Treatment preference and recruitment to pediatric RCTs: A systematic review

BACKGROUND

Recruitment to pediatric randomised controlled trials (RCTs) can be a challenge, with ethical issues surrounding assent and consent. Pediatric RCTs frequently recruit from a smaller pool of patients making adequate recruitment difficult. One factor which influences recruitment and retention in pediatric trials is patient and parent preferences for treatment.

PURPOSE

To systematically review pediatric RCTs reporting treatment preference.

METHODS

Database searches included: MEDLINE, CINAHL, EMBASE, and COCHRANE.Qualitative or quantitative papers were eligible if they reported: pediatric population, (0-17 years) recruited to an RCT and reported treatment preference for all or some of the participants/parents in any clinical area. Data extraction included: Number of eligible participants consenting to randomisation arms, number of eligible patients not randomised because of treatment preference, and any further information reported on preferences (e.g., if parent preference was different from child).

RESULTS

Fifty-two studies were included. The number of eligible families declining participation in an RCT because of preference for treatment varied widely (between 2 and 70%) in feasibility, conventional and preference trial designs. Some families consented to trial involvement despite having preferences for a specific treatment. Data relating to 'participant flow and recruitment' was not always reported consistently, therefore numbers who were lost to follow-up or withdrew due to preference could not be extracted.

CONCLUSIONS

Families often have treatment preferences which may affect trial recruitment. Whilst children appear to hold treatment preferences, this is rarely reported. Further investigation is needed to understand the reasons for preference and the impact preference has on RCT recruitment, retention and outcome.

A qualitative study of nurses' perceptions of a behavioural strategies e-learning program to reduce interruptions during medication administration

OBJECTIVES

We sought to evaluate the perceptions of nurses of an e-learning educational program to encourage the use of behavioural strategies-blocking, engaging, mediating, multitasking, and preventing-to reduce the negative effects of interruptions during medication administration.

DESIGN

A qualitative design was used to evaluate the impact of this e-learning educational intervention on nurses' behaviour.

SETTINGS

Two wards (palliative care and aged care) from two different hospitals within a large local health service within Sydney Australia, were included in the study. These wards were also involved in a cluster randomised trial to test the effectiveness of the program.

PARTICIPANTS

A purposive sample participated comprising nine registered and enrolled nurses certified to conduct medication administration, who had reviewed the educational modules.

METHODS

Two focus groups were conducted and these sessions were digitally recorded and transcribed verbatim. Thematic analysis identified seven themes.

RESULTS

The major themes identified included: perceptions of interruptions, accessing the program, content of the program, impact, maintaining good practice and facilitators and barriers to changing behaviour.

CONCLUSIONS

The use of embedded authentic images of patient interruptions and management strategies increased some nurses' perceived use of strategies to manage interruptions. Nurses varied in their perception as to whether they could change their behaviour with some describing change at the individual and ward team levels, while others described patient caseload and other health professionals as a barrier. The use of this innovative educational intervention is recommended for staff orientation, student nurses, medical officers and allied health staff. Further research is required in how this e-learning program can be used in combination with other effective interventions to reduce interruptions.

Belief-bias reasoning in non-clinical delusion-prone individuals

BACKGROUND AND OBJECTIVES

It has been proposed that people with delusions have difficulty inhibiting beliefs (i.e., "doxastic inhibition") so as to reason about them as if they might not be true. We used a continuity approach to test this proposal in non-clinical adults scoring high and low in psychometrically assessed delusion-proneness. High delusion-prone individuals were expected to show greater difficulty than low delusion-prone individuals on "conflict" items of a "belief-bias" reasoning task (i.e. when required to reason logically about statements that conflicted with reality), but not on "non-conflict" items.

METHODS

Twenty high delusion-prone and twenty low delusion-prone participants (according to the Peters et al. Delusions Inventory) completed a belief-bias reasoning task and tests of IQ, working memory and general inhibition (Excluded Letter Fluency, Stroop and Hayling Sentence Completion).

RESULTS

High delusion-prone individuals showed greater difficulty than low delusion-prone individuals on the Stroop and Excluded Letter Fluency tests of inhibition, but no greater difficulty on the conflict versus non-conflict items of the belief-bias task. They did, however, make significantly more errors overall on the belief-bias task, despite controlling for IQ, working memory and general inhibitory control.

LIMITATIONS

The study had a relatively small sample size and used non-clinical participants to test a theory of cognitive processing in individuals with clinically diagnosed delusions.

CONCLUSIONS

Results failed to support a role for doxastic inhibitory failure in non-clinical delusion-prone individuals. These individuals did, however, show difficulty with conditional reasoning about statements that may or may not conflict with reality, independent of any general cognitive or inhibitory deficits.

Belief-bias reasoning in non-clinical delusion-prone individuals

BACKGROUND AND OBJECTIVES

It has been proposed that people with delusions have difficulty inhibiting beliefs (i.e., "doxastic inhibition") so as to reason about them as if they might not be true. We used a continuity approach to test this proposal in non-clinical adults scoring high and low in psychometrically assessed delusion-proneness. High delusion-prone individuals were expected to show greater difficulty than low delusion-prone individuals on "conflict" items of a "belief-bias" reasoning task (i.e. when required to reason logically about statements that conflicted with reality), but not on "non-conflict" items.

METHODS

Twenty high delusion-prone and twenty low delusion-prone participants (according to the Peters et al. Delusions Inventory) completed a belief-bias reasoning task and tests of IQ, working memory and general inhibition (Excluded Letter Fluency, Stroop and Hayling Sentence Completion).

RESULTS

High delusion-prone individuals showed greater difficulty than low delusion-prone individuals on the Stroop and Excluded Letter Fluency tests of inhibition, but no greater difficulty on the conflict versus non-conflict items of the belief-bias task. They did, however, make significantly more errors overall on the belief-bias task, despite controlling for IQ, working memory and general inhibitory control.

LIMITATIONS

The study had a relatively small sample size and used non-clinical participants to test a theory of cognitive processing in individuals with clinically diagnosed delusions.

CONCLUSIONS

Results failed to support a role for doxastic inhibitory failure in non-clinical delusion-prone individuals. These individuals did, however, show difficulty with conditional reasoning about statements that may or may not conflict with reality, independent of any general cognitive or inhibitory deficits.

Abstract OT3-04-01: BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC)

Background: About 1/3 of patients with TNBC who receive preoperative therapy will experience a pathological complete response (pCR). Patients with residual disease have a markedly inferior overall survival (OS) compared to those who experience pCR. Recently, the CREATE-X trial demonstrated an improvement in disease free survival (DFS) and OS for post-neoadjuvant capecitebine; although the addition of capecitebine to standard therapy has not previously improved outcome across other non-selected adjuvant or neo-adjuvant trials. Prior data have also demonstrated that the residual tumors are genomically diverse and that these genetic changes are reflected at time of relapse.

Trial Design: This trial is a randomized phase II trial to determine whether a genomically guided therapy in the setting of incomplete response to standard neoadjuvant therapy will improve outcomes compared to standard of care. DNA from archived tumor samples collected at the time of surgery will be extracted and sequenced. The sequencing data will be interrogated for known genomic drivers of sensitivity or resistance to existing FDA approved agents. A cancer genomic tumor board (CGTB) will consider the genomic data along with the patient's prior treatment history, toxicities, and comorbidities and select the optimal therapy. Participants with a CGTB recommendation will be randomized to Experimental Arm A (genomically directed monotherapy) or Control Arm B (standard of care). Participants may have no CGTB recommendation either because sequencing did not identify a matched drug or because the drug was contraindicated and will be assigned to Control Arm B.

Eligibility criteria: Patients must have histologically confirmed TNBC with completion of all definitive local therapy and no evidence of metastatic disease. There must be significant residual disease characterized by >2cm primary tumor, or lymph node positivity or RCB classification II or III. An FFPE tumor block with tumor cellularity >20% is required. All patients must have completed preoperative chemotherapy including a taxane or anthracycline or both.

Specific aims: The Primary Aim is to compare 2-year DFS with a genomically directed therapy vs. standard of care. Secondary Aims include 1-year DFS, 5-year OS, collection of archival specimens for correlative studies, and to describe toxicities. Exploratory Aims are to describe the evolution of genomically directed therapies during the course of the study and to evaluate the drug specific effect on efficacy and toxicity.

Statistical methods: In order to detect an improvement in the fraction of patients free from disease at 2-year from 40% in the control Arm B to 63.2% in the genomically directed Experimental Arm A (corresponding to an HR=0.5), 136 participants will have 80% power to detect a difference in DFS using a two-side log-rank test with 0.05 level of significance.

Present accrual/target accrual: 38 accrued of 136 to be randomized.

Citation Format: Schneider B, Miller KD, Badve S, O'Neil B, Helft P, Chitambar C, Falkson C, Nanda R, McCormick M, Danso M, Blaya M, Langdon R, Lippman M, Paplomata E, Walling R, Thompson M, Robin E, Aggarwal L, Shalaby I, Canfield V, Adesunloye B, Lee T, Daily K, Ma C, Erban J, Radhakrishnan N, Bruetman D, Graham M, Reddy NA, Lynce FC, Radovich M. BRE12-158: A phase II randomized controlled trial of genomically directed therapy after preoperative chemotherapy in patients with triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-04-01.

A randomized, placebo-controlled, phase 1/2 study of tivantinib (ARQ 197) in combination with irinotecan and cetuximab in patients with metastatic colorectal cancer with wild-type KRAS who have received first-line systemic therapy

Cetuximab in combination with an irinotecan-containing regimen is a standard treatment in patients with KRAS wild-type (KRAS WT), metastatic colorectal cancer (mCRC). We investigated the addition of the oral MET inhibitor tivantinib to cetuximab + irinotecan (CETIRI) based on preclinical evidence that activation of the MET pathway may confer resistance to anti-EGFR therapy. Previously treated patients with KRAS WT advanced or mCRC were enrolled. The phase 1, open-label 3 + 3, dose-escalation study evaluated the safety and maximally tolerated dose of tivantinib plus CETIRI. The phase 2, randomized, double-blinded, placebo-controlled study of biweekly CETIRI plus tivantinib or placebo was restricted to patients who had received only one prior line of chemotherapy. The phase 2 primary endpoint was progression-free survival (PFS). The recommended phase 2 dose was tivantinib (360 mg/m(2) twice daily) with biweekly cetuximab (500 mg/m(2)) and irinotecan (180 mg/m(2)). Among 117 patients evaluable for phase 2 analysis, no statistically significant PFS difference was observed: 8.3 months on tivantinib vs. 7.3 months on placebo (HR, 0.85; 95% confidence interval, 0.55-1.33; P = 0.38). Subgroup analyses trended in favor of tivantinib in patients with MET-High tumors by immunohistochemistry, PTEN-Low tumors, or those pretreated with oxaliplatin, but subgroups were too small to draw conclusions. Neutropenia, diarrhea, nausea and rash were the most frequent severe adverse events in tivantinib-treated patients. The combination of tivantinib and CETIRI was well tolerated but did not significantly improve PFS in previously treated KRAS WT mCRC. Tivantinib may be more active in specific subgroups.

A Phase I/II Multicenter, Open-Label Study of the Oral Histone Deacetylase Inhibitor Abexinostat in Relapsed/Refractory Lymphoma

PURPOSE

Additional targeted therapeutics are needed for the treatment of lymphoma. Abexinostat is an oral pan-histone deacetylase inhibitor (HDACi) displaying potent activity in preclinical models. We conducted a multicenter phase I/II study (N = 55) with single-agent abexinostat in relapsed/refractory lymphoma.

EXPERIMENTAL DESIGN

In phase I, 25 heavily pretreated patients with any lymphoma subtype received oral abexinostat ranging from 30 to 60 mg/m(2) twice daily 5 days/week for 3 weeks or 7 days/week given every other week. Phase II evaluated abexinostat at the maximum tolerated dose in 30 patients with relapsed/refractory follicular lymphoma or mantle cell lymphoma.

RESULTS

The recommended phase II dose was 45 mg/m(2) twice daily (90 mg/m(2) total), 7 days/week given every other week. Of the 30 follicular lymphoma and mantle cell lymphoma patients enrolled in phase II, 25 (14 follicular lymphoma, 11 mantle cell lymphoma) were response-evaluable. Tumor size was reduced in 86% of follicular lymphoma patients with an investigator-assessed ORR of 64.3% for evaluable patients [intent-to-treat (ITT) ORR 56.3%]. Median duration of response was not reached, and median progression-free survival (PFS) was 20.5 months (1.2-22.3+). Of responding follicular lymphoma patients, 89% were on study/drug >8 months. In mantle cell lymphoma, the ORR was 27.3% for evaluable patients (ITT ORR 21.4%), and median PFS was 3.9 months (range, 0.1-11.5). Grade 3-4 treatment-related adverse events (phase II) with ≥ 10% incidence were thrombocytopenia (20%), fatigue (16.7%), and neutropenia (13.3%) with rare QTc prolongation and no deaths.

CONCLUSIONS

The pan-HDACi, abexinostat, was overall well tolerated and had significant clinical activity in follicular lymphoma, including highly durable responses in this multiply relapsed patient population.

The phenomenology of inner speech: comparison of schizophrenia patients with auditory verbal hallucinations and healthy controls

BACKGROUND

Despite the popularity of inner-speech theories of auditory verbal hallucinations (AVHs), little is known about the phenomenological qualities of inner speech in patients with schizophrenia who experience AVHs (Sz-AVHs), or how this compares to inner speech in the non-voice-hearing general population.

METHOD

We asked Sz-AVHs (n=29) and a non-voice-hearing general population sample (n=42) a series of questions about their experiences of hearing voices, if present, and their inner speech.

RESULTS

The inner speech reported by patients and controls was found to be almost identical in all respects. Furthermore, phenomenological qualities of AVHs (e.g. second- or third-person voices) did not relate to corresponding qualities in inner speech.

CONCLUSIONS

No discernable differences were found between the inner speech reported by Sz-AVHs and healthy controls. Implications for inner-speech theories of AVHs are discussed.

Hoosier Oncology Group randomized phase II study of docetaxel, vinorelbine, and estramustine in combination in hormone-refractory prostate cancer with pharmacogenetic survival analysis

PURPOSE

To determine the safety and efficacy of two docetaxel doublets in hormone-refractory prostate cancer (HRPC) patients and to examine the prognostic role of polymorphisms in host genes important to docetaxel metabolism and transport.

EXPERIMENTAL DESIGN

Sixty-four chemotherapy-naive patients with HRPC were randomized to docetaxel and vinorelbine (D, 20 mg/m2 i.v. days 1 and 8; V, 25 mg/m2 i.v. days 1 and 8) or docetaxel and estramustine phosphate (D, 60-70 mg/m2 i.v. day 1; E, 280 mg oral thrice daily days 1-5) administered q21d. Primary end point was clinically significant toxicity. A pharmacogenetic analysis of host genes was done in patients who received at least one cycle of docetaxel therapy.

RESULTS

Grade 3/4 toxicity occurred in 15.6% of DV patients and in 28.6% DE patients. Neither arm exceeded the threshold of clinically significant toxicity. In the DV arm, objective response rate was 33%, prostate-specific antigen response rate was 20%, and median survival was 16.2 months. In the DE arm, objective response rate was 67%, prostate-specific antigen response rate was 43%, and median survival was 19.7 months. Pharmacogenetic analyses showed a significant association between survival beyond 15 months and the ABCG2 421 C > A (Q141K) polymorphism compared with the wild-type (C/C) genotype (66% versus 27%; P = 0.05).

CONCLUSIONS

DV and DE doublets are active with a tolerable toxicity profile in patients with HRPC; however, efficacy does not seem superior to standard single-agent docetaxel. The ABCG2 421 C > A (Q141K) polymorphism may be an important predictor of response and survival in HRPC patients treated with docetaxel-based chemotherapy.

Disturbed communication in schizophrenia: the role of poor pragmatics and poor mind-reading

BACKGROUND

Disturbed speech in schizophrenia may reflect pragmatic deficits of expressive language. Pragmatic comprehension deficits also occur in schizophrenia. This study investigated whether poor 'mind-reading' (i.e. a general difficulty with inferring and monitoring other people's thoughts) causes pragmatic language impairments of both expression and comprehension in patients with schizophrenia.

METHOD

Mind-reading (or theory of mind) was tested in patients with schizophrenia and in healthy controls using a false-belief picture-sequencing task. Pragmatic comprehension skills were assessed using a test of non-literal speech interpretation. Clinical ratings of formal thought disorder (FTD) indexed the expressive language deficits of patients. To control for possible contributory effects of executive dysfunction, inhibitory control was tested using capture picture-sequences and executive-planning was tested using the Tower of London task.

RESULTS

False-belief picture-sequencing, understanding of irony and understanding of metaphors were all selectively impaired in the patients. Poor mind-reading (indexed by high error rate in sequencing false-belief stories) was associated with poor understanding of irony, but was unrelated to poor understanding of metaphors. Whereas poor appreciation of irony and poor mind-reading were associated with high ratings of positive formal thought disorder, high ratings of negative formal thought disorder were associated with poor understanding of metaphors and executive dysfunction.

CONCLUSIONS

Whereas poor mind-reading may contribute to positive aspects of formal thought disorder and impaired appreciation of irony in patients with schizophrenia; negative features of formal thought disorder and poor understanding of metaphors appear better explained by abnormal semantics. Overall, the findings of this study support the view that the functional basis of formal thought disorder in schizophrenia is not unitary.

Visual perspective-taking and schizotypy: evidence for a simulation-based account of mentalizing in normal adults

Modular theory-of-mind accounts attribute poor mentalizing to disruption of a cognitive module dedicated to computing higher-order representations of primary representations (metarepresentations). Since metarepresentational capacity is needed to mentalize about other people's beliefs but is not needed to judge visual perspectives (which can be done by mentally rotating primary representations of seen objects), this view predicts that visual perspective-taking will be intact in individuals with selective mentalizing impairments. Counter to that prediction, this study found evidence of disturbed visual perspective-taking in normal adults who score higher on the personality variable of schizotypy and who are known to be relatively poor mentalizers (despite intact ability to inhibit salient inappropriate information in order to reason consequentially on the basis of hypothetical states, other than mental states). Whereas high-schizotypal adults and low-schizotypal adults did not differ in their ability to judge item questions (asking the relative location of array features), high-schizotypal adults performed more poorly than low-schizotypal adults in judging appearance questions (asking how an array would appear from another perspective) under viewer-rotation instructions (asking subjects to imagine moving themselves relative to a fixed array) and performed better than low-schizotypal adults in judging appearance questions under array-rotation instructions (asking subjects to imagine rotating an array relative to their own fixed viewer position). Based on these and other findings we conclude that poor mentalizing in normal adults is better understood as an impairment of perspective-taking (visual and/or cognitive) and introduce the concept of allocentric simulation to explain the functional basis of this perspective-taking impairment.

DRC: a dual route cascaded model of visual word recognition and reading aloud

This article describes the Dual Route Cascaded (DRC) model, a computational model of visual word recognition and reading aloud. The DRC is a computational realization of the dual-route theory of reading, and is the only computational model of reading that can perform the 2 tasks most commonly used to study reading: lexical decision and reading aloud. For both tasks, the authors show that a wide variety of variables that influence human latencies influence the DRC model's latencies in exactly the same way. The DRC model simulates a number of such effects that other computational models of reading do not, but there appear to be no effects that any other current computational model of reading can simulate but that the DRC model cannot. The authors conclude that the DRC model is the most successful of the existing computational models of reading.

Coping styles of pregnant adolescents

This descriptive study examined the coping styles and specific strategies used by a group of pregnant adolescents attending an adolescent family support service. Seventy-one adolescents, with a mean age of 17 years, and a mean gestation of 25 weeks, completed the Revised Jalowiec Coping Scale (JCS-R). The findings demonstrated that the optimistic coping style (emotion-focused) was the most frequently used and most effective coping style for these young women. A confrontive coping style (problem-focused) was also used and found to be effective. A combination of problem-focused and emotion-focused styles is recommended, with an increased emphasis on problem-focused approaches. The focus by the adolescents on optimistic approaches is suggestive of a lack of understanding of the challenges that motherhood will place upon them, but is consistent with their age and developmental stage. A longitudinal study of coping styles and changes in style throughout pregnancy and early motherhood is recommended. Initial assessment and monitoring of coping styles of pregnant adolescents is proposed. This assessment would be the beginning point for a teaching program that highlights increased use of adaptive coping styles (problem-focused) with decreased use of maladaptive approaches, and includes emotion-focused styles. By expanding the repertoire of coping styles and strategies available to the adolescent, the public health nurse (PHN) prepares these vulnerable mothers for the challenges ahead.

DRC: a dual route cascaded model of visual word recognition and reading aloud

This article describes the Dual Route Cascaded (DRC) model, a computational model of visual word recognition and reading aloud. The DRC is a computational realization of the dual-route theory of reading, and is the only computational model of reading that can perform the 2 tasks most commonly used to study reading: lexical decision and reading aloud. For both tasks, the authors show that a wide variety of variables that influence human latencies influence the DRC model's latencies in exactly the same way. The DRC model simulates a number of such effects that other computational models of reading do not, but there appear to be no effects that any other current computational model of reading can simulate but that the DRC model cannot. The authors conclude that the DRC model is the most successful of the existing computational models of reading.

Feeding outcomes and influences within the neonatal unit

This study examined the feeding intention of mothers (n = 100), and the factors and beliefs, and changes in those factors or beliefs that influenced their choices, in the challenging environment of the neonatal unit. Mothers' experience and the frequency of nurse-assisted feeding activities were examined in mothers intending and not intending to breast-feed on discharge. Eighty-one per cent of mothers were either partially or fully breast-feeding or intending to do so on discharge. The most important factors identified as influencing this feeding choice included personal choice, with other influences being special benefits, more natural and feeling closer to the baby. Experiences such as infants receiving their first sucking feed from either the breast or bottle (inclusive of breast milk) and mothers expressing breast milk more frequently, were found to be significantly different and increased in frequency, in mothers intending to breast-feed. Differences in the mean weighted total daily nurse-assisted feeding score confirmed that these activities varied with gestational age (< or = 32 weeks [2.57], 32 to less than 35 weeks [3.86], and > or = 35 weeks [4.91]; F = 7.04, d.f. 55, P = 0.002), although there was insufficient power to determine differences between breast-feeding and non-breast-feeding mothers. The use of the Feeding Activities Calendar may have contributed to increased activity and high levels of breast-feeding in this preterm group.

A collaborative approach to developing nursing skills to meet service needs

Academics, educators and health service managers came together to explore, within their local area, the nature of the perceptions of beginning registered nurses (BRNs) and Nursing Unit Managers (NUMs) to the skills utilised by BRNs within the first six months of practice. A group of 71 BRNs and nine NUMs participated in a cross-sectional survey. BRNs were also asked to rate their preparedness in each particular skill, dependent on the method of teaching--theory/lectures, nursing laboratories and clinical experience. Some 21 skills, relating to medication/fluid administration and skin and wound care, were perceived by 95 per cent or more of the graduates as being used within the first six months. Similar perceptions existed for NUMs and BRNs for 52.4 per cent of the listed skills. Differences in perceptions have led to academics altering the scope of skills being taught and focusing assessment on critical skills for BRNs, and managers increasing awareness among NUMs as to the source of the differences and developing programs to improve clinical interpretation skills. Improvements in the experience of the BRN are likely to occur when all parties work together to bring about positive change. By Barbara Somerville,

Breastfeeding and Chinese mothers living in Australia

This study sought information on the breastfeeding rates, knowledge and beliefs of 101 migrant Chinese mothers living in south-west Sydney. Differences in beliefs about breastfeeding and bottle-feeding practices between migrant and indigenous groups of mothers were also examined. Sixty-five percent of Chinese mothers were fully breastfeeding their infants on discharge, with a further 6.9% partially breastfeeding. However, only 34% were still breastfeeding at three months. The most important factor to influence mothers' choice to breastfeed was the belief that it was 'good for the baby', whilst mothers choosing to bottle-feed were influenced by low milk supply and the belief that it was easier. Similar beliefs about breastfeeding and bottle-feeding were held by indigenous and migrant Chinese mothers, although concerns about the baby becoming too attached were markedly higher in the migrant group and may be related to sudden drops in breastfeeding rates at three months. Focusing ethno-specific services upon continuation of breastfeeding throughout the first six months of the infant's life is recommended, with a Chinese mothers' breastfeeding support network being posed as a possible approach.

Mentalising, schizotypy, and schizophrenia

Despite accumulating evidence that patients with schizophrenia perform poorly in mentalising tasks, doubts remain about the primacy of the role played by defective mentalising in schizophrenia. This study investigated the relationship between mentalising ability and self-reported schizotypal traits in non-clinical adults who reported no history of psychiatric illness in order to test two counter-proposals: (1) defective mentalising is a primary cause of psychotic symptoms in schizophrenia; and (2) defective mentalising in schizophrenia is a secondary consequence of the chronic asociality that is typical of general psychiatric illness. Mentalising ability was tested using a false-belief picture sequencing task that has been used elsewhere to demonstrate poor mentalising in patients with schizophrenia. Evidence of selective mentalising deficits in high schizotypal non-clinical subjects discounted the view that defective mentalising is restricted to psychiatric illness and strengthened the case for continuity models of psychosis-proneness. Furthermore, evidence that poor mentalisers in the normal population are more likely to self-report psychotic-like traits, as well as asocial or idiosyncratic behaviours, refuted suggestions that defective mentalising is linked solely to asocial symptomatology and supported the view that defective mentalising may have a fundamental role to play in the explanation of psychotic symptoms. In order to specify what that role might be, alternative theoretical accounts of defective mentalising were tested. Neither executive planning deficits nor failure to inhibit cognitively salient inappropriate information could adequately explain the pattern of selective mentalising deficits found in high schizotypal non-clinical subjects. Our findings suggest that there exists a domain-specific cognitive module that is dedicated to inferring and representing mental states which, when dysfunctional, causes defective mentalising that manifests phenomenologically in psychotic-like traits and impoverished social awareness of variable expression and ranging severity.

Recall of short word lists presented visually at fast rates: effects of phonological similarity and word length

Phonological similarity of visually presented list items impairs short-term serial recall. Lists of long words are also recalled less accurately than are lists of short words. These results have been attributed to phonological recoding and rehearsal. If subjects articulate irrelevant words during list presentation, both phonological similarity and word length effects are abolished. Experiments 1 and 2 examined effects of phonological similarity and recall instructions on recall of lists shown at fast rates (from one item per 0.114-0.50 sec), which might not permit phonological encoding and rehearsal. In Experiment 3, recall instructions and word length were manipulated using fast presentation rates. Both phonological similarity and word length effects were observed, and they were not dependent on recall instructions. Experiments 4 and 5 investigated the effects of irrelevant concurrent articulation on lists shown at fast rates. Both phonological similarity and word length effects were removed by concurrent articulation, as they were with slow presentation rates.

Defective Self and/or Other Mentalising in Schizophrenia: A Cognitive Neuropsychological Approach

The mentalising abilities of schizophrenic patients and normal controls were tested using picture sequencing and story-telling tasks that required subjects to infer causal mental states in story characters, and a recall task that required subjects to dissociate subjective mental states from objective realities. Selective mentalising deficits were found in some patients. For other patients, general sequencing errors, "sensory" mentalising, and poor recall of symbolic representations suggested more profound problems. Task results were best accounted for by dissociable cognitive abnormalities, rather than graded dysfunction of a central mentalising mechanism. Symptom profiles of patient subgroups and correlations between task measures and clinical ratings linked these cognitive abnormalities to specific symptoms. General sequencing difficulty was associated with both poverty symptoms and reality distortion, suggesting that two mechanisms may underpin such errors: one, inability to manipulate symbolic representations, being linked to poverty; the other, failure to critically evaluate plausible cause-and-effect, being linked to reality distortion. There was some evidence that defective self-monitoring underpins thought disorder. Impaired metarepresentation was linked to the autisticlike symptoms of flat affect, social dysfunction, and alogia, rather than reality distortion. Implications of these findings are discussed with respect to theoretical and methodological issues confronting current schizophrenia research.

Methylprednisolone does not influence endotoxin translocation during cardiopulmonary bypass

This study investigated whether the prophylactic administration of methylprednisolone sodium succinate (MPSS) could prevent an increase in plasma endotoxin levels during cardiac surgery with cardiopulmonary bypass. MPSS (1 g/patient) or saline was given intravenously with induction in the steroid (n = 6) and control (n = 7) groups, respectively. Blood samples were collected preinduction and postinduction, during and after cardiopulmonary bypass, and 1 and 24 hours postoperatively. Plasma endotoxin was determined by a chromogenic Limulus amebocyte lysate assay. There was an intraoperative increase in the level of plasma endotoxin that occurred primarily after initiation of cardiopulmonary bypass and removal of the aortic cross-clamp. Endotoxin at 1 and 24 hours postoperatively was lower than the peak intraoperative levels and approached the preinduction level in both groups. The pump prime and other administered fluids contained low levels of endotoxin that were at or below the preinduction or postinduction level of the patients. MPSS did not prevent or attenuate the degree of endotoxemia during cardiopulmonary bypass. The loss of normal gut mucosal barrier function during cardiopulmonary bypass may result in endotoxemia and/or bacterial translocation, either of which could initiate or contribute to postoperative complications.

Epithelial differentiation in the absence of extracellular matrix

To investigate the regulation of epithelial differentiation, normal human epidermal keratinocytes were cultured floating on the surface of culture medium without attachment to a solid substrate. Keratinocytes spread out on the surface of the medium, proliferated and differentiated either into several flat lacy sheets 1 to 3 cells thick (on medium containing 0.15 mM calcium) or formed one single aggregate of cells from 5 to 15 cells in thickness on medium containing 1.15 mM calcium. The cell aggregates demonstrated a pattern of ordered epithelial differentiation. Levels of progressive differentiation resembling the structure of normal human epidermis were identified by light microscopy, immunohistochemistry, and electron microscopy. Differentiation proceeded from cells at the air side toward cells at the medium side with basal appearing cells on the air side and keratinocytes expressing filaggrin and involucrin on the side toward the medium. These results demonstrate that organized epithelial differentiation can occur in the absence of extracellular matrix. In contrast with other air-liquid interface cultures, epithelial differentiation in the absence of extracellular matrix progresses from air towards medium.

Paracrine stimulation of melanocytes by keratinocytes through basic fibroblast growth factor

Melanocytes cultured in the presence of keratinocytes survive for weeks without added basic fibroblast growth factor (bFGF) and cyclic-adenosine-monophosphate (cAMP), the two factors needed for their proliferation in vitro. We show here that the growth factor for melanocytes produced by human keratinocytes is bFGF because its activity can be abolished by neutralizing antibodies to bFGF and by a bFGF synthetic peptide that inhibits the binding of the growth factor to its receptor. The melanocyte mitogen in keratinocytes is cell-associated and increases after irradiation with ultraviolet B (UVB). Northern blots reveal bFGF gene transcripts in keratinocytes but not melanocytes. These studies demonstrate that bFGF elaborated by keratinocytes in vitro sustains melanocyte growth and survival, and they suggest that keratinocyte-derived bFGF is the natural growth factor for normal human melanocytes in vivo.

Interleukin-1 alpha mRNA induced by cycloheximide PMA, and retinoic acid is reduced by dexamethasone in PAM-212 keratinocytes

Keratinocytes in culture produce detectable amounts of IL-1 alpha mRNA constitutively and can be stimulated to express increased amounts of IL-1 alpha mRNA by cycloheximide, PMA, and retinoic acid. Dexamethasone decreases the amount of IL-1 mRNA induced by these agents, as well as constitutive IL-1 alpha mRNA. RU 486, which interferes with glucocorticosteroid-receptor binding, decreases inhibition of TPA stimulation of IL-1 alpha mRNA by dexamethasone, which suggests that the inhibition by dexamethasone is through a conventional ligand-receptor mechanism.

Basic fibroblast growth factor from human keratinocytes is a natural mitogen for melanocytes

To survive and proliferate in pure culture, human melanocytes require basic fibroblast growth factor (bFGF) and cAMP. Without these factors, even in the presence of serum, the cells die. Melanocytes cultured in the presence of keratinocytes, however, survive for weeks without added bFGF and cAMP. We show here that the growth factor for melanocytes produced by human keratinocytes is bFGF because its activity can be abolished by neutralizing antibodies to bFGF and by a bFGF synthetic peptide that inhibits the binding of the growth factor to its receptor. The melanocyte mitogen in keratinocytes is cell associated and increases after irradiation with ultraviolet B. Northern blots reveal bFGF gene transcripts in keratinocytes but not melanocytes. These studies demonstrate that bFGF elaborated by keratinocytes in vitro sustains melanocyte growth and survival, and they suggest that keratinocyte-derived bFGF is the natural growth factor for normal human melanocytes in vivo.

Composite autologous-allogeneic skin replacement: development and clinical application

A major unsolved problem in skin restoration in severe burns is replacement of lost dermis. We report the development and clinical application of a composite grafting technique in which allogeneic skin is the source of dermis, and cultured autologous keratinocytes generate epidermis. Excised burn wounds are resurfaced with unmatched allograft. Immunosuppression from the burn and reduced immunoreactivity of the allograft permit successful allograft engraftment. Keratinocyte cultures are initiated from the patient. Allogeneic epidermis is removed, and the dermal bed is resurfaced with keratinocyte cultures. The allogeneic dermis promotes rapid (less than 7 days) stratification, maturation, and integration of the cultures and the synthesis of anchoring fibrils. One case followed 11 months has shown no evidence of rejection. We reason that removal of the epidermis from allograft eliminates the majority of cells constitutively expressing alloclass II antigens, leaving behind a viable allogeneic dermal bed that serves as an ideal substrate for engraftment and integration of keratinocyte cultures but does not initiate rejection.

Toxic epidermal necrolysis: an approach to management using cryopreserved allograft skin

Toxic epidermal necrolysis is an acute exfoliation of skin simulating a scald injury. Drug-induced toxic epidermal necrolysis has a mortality of greater than 50%. We report an 8-year-old girl with drug-induced toxic epidermal necrolysis who was treated with cryopreserved cadaver skin, with good outcome. The allograft was clinically and histologically viable. Graft keratinocytes demonstrated epiboly as reepithelialization by the host occurred along the host/graft interface. Host epidermis regenerated rapidly, presumably from adnexae, and displaced the viable allograft along the plane of the host/graft interface. The new epidermis appeared normal in all respects.

Human keratinocytes contain mRNA indistinguishable from monocyte interleukin 1 alpha and beta mRNA. Keratinocyte epidermal cell-derived thymocyte-activating factor is identical to interleukin 1

Keratinocytes produce an IL-1 like factor termed epidermal cell-derived thymocyte-activating factor (ETAF). In this study, we show that ETAF and IL-1 are identical by the following criteria: Both normal and malignant human keratinocytes contain mRNAs identical to monocytic IL-1 alpha and IL-1 beta mRNA, as determined by an S1 nuclease protection assay; and IL-1 activity in medium conditioned by these cells can be neutralized by antibodies specific for human IL-1. The IL-1 alpha and IL-1 beta mRNAs can be identified in cultured human keratinocytes in the absence of identifiable stimulation; this basal level of mRNA can be further induced to accumulate with certain defined stimuli. Cultured normal human keratinocytes (HFKs) contain 2-4 times more IL-1 alpha than IL-1 beta mRNA; in contrast, human peripheral blood monocytes contain 10-20 times more IL-1 beta than IL-1 alpha mRNA. The IL-1 activity released by these HFK can be neutralized by an antibody that neutralizes both alpha and beta IL-1, but not by an antibody that neutralizes only IL-1 beta. While human monocytes produce a large excess of IL-1 beta after appropriate stimulation, these data suggest that IL-1 alpha is a major (and may be the predominant) form of IL-1 produced by human keratinocytes.

Use of cultured epidermal autografts and dermal allografts as skin replacement after burn injury

An adult with burns over 55% of body surface area (80% of which were third degree) was treated with cadaver skin allografts. The allografts were later abraded to remove allogeneic epidermis and resurfaced with autogenous keratinocyte cultures. Complete reconstitution of skin, consisting of epidermal autograft and dermal allograft, was achieved.

Epidermal growth factor stimulates ornithine decarboxylase activity in cultured mammalian keratinocytes

The influence of epidermal growth factor (EGF) on ornithine decarboxylase has been examined in cultured bovine keratinocytes. Keratinocyte ornithine decarboxylase activity was maximal at pH 6.3 in MES buffer in the presence of dithiothreitol and EDTA. When cultured cells, deprived of serum, were exposed to EGF, the activity of ornithine decarboxylase was stimulated severalfold. Enzyme activity increased in a dose-dependent manner with EGF. The time course of this stimulation is unlike any previously reported in cultured cells. The increase in activity was maximal by 8 h. A small dip in activity was seen between 8 and 12 h. Increased activity was sustained for as long as 24 h after exposure to EGF. The prolonged increased in enzyme activity was reduced by actinomycin D. When cycloheximide was added 1 h before EGF, ornithine decarboxylase activity was obliterated. This is the first demonstration of ornithine decarboxylase stimulation following exposure to EGF in cultured keratinocytes. The prolonged duration of ornithine decarboxylase stimulation is unexplained but may be related to processing of EGF by the keratinocytes.

Induction of HMG CoA reductase by the administration of 20,25-diazacholesterol

This paper describes the direct examination of HMG CoA reductase activity in rats treated with 20,25-diazacholesterol. Conversion of acetyl CoA and HMG CoA to mevalonate increased to over 200% of control values in the microsomes and in the 12,000 g supernatant of liver homogenates after 5 days of treatment. The time course of induction coincided with the development of hypocholesterolemia. Animal weights, liver weights, and microsomal protein content did not vary significantly between animal groups. Incubations to which the compound was introduced in vitro in concentrations as great as 0.5 mM produced no significant difference from control incubations. Similar treatment of the animals with 7-ketocholesterol, a cholesterol derivative reported to repress HMG CoA reductase activity in tissue cultures, produced no appreciable difference in reductase activity or serum steroid levels in vivo.