Exploring the Incorporation of a Novel Cardiotoxicity Mobile Health App Into Care of Patients With Cancer: Qualitative Study of Patient and Provider Perspectives

BACKGROUND

Cardiotoxicity is a limitation of several cancer therapies and early recognition improves outcomes. Symptom-tracking mobile health (mHealth) apps are feasible and beneficial, but key elements for mHealth symptom-tracking to indicate early signs of cardiotoxicity are unknown.

OBJECTIVE

We explored considerations for the design of, and implementation into a large academic medical center, an mHealth symptom-tracking tool for early recognition of cardiotoxicity in patients with cancer after cancer therapy initiation.

METHODS

We conducted semistructured interviews of >50% of the providers (oncologists, cardio-oncologists, and radiation oncologists) who manage cancer treatment-related cardiotoxicity in the participating institution (n=11), and either interviews or co-design or both with 6 patients. Data were coded and analyzed using thematic analysis.

RESULTS

Providers indicated that there was no existing process to enable early recognition of cardiotoxicity and felt the app could reduce delays in diagnosis and lead to better patient outcomes. Signs and symptoms providers recommended for tracking included chest pain or tightness, shortness of breath, heart racing or palpitations, syncope, lightheadedness, edema, and excessive fatigue. Implementation barriers included determining who would receive symptom reports, ensuring all members of the patient's care team (eg, oncologist, cardiologist, and primary care) were informed of the symptom reports and could collaborate on care plans, and how to best integrate the app data into the electronic health record. Patients (n=6, 100%) agreed that the app would be useful for enhanced symptom capture and education and indicated willingness to use it.

CONCLUSIONS

Providers and patients agree that a patient-facing, cancer treatment-related cardiotoxicity symptom-tracking mHealth app would be beneficial. Additional studies evaluating the role of mHealth as a potential strategy for targeted early cardioprotective therapy initiation are needed.

First Measurement of the Nuclear-Recoil Ionization Yield in Silicon at 100 eV

We measured the nuclear-recoil ionization yield in silicon with a cryogenic phonon-sensitive gram-scale detector. Neutrons from a monoenergetic beam scatter off of the silicon nuclei at angles corresponding to energy depositions from 4 keV down to 100 eV, the lowest energy probed so far. The results show no sign of an ionization production threshold above 100 eV. These results call for further investigation of the ionization yield theory and a comprehensive determination of the detector response function at energies below the keV scale.

Constraints on Lightly Ionizing Particles from CDMSlite

The Cryogenic Dark Matter Search low ionization threshold experiment (CDMSlite) achieved efficient detection of very small recoil energies in its germanium target, resulting in sensitivity to lightly ionizing particles (LIPs) in a previously unexplored region of charge, mass, and velocity parameter space. We report first direct-detection limits calculated using the optimum interval method on the vertical intensity of cosmogenically produced LIPs with an electric charge smaller than e/(3×10^{5}), as well as the strongest limits for charge ≤e/160, with a minimum vertical intensity of 1.36×10^{-7}  cm^{-2} s^{-1} sr^{-1} at charge e/160. These results apply over a wide range of LIP masses (5  MeV/c^{2} to 100  TeV/c^{2}) and cover a wide range of βγ values (0.1-10^{6}), thus excluding nonrelativistic LIPs with βγ as small as 0.1 for the first time.

Light Dark Matter Search with a High-Resolution Athermal Phonon Detector Operated above Ground

We present limits on spin-independent dark matter-nucleon interactions using a 10.6 g Si athermal phonon detector with a baseline energy resolution of σ_{E}=3.86±0.04(stat)_{-0.00}^{+0.19}(syst)  eV. This exclusion analysis sets the most stringent dark matter-nucleon scattering cross-section limits achieved by a cryogenic detector for dark matter particle masses from 93 to 140  MeV/c^{2}, with a raw exposure of 9.9 g d acquired at an above-ground facility. This work illustrates the scientific potential of detectors with athermal phonon sensors with eV-scale energy resolution for future dark matter searches.

Venetoclax, bendamustine, and rituximab in patients with relapsed or refractory NHL: a phase Ib dose-finding study

Background

Venetoclax is a selective, potent inhibitor of the anti-apoptotic B-cell leukemia/lymphoma-2 protein approved for treatment of chronic lymphocytic leukemia. We conducted a dose-finding study of venetoclax in combination with bendamustine-rituximab (BR) in patients with relapsed/refractory non-Hodgkin's lymphoma (NHL).

Patients and methods

BR was given for six cycles at standard doses. Intermittent and continuous oral venetoclax administration was explored at 50-1200 mg daily doses. Co-primary objectives included safety, pharmacokinetics (PKs), maximum-tolerated dose (MTD), and recommended phase II dose (RP2D); secondary objective was preliminary efficacy.

Results

Sixty patients were enrolled: 32 with follicular lymphoma, 22 with diffuse large B-cell lymphoma, and 6 with marginal zone lymphoma. Nausea (70%), neutropenia (68%), diarrhea (55%), and thrombocytopenia (52%) were the most frequent adverse events (AEs). Most common grade 3/4 AEs were neutropenia (60%) and lymphopenia (38%). Serious AEs were reported in 24 patients; the most frequent were febrile neutropenia and disease progression (8% each). Five patients died from either disease progression (n = 4) or respiratory failure (n = 1). MTD was not reached; RP2D for venetoclax-BR combination was established as 800 mg daily continuously. Venetoclax PK exposure with and without BR was comparable. For all patients, overall response rate was 65%. Median duration of overall response, overall survival, and progression-free survival was 38.3 months [95% confidence interval (CI) 10.4-NR], not yet reached, and 10.7 months (95% CI 4.3-21.0), respectively.

Conclusions

This study established the safety profile of venetoclax in combination with BR, and results demonstrated tolerability and preliminary efficacy of the combination. Additional follow-up is needed to better determine the future role of BR plus venetoclax in the treatment of relapsed/refractory B-cell NHL.

Trial registered

Clinicaltrials.gov, NCT01594229.

Modulation of pain via expectation of its location

BACKGROUND

The spatial precision of expectancy effects on pain is unclear. We hypothesized that expecting nociceptive stimuli at particular skin sites would have an analgesic effect on nociceptive stimuli presented between them (middle zone).

METHODS

Laser stimuli (evoking pin-prick pain) were delivered to three discrete skin zones on the forearm, under two conditions. During 'Localization', participants' expectation of stimuli was spatially divided between two locations (expected stimuli in only the outer two skin zones): pain intensity and stimulus location were judged. During 'No-localization' (control condition), participants had no expectation concerning stimulus location; only pain intensity was rated. Additional experiments assessed the importance of the actual location on the forearm by: shifting all skin zones proximally towards the elbow (control for joint proximity, Experiment 2); adding a fourth zone distally (control for interaction between joint proximity and enhanced distal inhibition, Experiment 3).

RESULTS

All experiments demonstrated spatially specific pain modulation, but only Experiment 2 (near elbow) supported our hypothesis: middle zone pain intensity was significantly lower (p = 0.02) during Localization than No-localization. Experiment 1 (near wrist) found reduced pain intensity during Localization only for the distal zone (p = 0.04). Experiment 3 confirmed this effect: reduced pain during Localization occurred only for the most distal zone (p = 0.046).

CONCLUSION

Expecting a painful stimulus in non-adjacent skin sites has spatially specific effects on pain modulation, but this reflects an interaction between the expected location of stimulation and the actual location. This suggests a more complex connection between somatotopic maps and nociceptive modulation than previously thought; several distinct mechanisms likely contribute.

Survival after pelvic lymphadenectomy and radical cystectomy in patients with lymph-node metastatic transitional-cell carcinoma of the bladder

The objective of this study was to determine the clinical outcome of patients with invasive transitional cell carcinoma of the bladder and pelvic lymph node metastases treated by radical cystectomy and bilateral pelvic lymphadenectomy in a single institution. From January 1980 to December 1993, 116 patients with transitional cell carcinoma of the bladder underwent bilateral pelvic lymphadenectomy and radical cystectomy at the Montreal General Hospital. Of these patients, 25 (21.6%) were found to have nodal metastases and form the basis of this retrospective analysis. Extent of nodal disease was as follows: 7 (28%) with N1, 17 (68%) with N2, and 1 (4%) patient with N3 disease. Of the 25 patients, 9 (36%) were alive with no evidence of disease and 1 (4%) died at 42 months from cardiovascular disease without clinical evidence of cancer recurrence. The median follow-up interval for these 10 patients was 26.5 months (mean, 31.4 months; range, 7-104 months). Fourteen (56%) patients died of recurrent bladder cancer and one patient was alive with systemic disease at 14 months. The median survival was estimated at 27 months, with 73% alive at 1 year, 51% alive at 2 years, and 33% alive at 3 years. Our data suggests that long-term survival free of disease can be achieved by radical surgery in some patients with node-positive bladder cancer.

MRI finding of a papillary muscle cyst: a differential diagnosis

Cystic lesions of the papillary muscle in the form of myxoma, hydatid cyst, papillary fibroelastoma, blood-filled cysts and endodermal heterotopia are rare causes of embolic stroke. In view of the potential complications caused by these lesions, surgery is often advocated but there is no consensus on which patients qualify. We examined a differential diagnosis of a papillary muscle cystic lesion in a patient presenting with features of embolic disease and identified the imaging features on MRI that directed management.

Psychotropic prescribing in HIV

Psychiatric disorders frequently co-occur with HIV, as preceding conditions or consequent to HIV infection. This potentially compromises HIV diagnosis and antiretroviral (ARV) treatment adherence. We provide a brief guide to the diagnosis and treatment of common mental disorders in people living with HIV/AIDS, including: prescribing psychotropics in HIV; neuropsychiatric side-effects of ARVs and other medications commonly prescribed in HIV; and the diagnosis and treatment of depression, anxiety, psychosis, agitation, sleep disturbance, pain, and mania. Psychotropic treatments recommended were drawn primarily from those available in the public sector of South Africa.

Putting sexuality (back) into HIV/AIDS: issues, theory and practice

After more than twenty years of programming and activism aimed at stemming the sexual transmission of HIV (and addressing the needs of those most vulnerable to infection) the HIV/AIDS epidemic continues to grow worldwide. Taking up this concern, this paper argues that one of the reasons why HIV prevention has had limited success is because of inadequate conceptualization of human sexuality in such work. Giving sexuality a more prominent position in responses to the epidemic raises a range of issues, including theorization of gender, understanding of sexual subjectivity, the significance of pleasure (or lack of pleasure) in sexual decision-making, and conceptualization of sexual behaviour and culture. Taking these themes forward entails asking significant questions about the underlying paradigmatic and methodological commitments of mainstream HIV/AIDS research, especially the tendency to reproduce accounts of human sexuality as if it were a measurable form of conduct only. Advocating new approaches that take the meaning and symbolic value of sexualities into account complicates established orthodoxies in the field whilst offering potential for more effective HIV prevention strategies.

A review on the genetics of otosclerosis

BACKGROUND

The aetiology of otosclerosis is not fully understood despite intensive research. It is, however, certain that a genetic component plays a significant role in the manifestation of otosclerosis, although the precise mode of inheritance is still uncertain.

OBJECTIVE OF REVIEW

To provide an up-to-date review for the genetics of otosclerosis. The mode of inheritance, chromosomal and linkage studies are presented. In addition, the possible genetic relationship between otosclerosis and osteogenesis imperfecta, and the association between otosclerosis and specific human leucocyte antigen types are described.

TYPE OF REVIEW

Systematic analysis of the literature was focused on any information related to the genetics of otosclerosis.

SEARCH STRATEGY

A MEDLINE search (1960-2007) was undertaken to perform a comprehensive review. Articles were also identified through searches of the files of authors.

RESULTS

The majority of epidemiological studies on families with otosclerosis suggest an autosomal dominant mode of inheritance with reduced penetrance of approximately 40%. Genetic linkage studies have demonstrated the presence of six loci (OTSC1, OTSC2, OTSC3, OTSC4, OTSC5 and OTSC7) located on chromosomes 15q, 7q, 6p, 16q, 3q and 6q respectively. Although these loci have been mapped, no causative genes have been identified, and we have little idea of the molecular process involved in this disease. While clinical similarities and some unreplicated genetic association studies suggest an aetiological relationship between otosclerosis and osteogenesis imperfecta-type I, there is no definite evidence of a common pathological process between the two diseases.

CONCLUSIONS

Otosclerosis may be considered as a complex disease with relatively common monogenic forms. Knowledge of these genes could lead to substantial improvements in our ability to diagnose and possibly even prevent or treat this type of hearing deterioration.

Brief smoking cessation advice from practice nurses during routine cervical smear tests appointments: a cluster randomised controlled trial assessing feasibility, acceptability and potential effectiveness

The aim of this study is to assess the potential effectiveness, acceptability and feasibility of a brief smoking cessation intervention delivered as part of cervical screening. A cluster randomised controlled trial was conducted with clinic week as the unit of randomisation, comparing a group (n=121) receiving brief smoking cessation advice supplemented with written information given by practice nurses during cervical smear test appointments, with a group (n=121) not receiving this advice. Outcomes were intention to stop smoking (potential effectiveness); intention to attend for future cervical screening (acceptability); duration of intervention (feasibility). 172/242 (71%) and 153/242 (63%) participants completed 2-week and 10-week follow-ups, respectively. Compared to women in the control group, those in the intervention group had higher intentions to stop smoking at 2-weeks (adjusted mean difference 0.51, 95% CI: -0.02 to 1.03, P=0.06) and 10-weeks (adjusted mean difference 0.80, 95% CI 0.10 to 1.50, P=0.03). The two groups had similarly high intentions to attend for future screening. Consultations in the intervention arm took a mean of 4.98 min (95% CI: 3.69 to 6.27; P<0.001) longer than the control arm. In conclusion, brief smoking cessation advice given by practice nurses as part of cervical screening seems acceptable, feasible and potentially effective. Evidence is lacking on the effectiveness and cost effectiveness of this intervention in achieving biochemically validated smoking cessation.

Biomass effects on oxygen transfer in membrane bioreactors

Ten biomass samples from both municipal and industrial pilot and full scale submerged membrane bioreactors (MBRs) with mixed liquor suspended solids concentrations (MLSS) ranging from 7.2 to 30.2g L(-1) were studied at six air-flow rates (0.7, 1.3, 2.3, 3, 4.4 and 6m(3)m(-3)h(-1)). Statistical analyses were applied to identify the relative impacts of the various bulk biomass characteristics on oxygen transfer. Of the biomass characteristics studied, only solids concentration (correlated with viscosity), the carbohydrate fraction of the EPS (EPS(c)) and the chemical oxygen demand (COD) concentration of the SMP (SMP(COD)) were found to affect the oxygen transfer parameters k(L)a(20) (the oxygen transfer coefficient) and alpha-factor. The relative influence on k(L)a(20) was MLSS>aeration>EPS(c)>SMP(COD) and on alpha-factor was MLSS>SMP(COD)>EPS(c)>aeration. Both k(L)a(20) and alpha-factor increased with increasing aeration and EPS(c) and decreased with increasing MLSS and SMP(COD). MLSS was found to be the main parameter controlling the oxygen transfer.

Anti-tumour activity in non-small cell lung cancer models and toxicity profiles for novel ruthenium(II) based organo-metallic compounds

Novel ruthenium(II) organo-metallic compounds are active in ovarian cancer models [Aird RE, Cummings J, Ritchie AA, Muir M, Morris RE, Chen H, et al. In vitro and in vivo activity and cross resistance profiles of novel ruthenium(II) organometallic arene complexes in human ovarian cancer. Br J Cancer 2002;86(10):1652-7]. [(eta6-C6H5C6H5)Ru(en)Cl]+ (as a PF6 salt, where en=ethylenediamine (RM175)) has been evaluated in a 13-cell line panel. Particular sensitivity (approximately 10-fold lower than mean IC50) was noted in breast cancer and non-small cell lung cancer cell lines. In addition, IC50 in the A549 was 2 microM and RM175 (25 mg kg-1, days 1 and 5, i.p.) caused a significant (p=0.004) growth delay in a xenograft model. HC11 [(eta6-tetrahydroanthracene)Ru(en)Cl]PF6 was more potent in the A549 cell line (IC50 0.5 microM). HC11 (25 mg kg-1, days 1, 8 and 15, i.p.) was also active in vivo. Following RM175 25 mg kg-1, days 1 and 5, and 15 mg kg-1, days 1-5, HC11 25 and 40 mg kg-1, day 1, elevated alanine transaminase levels were detected, suggesting hepatotoxicity. No changes were observed in kidney or haematological parameters. In liver sections, multi-focal hepatic necrosis was seen, becoming confluent at high doses of HC11. In vitro studies confirmed that HC11 was more toxic than RM175 to fresh human hepatocytes and equitoxic to mithramycin. Liver toxicity may be related to the arene ligand and modification may reduce the potential for hepatic toxicity, while maintaining the anti-tumour activity seen.

X-linked adrenoleukodystrophy presenting as autosomal dominant pure hereditary spastic paraparesis

We present a family in which an initial clinical diagnosis of autosomal dominant pure hereditary spastic paraparesis (HSP) was made on the basis of a three generation pedigree in which both males and females presented with a spastic paraparesis. Subsequent biochemical and genetic analysis revealed that the family was in fact affected by the adrenomyeloneuropathy subtype of X-linked adrenoleukodystrophy. In the family described, both males and females were affected by a spastic paraparesis, and there was no male to male transmission, consistent with both autosomal dominant and X-linked inheritance. This report illustrates the importance of assaying very long chain fatty acids (VLCFAs) in any HSP family where there is no male to male transmission.

Coeliac disease: investigation of proposed causal variants in the CTLA4 gene region

Coeliac disease (CD) is an immune-mediated enteropathy triggered by gluten in genetically predisposed individuals. Patients with CD have an increased prevalence of other autoimmune disorders, including type 1 diabetes (T1D) and Graves' disease (GD). CD shares with these conditions certain HLA susceptibility alleles. A number of studies have also shown association of autoimmune diseases, including CD, with the CD28-cytotoxic T lymphocyte antigen 4 (CTLA4)-inducible costimulator (ICOS) region of chromosome 2q33, but until recently the precise causal variant has remained unknown. Recently, it was shown that, in GD, CT60 (+6230G>A), a single nucleotide polymorphism (SNP) at the end of the CTLA4 transcript, is associated with an alteration in the ratio of splice forms of the CTLA4 gene and that this ratio affects disease susceptibility. A similar but weaker association was found with T1D. There is also an independent association of GD and T1D with the SNP MH30 (-23 327G>C), which possibly affects promoter region function. Hypothesizing that CT60 and MH30 may be causal variants in other autoimmune disorders, we investigated these SNPs in CD using 149 family trios and 100 unrelated/unaffected controls. No association was detected with either SNP using both the transmission disequilibrium test (TDT) and case-control methods. Our study appears to have good power to detect moderate genetic effects, but possibly these SNPs exert too weak an effect on risk of CD to have been detected in our sample. Alternatively, the previously noted association of CD with the CTLA4 gene region may be due to different causal variants. Unlike T1D and GD, CD is not a true autoimmune disease, and CD has different associations at the CTLA4 exon 1 SNP +49G>A from all other autoimmune disorders. MH30, CT60, and other SNPs in the region may still warrant further investigation in other CD samples.

Personal reflections of mental health nurses training to use Hobson's Conversational Model (psychodynamic-interpersonal) of psychotherapy

Current mental health policy documents highlight the need for mental health nurses to become increasingly involved in the delivery of evidence-based psychological interventions. However, substantial evidence exists indicating that there is a paucity of training to adequately equip nurses to deliver these interventions and, even when training is available, there are barriers to their implementation into routine clinical practice. This paper reports on the personal reflections and experiences of a group of four mental health nurses undertaking training in the Conversational Model of psychotherapy (also known as psychodynamic-interpersonal 'PI' psychotherapy). These reflections highlight the rewards and challenges arising from the effort to undertake training in an evidence-based model of psychological intervention and from attempting to implement and sustain this training into routine practice.

Practice development in psychological interventions: mental health nurse involvement in the Conversational Model of psychotherapy

This paper describes a mental health nurse led practice development initiative in psychotherapy. Four mental health nurses have been trained to deliver the Conversational Model of psychotherapy (also known as psychodynamic-interpersonal (PI) psychotherapy) a non-cognitive behavioural therapy (CBT) with a robust evidence base. We report on the robust range of both processes and outcome measures being used to evaluate this initiative. We conclude that good quality evidence-based practice requires careful planning and preparation, adequate financial resources from Trusts, as well as commitment and motivation from the staff expected to be involved in such initiatives.

Pseudo-isolated FSH deficiency caused by an inhibin B-secreting granulosa cell tumour: case report

Isolated FSH deficiency due to a mutation in the FSHbeta subunit is characterized by an extremely low serum FSH concentration. We report a patient who presented with an FSH of 0.8 mIU/ml and infertility associated with anovulation. Endocrinological assessment and immunohistochemistry revealed that a granulosa cell tumour was secreting inhibin B and suppressing FSH; however, LH and estradiol were within their normal ranges. Upon removal of the tumour, inhibin B decreased and FSH levels rose to normal values. The patient subsequently conceived and delivered successfully. Based on this case and on those previously described in the literature, we suggest that inhibin B levels should be evaluated in anovulatory patients having a clinical presentation consistent with functional hypothalamic amenorrhoea and very low to normal values of FSH.

Screening of patients with hereditary spastic paraplegia reveals seven novel mutations in the SPG4 (Spastin) gene

Hereditary spastic paraplegia (HSP) is a heterogeneous condition characterised in its pure form by progressive lower limb spasticity. Mutations in SPG4 (encoding spastin) may be responsible for up to 40% of autosomal dominant (AD) cases. A cohort of 41 mostly pure HSP patients from Britain and Austria, 30 of whom displayed AD inheritance, was screened for mutations in SPG4 by single strand conformation polymorphism (SSCP) analysis followed by sequencing of samples with mobility shifts. We identified eight SPG4 mutations in pure AD HSP patients, seven of which were novel: one missense mutation within the AAA cassette (1633G>T), two splice site mutations (1130-1G>T, 1853+2T>A) and four frameshift mutations (190_208dup19, 1259_1260delGT, 1702_1705delGAAG, 1845delG). A novel duplication in intron 11 (1538+42_45dupTATA) was also detected. We report the HUGO-approved nomenclature of these mutations as well. Furthermore, we detected a silent change (1004G>A; P293P), previously reported as a mutation, which was also present in controls. The frequency of SPG4 mutations detected in pure AD HSP was 33.3%, suggesting that screening of such patients for SPG4 mutations is worthwhile. Most patients will have unique mutations. Screening of SPG4 in apparently isolated cases of HSP may be of less value.

Science in motion: common molecular pathological themes emerge in the hereditary spastic paraplegias

The hereditary spastic paraplegias are a group of neurodegenerative conditions that all share the principal clinical feature of progressive lower limb spastic paralysis, caused by either failure of development or progressive degeneration of the corticospinal tract. The conditions are characterised by extreme genetic heterogeneity, with at least 20 genes involved. Until recently, no functional overlap was apparent in the associated molecular pathological mechanisms. However, with recent progress in hereditary spastic paraplegia gene identification, common pathological themes are now emerging.

Nursing at the edge of the world: nurses on St Kilda

In the early twenty-first century geographically isolated communities continue to experience unequal access to health care. The advent of new technologies such as telemedicine do not overcome the financial constraints of employing professionals such as health visitors or district nurses to meet the needs of these remote areas. In late nineteenth century Britain there were few more isolated communities than the St Kildans. Although it is 70 years since St Kilda was evacuated it continues to capture the popular imagination. This archipelago of islands lies less than 50 miles west of the Outer Hebrides yet remains inaccessible by sea except on the calmest of summer days. Isolation such as this may have been acceptable, even desirable, to the islanders for generations but became problematic with their increasing reliance on supply boats for food. As the population dwindled it became more difficult to be self-sufficient, with few able-bodied men to row to the nearby rocks and climb to harvest the seabirds that were their staple diet. The rocks, or stacs, as they are known, have sheer cliff faces rising spectacularly from the sea. It would be logical to assume that the population had difficulty expanding due to the high male mortality rate from accidents on the these pinnacles. But it was not the skillful rock climbers that were dying in large numbers, it was their babies. Sustained infant mortality rates of between 50-70 per cent during the nineteenth century contributed to the consistently low population levels which led to the eventual death of the community. It is surprising in this context to learn that the first nurses to serve the St Kildans were ostracised and rejected by the islanders.

Factors affecting how patients sleep in the hospital environment

Promoting an environment conductive to sleep in hospital is a challenge. Although patients may appear to sleep in hospital, it may not be refreshing or restorative. The reasons for this can be categorized into three groups: environmental, physiological and psychological. These factors can work concomitantly, making sleep virtually impossible for some patients. Nurses can help their patients by understanding what influences sleep patterns and acting on this knowledge. This may include a variety of interventions, from allowing patients to carry out their own bedtime routine, to explaining to elderly people how their sleeping patterns changes with age.

The Escherichia coli CcmG protein fulfils a specific role in cytochrome c assembly

In Escherichia coli K-12, c-type cytochromes are synthesized only during anaerobic growth with trimethylamine-N-oxide, nitrite or low concentrations of nitrate as the terminal electron acceptor. A thioredoxin-like protein, CcmG, is one of 12 proteins required for their assembly in the periplasm. Its postulated function is to reduce disulphide bonds formed between correctly paired cysteine residues in the cytochrome c apoproteins prior to haem attachment by CcmF and CcmH. We report that loss of CcmG synthesis by mutation was not compensated by a second mutation in disulphide-bond-forming proteins, DsbA or DsbB, or by the chemical reductant, 2-mercaptoethanesulphonic acid. An anti-CcmG polyclonal antibody was used in Western-blot analysis to probe the redox state of CcmG in mutants defective in the synthesis of other proteins essential for cytochrome c assembly. The oxidized form of CcmG accumulated not only in trxA or dipZ mutants defective in the transfer of electrons from the cytoplasm for disulphide isomerization and reduction reactions in the periplasm, but also in ccmF and ccmH mutants. The requirement of both CcmF and CcmH for the reduction of the disulphide bond in CcmG indicates that CcmG functions later than CcmF and CcmH in cytochrome c assembly, rather than in electron transfer from the membrane-associated DipZ (also known as DsbD) to CcmH. The data support a model proposed by others in which CcmG catalyses one of the last reactions specific to cytochrome c assembly.

Mutation analysis of the spastin gene (SPG4) in patients with hereditary spastic paraparesis

BACKGROUND

Hereditary spastic paraparesis is a genetically heterogeneous condition. Recently, mutations in the spastin gene were reported in families linked to the common SPG4 locus on chromosome 2p21-22.

OBJECTIVES

To study a population of patients with hereditary spastic paraparesis for mutations in the spastin gene (SPG4) on chromosome 2p21-22.

METHODS

DNA from 32 patients (12 from families known to be linked to SPG4) was analysed for mutations in the spastin gene by single strand conformational polymorphism analysis and sequencing. All patients were also examined clinically.

RESULTS

Thirteen SPG4 mutations were identified, 11 of which are novel. These mutations include missense, nonsense, frameshift, and splice site mutations, the majority of which affect the AAA cassette. We also describe a nucleotide substitution outside this conserved region which appears to behave as a recessive mutation.

CONCLUSIONS

Recurrent mutations in the spastin gene are uncommon. This reduces the ease of mutation detection as a part of the diagnostic work up of patients with hereditary spastic paraparesis. Our findings have important implications for the presumed function of spastin and schemes for mutation detection in HSP patients.

Prescribing costs. Braking point

A joint hospital, health authority and PCG initiative to improve prescribing has produced significant savings in the PCG involved. The venture included the appointment of a medicines management pharmacist to work with practices, and a survey to ascertain GPs' prescribing needs. GPs considered the most important issues to be developing local disease management guidelines, education and repeat prescribing. Guidelines on dyspepsia management have resulted in a 4.9 per cent reduction in the cost of prescribing gastrointestinal drugs. Antibiotic prescribing has also fallen.

A locus for autosomal dominant "pure" hereditary spastic paraplegia maps to chromosome 19q13

Genetic loci for autosomal dominant pure hereditary spastic paraplegia (ADPHSP) have been mapped to chromosomes 2p, 8q, 12q, 14q, and 15q. We undertook a genomewide linkage screen of a large family with ADPHSP, for which linkage at all previously identified ADPHSP loci was excluded. Analysis of markers on chromosome 19q gave a peak pairwise LOD score of 3.72 at D19S420, allowing assignment of a novel ADPHSP locus (which we have termed "SPG12") to this region. Haplotype construction and analysis of recombination events narrowed the SPG12 locus to a 16.1-cM region between markers D19S868 and D19S902.

Pulmonary embolism: an overview of treatment and nursing issues

Pulmonary embolism presents with a vague clinical picture. Pathophysiological effects vary from small pulmonary infarcts to life-threatening cardiogenic shock. Therefore, radiological investigation to confirm the diagnosis is required to institute appropriate treatment. This ranges from heparin therapy to surgical embolectomy. Care of this patient group requires vigilant nursing, because of not only the risk of further embolic episodes, but also the potential serious complications of treatment. Prevention of venous thromboembolism can be pharmacological or mechanical. The proactive role that nurses take in prevention of this potentially fatal disease process is often overlooked by the medical literature.

Autosomal dominant spastic paraplegia: refined SPG8 locus and additional genetic heterogeneity

OBJECTIVE

To map the gene responsible for autosomal dominant pure hereditary spastic paraplegia (ADPHSP) in a large affected family.

BACKGROUND

Autosomal dominant pure hereditary spastic paraplegia (ADPHSP) is genetically heterogeneous, and loci have been mapped at chromosomes 2p (SPG4), 14q (SPG3), 15q (SPG6), and recently, in a single family, at chromosome 8q24 (SPG8).

METHODS

The authors carried out a genomewide linkage screen on a large family with ADPHSP, for which linkage to the chromosome 2, 14, and 15 loci was excluded.

RESULTS

Analysis of markers on chromosome 8q24 gave a peak two-point lod score of 4.49 at marker D8S1799. Analysis of recombination events in this family and in the previously published SPG8-linked family narrowed the SPG8 locus from 6.2 cM to a 3.4-cM region between markers D8S1804 and D8S1179. In another four families, linkage to all four known ADPHSP loci was excluded. The SPG8-linked family had a significantly older mean age at onset of symptoms and had significantly more wheelchair-using patients than the four linkage-excluded families.

CONCLUSIONS

These results contain the presence of an autosomal dominant pure hereditary spastic paraplegia (ADPHSP) locus at chromosome 8q24 and strongly suggest that there are at least five ADPHSP loci. The data provide additional evidence for locus-phenotype correlations in ADPHSP.