Remote consultations in community mental health: A qualitative study of clinical teams

WHAT IS KNOWN ON THE SUBJECT?: Mental health care can be delivered remotely through video and telephone consultations. Remote consultations may be cheaper and more efficient than in person consultations.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Accessing community mental health care through remote consultations is perceived as not possible or beneficial for all service users. Delivering remote consultations may not be practical or appropriate for all clinicians or community mental health teams. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Remote consultation cannot be a 'one-size-fits-all' model of community mental health care. A flexible approach is needed to offering remote consultation that considers its suitability for the service-user, service and clinician.

ABSTRACT

INTRODUCTION: Responding to COVID-19, community mental health teams in the UK NHS abruptly adopted remote consultations. Whilst they have demonstrable effectiveness, efficiency, and economic benefits, questions remain around the acceptability, feasibility and medicolegal implications of delivering community mental health care remotely.

AIM

To explore perceived advantages, challenges, and practice adaptations of delivering community mental health care remotely.

METHODS

Ten community mental health teams in an NHS trust participated in a service evaluation about remote consultation. Fifty team discussions about remote consultation were recorded April-December 2020. Data analysis used a framework approach with themes being coded within a matrix.

RESULTS

Three major horizontal themes of operations and team functioning, clinical pathways, and impact on staff were generated, with vertical themes of advantages, challenges, equity and adaptations.

DISCUSSION

Remote consultation is an attractive model of community mental healthcare. Clinical staff note benefits at individual (staff and service-user), team, and service levels. However, it is not perceived as a universally beneficial or practical approach, and there are concerns relating to access equality.

IMPLICATIONS FOR PRACTICE

The suitability of remote consultation needs to be considered for each service-user, clinical population and clinical role. This requires a flexible and hybrid approach, attuned to safeguarding equality.

Reflections on the experiences of attending peer support groups for fathers of children with cancer

Fathers appear to be less researched than mothers, in particular with regard to their emotional well-being during their child's cancer diagnosis and treatment. This study investigates a small-scale service evaluation of a father's support group for fathers of children with cancer in a paediatric oncology and haematology service. The group was set up in October 2017 to enable a safe and supportive reflective space for fathers of children with cancer. The group was open to fathers with a child on the ward on treatment, as well as fathers with children out of treatment, and in remission in the community. Data were analysed using Interpretive Phenomenological Analysis. A number of themes are identified and discussed, including the emotional impact, ways of coping, gender roles, loss and feeling part of an oncology family. The fathers valued hearing each other's stories about their child's cancer diagnosis and experiences as this appeared to empower them in helping each other to feel a sense of normalisation for their feelings. They appreciated the group structure and discussed further ways for group improvement. Suggestions are made for developing services to meet emotional support needs of fathers of children with cancer.

Human HtrA, an evolutionarily conserved serine protease identified as a differentially expressed gene product in osteoarthritic cartilage

The human homologue of the Escherichia coli htrA gene product was identified by the differential display analysis of transcripts expressed in osteoarthritic cartilage. This transcript was identified previously as being repressed in SV40-transformed fibroblasts (Zumbrunn, J., and Trueb, B. (1996) FEBS Lett. 398, 187-192). Levels of HtrA mRNA were elevated approximately 7-fold in cartilage from individuals with osteoarthritis compared with nonarthritic controls. Differential expression of human HtrA protein was confirmed by an immunoblot analysis of cartilage extracts. Human HtrA protein expressed in heterologous systems was secreted and exhibited endoproteolytic activity, including autocatalytic cleavage. Conversion by mutagenesis of the putative active site serine 328 to alanine eliminated the enzymatic activity. Serine 328 was also found to be required for the formation of a stable complex with alpha1-antitrypsin. We have determined that the HtrA gene is highly conserved among mammalian species: the amino acid sequences encoded by HtrA cDNA clones from cow, rabbit, and guinea pig are 98% identical to human. In E. coli, a functional htrA gene product is required for cell survival after heat shock or oxidative stress; its role appears to be the degradation of denatured proteins. We propose that mammalian HtrA, with the addition of a new functionality during evolution, i.e. a mac25 homology domain, plays an important role in cell growth regulation.

Regulation of c-fos expression in transgenic mice requires multiple interdependent transcription control elements

Transcription control regions of eukaryotic genes contain multiple sequence elements proposed to function independently to regulate transcription. We developed transgenic mice carrying fos-lacZ fusion genes with clustered point mutations in each of several distinct regulatory sequences: the sis-inducible element, the serum response element, the fos AP-1 site, and the calcium/cAMP response element. Analysis of Fos-lacZ expression in the CNS and in cultured cells demonstrated that all of the regulatory elements tested were required in concert for tissue- and stimulus-specific regulation of the c-fos promoter. This implies that the regulation of c-fos expression requires the concerted action of multiple control elements that direct the assembly of an interdependent transcription complex.

Fos is a preferential target of glucocorticoid receptor inhibition of AP-1 activity in vitro

Several regulatory interactions between the AP-1 and the nuclear hormone receptor families of transcription factors have been reported. However, the molecular mechanisms that underlie these interactions remain unknown, and models derived from transient-transfection experiments are contradictory. We have investigated the effect of the purified glucocorticoid receptor (GR) DNA-binding domain (GR residues 440 to 533 [GR440-533]) on DNA binding and transcription activation by Fos-Jun heterodimers and Jun homodimers. GR440-533 differentially inhibited DNA binding and transcription activation by Fos-Jun heterodimers. Inhibition of Jun homodimers required a 10-fold-higher concentration of GR440-533. An excess of Fos monomers protected Fos-Jun heterodimers from inhibition by GR440-533. Surprisingly, regions outside the leucine zipper and basic region were required for GR inhibition of Fos and Jun DNA binding. The region of GR440-533 required for inhibition of Fos-Jun DNA binding was localized to the zinc finger DNA-binding domain. However, inhibition of Fos-Jun DNA binding was independent of DNA binding by GR440-533. GR440-533 also differentially inhibited Fos-Jun heterodimer binding to the proliferin plfG element. Differential inhibition of DNA binding by different AP-1 family complexes provides a potential mechanism for the diverse interactions between nuclear hormone receptors and AP-1 family proteins at different promoters and in different cell types.

Jun is phosphorylated by several protein kinases at the same sites that are modified in serum-stimulated fibroblasts

c-jun is a member of the family of immediate-early genes whose expression is induced by factors such as serum stimulation, phorbol ester, and differentiation signals. Here we show that increased Jun synthesis after serum stimulation is accompanied by a concomitant increase in phosphorylation. Several serine-threonine kinases were evaluated for their ability to phosphorylate Jun in vitro. p34cdc2, protein kinase C, casein kinase II, and pp44mapk phosphorylated Jun efficiently, whereas cyclic AMP-dependent protein kinase and glycogen synthase kinase III did not. The sites phosphorylated by p34cdc2 were similar to those phosphorylated in vivo after serum induction. The major sites of phosphorylation were mapped to serines 63, 73, and 246. Phosphorylation of full-length Jun with several kinases did not affect the DNA-binding activity of Jun homodimers or Fos-Jun heterodimers. Comparison of the DNA binding and in vitro transcription properties of wild-type and mutated proteins containing either alanine or aspartic acid residues in place of Ser-63, -73, and -246 revealed only minor differences among homodimeric complexes and no differences among Fos-Jun heterodimers. Thus, phosphorylation of Jun did not produce a significant change in dimerization, DNA-binding, or in vitro transcription activity. The regulatory role of phosphorylation in the modulation of Jun function is likely to be considerably more complex than previously suggested.

fos-lacZ transgenic mice: mapping sites of gene induction in the central nervous system

A transgenic mouse line containing a fos-lacZ fusion gene was derived in which beta-galactosidase activity identified cell populations expressing fos either constitutively or after stimulation. Seizures and light pulses induced nuclear lacZ activity in defined populations of neurons in vivo, and an array of neurotransmitters, including glutamate, induced the transgene in primary brain cultures. In unstimulated mice, the major sites of fos-lacZ expression were skin, hair follicle, and bone. fos-lacZ mice provide a new avenue for activity mapping studies based on gene expression.

Transcriptional regulation by Fos and Jun in vitro: interaction among multiple activator and regulatory domains

The proteins encoded by the proto-oncogenes c-fos and c-jun (Fos and Jun, respectively) form a heterodimeric complex that regulates transcription by interacting with the DNA-regulatory element known as the activator protein 1 (AP-1) binding site. Fos and Jun are members of a family of related transcription factors that dimerize via a leucine zipper structure and interact with DNA through a bipartite domain formed between regions of each protein that are rich in basic amino acids. Here we have defined other domains in the Fos-Jun heterodimer that contribute to transcriptional function in vitro. Although DNA-binding specificity is mediated by the leucine zipper and basic regions, Jun also contains a proline- and glutamine-rich region that functions as an ancillary DNA-binding domain but does not contribute directly to transcriptional activation. Transcriptional stimulation in vitro was associated with two regions in Fos and a single N-terminal activation domain in Jun. These activator regions were capable of operating independently; however, they appear to function cooperatively in the heterodimeric complex. The activity of these domains was modulated by inhibitory regions in Fos and Jun that repressed transcription in vitro. In the context of the heterodimer, the Jun activation domain was the major contributor to transcriptional stimulation and the inhibitory regions in Fos were the major contributors to transcriptional repression in vitro. Potentially, the inhibitory domains could serve a regulatory function in vivo. Thus, transcriptional regulation by the Fos-Jun heterodimer results from a complex integration of multiple activator and regulatory domains.

Regulation of a fos-lacZ fusion gene: a paradigm for quantitative analysis of stimulus-transcription coupling

Expression of the c-fos protooncogene is induced by a great variety of extracellular stimuli. A fos-lacZ fusion gene has been constructed that recapitulates this regulation. The fos-lacZ gene was introduced into B104 neuroblastoma cells for use in a quantitative assay for stimulus-transcription coupling. Both alpha- and beta-adrenergic agonists, dibutyryl cAMP, and phorbol ester induced beta-galactosidase activity in a dose-dependent manner. Thus, the interactions of receptors with agonists and antagonists, as well as intracellular second messenger-mediated signaling events, can be analyzed quantitatively. This approach represents a prototypic method for investigating stimulus-response coupling based upon gene expression.

A ubiquitous nuclear protein stimulates the DNA-binding activity of fos and jun indirectly

The protooncogenes c-fos and c-jun encode nuclear proteins (fos and jun, respectively) that function cooperatively as a heterodimeric protein complex in the regulation of gene transcription. These proteins dimerize via a structural motif known as the leucine zipper and bind to activator protein-1 sites via a conserved domain that is rich in basic amino acids. Previously, we demonstrated that while fos and jun polypeptides expressed in Escherichia coli dimerize efficiently, they exhibit only a low level of DNA-binding activity. Here we show that the DNA-binding activity of fos-jun heterodimers and jun-jun homodimers is stimulated dramatically by a ubiquitous nuclear protein. This protein does not appear to participate in the DNA-protein complex, and it does not affect the specificity of the interaction with DNA. These results suggest that a nuclear protein regulates the DNA-binding activity of fos and jun indirectly.

Fos and jun cooperate in transcriptional regulation via heterologous activation domains

The products of c-fos and c-jun (Fos and Jun) function in gene regulation by interacting with the AP-1 binding site. Here we have examined the contribution of Fos and Jun toward transcriptional activity by using Fos and Jun polypeptides purified from Escherichia coli. Fos contained a transcriptional activation domain as well as a region which exerted a negative influence on transcriptional activity in vitro. Moreover, distinct activation domains in both Fos and Jun functioned cooperatively in transcriptional stimulation. Thus, regulation of gene expression by Fos and Jun results from an integration of several functional domains in a bimolecular complex.

Nucleotide sequence analysis of the L gene of vesicular stomatitis virus (New Jersey serotype): identification of conserved domains in L proteins of nonsegmented negative-strand RNA viruses

We have determined the nucleotide sequence of the L gene of vesicular stomatitis virus (VSV), New Jersey serotype (Ogden strain) by primer extension dideoxy sequencing of the genomic RNA with reverse transcriptase. This analysis completes the entire genomic sequence of the VSVNJ (Ogden). Comparison of the deduced amino acid sequence of this L protein with those reported for L proteins of Indiana serotype and Hazelhurst strain of New Jersey serotype revealed an extensive sequence similarity among all three proteins. The comparison was further extended to the L proteins of other nonsegmented negative-strand RNA viruses, namely the rabies virus and four members of the paramyxovirus family: measles, Newcastle disease, human parainfluenza 3, and Sendai viruses. Our findings confirmed the existence of conserved as well as unique domains in the L proteins, suggesting an evolutionary relationship among these viruses.

Expression and purification of the leucine zipper and DNA-binding domains of Fos and Jun: both Fos and Jun contact DNA directly

The protein products of the fos and jun protooncogenes interact cooperatively in the form of a heterodimer with the activator protein 1 (AP-1) regulatory element. To characterize the properties of these proteins, we have expressed polypeptides comprised of the dimerization and DNA-binding domains of Fos and Jun in Escherichia coli. The mini-Fos (wbFos) and the mini-Jun (wbJun) proteins were purified to apparent homogeneity by using a nickel affinity chromatography procedure. Purified wbFos and wbJun associated rapidly in vitro and interacted cooperatively with the human metallothionein IIA AP-1-binding site. However, efficient DNA binding of wbJun and wbFos-wbJun complexes required an additional activity present in nuclear extracts. This activity was sensitive to alkylating agents and could be partially mimicked by the presence of reducing and stabilizing agents. DNase I footprinting experiments demonstrated that Jun homodimeric complexes and Fos-Jun heterodimeric complexes interacted with the same site on the human metallothionein IIA gene. Moreover, UV-crosslinking studies demonstrated that Fos and Jun contact DNA directly and that both proteins interacted equivalently with either strand of the AP-1-binding site.

Sensitivity to bleomycin and hydrogen peroxide of DNA repair-defective mutants in Neurospora crassa

Mutations were induced in Neurospora which cause increased sensitivity to MMS (methyl methane-sulfonate) and other mutagens. Genetic analysis of such mus demonstrated that some of them defined new DNA repair genes (mus-21, and mus-27 to mus-30), while others represented new alleles in previously known genes. To characterize them further, and especially to identify rec- types which have not yet been found in this species, many MMS-sensitive strains were tested for cross-sensitivities to bleomycin (BLM) and to hydrogen peroxide (H2O2) to which some rec- of other species are hypersensitive. In Neurospora, many of the MMS-sensitive mutants were found to be cross-sensitive to BLM and frequently these were also hypersensitive to ionizing radiation. Bleomycin sensitivity was demonstrated for all alleles of 10 different genes, 4 of them new ones, with mus-27 being the most sensitive of the latter (resembling uvs-6; Koga and Schroeder, 1987, Mutation Res., 183, 139). In contrast, very few of the MMS-sensitive mutants were hypersensitive to H2O2 and, in general, results of H2O2 tests were variable and differences between strains small. However, consistent deviations from wild type were observed in a few cases (most clearly for mus-9 and mus-11) when results from treatments of germinating conidia were compared with those of non-growing ones.

Intergenic sequences of the vesicular stomatitis virus genome (New Jersey serotype): evidence for two transcription initiation sites within the L gene

The intergenic sequences of vesicular stomatitis virus of the New Jersey serotype [VSV (NJ): Ogden strain] have been determined by dideoxy sequencing across the gene junctions of the viral RNA genome using deoxyoligonucleotide primers. The N-NS, NS-M, and M-G intergenic sequences of VSV (NJ) are identical to the consensus intergenic sequence for VSV of the Indiana serotype [VSV (IND)]: 3'-AUACU7GAUUGUCNNNAG-5' (genome sense; N denotes any nucleotide), where 3'-AUACU7-5' encodes the 3' terminus and the start of the polyadenylate tract of the preceding mRNA, 3'-UUGUCNNNAG-5' encodes the 5' terminus of the succeeding mRNA, and 3'-GA-5' is a nontranscribed dinucleotide. Notably, the NS-M junction of VSV (NJ) does not contain the anomalous dinucleotide 3'-CA-5' which is found at the NS-M junction of VSV (IND). In striking contrast to VSV (IND), the G-L intergenic sequence of VSV (NJ) contains a 19-base insertion between the nontranscribed dinucleotide and the consensus mRNA start sequence. During in vitro transcription, the L mRNA of VSV (NJ) may initiate at two distinct sites: the first start site (3'-CCUUAUCUUC-5') is that flanking the nontranscribed dinucleotide, and the second start site is a consensus mRNA start sequence located 20 bases downstream from the nontranscribed dinucleotide. However, the L mRNA isolated form VSV (NJ)-infected cells appears to initiate only at the consensus start sequence. The possible role of these start sites in L mRNA synthesis is discussed.

Complete nucleotide sequence of the matrix protein mRNA and three intergenic junctions of human parainfluenza virus type 3

The complete sequence of the gene encoding the matrix protein (M) of human parainfluenza virus type 3 (PIV-3) was determined from cDNA clones and from primer extension dideoxy sequencing of the viral genome. The M mRNA is 1150 nucleotides in length, exclusive of polyadenylate, and codes for a protein of 353 amino acids, having a calculated molecular weight of 39,480. The M protein of PIV-3 was found to have a high degree of sequence homology with that of a closely related paramyxovirus, Sendai virus, and to a lesser extent it contained sequence homology with two more distant paramyxoviruses, measles virus and canine distemper virus. We also determined the sequences of the intergenic junctions for the first four genes of PIV-3: NP, P, M, and F. Comparison of these sequences yielded a consensus mRNA start sequence of 5'-AGGANNAAAGA-3', an mRNA end sequence of 5'-UAAGAAAAA-3', and an intergenic sequence of 5'-CUU-3'. The end sequence of the M gene is unusual in that it contains an eight base insertion prior to the A5 tract found in the consensus sequence. This disruption appears to cause a high frequency of readthrough by the viral transcriptase at this junction.

Messenger RNA encoding the phosphoprotein (P) gene of human parainfluenza virus 3 is bicistronic

The complete nucleotide sequence of the phosphoprotein (P) mRNA of human parainfluenza virus 3 (PIV-3) was derived from two cDNA clones spanning almost the entire P gene. The mRNA, excluding the poly(A) tail, is 2014 nucleotides long and is bicistronic. The first open reading frame (ORF) codes for the phosphoprotein (P) of mol wt 68,860. Seven nucleotides downstream from the first AUG codon, in a +1 reading frame, there is an additional ORF which can code for a polypeptide of mol wt 23,266. The latter protein appears to be similar to the C proteins found in cells infected with several paramyxoviruses. Comparison of the predicted amino acid sequence of the P and C proteins of PIV-3 with the corresponding Sendai virus proteins reveals considerable homology at the C-terminal half. In contrast, the P and C proteins of PIV-3 share very little homology with the measles virus P and C proteins, respectively.

Purified matrix protein of vesicular stomatitis virus blocks viral transcription in vitro

One of the major structural proteins of vesicular stomatitis virus is a small, nonglycosylated, matrix protein which associates with the nucleocapsid core during final stages of morphogenesis and budding. Biochemical and genetic studies suggested that the matrix protein regulates RNA synthesis both in vitro and in vivo. We have purified biologically active matrix protein from the virus and have directly shown that it significantly inhibits RNA synthesis in vitro mediated by the virion-associated RNA polymerase at low ionic strength (0.02 M). The inhibition was greater than 80% when the ratio of matrix protein to the major nucleocapsid protein in the transcribing complex was 2:1 (wt/wt). The inhibition was found to be at the level of RNA chain elongation and not at the initiation step. Electron microscopic studies revealed that inhibition of transcription by matrix protein was accompanied by a profound structural change of the transcribing nucleocapsid from an extended structure to a highly compact form. At higher ionic strength (0.12 M), the matrix protein failed to interact with the nucleocapsid. The matrix protein appears to be involved in condensing the nucleocapsid and blocking transcription during maturation of the virus particle.

Genetic recombination in avian retroviruses

The avian retroviruses--and probably other retroviruses as well--undergo a variety of recombinational events with relatively high efficiency. An understanding of the molecular basis of these events should provide insight into the important biological properties these agents exhibit when they become integrated into somatic or germ-line host cells, when they exchange genetic information among themselves, or when they transduce host cell genes. In this article we review molecular models for homologous recombination, against a background of the other types of recombination events that are typical of these viruses. It seems probable that the retroviruses will provide useful models for analysis of a variety of DNA rearrangements known to occur in eukaryotic cells.

Cortical thickness measurements and photon absorptiometry for determination of bone quantity

Reproducibility of estimates of cortical bone quantity in the appendicular skeleton by two methods was studied in healthy individuals and patients undergoing long-term hemodialysis. Repeated measurements of cortical thickness (CT) at the midpoint of the second metacarpal were taken from single radiographs of both hands by two independent observers. Repeated measurements by the same observer were more reproducible and the degree of reproducibility was far greater in healthy subjects than in dialysis patients. Repeated measurements were made of bone mineral content (BMC) and bone width (W) of the distal radius by photon absorptiometry. Repeated BMC/W determinations were highly reproducible in both healthy subjects and dialysis patients. High correlation was found between BMC and cross-sectional cortical area and between both simple cortical thickness and cortical area/width. Thus the photon absorptiometric technique is superior for the serial monitoring of bone quantity, particularly in patients with uremic osteodystrophy, but results obtained by the two methods in group studies should be comparable.

Large-scale production of lambda bacteriophage and purified lambda deoxyribonucleic acid

Large amounts of a heat-inducible phage lambda mutant (lambdaCI857) may be obtained under standardized conditions. The phage is harvested by simple polyethylene glycol (C 6000) precipitation and purified by CsCl density gradient banding. Deoxyribonucleic acid (DNA) is extracted by cold phenol and purified by sucrose density gradient sedimentation to yield a homogenous population of unbroken lambda DNA molecules.