Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Clinical consensus regarding the importance of rapid reduction in depressive symptoms in major depressive disorder with acute suicidal ideation or behavior (MDSI)

Introduction

Patients with major depressive disorder (MDD) with acute suicidal ideation or behavior (MDSI) require immediate intervention. Though oral antidepressants can be effective at reducing depressive symptoms, they can take 4–6 weeks to reach full effect.

Objectives

This study aimed to identify unmet needs in the treatment of patients with MDSI, specifically exploring the potential clinical benefits of rapid reduction of depressive symptoms.

Methods

A Delphi panel consisting of practicing psychiatrists (n=12) from the US, Canada and EU was conducted between December 2020–June 2021. Panelists were screened to ensure they had sufficient experience with managing patients with MDD and MDSI. Panelists completed two survey rounds, and a virtual consensus meeting.

Results

This research confirmed current unmet needs in the treatment of patients with MDSI.

Hopelessness, functional impairment, worsening of MDD symptoms, recurrent hospitalization and higher risk of suicide attempt were considered as key consequences of the slow onset of action of oral antidepressants.

Treatment with rapid acting antidepressant was anticipated by panelists to provide short-term benefit such as rapid reduction of core MDD symptoms which may contribute to shorter hospital stays and improved patient engagement/compliance, allowing for earlier interventions and improved patient outcomes. For long-term benefits, panelists agreed that improved daily functioning and increased trust/confidence in treatment options, constitute key benefits of rapid-acting treatments

Conclusions

There is need for rapid-acting treatments which may help address key unmet needs and provide clinically meaningful benefits driven by the rapid relief of depressive symptoms particularly in patients with MDSI.

Disclosure

SB, ED, KJ, MO’H, QZ, MM, MH, SR, JA and DZ are employees of Janssen and hold stock in Johnson & Johnson Inc. AN is currently employed by Neurocrine Biosciences Inc. RP is an employee of Adelphi Values PROVE hired by Janssen.

Posttraumatic Stress Disorder and Justice Involvement Among Military Veterans: A Systematic Review and Meta-Analysis

There is evidence of an association between posttraumatic stress disorder (PTSD) and criminal justice involvement among military veterans. For this study, we systematically reviewed the literature to examine the association between PTSD and criminal justice involvement among military veterans, assess the magnitude of this association, and identify strengths and limitations of the underlying evidence. Five databases were searched for a larger scoping review, and observational studies that assessed PTSD and criminal justice involvement were selected from the scoping review database (N = 191). Meta-analyses were conducted, pooling odds ratios (ORs) via restricted maximum likelihood random-effects models. The main outcomes were criminal justice involvement (i.e., documentation of arrest) and PTSD (i.e., PTSD assessment score indicating probable PTSD). Of 143 unique articles identified, 10 studies were eligible for the meta-analysis. Veterans with PTSD had higher odds of criminal justice involvement (OR = 1.61, 95% CI [1.16, 2.23], p = .002) and arrest for violent offenses (OR = 1.59, 95% CI [1.15, 2.19], p = .002) compared to veterans without PTSD. The odds ratio of criminal justice involvement among military veterans with PTSD assessed using the PTSD Checklist was 1.98, 95% CI [1.08, 3.63], p = .014. Considerable heterogeneity was identified, but no evidence of publication bias was found. Criminal justice involvement and PTSD are linked among military veterans, highlighting an important need for clinicians and healthcare systems working with this population to prioritize PTSD treatment to reduce veterans' new and recurring risk of criminal justice involvement.

Clients of VA-Housed Legal Clinics: Legal and Psychosocial Needs When Seeking Services and Two Months Later

Veterans often need civil legal services, yet little is known about veterans’ use and consequences of these services. This study examined veterans seeking legal services at VA-housed legal clinics. Baseline data from 61 clients of two VA-housed legal clinics were used to identify clients’ legal needs and psychosocial characteristics. Data collected from 49 (80%) of the same clients two months later were used to address clients’ improvement and satisfaction after receiving legal services. At baseline, clients reported a mean of 6.0 (SD = 4.2) legal needs, with the most common being help obtaining VA benefits (87%). Clients represented a vulnerable population in that most had an extensive criminal history (e.g., had been arrested, charged, and incarcerated) and multiple health care needs (had a chronic medical condition, had recently received treatment in an emergency department, and had received psychological treatment due to significant psychological symptoms). At follow-up, clients reported a mean of 4.4 (SD = 3.8) legal needs. Tests to identify changes between baseline and follow-up on legal needs, housing arrangement, psychological symptoms, and substance use yielded few significant results. Most participants did not receive additional help with their legal matters after the baseline appointment. At follow-up, clients reported that few of their legal needs were met but also that they were mostly satisfied with the legal services they received. Findings suggest that because clients may need more intensive legal intervention of longer duration to resolve their legal needs and achieve better housing and health status, VA-housed legal clinics require greater resources and expansion.

The Distribution and Possible Roles of Small Cardioactive Peptide in the Nudibranch Melibe leonina

The neuropeptide small cardioactive peptide (SCP) plays an integrative role in exciting various motor programs involved in feeding and locomotion in a number of gastropod species. In this study, immunohistochemistry, using monoclonal antibodies against SCPB, was used to localize SCPB-like-immunoreactive neurons in the central nervous system, and map their connections to various tissues, in the nudibranch, Melibe leonina. Approximately 28-36 SCPB-like-immunoreactive neurons were identified in the M. leonina brain, as well as one large neuron in each of the buccal ganglia. The neuropil of the pedal ganglia contained the most SCPB-like-immunoreactive varicosities, although only a small portion of these were due to SCPB-like-immunoreactive neurons in the same ganglion. This suggests that much of the SCPB-like immunoreactivity in the neuropil of the pedal ganglia was from neurons in other ganglia that projected through the pedal-pedal connectives or the connectives from the cerebral and pleural ganglia. We also observed extensive SCPB innervation along the length of the esophagus. Therefore, we investigated the impact of SCPB on locomotion in intact animals, as well as peristaltic contractions of the isolated esophagus. Injection of intact animals with SCPB at night led to a significant increase in crawling and swimming, compared to control animals injected with saline. Furthermore, perfusion of isolated brains with SCPB initiated expression of the swim motor program. Application of SCPB to the isolated quiescent esophagus initiated rhythmic peristaltic contractions, and this occurred in preparations both with and without the buccal ganglia being attached. All these data, taken together, suggest that SCPB could be released at night to arouse animals and enhance the expression of both feeding and swimming motor programs in M. leonina.

Systematic Review of Criminal and Legal Involvement After Substance Use and Mental Health Treatment Among Veterans: Building Toward Needed Research

Evidence indicates that substance use and mental health treatment is often associated with reduced criminal activity. The present systematic review examined this association among military veterans, and aimed to provide a comprehensive summary of needed research to further contribute to reduced criminal activity among veterans. This systematic review was derived from a scoping review that mapped existing research on justice-involved veterans' health. For the current systematic review, a subset of 20 publications was selected that addressed the question of whether criminal activity declines among veterans treated for substance use and mental health disorders. Generally, veterans improved on criminal outcomes from pre- to post-treatment for opioid use, other substance use, or mental health conditions, and more sustained treatment was associated with better outcomes. This occurred despite high rates of criminal involvement among veterans prior to entering treatment. Needed are substance use and mental health treatment studies that include women justice-involved veterans, follow criminally-active veterans for longer periods of time, and use validated and reliable measures of criminal activity with fully transparent statistical procedures. Future randomized trials should evaluate new treatments against evidence-based treatments (versus no-treatment control conditions). Subsequent studies should examine how to link veterans to effective treatments, facilitate sustained treatment engagement, and ensure the availability of effective treatments, and examine mechanisms (mediators and moderators) that explain the association of treatment with reduced criminal activity among veterans. Best practices are needed for reducing criminal activity among the minority of justice-involved veterans who do not have diagnosed substance use and/or mental health disorders.

National Survey of Legal Clinics Housed by the Department of Veterans Affairs to Inform Partnerships with Health and Community Services

Legal clinics housed by the Department of Veterans Affairs (VA) help veterans eliminate service access barriers. In this survey of 95 VA-housed legal clinics (70% of clinics), clients' legal problems were mainly estate planning, family, obtaining VA benefits, and housing (14-17% of clients). Most clinics rarely interacted with VA health care providers, did not have access to clients' VA health care records, and did not track clients' VA health care access (58-81% of clinics); 32% did not have dedicated and adequate space. Most clinic staff members were unpaid. Survey findings-that most VA-housed legal clinics do not interact with VA health care or directly address clients' mental health and substance use needs, and lack funds to serve fully all veterans seeking services-suggest that VA and community agencies should enact policies that expand and fund veterans' legal services and health system interactions to address health inequities and improve health outcomes.

Corrosion threshold data of metallic materials in various operating environment of offshore wind turbine parts (tower, foundation, and nacelle/gearbox)

This paper outlines corrosion thresholds for different environmental conditions of metallic materials commonly used in the tower, foundation, and nacelle/gearbox of an offshore wind turbine. These threshold values were derived from laboratory corrosion testing employing electrochemical analysis techniques, using the media/solvents that are representative to the operating environment of those wind turbine parts, such as seawater, grease, oils/lubricants, or their combination, at room temperature and at 328K. These values can provide an indication when general/local corrosion or protective film/surface damages have occurred. They can thus be utilised for detecting and monitoring corrosion at certain locations in the wind turbine structure. The presented data have been verified and validated to ensure their repeatability and reliability by means of numerous laboratory tests in accordance to the relevant engineering test standards and an extensive literature/published data review.

A scoping review of military veterans involved in the criminal justice system and their health and healthcare

BACKGROUND

In the criminal justice system, special populations, such as older adults or patients with infectious diseases, have been identified as particularly vulnerable to poor health outcomes. Military veterans involved in the criminal justice system are also a vulnerable population warranting attention because of their unique healthcare needs. This review aims to provide an overview of existing literature on justice-involved veterans' health and healthcare to identify research gaps and inform policy and practice.

METHODS

A systematic search was conducted to identify research articles related to justice-involved veterans' health and healthcare that were published prior to December 2017. Study characteristics including healthcare category, study design, sample size, and funding source were extracted and summarized with the aim of providing an overview of extant literature.

RESULTS

The search strategy initially identified 1830 unique abstracts with 1387 abstracts then excluded. Full-text review of 443 articles was conducted with 252 excluded. There were 191 articles included, most related to veterans' mental health (130/191, 68%) or homelessness (24/191, 13%). Most studies used an observational design (173/191, 91%).

CONCLUSIONS

Knowledge gaps identified from the review provide guidance on future areas of research. Studies on different sociodemographic groups, medical conditions, and the management of multiple conditions and psychosocial challenges are needed. Developing and testing interventions, especially randomized trials, to address justice-involved veterans care needs will help to improve their health and healthcare. Finally, an integrated conceptual framework that draws from diverse disciplines, such as criminology, health services, psychology, and implementation science is needed to inform research, policy and practice focused on justice-involved veterans.

Effect on the mechanical properties of type I collagen of intra-molecular lysine-arginine derived advanced glycation end-product cross-linking

Non-enzymatic advanced glycation end product (AGE) cross-linking of collagen molecules has been hypothesised to result in significant changes to the mechanical properties of the connective tissues within the body, potentially resulting in a number of age related diseases. We have investigated the effect of two of these cross-links, glucosepane and DOGDIC, on the tensile and lateral moduli of the collagen molecule through the use of a steered molecular dynamics approach, using previously identified preferential formation sites for intra-molecular cross-links. Our results show that the presence of intra-molecular AGE cross-links increases the tensile and lateral Young's moduli in the low strain domain by between 3.0-8.5% and 2.9-60.3% respectively, with little effect exhibited at higher strains.

Content analysis of homeless smokers' perspectives on established and alternative smoking interventions

BACKGROUND

Cigarette smoking is 5 times more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by smoking-related morbidity and mortality. Homeless smokers report interest in changing their smoking behavior; however, established smoking cessation interventions are neither desirable to nor highly effective for most members of this population. The aim of this study was to document homeless smokers' perceptions of established smoking interventions as well as self-generated, alternative smoking interventions to elucidate points for intervention enhancement.

METHODS

Participants (N=25) were homeless smokers who responded to semistructured interviews regarding smoking and nicotine use as well as experiences with established and alternative smoking interventions. Conventional content analysis was used to organize data and identify themes.

RESULTS

Participants appreciated providers' initiation of conversations about smoking. They did not, however, feel simple advice to quit was a helpful approach. Instead, they suggested providers use a nonjudgmental, compassionate style, offer more support, and discuss a broader menu of options, including nonabstinence-based ways to reduce smoking-related harm and improve health-related quality of life. Most participants preferred engaging in their own self-defined, alternative smoking interventions, including obtaining nicotine more safely (e.g., vaping, using smokeless tobacco) and using behavioral (e.g., engaging in creative activities and hobbies) and cognitive strategies (e.g., reminding themselves about the positive aspects of not smoking and the negative consequences of smoking). Abrupt, unaided quit attempts were largely unsuccessful.

CONCLUSIONS

The vast majority of participants with the lived experience of homelessness and smoking were uninterested in established smoking cessation approaches. They did, however, have creative ideas about alternative smoking interventions that providers may support to reduce smoking-related harm and enhance quality of life. These ideas included providing information about the relative risks of smoking and the relative benefits of alternative strategies to obtaining nicotine and avoiding smoking.

Discussing sudden unexpected death in epilepsy: Are we empowering our patients? A questionnaire survey

OBJECTIVE

To examine patient knowledge about sudden unexpected death in epilepsy (SUDEP) compared to other risks in epilepsy. To explore patients' experiences surrounding SUDEP disclosure and opinions on how information should be delivered.

DESIGN

A cross-sectional questionnaire.

SETTING

Royal Free Hospital, London outpatient epilepsy clinics.

PARTICIPANTS

New and follow-up patients attending epilepsy clinics at a London teaching hospital over six months. Patients identified as being at risk of suffering negative emotional or psychological consequences of SUDEP discussions were excluded.

MAIN OUTCOME MEASURES

Patient knowledge about epilepsy risks; patient opinion regarding source, timing and delivery of SUDEP information; impact on health seeking behaviour.

RESULTS

Ninety-eight per cent of patients were aware of medication adherence, 84% of factors influencing seizure frequency, 78% of driving regulations, 50% of SUDEP and 38% of status epilepticus; 72% of patients felt that SUDEP information should be given to all patients. Preferences for timing of SUDEP discussions varied between those wanting information at diagnosis (40%) and those preferring to receive it after three clinic appointments (18%) to avoid information overload at the first consultation. Emotional responses (48% positive, 38% negative) predominated over measurable behavioural change following SUDEP discussions.

CONCLUSIONS

Less than half the patients knew about SUDEP and status epilepticus. Although the majority of patients with epilepsy wish to be informed about SUDEP early on in their diagnosis, information must be delivered in a way that promotes patient knowledge and empowerment.

Decidual GM-CSF is a critical common intermediate necessary for thrombin and TNF induced in-vitro fetal membrane weakening

INTRODUCTION

Inflammation/infection and decidual bleeding/abruption are highly associated with pPROM. As no animal model for pPROM exists, we have developed an in-vitro model system for the study of human fetal membrane (FM) weakening/rupture. Using it we have demonstrated that both TNF/IL-1 (modeling inflammation) and thrombin (modeling bleeding) weaken full thickness FM in a dose dependent manner concomitant with inducing biochemical changes similar to those seen in the FM physiological weak zone.

METHODS

As the physiological site of infection and bleeding is the choriodecidua (CD), we modified our model system with full thickness FM tissue mounted on modified Transwell culture inserts to permit directional TNF/thrombin exposure on the decidua only (rather than both sides of the FM). After incubation, medium was sampled separately from the CD facing (maternal side) or from the amnion facing (fetal side) compartments and probed for cytokine release and confirmed with western blots. The FM was strength tested within the insert.

RESULTS

Full-thickness FM fragments exposed to TNF or thrombin on CD side only showed dose dependent weakening and biochemical changes consistent with previous reports. Concomitantly, GM-CSF increased markedly on the CD but not the amnion side. Numerous proteases including MMP1 and MMP3 also increased on the CD side. Pre-incubation with GM-CSF antibody blocked both thrombin and TNF induced weakening. Finally, GM-CSF weakened FM in a dose dependent manner.

DISCUSSION

GM-CSF is a critical common intermediate in the thrombin and TNF FM weakening pathways.

Application and feasibility of systemic lupus erythematosus reproductive health care quality indicators at a public urban rheumatology clinic

OBJECTIVES

Quality indicators (QIs) are evidence-based processes of care designed to represent the current standard of care. Reproductive health QIs for the care of patients with systemic lupus erythematosus (SLE) have recently been developed, and examine areas such as pregnancy screening for autoantibodies, treatment of pregnancy-associated antiphospholipid syndrome, and contraceptive counseling. This study was designed to investigate our performance on these QIs and to explore potential gaps in care and demographic predictors of adherence to the QIs in a safety-net hospital.

METHODS

We performed a record review of patients with a diagnosis of SLE at Denver Health Medical Center (DH) through an electronic query of existing medical records and via chart review. Data were limited to female patients between the ages of 18 and 50 who were seen between July 2006 and August 2011.

RESULTS

A total of 137 female patients between the ages of 18 and 50 were identified by ICD-9 code and confirmed by chart review to have SLE. Of these, 122 patients met the updated 1997 American College of Rheumatology SLE criteria and had intact reproductive systems. Only 15 pregnancies were documented during this five-year period, and adherence to autoantibody screening was 100 percent. We did not have any patients who were pregnant and met criteria for pregnancy-associated antiphospholipid syndrome. Sixty-five patients (53%) received potentially teratogenic medications, and 30 (46%) had documented discussions about these medications' potential risk upon their initiation. Predictors of whether patients received appropriate counseling included younger age (OR 0.92, CI 0.87-0.98) and those who did not describe English as their primary language (OR 0.24, CI 0.07-0.87) in the multivariate analysis.

CONCLUSIONS

We were able to detect an important gap in care regarding teratogenic medication education to SLE patients of childbearing potential in our public health academic clinic, as only one in two eligible patients had documented appropriate counseling at the initiation of a teratogenic medication.

Preclinical characterisation of the GM-CSF receptor as a therapeutic target in rheumatoid arthritis

Objective

Previous work has suggested that the granulocyte macrophage colony stimulating factor (GM-CSF)–GM-CSF receptor α axis (GM-CSFRα) may provide a new therapeutic target for the treatment of rheumatoid arthritis (RA). Therefore, we investigated the cellular expression of GM-CSFRα in RA synovial tissue and investigated the effects of anti-GM-CSFRα antibody treatment in vitro and in vivo in a preclinical model of RA.

Methods

We compared GM-CSFRα expression on macrophages positive for CD68 or CD163 on synovial biopsy samples from patients with RA or psoriatic arthritis (PsA) to disease controls. In addition, we studied the effects of CAM-3003, an anti-GM-CSFR antibody in a collagen induced arthritis model of RA in DBA/1 mice. The pharmacokinetic profile of CAM-3003 was studied in naïve CD1(ICR) mice (see online supplement) and used to interpret the results of the pharmacodynamic studies in BALB/c mice.

Results

GM-CSFRα was expressed by CD68 positive and CD163 positive macrophages in the synovium, and there was a significant increase in GM-CSFRα positive cells in patients in patients with RA as well as patients with PsA compared with patients with osteoarthritis and healthy controls. In the collagen induced arthritis model there was a dose dependent reduction of clinical arthritis scores and the number of F4/80 positive macrophages in the inflamed synovium after CAM-3003 treatment. In BALB/c mice CAM-3003 inhibited recombinant GM-CSF mediated margination of peripheral blood monocytes and neutrophils.

Conclusions

The findings support the ongoing development of therapies aimed at interfering with GM-CSF or its receptor in various forms of arthritis, such as RA and PsA.

Protein engineering and preclinical development of a GM-CSF receptor antibody for the treatment of rheumatoid arthritis

BACKGROUND AND PURPOSE

For antibody therapies against receptor targets, in vivo outcomes can be difficult to predict because of target-mediated clearance or antigen 'sink' effects. The purpose of this work was to engineer an antibody to the GM-CSF receptor α (GM-CSFRα) with pharmacological properties optimized for chronic, s.c. treatment of rheumatoid arthritis (RA) patients.

EXPERIMENTAL APPROACH

We used an in silico model of receptor occupancy to guide the target affinity and a combinatorial phage display approach for affinity maturation. Mechanism of action and internalization assays were performed on the optimized antibody in vitro before refining the modelling predictions of the eventual dosing in man. Finally, in vivo pharmacology studies in cynomolgus monkeys were carried out to inform the predictions and support future clinical development.

KEY RESULTS

Antibody potency was improved 8600-fold, and the target affinity was reached. The refined model predicted pharmacodynamic effects at doses as low as 1 mg kg(-1) and a study in cynomolgus monkeys confirmed in vivo efficacy at 1 mg kg(-1) dosing.

CONCLUSIONS AND IMPLICATIONS

This rational approach to antibody drug discovery enabled the isolation of a potent molecule compatible with chronic, s.c. self-administration by RA patients. We believe this general approach enables the development of optimal biopharmaceuticals.

Theta*: Any-Angle Path Planning on Grids

Grids with blocked and unblocked cells are often used to represent terrain in robotics and video games. However, paths formed by grid edges can be longer than true shortest paths in the terrain since their headings are artificially constrained. We present two new correct and complete any-angle path-planning algorithms that avoid this shortcoming. Basic Theta* and Angle-Propagation Theta* are both variants of A* that propagate information along grid edges without constraining paths to grid edges. Basic Theta* is simple to understand and implement, fast and finds short paths. However, it is not guaranteed to find true shortest paths. Angle-Propagation Theta* achieves a better worst-case complexity per vertex expansion than Basic Theta* by propagating angle ranges when it expands vertices, but is more complex, not as fast and finds slightly longer paths. We refer to Basic Theta* and Angle-Propagation Theta* collectively as Theta*. Theta* has unique properties, which we analyze in detail. We show experimentally that it finds shorter paths than both A* with post-smoothed paths and Field D* (the only other version of A* we know of that propagates information along grid edges without constraining paths to grid edges) with a runtime comparable to that of A* on grids. Finally, we extend Theta* to grids that contain unblocked cells with non-uniform traversal costs and introduce variants of Theta* which provide different tradeoffs between path length and runtime.

The factors associated with effective folic acid prophylaxis in the peri-conceptional period in women attending an ante-natal clinic

The aim of this study was to examine whether folic acid supplements had been taken and dietary folate intake increased in 662 pregnant women attending the antenatal clinic at St Mary's Hospital, Portsmouth. An assessment was also made of the factors that influenced correct compliance with the recommendations of the Expert Advisory Group on folic acid. Thirty-seven percent (245/662) women had taken folic acid supplements and 26.4% (175/ 662) increased their dietary folate before or during early pregnancy. The majority of women who commenced folic acid supplements after conception did so after the neural tube had closed (220/247). Women were more likely to have adhered to the Expert Advisory Group's recommendations if the pregnancy was planned, the woman was primiparous, there was no past or family history of neural tube defect and the patient had the correct existing knowledge of folic acid prophylaxis. The relevance of these findings to the current Health Education Authority's folic awareness campaign is discussed.

Cost effectiveness of statin therapy for the primary prevention of coronary heart disease

Cholesterol lowering statin therapy accounted for over 10% of total drug acquisition costs (87.5 million euros) under the Community Drugs Schemes in Ireland in 2004. Not surprisingly, the issue of value for money and cost effectiveness arises. Whilst statin therapy has proven cost effective in patients with established cardiovascular disease this is the first economic evaluation of statin therapy for primary prevention in the Irish healthcare setting. Using economic modelling techniques the incremental cost effectiveness of statin therapy in high risk individuals i.e. 10 year risk exceeding 15% ranged from 17,900 euros per life year gained (LYG) to 33,800 euros/LYG under the GMS scheme. Corresponding figures for the Drug Payment scheme were 24,500 euros/ LYG to 48,500 euros/LYG. All the statins could be considered cost effective i.e. threshold below 50,000 euros/LYG however atorvastatin proved the most cost effective statin in this pharmacoeconomic study.

Rejection of atrial sensing artifacts by a pacing lead with short tip-to-ring spacing

AIMS

The ability of a new pacing lead design, with a 10 mm tip-to-ring spacing, to facilitate rejection of sensed far field R-waves and myopotentials was evaluated.

METHODS AND RESULTS

Measurements were performed in 66 patients. The occurrence of far field R-wave sensing and myopotential sensing was determined by means of the surface ECG and the ECG markers provided by the pacemaker. At an atrial sensitivity of 0.25 mV and an atrial blanking of 50 ms far field R-wave sensing was observed in 12 patients (18.2%) and at an atrial sensitivity of 1.0 mV no far-field R-wave sensing was observed. Myopotentials were sensed in 3 patients. In all patients the measured P-wave amplitude was at least twice the estimated amplitude of the far field R-wave at an atrial blanking of 50 ms.

CONCLUSION

The results from this study show that a small tip-to-ring spacing allows for programming of a high atrial sensitivity and short atrial blanking with an acceptably low risk for atrial artifact sensing.

Injectable silicone implants as vaccine delivery vehicles

Injectable silicone implants were assessed as vaccine delivery vehicles in sheep, using either the model antigen avidin or Clostridium tetani and Clostridium novyi toxoids. Two types of implant were compared, the matrix type, that has been shown to deliver antigen in vitro in a first-order profile over approximately 1 month, and the covered rod type, that delivers antigen for several months in a zero-order profile. The implants were prepared using lyophilized antigen and adjuvant (in this case, recombinant ovine interleukin-1beta; rovIL-1beta) and manufactured in the absence of extremes of temperature or pH or the use of organic solvents. Use of the matrix type implant was capable of inducing antibody responses equivalent to those induced by conventional vaccination with aluminium hydroxide adjuvant ("alum"). The use of the covered rod implants, that release very low levels of antigen over a long period, induced responses that were markedly enhanced over the alum control groups. The covered rod implant also favoured production of both IgG1 and IgG2 isotypes in contrast to responses of matrix-vaccinated sheep and conventionally vaccinated control sheep in which IgG1 predominated. Prolonged duration of the antibody response was also observed following vaccination with covered rod implants. Dose-response analysis using the matrix implant demonstrated a trend towards improved responses for lower antigen doses. Clostridial vaccination of sheep showed that protective antibody titres up to 4-fold higher than for alum-adjuvanted groups could be induced by administering the antigen in the covered rod implant. Responses elicited by all implant groups were dependent on the inclusion of adjuvant into the implant formulation.

Contribution of germline MLH1 and MSH2 mutations to lobular carcinoma in situ of the breast

Lobular carcinoma in situ (LCIS) is an unusual histological pattern of non-invasive neoplastic disease of the breast occurring predominantly in women aged between 40 and 50 years. LCIS is frequently multicentric and bilateral suggesting a genetic basis to the disease. The high frequency of microsatellite instability in lobular breast cancers, coupled with increased risk of breast cancer associated with germline mismatch repair gene mutations raises the possibility that mutations MSH2 or MLH1 might confer susceptibility to LCIS. To explore this possibility we have examined a series of 71 LCIS patients for germline MSH2 and MLH1 mutations. No mutations were detected in MSH2. Two sequence variants were identified in MLH1. The first was a CTT-->CAT substitution, codon 607 (exon 16) changing leucine to histidine. The other mutation detected in MLH1 was a TAC-->TAA substitution codon 750 (exon 19) creating a stop codon, predicted to generate a truncated protein. These findings suggest that mutations in MLH1 may underlie a subset of LCIS cases.

Effects of prenatal dexamethasone on spatial learning and response to stress is influenced by maternal factors

The present study investigated the effect of prenatal dexamethasone (Dex) exposure on early perinatal events, hippocampal function, and response to stress. Pregnant rats received Dex in the evening water (2.5 microg/ml) or tap water (Veh) from gestational day 15 until delivery. On the day of parturition, pups were randomized, cross-fostered, and reduced to eight or nine per dam. Four groups resulted: Veh-Veh (offspring exposed to Veh in utero, rearing mother treated with Veh during gestation), Veh-Dex, Dex-Veh, and Dex-Dex. Spatial visual memory was evaluated with the Morris water maze. The corticosterone response to restraint stress was examined, and the expression of hippocampal glucocorticoid and mineralocorticoid receptors mRNA was determined by in situ hybridization. Exposure to Dex caused restlessness in mothers, low birth weights, and poor weight gain in the offspring. The Dex-Dex males had impaired spatial learning, inability to rapidly terminate the adrenocortical response to stress, and decreased hippocampal glucocorticoid receptor (GR) mRNA expression. In contrast, Dex-exposed animals reared by Veh-treated mothers had adequate spatial learning, enhanced glucocorticoid feedback, and increased hippocampal GR mRNA. We conclude that the environment provided by a healthy mother during the postnatal period can prevent the detrimental effects of prenatal Dex administration on cognition, GR mRNA expression of the hippocampus, and the quality of the stress response.

Lobular carcinoma in situ of the breast is not caused by constitutional mutations in the E-cadherin gene

Lobular carcinoma in situ (LCIS) is an unusual histological pattern of non-invasive neoplastic disease of the breast occurring predominantly in women aged between 40 and 50 years. LCIS is frequently multicentric and bilateral, and there is evidence that it is associated with an elevated familial risk of breast cancer. Although women with LCIS suffer an increased risk of invasive breast disease, this risk is moderate suggesting that LCIS may result from mutation of a gene or genes conferring a high risk of LCIS, but a lower risk of invasive breast cancer. The high frequency of somatic mutations in E-cadherin in LCIS, coupled with recent reports that germline mutations in this gene can predispose to diffuse gastric cancer, raised the possibility that constitutional E-cadherin mutations may confer susceptibility to LCIS. In order to explore this possibility we have examined a series of 65 LCIS patients for germline E-cadherin mutations. Four polymorphisms were detected but no pathogenic mutations were identified. The results indicate that E-cadherin is unlikely to act as a susceptibility gene for LCIS.

Suckling defect in mice lacking the soluble haemopoietin receptor NR6

Cytokines control a variety of cellular responses including proliferation, differentiation, survival and functional activation, via binding to specific receptors expressed on the surface of target cells [1]. The cytokine receptors of the haemopoietin family are defined by the presence of a conserved 200 amino acid extracellular domain known as the haemopoietin domain [2]. We report here the isolation of NR6, a haemopoietin receptor that, like the p40 subunit of interleukin-12 (IL-12) [3] and the EBI3 gene induced by Epstein-Barr virus infection in lymphocytes [4], contains a typical haemopoietin domain but lacks transmembrane and cytoplasmic domains. Although in situ hybridisation revealed NR6 expression at multiple sites in the developing embryo, mice lacking NR6 did not display obvious abnormalities and were born in the expected numbers. Neonatal NR6(-/-) mice failed to suckle, however, and died within 24 hours of birth, suggesting that NR6 is necessary for the recognition or processing of pheromonal signals or for the mechanics of suckling itself. In addition, NR6(-/-) mice had reduced numbers of haemopoietic progenitor cells, suggesting a potential role in the regulation of primitive haemopoiesis.

Bicalutamide dosages used in the treatment of prostate cancer

BACKGROUND

Androgen deprivation is often used for the treatment of patients with prostate cancer. Androgen deprivation can be achieved by surgical castration or medical castration, with or without using an antiandrogen. Each of these treatments may be used alone, or an antiandrogen may be used alongside castration to produce combined androgen blockade therapy.

METHODS

The nonsteroidal antiandrogen, bicalutamide (Casodex), has been evaluated as a component in combined androgen blockade and as monotherapy. We review the arguments that indicate why a 50-mg once-daily dose of bicalutamide is appropriate in combined androgen blockade, while ongoing clinical trials evaluate 150-mg once-daily as monotherapy in the treatment of prostate cancer.

RESULTS

The choice of the 50-mg dose of bicalutamide when used in combined androgen blockade is supported by four main arguments. First, bicalutamide 50 mg is at least equivalent to, if not better than, flutamide 750 mg in terms of receptor affinity, potency, and favorable plasma concentration profile. Second, the reduction in testosterone concentrations produced by medical or surgical castration decreases the potential competition between bicalutamide and testosterone for androgen receptors in prostate cells, allowing the use of a lower dose of antiandrogen in combined androgen blockade than is necessary in monotherapy. Third, bicalutamide 50 mg has an excellent tolerability profile. Fourth, at the 50-mg dose, bicalutamide plus luteinizing hormone-releasing hormone analogue was equivalent to flutamide plus luteinizing hormone-releasing hormone analogue, although there was a trend towards longer survival with bicalutamide. Furthermore, investigations of higher doses of bicalutamide have justified evaluation of bicalutamide 150 mg as monotherapy. First, pharmacodynamic studies reveal an increasing prostate-specific antigen response with increasing dose, which appears to plateau at a dose of around 150-200 mg. Second, in an analysis with 31% mortality, bicalutamide 150 mg appeared to have equivalent efficacy compared with castration in terms of survival in patients with nonmetastatic prostate cancer.

CONCLUSIONS

On the basis of available data, bicalutamide 50 mg is an appropriate dose to use in combined androgen blockade, while 150 mg is being evaluated in ongoing clinical trials as a suitable dose for monotherapy.

A viral mechanism for inhibition of p300 and PCAF acetyltransferase activity

Nucleosomal histone modification is believed to be a critical step in the activation of RNA polymerase II-dependent transcription. p300/CBP and PCAF histone acetyltransferases (HATs) are coactivators for several transcription factors, including nuclear hormone receptors, p53, and Stat1alpha, and participate in transcription by forming an activation complex and by promoting histone acetylation. The adenoviral E1A oncoprotein represses transcriptional signaling by binding to p300/CBP and displacing PCAF and p/CIP proteins from the complex. Here, we show that E1A directly represses the HAT activity of both p300/CBP and PCAF in vitro and p300-dependent transcription in vivo. Additionally, E1A inhibits nucleosomal histone modifications by the PCAF complex and blocks p53 acetylation. These results demonstrate the modulation of HAT activity as a novel mechanism of transcriptional regulation.

DAN is a secreted glycoprotein related to Xenopus cerberus

We report that DAN, a potential cell cycle regulator and tumour suppressor, is a secreted glycoprotein related to Xenopus cerberus. DAN, cerberus, its mouse relative Cer-1/cer-l/Cerberus-like/Cerr1, and the recently described factor DRM/Gremlin, appear to be members of the cystine knot superfamily, which includes TGFbetas and BMPs. Like cerberus and mCer-1, DAN-induced cement glands as well as markers of anterior neural tissue and endoderm in Xenopus animal cap assays, features of BMP signalling blockade. During mouse embryogenesis, Dan was expressed from E8.5 in cranial mesenchyme and somites, then later in limb and facial mesenchyme. The pattern in somites was highly dynamic, with transcripts initially localized to the caudal half of the nascent epithelial somite, then, after maturation, to sclerotomal cells adjacent to the neural tube. Dan was also expressed in the developing myotome. The expression domains include sites in which BMP inhibition is known to be important for development. Thus, DAN appears to be a secreted factor belonging to the cystine knot superfamily, and one of a growing number of antagonists acting to modulate BMP signalling during development.

Murine cerberus homologue mCer-1: a candidate anterior patterning molecule

Xenopus cerberus (Xcer) is a cytokine expressed in anterior mesendoderm overlapping and surrounding Spemann's gastrula organiser. When misexpressed in blastomeres, Xcer can induce ectopic heads with well-defined brain, cement gland, olfactory placodes, cyclopic eye, and occasionally liver and heart. We report here the identification of mCer-1, a murine gene related to cerberus. Both mCer-1 and Xcer appear to belong to the cystine knot superfamily, which includes TGF beta s and BMPs. In Xenopus animal cap assays, mCer-1 and Xcer induced cement glands and markers of anterior neural tissue and endoderm, characteristic of BMP inhibition. Furthermore, both antagonised the ventrolateral mesoderm-inducing activity of coexpressed BMP4. In mouse embryos, mCer-1 was expressed at early gastrulation in a stripe of primitive endoderm along the future anterior side of the egg cylinder, a region essential for anterior patterning. A second phase of expression was detected in anterior embryonic mesendoderm, and by late-streak stages most of the anterior half of the embryo was positive, except for the node and cardiac progenitors. Expression was later seen in the cranial portion of the two most-recently formed somites and in two stripes within presomitic mesoderm. In embryos lacking Otx2, a homeogene with a demonstrated role in anterior patterning, mCer-1 was still expressed in an anterior zone, although often abnormally. The data suggest that mCer-1 shares structural, functional, and expression characteristics with Xcer and may participate in patterning the anterior of the embryo and nascent somite region, in part, through a BMP-inhibitory mechanism.

Evaluation of an ultrasonically guided venepuncture technique for the placement of permanent pacing electrodes

We have evaluated a method of puncturing the subclavian vein in its extrathoracic portion using an ultrasound guidance system. Seventy consecutive patients requiring permanent pacemakers were included in the study. The method was successful in 56 (80%) cases (23 dual chamber systems) and unsuitable or unsuccessful in 14 (20%) cases (2 dual chamber systems). The time taken to achieve a successful cannulation of the vein was similar to that taken with conventional subclavian venepuncture (average time taken for each venepuncture was 31 seconds, range 5-130 seconds). There was a significant "learning curve" in that nearly all of the unsuccessful cases were in the first half of the series. There were no major complications. Computerized Tomography (CT) confirms that the point of entry into the subclavian vein using this technique lies outside the thoracic cavity, thereby minimizing the risk of pneumothorax. This approach to the subclavian vein is an easy technique to learn, with few immediate complications and there may be less chance of lead fracture due to subclavian crush in the longer term.