Invited review: Modeling milk stability

Novel insights into the stability of milk and milk products during storage and processing result from describing caseins near neutral pH as hydrophilic, intrinsically disordered, proteins. Casein solubility is strongly influenced by pH and multivalent ion binding. Solubility is high at neutral pH or above but decreases as casein net charge approaches zero, allowing a condensed casein phase or gel to form then increases at lower pH. Of particular importance for casein micelle stability near neutral pH is the proportion of free caseins in the micelle (i.e., caseins not bound directly to nanoclusters of calcium phosphate). Free caseins are more soluble and better able to act as molecular chaperones (to prevent casein and whey protein aggregation) than bound caseins. Some free caseins are highly phosphorylated and can also act as mineral chaperones to inhibit the growth of calcium phosphate phases and prevent mineralized deposits from forming on membranes or heat exchangers. Thus, casein micelle stability is reduced when free caseins bind to amyloid fibrils, destabilized whey proteins or calcium phosphate. The multivalent-binding model of the casein micelle quantitatively describes these and other factors affecting the stability of milk and milk protein products during manufacture and storage.

Early intervention to prevent adverse child emotional and behavioural development following maternal depression in pregnancy: study protocol for a randomised controlled trial

BACKGROUND

Substantial evidence indicates that maternal depression during pregnancy (i.e., antenatal depression) is associated not only with maternal wellbeing but also with child emotional and behavioural development. Children of antenatally depressed women are at risk of emotional and behavioural problems, including internalising problems (e.g., anxiety and depression) and externalising problems (e.g., attention problems), that may last at least to adolescence. These enduring effects also constitute an enormous economic cost. Despite the seriousness of this problem, until recently there existed very few controlled studies evaluating whether active psychological treatment for antenatal depression can prevent adverse child outcomes. Our previous pilot randomised controlled trial (RCT) exploring the effect of cognitive behavioural therapy (CBT) for antenatal depression on child outcomes showed promising results. We aim to assess whether treating antenatal depression with an evidence-based 8-week structured CBT program can prevent or ameliorate adverse child developmental outcomes at 2 years of age.

METHODS

Pregnant women ≤ 30 weeks gestation diagnosed with a depressive disorder are recruited and randomised to CBT or treatment as usual (TAU). The target sample size is 230 and the primary outcome measure is the infant Internalising scale of the Child Behaviour Checklist (CBCL) at 24 months of age. Secondary infant outcome measures at 24 months are the Externalising scale of the CBCL and the motor and cognitive development subscales of the Ages & Stages Questionnaire (ASQ-3). Additional secondary outcome measures are subscales of the Revised Infant Behaviour Questionnaire (IBQ-R), ASQ-3 and the ASQ-Socio-Emotional (ASQ-SE) at 3 and 12 months of age and the quality of mother-infant interaction at 3 and 24 months. Maternal measures, including demographic data, depression diagnosis, depressive and anxiety symptoms, perceived stress and parenting stress, are collected across all time points.

DISCUSSION

The trial is ongoing and recruitment was slowed due to the COVID-19 pandemic. If results suggest a beneficial effect of antenatal depression treatment on infant outcomes, the project could have repercussions for standard antenatal care, for maternal and infant health services and for preventing the intergenerational transmission of mental health disorders.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register: ACTRN12618001925235 Date Registered: 27 November 2018.

Web-based treatment for depression in pregnancy: a feasibility study of Mum2BMoodBooster

BACKGROUND

Depression in pregnancy is prevalent, under-treated, and has serious impacts on the wellbeing of women and on child development. Internet programs can reach women who may not access traditional treatments due to distance, stigma or concern about taking medication. We adapted our online postnatal depression program, MumMoodBooster, for antenatal use. We aimed to trial feasibility, acceptability, and potential efficacy of the new Mum2BMoodBooster intervention with depressed pregnant women.

METHODS

Twenty-seven pregnant women with Edinburgh Postnatal Depression Scale score > 11 used the program in a feasibility trial. Twenty-one had current diagnoses of major or minor depression on the Structured Clinical Interview for the DSM-IV. Assessment of symptoms occurred at screening/baseline, post-test (8 weeks post-enrollment), and at follow-up (3 months postpartum) using the Patient Health Questionnaire (PHQ-9) and the Depression Anxiety Stress Scales (DASS-21).

RESULTS

In this feasibility trial, depression scores on both the PHQ-9 and the DASS-21, showed significant reductions representing large effects, with average symptom scores reduced by > 50%, and maintained in the 'minimal or no depression' range at 3 month follow-up. Anxiety scores also decreased significantly. Program usage was high with 74% of women visiting all six sessions. Program acceptability ratings were moderate to high.

CONCLUSIONS

Findings paralleled the magnitude of symptom reductions seen in randomised trials of the postnatal MumMoodBooster program, suggesting that Mum2BMoodBooster is an effective treatment for depressed pregnant women. Effective internet therapies are likely to become increasingly important as the COVID-19 pandemic continues to make face-to-face access to health care problematic during 'lockdowns'.

Internet and Face-to-face Cognitive Behavioral Therapy for Postnatal Depression Compared With Treatment as Usual: Randomized Controlled Trial of MumMoodBooster

BACKGROUND

Previous research has confirmed that symptoms of postnatal depression (PND) can be ameliorated through internet-delivered psychological interventions. Advantages of internet-delivered treatment include anonymity, convenience, and catering to women who are unable to access face-to-face (FTF) treatments. To date, no research has examined the efficacy of such interventions compared directly with FTF treatments in women clinically diagnosed with PND.

OBJECTIVE

This study aims to compare the efficacy of one of the first web-based cognitive behavioral therapy (CBT) interventions (internet CBT+coach calls) for PND (MumMoodBooster [MMB]) with FTF-CBT in a randomized controlled trial (RCT).

METHODS

In this study, 116 postnatal women with a Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) diagnosis of major or minor depression were randomized to MMB (39/116, 33.6%), FTF-CBT (39/116, 33.6%), or a treatment-as-usual (TAU) control condition (38/116, 32.8%). Diagnostic status was determined at baseline and at 21-week follow-up using the Structured Clinical Interview for the DSM-IV. Severity of anxiety and depressive symptoms was evaluated using the Depression Anxiety Stress Scales and the revised Beck Depression Inventory at baseline, 12-week follow-up (after treatment), and 21-week follow-up.

RESULTS

Of the 116 participants, 107 (92.2%) had a diagnosis of major depression at baseline. Rates of remission from a major or minor depressive episode at 21 weeks in both the FTF-CBT and MMB groups were superior to that of the TAU group (56.6% and 47.7% less likely to be depressed, respectively) and they were not significantly different from each other. Although remission rates differed between TAU and FTF-CBT, growth models showed that, in terms of symptom reduction across time, the FTF-CBT treatment was not significantly better than TAU. By comparison, MMB was statistically superior to both TAU and FTF-CBT in reducing symptoms of depression, anxiety, and stress from baseline to the 21-week follow-up (large and moderate effect sizes). Thus, after 21 weeks, the average symptom scores for depression and anxiety of women receiving MMB were approximately half those of women in both the TAU and FTF-CBT groups.

CONCLUSIONS

In this RCT, MMB was at least as effective as FTF-CBT in achieving remission from a diagnosed PND episode. MMB was superior to TAU and FTF-CBT in encouraging and maintaining reduction of symptom severity over the 21-week follow-up for depressed postnatal women. These findings replicate results of prior studies on MMB that showed clinically significant improvements in depressive symptoms, and they provide direct empirical support that internet-delivered treatment for depressed postnatal women is a viable alternative to FTF treatment. The generalizability of the results needs to be examined in future research, as RCTs of internet-based versus FTF treatments necessarily involve a subset of people who are willing to undertake either modality of treatment.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000881730; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364683&isReview=true.

Improving the mother-infant relationship following postnatal depression: a randomised controlled trial of a brief intervention (HUGS)

Postnatal depression (PND) disrupts the crucial mother-infant relationship on which optimal child development depends. However, few well-evaluated, brief mother-infant interaction interventions exist. This randomised controlled trial (RCT) aimed to evaluate the effect of a 4-session, group-based mother-infant interaction intervention ('HUGS'), compared to a control playgroup, both following cognitive-behavioural therapy for PND, on mother-infant relationships and early child development. It was hypothesised that dyads receiving the HUGS intervention would show larger improvements than control dyads. Mothers (n = 77; M age = 32 years) diagnosed with major or minor depressive disorder using the Structured Clinical Interview for the DSM-IV participated with their infants (<12 months). Primary outcomes were observed mother-infant interactions using the Parent Child Early Relational Assessment (ERA) and maternal parenting stress using the Parenting Stress Index (PSI). Data were collected at baseline, post-PND treatment, post-HUGS intervention and 6-month post-HUGS follow-up. Seventy-four percent of HUGS dyads attended at least half of the HUGS sessions (≥2). Significant group differences emerged at the 6-month follow-up (but were not significant immediately post-HUGS). At 6-month follow-up, HUGS dyads showed significantly improved parental positive affective involvement and verbalisation (ERA; F_{1, 47} = 4.96, p = .03, η_p² = .10) and less impaired bonding (F_{1, 45} = 4.55, p = .04, η_p² = .09) than control dyads. No differences were found on the PSI or on child development outcomes. Both groups improved substantially (around 30 points) on the PSI following PND treatment, so that average scores were below the clinically significant threshold when beginning HUGS and the control playgroup. Findings suggest that incorporating HUGS intervention following PND treatment is effective for improving mother-infant relationships. A longer-term follow-up and larger sample size may be needed for improved mother-infant relationships to show an impact on observable child developmental outcomes. Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001110875).

Introducing PEEP: The psychiatry early experience programme

At Guy's King's and St Thomas’ School of Medicine, a unique initiative is the Psychiatry Early Experience Programme (PEEP), which allows students to shadow psychiatry trainees at work several times a year. The students’ attitudes towards psychiatry and the scheme are regularly assessed and initial results are already available.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Automated Assessment of Movement Impairment in Huntington's Disease

Quantitative assessment of movement impairment in Huntington's disease (HD) is essential to monitoring of disease progression. This paper aimed to develop and validate a novel low cost, objective automated system for the evaluation of upper limb movement impairment in HD in order to eliminate the inconsistency of the assessor and offer a more sensitive, continuous assessment scale. Patients with genetically confirmed HD and healthy controls were recruited to this observational study. Demographic data, including age (years), gender, and unified HD rating scale total motor score (UHDRS-TMS), were recorded. For the purposes of this paper, a modified upper limb motor impairment score (mULMS) was generated from the UHDRS-TMS. All participants completed a brief, standardized clinical assessment of upper limb dexterity while wearing a tri-axial accelerometer on each wrist and on the sternum. The captured acceleration data were used to develop an automatic classification system for discriminating between healthy and HD participants and to automatically generate a continuous movement impairment score (MIS) that reflected the degree of the movement impairment. Data from 48 healthy and 44 HD participants was used to validate the developed system, which achieved 98.78% accuracy in discriminating between healthy and HD participants. The Pearson correlation coefficient between the automatic MIS and the clinician rated mULMS was 0.77 with a p-value < 0.01. The approach presented in this paper demonstrates the possibility of an automated objective, consistent, and sensitive assessment of the HD movement impairment.

Surviving psychiatry on-calls

Introduction

Out of hours, there is only one on-site junior doctor. First year psychiatry trainees (CT1s) and GP trainees may have no prior experience in psychiatry. On-call shifts are therefore potentially daunting for new trainees.

Objectives

Expand the resources available for trainees when on-call.

Methods

We issued questionnaires to CT1s asking if they would have appreciated more information about on-call scenarios and in what format.

Based on the questionnaire results we implemented some changes. These were:

The handout was given to new trainees in February 2016 and in August 2016. The video was shown to new trainees in August 2016. Trainees provided feedback on the resources.

Results

Of 24 CT1s, 15 (63%) were “neutral” or “disagreed” that they had felt prepared for on-calls.

CT1s wanted additional resources, especially a paper handout or phone download.

Feedback on the “pocket-guide” from trainees in February 2016 (n = 8) was positive (62.5% reported increased confidence in on-call situations). Feedback is also being collected from trainees who received the guide in August 2016.

Trainees in August 2016 (n = 36) liked the video – no trainees “disagreed” with statements asking if the video had been useful.

The video improved the confidence of trainees about on-call situations by an average of 2.8 points.

Conclusions

We have expanded available resources relating to on-calls and improved confidence. Further improvements would include making resources more easily available in downloadable formats.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Combined effect of toe out gait and high tibial osteotomy on knee adduction moment in patients with varus knee deformity

BACKGROUND

Gait adaptations, including toe out gait, have been proposed as treatments for knee osteoarthritis. The clinical application of toe out gait, however, is unclear. This study aims to identify the changes in Knee adduction moment in varus knee deformity assessing toe out gait as an alternative to high tibial osteotomy, and if any change in dynamic loading persists post operatively, when anatomical alignment is restored.

METHODS

Three-dimensional motion analysis was performed on 17 patients with medial compartment knee osteoarthritis and varus deformity prior to undergoing high tibial osteotomy, 13 patients were assessed post-operatively, and results compared to 13 healthy controls.

FINDINGS

Pre-operatively, there was no significant difference between natural and toe out gait for measures of knee adduction moment. Post high tibial osteotomy, first (2.70 to 1.51% BW·h) and second peak (2.28 to 1.21% BW·h) knee adduction moment were significantly reduced, as was knee adduction angular impulse (1.00 to 0.52% BW·h·s), to a healthy level. Adopting toe out gait post-operatively reduced the second peak further to a level below that of healthy controls.

INTERPRETATION

Increasing the foot progression angle from 20° (natural) to 30° in isolation did not significantly alter the knee adduction moment or angular impulse. This suggests that adopting a toe out gait, in isolation, in an already high natural foot progression angle, is not of benefit. Adopting toe out gait post-operatively, however, resulted in a further reduction in the second peak to below that of the healthy control cohort, however, this may increase lateral compartment load.

Internet Cognitive Behavioral Therapy for Women With Postnatal Depression: A Randomized Controlled Trial of MumMoodBooster

BACKGROUND

There are few published controlled trials examining the efficacy of Internet-based treatment for postnatal depression (PND) and none that assess diagnostic status (clinical remission) as the primary outcome. This is despite the need to improve treatment uptake and accessibility because fewer than 50% of postnatally depressed women seek help, even when identified as depressed.

OBJECTIVE

In a randomized controlled trial (RCT), we aimed to test the efficacy of a 6-session Internet intervention (the MumMoodBooster program, previously evaluated in a feasibility trial) in a sample of postnatal women with a clinical diagnosis of depression. The MumMoodBooster program is a cognitive behavioral therapy (CBT) intervention, is highly interactive, includes a partner website, and was supported by low-intensity telephone coaching.

METHODS

This was a parallel 2-group RCT (N=43) comparing the Internet CBT treatment (n=21) to treatment as usual (n=22). At baseline and at 12 weeks after enrollment, women's diagnostic status was assessed by telephone with the Standardized Clinical Interview for DSM-IV (SCID-IV) and symptom severity with the Beck Depression Inventory (BDI-II). Depression symptoms were measured repeatedly throughout the study period with the Patient Health Questionnaire (PHQ-9).

RESULTS

At the end of the study, 79% (15/19) of women who received the Internet CBT treatment no longer met diagnostic criteria for depression on the SCID-IV (these outcome data were missing for 2 intervention participants). This contrasted with only 18% (4/22) remission in the treatment as usual condition. Depression scores on the BDI-II showed a large effect favoring the intervention group (d=.83, 95% CI 0.20-1.45). Small to medium effects were found on the PHQ-9 and on measures of anxiety and stress. Adherence to the program was very good with 86% (18/21) of users completing all sessions; satisfaction with the program was rated 3.1 out of 4 on average.

CONCLUSIONS

Our results suggest that our Internet CBT program, MumMoodBooster, is an effective treatment option for women clinically diagnosed with PND. This is one of only two controlled evaluations of specialized online psychological treatment among women clinically diagnosed with PND. MumMoodBooster appears to be a feasible, effective treatment option, which is potentially accessible to large numbers of women in metropolitan, rural, and remote areas. Future work might be focused profitably on establishing comparability with face-to-face treatments and purely self-guided delivery. We have commenced a larger RCT comparing MumMoodBooster with face-to-face CBT.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000113752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363561 (Archived by WebCite® at http://www.webcitation.org/6f64kuyLf).

Feasibility study and pilot randomised trial of an antenatal depression treatment with infant follow-up

Substantial evidence links antenatal depression, anxiety and stress with negative effects on foetal development, resulting in enduring problems in child development. Despite this, there is a paucity of research on intervention programmes designed to address depression and anxiety, and none that include infant outcomes. We aimed to evaluate the efficacy of a brief treatment for maternal depression and anxiety in pregnancy in a sample of women with a diagnosed depressive disorder. We developed a cognitive behavioural therapy treatment for antenatal depression and anxiety and evaluated it in a feasibility trial. This was followed by a pilot randomised controlled trial (RCT) which collected data on the efficacy of the brief intervention and follow-up data on infants. The feasibility study (n = 25) yielded promising results for adherence, acceptability and improvements in depression and anxiety (Beck Depression Inventory and Beck Anxiety Inventory). The RCT (n = 54) again showed excellent adherence and acceptability and supported the efficacy of the treatment. Strong reductions in anxiety were observed during pregnancy, and improvements in depression were maintained at 9 months representing a moderately large effect size. Nine-month infant outcomes showed several medium to large effects favouring the intervention in domains including problem solving, self-regulation and stress reactivity, which were independent of maternal postnatal mood. Treating severe depression and anxiety during pregnancy with a brief cognitive behavioural therapy (CBT) intervention appears feasible and worthwhile. To reliably detect clinically meaningful effects on infant outcomes, larger RCTs are likely to be required.

Dynamic footprint of sequestration in the molecular fluctuations of osteopontin

The sequestration of calcium phosphate by unfolded proteins is fundamental to the stabilization of biofluids supersaturated with respect to hydroxyapatite, such as milk, blood or urine. The unfolded state of osteopontin (OPN) is thought to be a prerequisite for this activity, which leads to the formation of core-shell calcium phosphate nanoclusters. We report on the structures and dynamics of a native OPN peptide from bovine milk, studied by neutron spectroscopy and small-angle X-ray and neutron scattering. The effects of sequestration are quantified on the nanosecond- ångström resolution by elastic incoherent neutron scattering. The molecular fluctuations of the free phosphopeptide are in agreement with a highly flexible protein. An increased resilience to diffusive motions of OPN is corroborated by molecular fluctuations similar to those observed for globular proteins, yet retaining conformational flexibilities. The results bring insight into the modulation of the activity of OPN and phosphopeptides with a role in the control of biomineralization. The quantification of such effects provides an important handle for the future design of new peptides based on the dynamics-activity relationship.

Early intervention to protect the mother-infant relationship following postnatal depression: study protocol for a randomised controlled trial

BACKGROUND

At least 13% of mothers experience depression in the first postnatal year, with accompanying feelings of despair and a range of debilitating symptoms. Serious sequelae include disturbances in the mother-infant relationship and poor long-term cognitive and behavioural outcomes for the child. Surprisingly, treatment of maternal symptoms of postnatal depression does not improve the mother-infant relationship for a majority of women. Targeted interventions to improve the mother-infant relationship following postnatal depression are scarce and, of those that exist, the majority are not evaluated in randomised controlled trials. This study aims to evaluate a brief targeted mother-infant intervention, to follow cognitive behavioural therapy treatment of postnatal depression, which has the potential to improve developmental outcomes of children of depressed mothers.

METHODS/DESIGN

The proposed study is a two-arm randomised controlled trial with follow-up to 6 months. One hundred participants will be recruited via referrals from health professionals including maternal and child health nurses and general practitioners, as well as self-referrals from women who have seen promotional materials for the study. Women who meet inclusion criteria (infant aged <12 months, women 18+ years of age) will complete the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-IV-TR Axis I Disorders. Those with a clinical diagnosis of current major or minor depressive disorder and who do not meet exclusion criteria (that is, currently receiving treatment for depression, significant difficulty with English, medium to high suicide risk, current self-harm, current substance abuse, current post-traumatic stress disorder, current manic/hypomanic episode or psychotic symptoms) will be randomised to receive either a 4-session mother-infant intervention (HUGS: Happiness Understanding Giving and Sharing) or a 4-session attention placebo playgroup (Playtime) following a 12-session postnatal depression group treatment programme. Primary outcome measures are the Parenting Stress Index (self-report measure) and the Parent-child Early Relational Assessment (observational measure coded by a blinded observer). Measurements are taken at baseline, after the postnatal depression programme, post-HUGS/Playtime, and at 6 months post-HUGS/Playtime.

DISCUSSION

This research addresses the need for specific treatment for mother-infant interactional difficulties following postnatal depression. There is a need to investigate interventions in randomised trials to prevent detrimental effects on child development and make available evidence-based treatments.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register: ACTRN12612001110875. Date Registered: 17 October 2012.

A novel objective classification method to discriminate and monitor recovery in subgroups of chronic low back pain

Background:

The heterogeneity of chronic low back pain (CLBP) can be deleterious to its successful management. Classification systems (CSs) that subclassify CLBP in order to target treatments rely on clinical judgement; therefore, less subjective classification is preferable. This study aims to determine whether the Cardiff Classifier (CC), which is an objective classification system based on Dempster-Shafer theory can discriminate between CLBP subgroups on the basis of spinal-pelvic repositioning errors (RE), and establish the most sensitive parameters for discriminating subgroups of CLBP and predicting recovery.

Methods:

Baseline and post-motor learning intervention (MLI) REs from 87 CLBP individuals with flexion (FP, n=50); passive extension (PEP, n=14); and active extension (AEP, n=23) pattern disorder (subclassified by a clinical multi-dimensional CS); and REs from 31 healthy (H) participants were recorded. These REs were inputted into the CC to provide objective and visual indicators of CLBP subgroups and MLI effect. REs were transformed into a set of three belief values: healthy (H); CLBP; and uncertainty. Each participant's status was visually represented as a single point in a simplex plot. Participants on the left of the central line were considered healthy and those on the right of it were considered to have CLBP characteristics.

Results:

The CC's accuracy in discriminating between: FP and H was 85.2%; AEP and H was 96.3%; and PEP and H was 100%. Combining all CLBP reduced the CC's accuracy to 68.6%. The most distinguishing parameter for FP was sitting lumbar RE, and for AEP/PEP it was standing lumbar RE. CC distinguished pre- and post-intervention REs with 85.7% accuracy for FP and 90% for AEP with respective sitting lumbar and standing pelvic RE as the most sensitive predictors of recovery.

Conclusions:

This is the first application of CC in CLBP. The CC accurately discerned three clinical CLBP subgroups and identified parameters that most accurately characterise each subgroup and best predict post-intervention recovery. The CC enhanced classification accuracy to discern between CLBP and H when patients were subclassified. CC should be further tested using clinical classification data.

Implications:

CLBP classification is a complex process requiring high level clinical expertise to synthesize a unique set of physical/clinical characteristics in each CLBP person. The CC can order complex data sets to aid clinicians’ interpretation to target therapy and identify the most sensitive parameters for monitoring recovery thus enhancing classification robustness.

In-vivo confirmation of the use of the dart thrower's motion during activities of daily living

The dart thrower's motion is a wrist rotation along an oblique plane from radial extension to ulnar flexion. We report an in-vivo study to confirm the use of the dart thrower's motion during activities of daily living. Global wrist motion in ten volunteers was recorded using a three-dimensional optoelectronic motion capture system, in which digital infra-red cameras track the movement of retro-reflective marker clusters. Global wrist motion has been approximated to the dart thrower's motion when hammering a nail, throwing a ball, drinking from a glass, pouring from a jug and twisting the lid of a jar, but not when combing hair or manipulating buttons. The dart thrower's motion is the plane of global wrist motion used during most activities of daily living. Arthrodesis of the radiocarpal joint instead of the midcarpal joint will allow better wrist function during most activities of daily living by preserving the dart thrower's motion.

Invited review: Caseins and the casein micelle: their biological functions, structures, and behavior in foods

A typical casein micelle contains thousands of casein molecules, most of which form thermodynamically stable complexes with nanoclusters of amorphous calcium phosphate. Like many other unfolded proteins, caseins have an actual or potential tendency to assemble into toxic amyloid fibrils, particularly at the high concentrations found in milk. Fibrils do not form in milk because an alternative aggregation pathway is followed that results in formation of the casein micelle. As a result of forming micelles, nutritious milk can be secreted and stored without causing either pathological calcification or amyloidosis of the mother's mammary tissue. The ability to sequester nanoclusters of amorphous calcium phosphate in a stable complex is not unique to caseins. It has been demonstrated using a number of noncasein secreted phosphoproteins and may be of general physiological importance in preventing calcification of other biofluids and soft tissues. Thus, competent noncasein phosphoproteins have similar patterns of phosphorylation and the same type of flexible, unfolded conformation as caseins. The ability to suppress amyloid fibril formation by forming an alternative amorphous aggregate is also not unique to caseins and underlies the action of molecular chaperones such as the small heat-shock proteins. The open structure of the protein matrix of casein micelles is fragile and easily perturbed by changes in its environment. Perturbations can cause the polypeptide chains to segregate into regions of greater and lesser density. As a result, the reliable determination of the native structure of casein micelles continues to be extremely challenging. The biological functions of caseins, such as their chaperone activity, are determined by their composition and flexible conformation and by how the casein polypeptide chains interact with each other. These same properties determine how caseins behave in the manufacture of many dairy products and how they can be used as functional ingredients in other foods.

An audit to identify factors that are more commonly associated with depressed patients on augmentation therapy under the befordshire east community mental health team (BECMHT)

Background

Whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care.

Aims and methods

An Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression.

Results

Of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy.

Discussion

There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and ‘other suicide risk factors’.

Conclusion

Generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.

An audit to identify factors affecting response to treatment among depressed patients who have documented suicidal ideation/attempts in a bedfordshire community mental health team

Introduction

In recent years there has been a move towards treating depressed patients in the community.One factor that may reduce the likelihood of discharge from secondary care is suicidality. The aim of this audit was to identify factors associated with continued suicidality among Community patients.

Subjects and methods

We searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and ‘other risk’ factors (e.g. financial problems or homelessness). We assessed the latest clinic letter, to see if patients were still reporting suicidality. We compared the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y).

Results

Of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Alcohol problems, drug problems and ‘other’ risk factors were more common among group Y than group N. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y.

Discussion

The audit provides an insight into the factors that might influence outcomes among depressed patients.

Conclusions

Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the present data. The audit provides a useful starting point, especially in considering the treatment of patients within the CMHT.

Posttransplantation hepatitis B prophylaxis with combination oral nucleoside and nucleotide analog therapy

Liver transplant recipients are at risk of developing recurrent hepatitis B after liver transplantation for hepatitis B virus (HBV)-related liver disease. We evaluated the efficacy of a new hepatitis B prophylaxis regimen involving conversion from at least 12 months of HBIg with lamivudine to combination therapy with an oral nucleoside and nucleotide analog. Between June 2008 and May 2010, a total of 61 liver transplant recipients were converted to a combination of a nucleoside and nucleotide analog. The mean (±standard deviation) follow-up time after conversion was 15.0 (±6.1) months. Recurrent HBV occurred in two (3.3%) patients at 3.1 and 16.6 months after HBIg cessation. The overall person time incidence rate for HBV recurrence after HBIg cessation was 2.7 cases per 100 person-years. The estimate of HBV recurrence was 1.7% at 1 year after HBIg cessation. HBIg cessation a minimum of 12 months after liver transplantation with subsequent combination therapy with a nucleoside and nucleotide analog provides effective prophylaxis against recurrent HBV infection. The clinical implications of HBsAg detection without clinical, biochemical or molecular manifestations of recurrent hepatitis B require further study.

Cell cycle phase progression analysis identifies unique replication phenotypes of major prognostic and predictive significance in cancer

Abstract #5066

BACKGROUND: The cell cycle machinery acts as an integration point for information transduced through complex and redundant upstream oncogenic signalling pathways. Multiparameter analysis of core regulatory proteins involved in G1-S and G2-M cell cycle phase transitions provides a powerful biomarker readout for assessment of the cell cycle state. We have applied this novel algorithm to breast cancer, investigating its cell cycle kinetics, and determining how this impacts on pathobiology and disease progression in-vivo.&#x2028; METHODS AND FINDINGS: Protein expression profiles of key constituents of the DNA replication licensing pathway (Mcm2, geminin) and mitotic machinery (Plk1, Aurora A, Aurora substrate Histone H3S10ph), mediators of G1-S and G2-M transition respectively, were generated for a cohort of 182 patients. Arrested differentiation and development of genomic instability was associated with increased engagement of cells into the cell division cycle (p&lt;0.0001). Three unique cell cycle phenotypes were identified; (I) well differentiated tumours composed predominantly of Mcm2 negative cells indicative of an out-of-cycle state (18% of cases), (II) high Mcm2 expressing tumours but with low geminin, Aurora A, Plk1 and H3S10ph levels (S-G2-M progression markers) indicative of a G1 delayed/arrested state (24% cases), (III) high expressing Mcm2 tumours, but also expressing high levels of the S-G2-M progression markers, indicative of accelerated cell cycle progression (58% of cases). The accelerated cell cycle phenotype had a significantly higher risk of relapse when compared with out-of-cycle and G1 delayed/arrested tumour phenotypes (HR=3.90 [1.81-8.40], p&lt;0.001). Notably high grade tumours with the G1 delayed/arrested phenotype showed an identical low risk of relapse to well differentiated out-of-cycle tumours (HR=1.00 [0.22-4.46], p=0.99), suggesting that many patients are receiving inappropriate S-G2-M phase directed adjuvant chemotherapy.&#x2028; CONCLUSIONS: This biomarker algorithm provides novel insights into the cell cycle state of dynamic tumour cell populations in-vivo, information that impacts on individualised therapeutic decisions. The cell cycle phenotype has a major influence on disease progression, identifying those patients at most risk of relapse. Importantly, it is only patients displaying an accelerated phenotype, tumours that show S-G2-M phase transit, that are likely to derive benefit from S and G2-M phase specific adjuvant chemotherapeutic agents and mechanistic drugs.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5066.

[Gout as an unusual cause of pelvic pain]

An 89-year-old woman was admitted for high fever and debilitating pelvic pain, notably in the pubic area. Physical examination revealed multiple gouty tophi in her hands and feet. Laboratory investigation revealed severe leukocytosis and a sharply increased C-reactive protein level. The patient was treated with broad-spectrum antibiotics in view of the possibility of a serious bacterial infection, but there was no clinical effect. CT of the pelvis revealed an osteolytic process and a mass anterior to the pubic symphysis. Histological investigation of a biopsy revealed an inflammatory infiltrate with signs of gout. Culture of the biopsy specimen was negative. The diagnosis was confirmed by the finding ofneedle-like urate crystals under the polarizing microscope. After treatment with colchicine and later with prednisone, the symptoms disappeared. She was given uric acid-lowering therapy with allopurinol as a preventive measure.

Invited Review: β-Lactoglobulin: Binding Properties, Structure, and Function

beta-Lactoglobulin (beta-LG) is the major whey protein of ruminant species and is also present in the milks of many, but not all, other species. Its amino-acid sequence and 3-dimensional structure show that it is a lipocalin, a widely diverse family, most of which bind small hydrophobic ligands and thus may act as specific transporters, as does serum retinol binding protein. Bovine beta-LG binds a wide range of ligands, but this may not be the reason for its presence in milk. In reviewing the structure and physicochemical properties of the protein, we present the structures of the ligands cholesterol (at a resolution of 2.0A, R = 0.221; Rfree = 0.295) and vitamin D2 (at a resolution of 2.4A, R = 0.212; Rfree = 0.297) each bound to the central binding cavity of bovine beta-LG at pH 7.3. Neither ligand is fully visible in the electron density maps, and the less well-ordered regions are the polar end groups at the mouth of the binding site. In a separate experiment, a mercury ion was bound to the free Cys121 (at a resolution of 2.2A, R = 0.218; Rfree = 0.288) in a way that transmitted a small structural change through Asp137 via Arg148 to the dimer interface. It is not clear if the known dissociation that arises from the reaction of beta-LG with HgCl2 results from this perturbation. In reviewing the structural studies that reveal the ligand binding sites for long-chain fatty acids, retinoids, and steroids, only the central location, common to all lipocalins so far examined, is occupied under the conditions used. We find that there is no crystallographic evidence of another ligand binding site in our crystals grown in approximately 1.3 M citrate, although low ionic strength studies in solution indicate the possible presence of at least one other low affinity site. The apparent ability of the binding site to accommodate a wide range of ligands may point to a possible physiological function. However, by considering the lipocalin family in general, and the species distribution of beta-LG in particular, some speculation as to the physiological function can be made. beta-Lactoglobulin has been reported as being implicated, inter alia, in hydrophobic ligand transport and uptake, enzyme regulation, and the neonatal acquisition of passive immunity. However, these functions do not appear to be consistent between species. Sequence comparisons among members of the lipocalin family reveal that glycodelin, found in the human endometrium during early pregnancy, is the most closely related to beta-LG. Although the function of glycodelin is also unknown, it appears to have effects on the immune system and/or to be involved in differentiation. It is proposed that beta-LG, over-expressed in the lactating mammary gland of many, but not all, species, is primarily an important source of amino acids for the offspring of those animals that produce it, but that this function arose by gene duplication from the physiologically essential glycodelin. The other functions that have been associated with beta-LG in the neonate are, therefore, fortuitous.

Guidelines for evaluation of patients at risk for inherited breast and ovarian cancer: recommendations of the Department of Defense Familial Breast/Ovarian Cancer Research Project

Patients at high risk for inherited breast and/or ovarian cancer are frequently encountered in all medical specialties. Department of Defense, Health Affairs funding as part of the Breast Cancer Education and Awareness Program was used to develop a comprehensive program for the identification, counseling, genetic testing, and long-term follow-up of such high-risk patients. This article reports the recommendations for high-risk patient management based on 4 years of evaluation and care, including discussions of the approach to counseling, indications for genetic testing, post-testing counseling, patient surveillance with examination, imagining, and laboratory testing, and suggested options for surgical and chemoprophylaxis as well as lifestyle modifications.

Diagnostic criteria for testing for BRCA1 and BRCA2: the experience of the Department of Defense Familial Breast/Ovarian Cancer Research Project

The Department of Defense Familial Breast/Ovarian Cancer Research Project has offered genetic counseling and testing for BRCA1 and BRCA2 on a research basis to patients meeting specific diagnostic criteria, with risk for BRCA1 and BRCA2 mutations calculated based on the Couch model. In 2.5 years, 250 patients were evaluated and 101 patients met criteria requirements, including 33 who met criteria in more than one category. Ninety patients elected to undergo DNA testing. In this group of 90 patients, 14 mutations (15.5%) and 16 unclassified variants (17.7%) were identified. The most common inclusion criteria were onset of breast/ovarian cancer before age 45 years (n = 32) and onset of breast/ovarian cancer before age 45 years with strong family history (n = 21). However, when number of mutations and unclassified variants found were compared separately across all diagnostic criteria (including those of more than one capacity) using the chi 2 statistic, no significant differences were seen among the categories to suggest that one criterion was more predictive of mutations or variants than another. Couch risk values for patients with mutations showed a mean of 14% and ranged from 3.2 to 43.5% (range for all patients, 1.2-69.7%). These findings emphasize the importance of using multiple diagnostic criteria and suggest that a Couch risk value of > 3% may be useful in selecting patients for testing. The data also underscore the necessity of genetic counseling in the testing process, particularly given the large number of unclassified variants diagnosed and their uncertain status for disease predisposition.

Sequence variation in humans and other primates at six short tandem repeat loci used in forensic identity testing

A large number of alleles from the six different short tandem repeat (STR) loci FGA, D3S1358, vWA, CSF1PO, TPOX and TH01, used in human identity testing were sequenced to provide support for the robustness of fluorescent STR DNA typing by allele size. Sequence information for some of these loci (FGA, vWA, TH01) is an extension of published work, whereas no extensive sequence information is available with respect to the D3S1358, CSF1PO, and TPOX loci. Sequencing of alleles at each locus has provided quantitative data with respect to the true nucleotide length of common alleles, and of alleles that vary in length from the common alleles. All alleles that were identified as "off-ladder" alleles through fluorescent typing at these STR loci have proven to be true length variant alleles. Sequencing at the D3S1358 and CSF1PO loci allowed for the establishment of a common nomenclature for these loci. A correlation between percent stutter and the length of the core tandem repeat is demonstrated at the FGA locus. Alleles in which the core tandem repeat is interrupted by a repeat unit of different sequence have a reduced percent stutter. DNA samples from three non-human primates (chimpanzee, orangutan, and gorilla) were compared to the human sequences, and shown to differ markedly across loci with respect to their homology. The effects of primer binding site mutations on the amplification efficiency at a particular locus, and methods used to interpret amplification imbalance of heterozygous alleles at a locus is also addressed.

The correctional Officer's role in Mental Health treatment of youthful offenders

This paper explores issues specific to the provision of effective mental health treatment for juvenile offenders within juvenile justice departments. A multifaceted treatment approach in this setting should include security officers as well as the customary mental health and medical professionals. Confidentiality issues direct correctional policies that require medical, mental health and security records to remain separate. Such limitations in the exchange of information reduce the likelihood that correctional officers would be considered as part of the treatment team. With high inmate to professional staff ratio and the growing attention to outcomes, this approach needs to be considered.