The pain experience of elderly hospice patients with cancer

Purpose/objectives. A grounded theory design was used to identify, describe, and generate a theoretical analysis of the pain experience of elderly hospice patients with cancer. ^ Sample. Eleven participants over the age of 65, receiving services from a for-profit hospice were interviewed in their homes. ^ Methods. Broad unstructured face to face audio-taped interviews were transcribed verbatim and analyzed using constant-comparative method of analysis. ^ Findings. Pain was described as a hierarchy of chronic, acute, and psychological pain with psychological pain as the worst. Suffering was the basic social problem of pain. Participants dealt with suffering by the basic social process of enduring. Enduring had two sub-processes, maintaining hope and adjusting. Trusting in a higher being and finding meaning were mechanisms of maintaining hope. Mechanisms of adjusting were dealing with uncertainty, accepting, and minimizing pain. ^ Implications for nursing practice. Nurses need to recognize and value the hard work of enduring to deal with suffering. Assisting elderly hospice patients with cancer to address the sub-processes of enduring and their mechanisms can foster enduring. ^

Regulation of myogenesis and suppression of {\it mck\/} 5$\sp\prime$ enhancer elements by TGF$\beta$ and RAS

The regulation of muscle differentiation, like cell differentiation in general, is only now beginning to be understood. Here are described several key features to myogenesis: a beginning, some intermediary events, and an endpoint. Muscle differentiation proceeds spontaneously when myoblasts are cultured in serum-poor medium. Transforming growth factor type $\beta$ (TGF$\beta$), a component of fetal serum, was found to potently suppress muscle differentiation. Prolonged blockade of differentiation required replenishing TGF$\beta$. When TGF$\beta$ was removed, cells rapidly differentiated. Both TGF$\beta$ and RAS, which also blocks myogenesis, suppress the genes for a series of muscle-specific proteins. Regions that regulate transcription of one such gene, muscle creatine kinase (mck), were located by linking progressively smaller parts of the mck 5$\sp\prime$ region to the marker gene cat and testing the constructs for regulated expression of cat in myoblasts and muscle cells. The mck promoter is not muscle-specific but requires activation. Two enhancers were found: a weak, developmentally regulated enhancer within the first intron, and a strong, compact, and tightly developmentally regulated enhancer about 1.2 Kb upstream of the transcription start site. Activity of this enhancer is eliminated by activated ras. Suppression of activated N-RAS restores potency to the upstream enhancer. Further deletion shows the mck 5$\sp\prime$ enhancer to contain an enhancer core with low but significant muscle-specific activity, and at least one peripheral element that augments core activity. The core and this peripheral element were comprised almost entirely of factor-binding motifs. The peripheral element was inactive as a single copy, but was constitutively active in multiple copies. Regions flanking the peripheral element augmented its activity and conferred partial muscle-specificity. The enhancer core is also modulated by its 5$\sp\prime$ flanking region in a complex manner. Site-specific mutants covering most of the enhancer core and interesting flanking sequences have been made; all mutants tested diminish the activity of the 5$\sp\prime$ enhancer. Alteration of the site to which MyoD1 is reported to bind completely inactivates the enhancer. A theoretical analysis of cooperativity is presented, through which the binding of a constitutively expressed nuclear factor is shown to have weak positive cooperativity. In summary, TGF$\beta$, RAS, and enhancer-binding factors are found to be initial, intermediary, and final regulators, respectively, of muscle differentiation. ^