treatment, including rest, physical therapy, and injections of steroids into the wrist and hand, had not been beneficial. From the history and findings, we believe that these fractures were caused by a direct blow against the hook of the hamate caused by the handle of the tennis racket, golf club, or bat during a swing, and not by indirect force produced by the ligaments and muscles attached to the hook. The fracture was demonstrated in all twenty patients by a roentgenogram (profile view) of the carpal tunnel.

Fusion of the first metacarpotrapezial joint for degenerative arthritis.

During a twelve-year period, twenty-eight patients (thirty thumbs) were treated for painful idiopathic arthritis of the metacarpotrapezial joint of the thumb by fusion. Failure of fusion occurred in two thumbs, and in both instances a solid fusion followed a second procedure. Fusion of the metacarpotrapezial joint did not predispose to painful arthritis of the trapezioscaphoid joint, even in patients with pre-existing roentgenographic evidence of minor degenerative changes in this joint. The results after long-term follow-up were gratifying, the patients having painless and stable thumbs with excellent strength. Although patients noted a minor loss of thumb motion, they did not consider this a problem. Fusion is a satisfactory procedure for patients who need or desire a strong, painless thumb, and seems especially worth while in the dominant thumb when both thumbs require surgical treatment.

The history of carpal tunnel syndrome.

Carpal tunnel syndrome is the most frequently diagnosed, best understood and most easily treated entrapment neuropathy. During the first half of the 20th century, however, most patients with carpal tunnel syndrome were diagnosed as having compression of either the brachial plexus or thenar nerve motor branch of the median nerve. As late as 1950, only twelve patients with operative release of the transverse carpal ligament for idiopathic carpal tunnel syndrome had been reported. The delay in accurate anatomical localization of this compressive neuropathy can be attributed both to the confusion caused by the diverse manifestations of median nerve compression in the carpal tunnel, and to some interesting developments that altered early investigations in this area.