Suicide rates in the UK Armed Forces, compared with the general workforce and merchant shipping during peacetime years since 1900

INTRODUCTION

The main objective was to compare suicide rates and their trends across the three UK Armed forces (Royal Navy, Army and Royal Air Force) from 1900 to 2020. Further objectives were to compare suicide rates with those in the corresponding general population and in UK merchant shipping and to discuss preventative measures.

METHODS

Examination of annual mortality reports and returns, death inquiry files and official statistics. The main outcome measure was the suicide rate per 100 000 population employed.

RESULTS

Since 1990, there have been significant reductions in suicide rates in each of the Armed Forces, although a non-significant increase in the Army since 2010. Compared with the corresponding general population, during the most recent decade from 2010 up to 2020, suicide rates were 73% lower in the Royal Air Force, 56% lower in the Royal Navy and 43% lower in the Army. Suicide rates have been significantly decreased in the Royal Air Force since the 1950s, in the Royal Navy since the 1970s and in the Army since the 1980s (comparisons for the Royal Navy and the Army were not available from the late 1940s to the 1960s).During the earliest decades from 1900 to the 1930s, suicide rates in the Armed Forces were mostly quite similar or moderately increased compared with the general population, but far lower than in merchant shipping. Following legislative changes in the last 30 years, suicide rates through poisoning by gases and through firearms or explosives have fallen sharply.

CONCLUSIONS

The study shows that suicide rates in the Armed Forces have been lower than in the general population over many decades. The sharp reductions in suicide rates over the last 30 years suggest the effectiveness of recent preventative measures, including reductions in access to a method of suicide and well-being initiatives.

Pediatricians as Childhood Development Advocacy Champions in Kenya and Tanzania: A Case Study

Early childhood development (ECD) is instrumental to shaping educational, emotional, and economic trajectories; alleviating poverty; and achieving gender equality. Pediatricians are experts in children's health and trusted sources of guidance for families and clinicians and thus are optimal ECD champions. This case study describes collaboration by the American Academy of Pediatrics, Kenya Pediatric Association, and Pediatric Association of Tanzania to activate pediatricians as ECD champions in Kenya and Tanzania. From July 2020 through January 2021, the collaborators assessed ECD needs by interviewing 20 key informants per country from governmental ministries, nongovernmental organizations, and clinical practice and assessing datasets and policy documents. In 2021, the societies recruited 15 pediatricians per country as champions; surveyed their knowledge, attitudes, and practices; and trained them on 4 core competencies: understanding early brain development science; developmental and behavioral screening, surveillance, and diagnosis; integration of ECD promotion into clinical practice; and advocacy skills for ECD and nurturing care. In 2021, each society established advocacy-in-action projects to advance ECD. In Kenya, the cohort surveyed clinicians on barriers to ECD, implemented a 2-day in-person training for 90 providers, and developed a 5-week Fundamentals of ECD course, taken by 113 pediatricians from 7 African countries. In Tanzania, champions conducted ECD training workshops for 78 health managers and 189 health care providers in 9 facilities in 7 regions and established 9 ECD corners with toys and information in health care facilities. These results highlight considerations for supporting ECD, including building on existing strengths, infrastructure, and networks; strengthening ECD knowledge among pediatricians; and advocacy skill-building.

The virtual knee clinic - A tool to streamline new outpatient referrals

INTRODUCTION

Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol.

METHODS

Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation.

RESULTS

1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p < 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) DISCUSSION: The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel.

Forgotten fatalities: British military, mining and maritime accidents since 1900

Background

Comparative long-term trends in fatal accident rates in the UK’s most hazardous occupations have not been reported.

Aims

To compare trends in fatal accident rates in six of the most hazardous occupations (the three armed forces, merchant shipping, sea fishing and coal mining) and the general British workforce during peacetime years since 1900.

Methods

Examinations of annual mortality reports, returns, inquiry files and statistics. The main outcome measure was the fatal accident rate per 100 000 population employed.

Results

These six occupations accounted for ~40% of all fatal accidents in the British workforce. Fatal accident rates were highest in merchant shipping to 1914 (400–600 per 100 000) and in the Royal Air Force and sea fishing by the early 1920s (around 300 per 100 000). Since the 1950s sea fishing has remained the most hazardous occupation (50–200). Widespread reductions in fatal accident rates for each occupation have been greatest in recent years in the three armed forces and merchant shipping. Compared with the general workforce, relative risks of fatalities have increased in recent decades in all these occupations except shipping.

Conclusions

All six occupations still have high fatal accident rates. The greatly increased fatalities in sea fishing generally and in the Royal Air Force during its early years reflect, for different reasons, cultures of extreme risk-taking in these two sectors. Reductions in fatality rates in the armed forces over the last 20 years are due largely to decreases in land transport accidents.

Global immunization systems strengthening through pediatric societies: the promise of private-public partnerships in Indonesia

Vaccines are one of the most successful health interventions in history. Yet, vaccine-preventable diseases still claim the lives of 2.5 million individuals globally every year. Approximately 60% of the 19.4 million infants that did not have access to routine immunization services in 2018 live in 10 countries, one of which is Indonesia. In order to reach global targets, it is critical for countries such as Indonesia to prioritize, tailor, and operationalize vaccination strategies to address immunization gaps. Pediatricians and national pediatric societies (NPS) are trusted stakeholders in their countries and are uniquely qualified to promote vaccination programs. The American Academy of Pediatrics (AAP) partnered with the Indonesian Pediatric Society (IPS), with support from the US Centers for Disease Control and Prevention (CDC), to initiate a multiyear project to build the capacity of IPS, individual members, and other child health clinicians to strategically advocate for improved immunization services across both public and private sectors.

Experimental Observation of Convective Cell Formation due to a Fast Wave Antenna in the Large Plasma Device

An experiment in a linear device, the Large Plasma Device, is used to study sheaths caused by an actively powered radio frequency (rf) antenna. The rf antenna used in the experiment consists of a single current strap recessed inside a copper box enclosure without a Faraday screen. A large increase in the plasma potential was observed along magnetic field lines that connect to the antenna limiter. The electric field from the spatial variation of the rectified plasma potential generated E[over →]×B[over →]_{0} flows, often referred to as convective cells. The presence of the flows generated by these potentials is confirmed by Mach probes. The observed convective cell flows are seen to cause the plasma in front of the antenna to flow away and cause a density modification near the antenna edge. These can cause hot spots and damage to the antenna and can result in a decrease in the ion cyclotron range of frequencies antenna coupling.

Longitudinal estimation of Plasmodium falciparum prevalence in relation to malaria prevention measures in six sub-Saharan African countries

BACKGROUND

Plasmodium falciparum prevalence (PfPR) is a widely used metric for assessing malaria transmission intensity. This study was carried out concurrently with the RTS,S/AS01 candidate malaria vaccine Phase III trial and estimated PfPR over ≤ 4 standardized cross-sectional surveys.

METHODS

This epidemiology study (NCT01190202) was conducted in 8 sites from 6 countries (Burkina Faso, Gabon, Ghana, Kenya, Malawi, and Tanzania), between March 2011 and December 2013. Participants were enrolled in a 2:1:1 ratio according to age category: 6 months-4 years, 5-19 years, and ≥ 20 years, respectively, per year and per centre. All sites carried out surveys 1-3 while survey 4 was conducted only in 3 sites. Surveys were usually performed during the peak malaria parasite transmission season, in one home visit, when medical history and malaria risk factors/prevention measures were collected, and a blood sample taken for rapid diagnostic test, microscopy, and haemoglobin measurement. PfPR was estimated by site and age category.

RESULTS

Overall, 6401 (survey 1), 6411 (survey 2), 6400 (survey 3), and 2399 (survey 4) individuals were included in the analyses. In the 6 months-4 years age group, the lowest prevalence (assessed using microscopy) was observed in 2 Tanzanian centres (4.6% for Korogwe and 9.95% for Bagamoyo) and Lambaréné, Gabon (6.0%), while the highest PfPR was recorded for Nanoro, Burkina Faso (52.5%). PfPR significantly decreased over the 3 years in Agogo (Ghana), Kombewa (Kenya), Lilongwe (Malawi), and Bagamoyo (Tanzania), and a trend for increased PfPR was observed over the 4 surveys for Kintampo, Ghana. Over the 4 surveys, for all sites, PfPR was predominantly higher in the 5-19 years group than in the other age categories. Occurrence of fever and anaemia was associated with high P. falciparum parasitaemia. Univariate analyses showed a significant association of anti-malarial treatment in 4 surveys (odds ratios [ORs]: 0.52, 0.52, 0.68, 0.41) and bed net use in 2 surveys (ORs: 0.63, 0.68, 1.03, 1.78) with lower risk of malaria infection.

CONCLUSION

Local PfPR differed substantially between sites and age groups. In children 6 months-4 years old, a significant decrease in prevalence over the 3 years was observed in 4 out of the 8 study sites. Trial registration Clinical Trials.gov identifier: NCT01190202:NCT. GSK Study ID numbers: 114001.

A retrospective case comparison study of the relationship between an Integrated Care Pathway for people diagnosed with schizophrenia in acute mental health care and service users' length of stay, readmission rates and follow-up within 7 days of discharge

WHAT IS KNOWN ON THE SUBJECT?: There is some evidence reporting the value of diagnostic-driven Integrated Care Pathways (ICPs) in reducing service users' length of inpatient stay, readmission rates and follow-up within seven days of discharge, but this evidence is untested in studies comparing care using ICP with other forms of care planning. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE?: This study present findings from research comparing care in a Trust that uses an ICP with a Trust using another form of care planning to direct the care of people diagnosed with schizophrenia. We were interested particularly in whether using an ICP was linked to length of inpatient stay, readmission rates and follow-up care within seven days of discharge. The results compare ICP driven care with another form of care. This study adds to the international evidence by being among the first to compare empirically, outcomes in a mental health Trust using an ICP with a Trust not using an ICP to direct care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses are central to the delivery of the psychosocial aspects of ICPs in particular and judging by the link between psychosocial interventions and quality of mental health care, it is possible that nurse-led psychosocial interventions contributed to the reduced length of stay.

ABSTRACT

Background Integrated Care Pathways (ICPs) are used to deliver mental health services, yet evidence relating to outcomes is mixed. Aim To compare service users' length of stay, readmission rates and follow-up within 7 days of discharge in a mental health Trust using an ICP to direct the care of people diagnosed with schizophrenia with a Trust using a nonICP method of care planning in England.

METHOD

A cohort study with a random sample of 400 service users with outcomes analysed retrospectively. Results The ICP Trust had a 13.5 day shorter average length of stay, this difference was statistically significant. No statistically significant differences were observed in rates of readmission or follow-up within 7 days of discharge. Discussion and implications Mental health nurses are central to the delivery of the psychosocial aspects of ICPs in particular and judging by the link between psychosocial interventions and quality of mental health care, it is possible that nurse-led psychosocial interventions contributed to the reduced length of stay.

Exercise for depression in adolescents: A meta-analysis of randomised controlled trials

Background

The reported lifetime prevalence of depression in adolescents has increased drastically in recent decades. Depression in this population can be particularly damaging and can frequently have a long-lasting adverse impact. The common treatment approach includes psychological therapy and/or anti-depressant medication. However, the efficacy of these approaches, both singularly and combined, is far from conclusive. Recently, there have been an increased number of studies investigating the effect of exercise and physical activity on adolescent depression, however, despite this increased attention, there are no recent reviews and meta-analyses synthesising such studies.

Aim

The review examines the treatment effect of exercise on depression symptoms for adolescents aged 13–17 years of age.

Methods

A systematic search of seven electronic databases identified relevant randomised controlled trials. Screening, data extraction and trial methodological quality were undertaken by two independent researchers. Standardized mean differences were used for pooling post-intervention depressive symptom scores.

Results

Eleven trials met the inclusion criteria, eight of which provided the necessary data for calculation of standardized effect size. Exercise showed a statistically significant moderate overall effect on depressive symptom reduction. Sensitivity analyses were also conducted and will be presented.

Discussion

Exercise and physical activity appear to improve depression symptoms in adolescents, especially in clinical samples, suggesting that exercise may be a useful treatment strategy for adolescents with depression.

Conclusion

Despite the positive findings, large clinical trials that adequately minimise bias are required for firmer conclusions on the effectiveness of exercise as an antidepressant treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Ipilimumab and Bevacizumab in Glioblastoma

The median survival in glioblastoma is just over a year, with no standard second-line therapy. Ipilimumab is an immune checkpoint inhibitor that activates the anti-tumour immune response by cytotoxic T-lymphocyte antigen-4 blockade. There is significant evidence supporting its role in the treatment of malignant melanoma, including in patients with brain metastases. The addition of the anti-angiogenesis agent, bevacizumab, seems to offer additional benefit and limit the immune-related side-effects of ipilimumab in melanoma. To date there have been no clinical trials investigating this combination in glioblastoma. In this single practice case series, 20 patients with glioblastoma were consented for and treated with ipilimumab and bevacizumab in combination. Safety, tolerability and the response to treatment were reviewed for all patients. Three patients were treated after palliative first-line radiotherapy, one patient after first-line chemoradiation and 16 patients were treated with recurrent disease. Sixty-five per cent of patients completed four cycles of 3 weekly ipilimumab therapy, administered with 2 weekly bevacizumab. Radiographic responses for patients with recurrent disease were evaluated by Response Assessment in Neuro-oncology (RANO) criteria; 31% of patients showed a partial response, 31% had stable disease and 38% had disease progression. The treatment combination was well tolerated, with treatment terminated before completion due to adverse events in two patients. Autoimmune toxicity was manageable with systemic corticosteroid therapy. Ipilimumab and bevacizumab in combination show promising activity with a predictable and manageable toxicity profile, warranting further clinical studies.

Consistency of secondary colour vision tests in transport industries

BACKGROUND

Occupational colour vision testing is a requirement in a number of transport industries, and there are a number of tests that are considered acceptable by the various industry regulatory bodies.

AIMS

To review the occupational colour vision tests currently in use nationally and internationally and determine whether they give consistent results.

METHODS

A systematic review of the evidence was carried out according to standard methods. The Ovid Medline database was searched from 1946 to March 2013 using a broad and inclusive strategy.

RESULTS

A total of 8951 citations were identified, from which 20 papers were selected for data analysis. Of these papers, 13 of 20 assessed test sensitivity and specificity, and 11 papers measured the number, type and severity of colour vision deficiency of subjects passing the tests. Three studies also measured test repeatability. The quality of studies included was generally good. Sensitivity and specificity ranged from 64% to 100% and 88% to 100%, respectively. The studies evaluating the newer screen-based tests reported the highest sensitivity and specificity. The marked variability reported between tests and within tests can be attributed to many factors including test protocol, sample selection, test distance and time for dark adaptation.

CONCLUSIONS

There was low consistency between the colour vision tests examined. Lantern tests cannot be used to identify type or severity of colour vision deficit and, when used as a screening test for 'colour safe' status, give variable results. These results highlight the need for standardization across the transport industries.

Exercise for adolescents with depression: valued aspects and perceived change

INTRODUCTION

Despite systematic reviews demonstrating an association between exercise participation and reduced depressive symptoms in young people, there is no qualitative research exploring the experience of depressed adolescents who have engaged in an exercise intervention.

AIMS

To explore the experience of depressed adolescents who had recently engaged in a preferred intensity exercise intervention.

METHOD

The participants (n = 26) were recruited through health and social care services, were all in treatment for depression, and were purposefully sampled for interview following engagement in a preferred intensity exercise intervention, which was being evaluated via a pragmatic randomized controlled trial. A thematic approach was undertaken to analyse and organize the data.

RESULTS

Numerous beneficial changes were reported by participants alongside specific aspects of the intervention that were valued.

DISCUSSION AND IMPLICATIONS

The findings suggest that preferred intensity exercise can lead to feelings of improved mood, enjoyment and achievement, alongside benefits that transcend depressive symptom reduction. Considering mental health nurses are in key positions to promote exercise in this population, the current findings provide vital information for this purpose.

Development of a transmission-blocking malaria vaccine: progress, challenges, and the path forward

New interventions are needed to reduce morbidity and mortality associated with malaria, as well as to accelerate elimination and eventual eradication. Interventions that can break the cycle of parasite transmission, and prevent its reintroduction, will be of particular importance in achieving the eradication goal. In this regard, vaccines that interrupt malaria transmission (VIMT) have been highlighted as an important intervention, including transmission-blocking vaccines that prevent human-to-mosquito transmission by targeting the sexual, sporogonic, or mosquito stages of the parasite (SSM-VIMT). While the significant potential of this vaccine approach has been appreciated for decades, the development and licensure pathways for vaccines that target transmission and the incidence of infection, as opposed to prevention of clinical malaria disease, remain ill-defined. This article describes the progress made in critical areas since 2010, highlights key challenges that remain, and outlines important next steps to maximize the potential for SSM-VIMTs to contribute to the broader malaria elimination and eradication objectives.

Bilateral femoral neck insufficiency fractures secondary to vitamin D deficiency and concurrent corticosteroid use--a case report

We present a rare case of a 67-year-old Indian female who was found to have bilateral insufficiency of the neck of femur fractures secondary to osteomalacia from vitamin D deficiency, with her symptoms exacerbated by a course of oral steroids prescribed for suspected polymyalgia rheumatica.

INTRODUCTION

Bilateral femoral neck fractures are rare and are known to be associated with a variety of conditions such as parathyroid or renal dysfunction.

METHOD

We present a rare case of a 67-year-old Indian female who was found to have bilateral insufficiency of the neck of femur fractures secondary to osteomalacia from vitamin D deficiency, with her symptoms exacerbated by a course of oral steroids prescribed for suspected polymyalgia rheumatica.

RESULT

In patients with severe bilateral hip pain and a normal pelvic radiograph, it is important to consider magnetic resonance imaging early to avoid missing this important diagnosis.

CONCLUSION

Osteomalacia and vitamin D deficiency is an important differential diagnosis in any patient presenting with bone and muscle pain. Vitamin D levels are easily available and deficiency is easily treated.

Randomized, controlled trial of the long term safety, immunogenicity and efficacy of RTS,S/AS02(D) malaria vaccine in infants living in a malaria-endemic region

BACKGROUND

The RTS,S/AS malaria candidate vaccine is being developed with the intent to be delivered, if approved, through the Expanded Programme on Immunization (EPI) of the World Health Organization. Safety, immunogenicity and efficacy of the RTS,S/AS02(D) vaccine candidate when integrated into a standard EPI schedule for infants have been reported over a nine-month surveillance period. This paper describes results following 20 months of follow up.

METHODS

This Phase IIb, single-centre, randomized controlled trial enrolled 340 infants in Tanzania to receive three doses of RTS,S/AS02(D) or hepatitis B vaccine at 8, 12, and 16 weeks of age. All infants also received DTPw/Hib (diphtheria and tetanus toxoids, whole-cell pertussis vaccine, conjugated Haemophilus influenzae type b vaccine) at the same timepoints. The study was double-blinded to month 9 and single-blinded from months 9 to 20.

RESULTS

From month 0 to 20, at least one SAE was reported in 57/170 infants who received RTS,S/AS02(D) (33.5%; 95% confidence interval [CI]: 26.5, 41.2) and 62/170 infants who received hepatitis B vaccine (36.5%; 95% CI: 29.2, 44.2). The SAE profile was similar in both vaccine groups; none were considered to be related to vaccination. At month 20, 18 months after completion of vaccination, 71.8% of recipients of RTS,S/AS02(D) and 3.8% of recipients of hepatitis B vaccine had seropositive titres for anti-CS antibodies; seroprotective levels of anti-HBs antibodies remained in 100% of recipients of RTS,S/AS02(D) and 97.7% recipients of hepatitis B vaccine. Anti-HBs antibody GMTs were higher in the RTS,S/AS02(D) group at all post-vaccination time points compared to control. According to protocol population, vaccine efficacy against multiple episodes of malaria disease was 50.7% (95% CI: -6.5 to 77.1, p = 0.072) and 26.7% (95% CI: -33.1 to 59.6, p = 0.307) over 12 and 18 months post vaccination, respectively. In the Intention to Treat population, over the 20-month follow up, vaccine efficacy against multiple episodes of malaria disease was 14.4% (95% CI: -41.9 to 48.4, p = 0.545).

CONCLUSIONS

The acceptable safety profile and good tolerability of RTS,S/AS02(D) in combination with EPI vaccines previously reported from month 0 to 9 was confirmed over a 20 month surveillance period in this infant population. Antibodies against both CS and HBsAg in the RTS,S/AS02(D) group remained significantly higher compared to control for the study duration. Over 18 months follow up, RTS,S/AS02(D) prevented approximately a quarter of malaria cases in the study population.

CLINICAL TRIALS

Gov identifier: NCT00289185.

A phase 3 trial of RTS,S/AS01 malaria vaccine in African infants

BACKGROUND

The candidate malaria vaccine RTS,S/AS01 reduced episodes of both clinical and severe malaria in children 5 to 17 months of age by approximately 50% in an ongoing phase 3 trial. We studied infants 6 to 12 weeks of age recruited for the same trial.

METHODS

We administered RTS,S/AS01 or a comparator vaccine to 6537 infants who were 6 to 12 weeks of age at the time of the first vaccination in conjunction with Expanded Program on Immunization (EPI) vaccines in a three-dose monthly schedule. Vaccine efficacy against the first or only episode of clinical malaria during the 12 months after vaccination, a coprimary end point, was analyzed with the use of Cox regression. Vaccine efficacy against all malaria episodes, vaccine efficacy against severe malaria, safety, and immunogenicity were also assessed.

RESULTS

The incidence of the first or only episode of clinical malaria in the intention-to-treat population during the 14 months after the first dose of vaccine was 0.31 per person-year in the RTS,S/AS01 group and 0.40 per person-year in the control group, for a vaccine efficacy of 30.1% (95% confidence interval [CI], 23.6 to 36.1). Vaccine efficacy in the per-protocol population was 31.3% (97.5% CI, 23.6 to 38.3). Vaccine efficacy against severe malaria was 26.0% (95% CI, -7.4 to 48.6) in the intention-to-treat population and 36.6% (95% CI, 4.6 to 57.7) in the per-protocol population. Serious adverse events occurred with a similar frequency in the two study groups. One month after administration of the third dose of RTS,S/AS01, 99.7% of children were positive for anti-circumsporozoite antibodies, with a geometric mean titer of 209 EU per milliliter (95% CI, 197 to 222).

CONCLUSIONS

The RTS,S/AS01 vaccine coadministered with EPI vaccines provided modest protection against both clinical and severe malaria in young infants. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619.).

Evaluation of the Chief Nursing Officer's Review of mental health nursing in England: findings from case studies in mental health trusts

This study is an evaluation of the implementation of the Chief Nursing Officer for England's Review of mental health nursing in mental health trusts (MHTs). The authors employed instrumental case studies in six MHTs. The results showed evidence of acceptance of the Review and some evidence of subsequent actions to implement the Review recommendations, but these were not widespread. A lack of an evidence-based implementation plan hampered the implementation as did an apparent lack of strategic nursing leadership in many MHTs. In conclusion, the vision for mental health nursing reported in the Chief Nursing Officer Review prompted various changes, directly and indirectly, among mental health nurses and the development of areas of good practice in education, practice and leadership. The positive changes evident in some areas may become widespread by a systematic policy implementation plan from the centre, supported by local leadership in practice.

Automatic tracking of individual migrating cells using low-magnification dark-field microscopy

Many fundamental biological processes, such as the search for food, immunological responses and wound healing, depend on cell migration. Video microscopy allows the magnitude and direction of cell migration to be documented. Here, we present a simple and inexpensive method for simultaneous tracking of hundreds of migrating cells over periods of several days. Low-magnification dark-field microscopy was used to visualize individual cells whereas time-lapse video images were acquired by computer for future analysis. We employed an automated tracking algorithm to identify individual cells on each video image allowing migration paths to be tracked using a nearest neighbour algorithm. To test the method, we followed the time-course of migration of 3T3 fibroblasts, endothelial cells and individual amoeba in the absence of any chemical stimulus gradient. All cell types showed a 'random walk' behaviour in which mean squared displacement in position increased linearly with time. We defined a 'migration coefficient' (D(mig)), analogous to a diffusion coefficient, which gave an estimate of cell migration rate. D(mig) depended on cell type and temperature. When amoebas were made to undergo chemotaxis, the cells no longer followed a random walk but instead moved at a near constant velocity (V(av)) towards the chemotactic stimulus.

First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children

BACKGROUND

An ongoing phase 3 study of the efficacy, safety, and immunogenicity of candidate malaria vaccine RTS,S/AS01 is being conducted in seven African countries.

METHODS

From March 2009 through January 2011, we enrolled 15,460 children in two age categories--6 to 12 weeks of age and 5 to 17 months of age--for vaccination with either RTS,S/AS01 or a non-malaria comparator vaccine. The primary end point of the analysis was vaccine efficacy against clinical malaria during the 12 months after vaccination in the first 6000 children 5 to 17 months of age at enrollment who received all three doses of vaccine according to protocol. After 250 children had an episode of severe malaria, we evaluated vaccine efficacy against severe malaria in both age categories.

RESULTS

In the 14 months after the first dose of vaccine, the incidence of first episodes of clinical malaria in the first 6000 children in the older age category was 0.32 episodes per person-year in the RTS,S/AS01 group and 0.55 episodes per person-year in the control group, for an efficacy of 50.4% (95% confidence interval [CI], 45.8 to 54.6) in the intention-to-treat population and 55.8% (97.5% CI, 50.6 to 60.4) in the per-protocol population. Vaccine efficacy against severe malaria was 45.1% (95% CI, 23.8 to 60.5) in the intention-to-treat population and 47.3% (95% CI, 22.4 to 64.2) in the per-protocol population. Vaccine efficacy against severe malaria in the combined age categories was 34.8% (95% CI, 16.2 to 49.2) in the per-protocol population during an average follow-up of 11 months. Serious adverse events occurred with a similar frequency in the two study groups. Among children in the older age category, the rate of generalized convulsive seizures after RTS,S/AS01 vaccination was 1.04 per 1000 doses (95% CI, 0.62 to 1.64).

CONCLUSIONS

The RTS,S/AS01 vaccine provided protection against both clinical and severe malaria in African children. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619 .).

Cord blood transplantation in Western Australia

BACKGROUND/AIMS

Thirty-one umbilical cord blood transplants performed in Western Australia were retrospectively examined in order to document local experience and relevant prognostic factors. Three cord units were from human leucocyte antigen-matched siblings and the remainder were unrelated single (n= 22) or double (n= 6) cord blood transplants.

METHODS

Twenty patients were transplanted for malignant conditions and 11 for non-malignant conditions. Cord units contained a median of 5.6 × 107 total nucleated cells/kg and 1.4 × 105 CD34+ cells/kg. Cumulative incidence of neutrophil engraftment was 76% at day 60.

RESULTS

Of those who did not engraft, two patients remain alive following subsequent allogeneic bone marrow transplant. There were no deaths caused by graft-versus-host disease. Overall survival at median follow up of 28 months was 62%. Two year overall survival was influenced by type of disease (non-malignant = 91 ± 9% vs malignant = 41 ± 13%, P= 0.005), total nucleated cell dose (>3.5 × 107/kg = 87 ± 9% vs <3.5 × 107/kg = 34 ± 15%, P= 0.01) and CD34 dose (>1.7 × 105/kg = 92% vs <1.7 × 105/kg = 46%, P= 0.04). Age and human leucocyte antigen match did not influence survival. Four relapses occurred, all of which were fatal.

CONCLUSION

Cord blood transplantation for malignant and non-malignant disease is practised in Western Australia and outcomes are satisfactory. Trends and techniques in cord blood transplantation in this state are comparable with those observed nationally and overseas. Although numbers are small, cell dose appears to be predictive of overall survival

Development of standardized laboratory methods and quality processes for a phase III study of the RTS, S/AS01 candidate malaria vaccine

BACKGROUND

A pivotal phase III study of the RTS,S/AS01 malaria candidate vaccine is ongoing in several research centres across Africa. The development and establishment of quality systems was a requirement for trial conduct to meet international regulatory standards, as well as providing an important capacity strengthening opportunity for study centres.

METHODS

Standardized laboratory methods and quality assurance processes were implemented at each of the study centres, facilitated by funding partners.

RESULTS

A robust protocol for determination of parasite density based on actual blood cell counts was set up in accordance with World Health Organization recommendations. Automated equipment including haematology and biochemistry analyzers were put in place with standard methods for bedside testing of glycaemia, base excess and lactacidaemia. Facilities for X-rays and basic microbiology testing were also provided or upgraded alongside health care infrastructure in some centres. External quality assurance assessment of all major laboratory methods was established and method qualification by each laboratory demonstrated. The resulting capacity strengthening has ensured laboratory evaluations are conducted locally to the high standards required in clinical trials.

CONCLUSION

Major efforts by study centres, together with support from collaborating parties, have allowed standardized methods and robust quality assurance processes to be put in place for the phase III evaluation of the RTS, S/AS01 malaria candidate vaccine. Extensive training programmes, coupled with continuous commitment from research centre staff, have been the key elements behind the successful implementation of quality processes. It is expected these activities will culminate in healthcare benefits for the subjects and communities participating in these trials.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00866619.

Efficacy of RTS,S/AS01E malaria vaccine and exploratory analysis on anti-circumsporozoite antibody titres and protection in children aged 5-17 months in Kenya and Tanzania: a randomised controlled trial

Background

RTS,S/AS01E is the lead candidate malaria vaccine. We recently showed efficacy against clinical falciparum malaria in 5–17 month old children, during an average of 8 months follow-up. We aimed to assess the efficacy of RTS,S/AS01E during 15 months of follow-up.

Methods

Between March, 2007, and October, 2008, we enrolled healthy children aged 5–17 months in Kilifi, Kenya, and Korogwe, Tanzania. Computer-generated block randomisation was used to randomly assign participants (1:1) to receive three doses (at month 0, 1, and 2) of either RTS,S/AS01E or human diploid-cell rabies vaccine. The primary endpoint was time to first clinical malaria episode, defined as the presence of fever (temperature ≥37·5°C) and a Plasmodium falciparum density of 2500/μL or more. Follow-up was 12 months for children from Korogwe and 15 months for children from Kilifi. Primary analysis was per protocol. In a post-hoc modelling analysis we characterised the associations between anti-circumsporozoite antibodies and protection against clinical malaria episodes. This study is registered with ClinicalTrials.gov, number NCT00380393.

Findings

894 children were assigned, 447 in each treatment group. In the per-protocol analysis, 82 of 415 children in the RTS,S/AS01E group and 125 of 420 in the rabies vaccine group had first or only clinical malaria episode by 12 months, vaccine efficacy 39·2% (95% CI 19·5–54·1, p=0·0005). At 15 months follow-up, 58 of 209 children in the RTS,S/AS01E group and 85 of 206 in the rabies vaccine group had first or only clinical malaria episode, vaccine efficacy 45·8% (24·1–61·3, p=0·0004). At 12 months after the third dose, anti-circumsporozoite antibody titre data were available for 390 children in the RTS,S/AS01E group and 391 in the rabies group. A mean of 15 months (range 12–18 months) data were available for 172 children in the RTS,S/AS01E group and 155 in the rabies group. These titres at 1 month after the third dose were not associated with protection, but titres at 6·5 months were. The level of protection increased abruptly over a narrow range of antibody concentrations. The most common adverse events were pneumonia, febrile convulsion, gastroenteritis, and P falciparum malaria.

Interpretation

RTS,S/AS01E confers sustained efficacy for at least 15 months and shows promise as a potential public health intervention against childhood malaria in malaria endemic countries.

Funding

PATH Malaria Vaccine Initiative (MVI), GlaxoSmithKline.

A randomized trial assessing the safety and immunogenicity of AS01 and AS02 adjuvanted RTS,S malaria vaccine candidates in children in Gabon

Background

The malaria vaccine candidate antigen RTS,S includes parts of the pre-erythrocytic stage circumsporozoite protein fused to the Hepatitis B surface antigen. Two Adjuvant Systems are in development for this vaccine, an oil-in water emulsion – based formulation (AS02) and a formulation based on liposomes (AS01).

Methods & Principal Findings

In this Phase II, double-blind study (NCT00307021), 180 healthy Gabonese children aged 18 months to 4 years were randomized to receive either RTS,S/AS01_E or RTS,S/AS02_D, on a 0–1–2 month vaccination schedule. The children were followed-up daily for six days after each vaccination and monthly for 14 months. Blood samples were collected at 4 time-points. Both vaccines were well tolerated. Safety parameters were distributed similarly between the two groups. Both vaccines elicited a strong specific immune response after Doses 2 and 3 with a ratio of anti-CS GMT titers (AS02_D/AS01_E) of 0.88 (95% CI: 0.68–1.15) post-Dose 3. After Doses 2 and 3 of experimental vaccines, anti-CS and anti-HBs antibody GMTs were higher in children who had been previously vaccinated with at least one dose of hepatitis B vaccine compared to those not previously vaccinated.

Conclusions

RTS,S/AS01_E proved similarly as well tolerated and immunogenic as RTS,S/AS02_D, completing an essential step in the age de-escalation process within the RTS,S clinical development plan.

Trial Registration

ClinicalTrials.gov. NCT00307021

Altered antibody responses in mannose-binding lectin-A deficient mice do not affect Trichuris muris or Schistosoma mansoni infections

Parasitic helminths possess surface glycoconjugates that are recognized by the serum collectin molecule, mannose-binding lectin (MBL). Once bound, MBL triggers the lectin pathway of complement. Mice have two MBL, MBL-A and MBL-C. We previously showed that MBL-A deficient (MBL-A(-/-)) mice have enhanced survival of Brugia malayi microfilariae and abrogated microfilariae-specific IgM responses. In this study we show that MBL-A deficiency does not alter immunity to either Trichuris muris or Schistosoma mansoni. However, anti-nematode IgM levels were significantly lower in T. muris infected MBL-A(-/-) than wild-type mice. Interestingly nematode-specific IgG1 and IgG2a levels were higher in MBL-A(-/-) mice. Although, larval schistosomes are surrounded by a complement-sensitive membranous tegument, neither adult worm development, egg output, egg granuloma size nor cellular composition was affected in MBL-A(-/-) mice. In contrast to anti-nematode IgM responses, anti-schistosome IgM (and also IgG1 and IgG2b) responses were unaltered from wild-type mice. Anti-schistosome IgG2a was elevated, while IgG3 was significantly lowered, in MBL-A(-/-) mice. These results suggest that MBL-A is not a necessary component for immunity to either T. muris or S. mansoni helminths, however, MBL-A appears to be necessary for the development of specific IgM responses to nematode antigens.

Safety and immunogenicity of RTS,S/AS02D malaria vaccine in infants

BACKGROUND

The RTS,S/AS malaria vaccine is being developed for delivery through the World Health Organization's Expanded Program on Immunization (EPI). We assessed the feasibility of integrating RTS,S/AS02D into a standard EPI schedule for infants.

METHODS

In this phase 2B, single-center, double-blind, controlled trial involving 340 infants in Bagamoyo, Tanzania, we randomly assigned 340 infants to receive three doses of either the RTS,S/AS02D vaccine or the hepatitis B vaccine at 8, 12, and 16 weeks of age. All infants also received a vaccine containing diphtheria and tetanus toxoids, whole-cell pertussis vaccine, and conjugated Haemophilus influenzae type b vaccine (DTPw/Hib). The primary objectives were the occurrence of serious adverse events during a 9-month surveillance period and a demonstration of noninferiority of the responses to the EPI vaccines (DTPw/Hib and hepatitis B surface antigen) with coadministration of the RTS,S/AS02D vaccine, as compared with the hepatitis B vaccine. The detection of antibodies against Plasmodium falciparum circumsporozoite and efficacy against malaria infection were secondary objectives.

RESULTS

At least one serious adverse event was reported in 31 of 170 infants who received the RTS,S/AS02D vaccine (18.2%; 95% confidence interval [CI], 12.7 to 24.9) and in 42 of 170 infants who received the hepatitis B vaccine (24.7%; 95% CI, 18.4 to 31.9). The results showed the noninferiority of the RTS,S/AS02D vaccine in terms of antibody responses to EPI antigens. One month after vaccination, 98.6% of infants receiving the RTS,S/AS02D vaccine had seropositive titers for anticircumsporozoite antibodies on enzyme-linked immunosorbent assay (ELISA). During the 6-month period after the third dose of vaccine, the efficacy of the RTS,S/AS02D vaccine against first infection with P. falciparum malaria was 65.2% (95% CI, 20.7 to 84.7; P=0.01).

CONCLUSIONS

The use of the RTS,S/AS02D vaccine in infants had a promising safety profile, did not interfere with the immunologic responses to coadministered EPI antigens, and reduced the incidence of malaria infection. (ClinicalTrials.gov number, NCT00289185.)

Efficacy of RTS,S/AS01E vaccine against malaria in children 5 to 17 months of age

BACKGROUND

Plasmodium falciparum malaria is a pressing global health problem. A previous study of the malaria vaccine RTS,S (which targets the circumsporozoite protein), given with an adjuvant system (AS02A), showed a 30% rate of protection against clinical malaria in children 1 to 4 years of age. We evaluated the efficacy of RTS,S given with a more immunogenic adjuvant system (AS01E) in children 5 to 17 months of age, a target population for vaccine licensure.

METHODS

We conducted a double-blind, randomized trial of RTS,S/AS01E vaccine as compared with rabies vaccine in children in Kilifi, Kenya, and Korogwe, Tanzania. The primary end point was fever with a falciparum parasitemia density of more than 2500 parasites per microliter, and the mean duration of follow-up was 7.9 months (range, 4.5 to 10.5).

RESULTS

A total of 894 children were randomly assigned to receive the RTS,S/AS01E vaccine or the control (rabies) vaccine. Among the 809 children who completed the study procedures according to the protocol, the cumulative number in whom clinical malaria developed was 32 of 402 assigned to receive RTS,S/AS01E and 66 of 407 assigned to receive the rabies vaccine; the adjusted efficacy rate for RTS,S/AS01E was 53% (95% confidence interval [CI], 28 to 69; P<0.001) on the basis of Cox regression. Overall, there were 38 episodes of clinical malaria among recipients of RTS,S/AS01E, as compared with 86 episodes among recipients of the rabies vaccine, with an adjusted rate of efficacy against all malarial episodes of 56% (95% CI, 31 to 72; P<0.001). All 894 children were included in the intention-to-treat analysis, which showed an unadjusted efficacy rate of 49% (95% CI, 26 to 65; P<0.001). There were fewer serious adverse events among recipients of RTS,S/AS01E, and this reduction was not only due to a difference in the number of admissions directly attributable to malaria.

CONCLUSIONS

RTS,S/AS01E shows promise as a candidate malaria vaccine. (ClinicalTrials.gov number, NCT00380393.)

Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm

All members of medical staff, including students, were asked to participate in a self-administered questionnaire concerning patterns of mobile phone use and care. Participants' phones were cultured for micro-organisms. Healthcare professionals working in close proximity to sensitive equipment were surveyed concerning adverse events associated with mobile phones. Telephone operators were asked to monitor time elapsed as they attempted to contact medical staff by various methods. Of 266 medical staff and students at the time of the study, 116 completed questionnaires (response rate=44%). Almost all (98%) used mobile phones: 67% used their mobile phones for hospital-related matters; 47% reported using their phone while attending patients. Only 3% reported washing their hands after use and 53% reported never cleaning their phone. In total, 101 mobile phones were cultured for micro-organisms; 45% were culture-positive and 15% grew Gram-negative pathogens. The survey of staff working in close proximity to sensitive equipment revealed only one report of minor interference with life-saving equipment. Telephone operators were able to contact medical staff within 2 min most easily by mobile phone. Mobile phones were used widely by staff and were considered by most participants as a more efficient means of communication. However, microbial contamination is a risk associated with the infrequent cleaning of phones. Hospitals should develop policies to address the hygiene of mobile phones.

Vaccine knowledge and practices of primary care providers of exempt vs. vaccinated children

OBJECTIVES

Compare vaccine knowledge, attitudes and practices of primary care providers for fully vaccinated children and children who are exempt from school immunization requirements.

METHODS

We conducted a mailed survey of parent-identified primary care providers from four states to measure perceived risks and benefits of vaccination and other key immunization beliefs. Frequencies of responses were stratified by type of provider, identified by exempt versus vaccinated children. Logistic regression was used to calculate odds ratios for responses by provider type.

RESULTS

551 surveys were completed (84.3% response rate). Providers for exempt children had similar attitudes to providers for non-exempt children. However, there were statistically significant increased concerns among providers for exempt children regarding vaccine safety and lack of perceived individual and community benefits for vaccines compared to other providers.

CONCLUSIONS

The great majority of providers for exempt children had similar attitudes about vaccine safety, effectiveness and benefits as providers of non-exempt children. Although providers for exempt children were more likely to believe that multiple vaccines weaken a child's immune system and were concerned about vaccine safety and less likely to consider vaccines were beneficial, a substantial proportion of providers of both exempt and vaccinated children have concerns about vaccine safety and believe that CDC underestimates the frequency of vaccine side effects. Effective continuing education of providers about the risks and benefits of immunization and including in vaccine recommendations more information on pre and post licensing vaccine safety evaluations may help address these concerns.

Differential Y-chromosome Anatolian influences on the Greek and Cretan Neolithic

The earliest Neolithic sites of Europe are located in Crete and mainland Greece. A debate persists concerning whether these farmers originated in neighboring Anatolia and the role of maritime colonization. To address these issues 171 samples were collected from areas near three known early Neolithic settlements in Greece together with 193 samples from Crete. An analysis of Y-chromosome haplogroups determined that the samples from the Greek Neolithic sites showed strong affinity to Balkan data, while Crete shows affinity with central/Mediterranean Anatolia. Haplogroup J2b-M12 was frequent in Thessaly and Greek Macedonia while haplogroup J2a-M410 was scarce. Alternatively, Crete, like Anatolia showed a high frequency of J2a-M410 and a low frequency of J2b-M12. This dichotomy parallels archaeobotanical evidence, specifically that while bread wheat (Triticum aestivum) is known from Neolithic Anatolia, Crete and southern Italy; it is absent from earliest Neolithic Greece. The expansion time of YSTR variation for haplogroup E3b1a2-V13, in the Peloponnese was consistent with an indigenous Mesolithic presence. In turn, two distinctive haplogroups, J2a1h-M319 and J2a1b1-M92, have demographic properties consistent with Bronze Age expansions in Crete, arguably from NW/W Anatolia and Syro-Palestine, while a later mainland (Mycenaean) contribution to Crete is indicated by relative frequencies of V13.

A phase III randomized trial of intensive induction and consolidation chemotherapy ± oblimersen, a pro-apoptotic Bcl-2 antisense oligonucleotide in untreated acute myeloid leukemia patients >60 years old

7012

Background: Overexpression of Bcl-2, an inhibitor of apoptosis, may render AML cells resistant to chemotherapy and has been associated with unfavorable outcome. Genasense is a phosphorothioate 18-mer antisense oligonucleotide directed against the first 6 codons of Bcl-2. In a phase I study of older (≥60 yrs) AML patients (pts) treated with Genasense in combination with cytarabine (Ara-C) and daunorubicin (DNR) induction and with high-dose cytarabine (HiDAC) consolidation, no antisense-related toxicity was reported. Furthermore, overexpression of Bcl-2 at diagnosis and down-regulation of the Bcl-2 target after antisense treatment was shown in pts achieving complete remission (CR). Methods: A phase III trial (CALGB 10201) randomized untreated older AML pts to induction treatment with Ara-C (100 mg/m2/d by CIVI on days 4–10) and DNR (60 mg/m2/d on days 4–6) followed by consolidation therapy with HiDAC (2 g/m2/d on days 4–8) with (Arm A) or without (Arm B) Genasense (7 mg/m2/d CIVI on days 1–10 for induction and days 1–8 for consolidation). The study was powered to identify a survival advantage for pts receiving Genasense. Results: 503 pts enrolled between 12/03 and 10/06; 76 had prior MDS and 24 prior chemoradiotherapy for unrelated cancers. The arms were balanced for age, sex, race, and performance status. No differences in toxicities were observed between the 2 arms. An interim futility analysis performed at 34 months from initiation of the study showed no differences in CR rates (48% vs 52%; p=0.75) or overall survival (OS; p=0.83) between the 2 arms. Estimated OS at 1 yr was 36% for Arm A and 40% for Arm B. Similarly, there were no differences in disease-free survival from date of CR (DFS; p=0.78) or event-free survival (EFS; p=0.77). DFS and EFS rates at 1 yr were 40% and 25% for Arm A, and 43% and 7% for Arm B, respectively. Conclusions: Addition of Genasense to induction and consolidation chemotherapy failed to improve the outcome of older AML pts. Pretreatment levels and post-antisense treatment changes in Bcl-2 expression are now being measured and correlated with outcome.

No significant financial relationships to disclose.

High-dose carmustine (BCNU), etoposide (VP-16), cytarabine (Ara-C), and cyclophosphamide-BVAC with autologous transplant (ASCT) in relapsed and refractory Hodgkin disease (HD): Long-term follow-up of 89 patients

8068

Background: High dose chemotherapy followed by ASCT has been established as the therapy for refractory and relapsed HD. Relapse remains the primary contributor to an unsuccessful outcome after ASCT. Intensification of the conditioning regimen is one means of decreasing relapse and improving results. We report our experience with an augmented preparative regimen in patients (pts) with relapsed or refractory HD undergoing ASCT. Methods: Retrospective analysis of 89 consecutive pts from October 1984 to October 2004. All pts received high-dose chemotherapy with BCNU 600mg/m2 IV day -8, Etoposide 400mg/m2/day days -7, -6, -5, and -4, Ara-C 3gm/m2 IV every 12 hours for 8 doses starting day -7, and Cyclophosphamide 90mg/kg IV on day-2 followed by bone marrow (40 pts), peripheral blood (43 pts) or both (6 pts) rescue. Ten pts received planned XRT post-transplant. Survival data were estimated using Kaplan-Meier curves. Cox proportional hazards regression was used to assess the impact of variables on disease-free survival (DFS) and overall survival (OS). Results: A total of 89 pts were identified. Median age was 31 (range 16–62); 51 pts (57.3%) had received one prior therapy at the time of transplant. At transplant only 28 pts (34.6%) were in CR; 79.8% had sensitive disease (CR plus PR).Time to transplant was < 1 year for 17% of pts. With a median follow-up of 811 days, the 5 and 10-year DFS rates were 63.3% and 60.4%, respectively. The estimated 5 and 10- year OS rates were 47.3% and 33.7%. The rate of secondary malignancies at 10 years was 7.8%. Lack of B symptoms and stage at transplant were associated with improved DFS (p= 0.01 and p= 0.0005, respectively) and OS (p=0.002 and p=0.02, respectively). Patients with primary induction failure and resistant relapse did as well as patients with sensitive disease. Conclusions: Though ASCT has been beneficial in prolonging DFS and OS in pts with chemosensitive HD, there has been conflicting data regarding refractory disease. We propose that an intensified regimen, i.e. BVAC, may be of benefit in that setting. Only a large randomized trial can determine whether intensification of the preparative regimen can improve OS for such a population.

No significant financial relationships to disclose.

Rate, extent and concentration dependence of histamine-evoked Weibel-Palade body exocytosis determined from individual fusion events in human endothelial cells

The rate, concentration dependence and extent of histamine-evoked Weibel-Palade body (WPB) exocytosis were investigated with time-resolved fluorescence microscopy in cultured human umbilical vein endothelial cells expressing WPB-targeted chimeras of enhanced green fluorescent protein (EGFP). Exocytosis of single WPBs was characterized by an increase in EGFP fluorescence, morphological changes and release of WPB contents. The fluorescence increase was due to a rise of intra-WPB pH from resting levels, estimated as pH 5.45+/-0.26 (s.d., n=144), to pH 7.40. It coincided with uptake of extracellular Alexa-647, indicating the formation of a fusion pore, prior to loss of fluorescent contents. Delays between the increase in intracellular free calcium ion concentration evoked by histamine and the first fusion event were 10.0+/-4.42 s (n=9 cells) at 0.3 microM histamine and 1.57+/-0.21 s (n=15 cells) at 100 microM histamine, indicating the existence of a slow process or processes in histamine-evoked WPB exocytosis. The maximum rates of exocytosis were 1.20+/-0.16 WPB s(-1) (n=9) at 0.3 microM and 3.66+/-0.45 WPB s(-1) at 100 microM histamine (n=15). These occurred 2-5 s after histamine addition and declined to lower rates with continued stimulation. The initial delays and maximal rate of exocytosis were unaffected by removal of external Ca2+ indicating that the initial burst of secretion is driven by Ca2+ release from internal stores, but sustained exocytosis required external Ca2+. Data were compared to exocytosis evoked by a maximal concentration of the strong secretagogue ionomycin (1 microM), for which there was a delay between calcium elevation and secretion of 1.67+/-0.24 s (n=6), and a peak fusion rate of approximately 10 WPB s(-1).

BRCA1 and BRCA2 as molecular targets for phytochemicals indole-3-carbinol and genistein in breast and prostate cancer cells

Indole-3-carbinol (I3C) and genistein are naturally occurring chemicals derived from cruciferous vegetables and soy, respectively, with potential cancer prevention activity for hormone-responsive tumours (e.g., breast and prostate cancers). Previously, we showed that I3C induces BRCA1 expression and that both I3C and BRCA1 inhibit oestrogen (E2)-stimulated oestrogen receptor (ER-α) activity in human breast cancer cells. We now report that both I3C and genistein induce the expression of both breast cancer susceptibility genes (BRCA1 and BRCA2) in breast (MCF-7 and T47D) and prostate (DU-145 and LNCaP) cancer cell types, in a time- and dose-dependent fashion. Induction of the BRCA genes occurred at low doses of I3C (20 μM) and genistein (0.5–1.0 μM), suggesting potential relevance to cancer prevention. A combination of I3C and genistein gave greater than expected induction of BRCA expression. Studies using small interfering RNAs (siRNAs) and BRCA expression vectors suggest that the phytochemical induction of BRCA2 is due, in part, to BRCA1. Functional studies suggest that I3C-mediated cytoxicity is, in part, dependent upon BRCA1 and BRCA2. Inhibition of E2-stimulated ER-α activity by I3C and genistein was dependent upon BRCA1; and inhibition of ligand-inducible androgen receptor (AR) activity by I3C and genistein was partially reversed by BRCA1-siRNA. Finally, we provide evidence suggesting that the phytochemical induction of BRCA1 expression is due, in part, to endoplasmic reticulum stress response signalling. These findings suggest that the BRCA genes are molecular targets for some of the activities of I3C and genistein.

An evaluation of the FRIENDS programme: a cognitive behaviour therapy intervention to promote emotional resilience

AIMS

To evaluate the efficacy and acceptability of the FRIENDS programme.

METHODS

Uncontrolled before and after assessment of the FRIENDS programme, a 10 session cognitive behaviour therapy programme. A total of 213 children aged 9-10 years from six primary schools were studied.

MAIN OUTCOME MEASURES

Spence Children's Anxiety Scale, Culture Free Self-Esteem Questionnaire, qualitative assessment of acceptability.

RESULTS

End of programme data from 197 children (92.5% of eligible sample) showed significantly lower rates of anxiety (t = 2.95, df = 384) and significantly improved levels of self-esteem (t = 3.13, df = 386). Significant improvements were obtained in over half of those children with the most severe emotional problems. A total of 190 children (89.2%) completed a qualitative assessment of acceptability: 154 (81%) thought it was fun, 147 (77.4%) would recommend it to a friend; 137 (72.8%) thought they had learned new skills, and 78 (41.1%) had helped someone else with their new skills.

CONCLUSIONS

The FRIENDS programme appears to be an efficacious and acceptable way to promote emotional resilience (reduced anxiety and increased self-esteem) in primary school aged children, consistent with previous studies in Australia. Further controlled studies are needed to assess natural history of anxiety and self-esteem and whether benefits are maintained over time.