Exploring service provider perspectives on service user engagement across service components in coordinated specialty care programs for psychosis

Engagement in services is a core element to successful outcomes for service users and programs. In coordinated specialty care (CSC) programs, designed for individuals experiencing first-episode psychosis, engagement has only been measured programmatically and not by service component. This qualitative study sought to explore provider perspectives on service user engagement in service components of CSC. Semistructured interviews were conducted with 20 service providers from five community-based early intervention programs for psychosis in the United States. Interviews were recorded and transcribed verbatim, and thematic analysis was used to analyze the data collected. Provider participants described barriers and facilitators that contribute to disengagement or engagement in four service components within early intervention programs: individual psychotherapy, family education and support, medication management, and vocational services. Barriers identified included substance use, stigma, trauma, and external pressures. Identified barriers to engagement in CSC were both unique to individual components and cut across them. By better understanding the complexity of barriers and their intersections within and across CSC components, there can be more effective policy and program development to reduce disengagement and hopefully increase positive outcomes for service users. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Multifaceted Technical Assistance Strategy to Facilitate Measurement Delivery in Coordinated Specialty Care

In recent years, coordinated specialty care (CSC) providers have worked to harmonize and deliver data collection measures across programs so that they can provide data that enable measurement-informed care. However, the strategies that can effectively support the integration of a core assessment battery in clinical care remain unclear. This column presents an evaluation of a multifaceted technical assistance strategy for the delivery and completion of an assessment battery in nine CSC programs (N=247 clients). The findings suggest that a multifaceted technical assistance strategy can effectively support the integration of a comprehensive assessment battery in the care delivered by providers. Similar technical assistance strategies may assist CSC providers as they move toward providing data-driven care in an effort to improve quality of care.

Exploring Provider Perspectives on Implementing Coordinated Specialty Care: A Qualitative Study

This study aimed to explore clinician roles and experiences related to the implementation and sustainability of coordinated specialty care (CSC) programs for first episode psychosis. Qualitative interviews were conducted with 20 CSC providers and team members, recruited from five CSC programs. Using a semi-structured guide, interviews explored experiences with the delivery of CSC in the context of community-based outpatient mental health agencies and the challenges with implementation. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Themes were parsed into two overarching categories, provider, and organizational-level factors, and further distilled into subthemes which interacted with one another to form an interacting web of barriers to successful programmatic implementation for CSC programs. Study findings have important implications for development of future policy for financing mental health agencies, the creation of additional materials, supports for the model, and hiring and retention of staff for future implemented CSC programs.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

825 Hip Fractures in the Emergency Department: Are we keeping to the Big Six Standard?

Introduction

Hip fractures are the most common serious injury in older people (1) with 7364 patients attending the Emergency Department (ED) with a hip fracture in Scotland in 2019 (2). The “Big Six” are key areas in the acute management of hip fractures as outlined in standard 2 of the Scottish Hip Fracture Audit (SHFA): New Early Warning Score; cognition; Water Low Pressure Score; intravenous (IV) access and bloods; nil-by-mouth and IV fluids; and analgesia. In 2019, Ayr ED had a compliance rate of approximately 37.5% with the “Big Six” (2).

Method

One month of hip fracture data (n = 20) relating to the “Big Six” was collected from the Symphony software and audited. Areas where improvements could be made were highlighted to staff, and a further one-month data collection (n = 17) was carried out.

Results

From the first to second round the “Big Six” checklist completion rate increased from 30% to 41% (p = 0.68) and the “Big Six” compliance increased from 60% to 71% (p = 0.5).

Conclusions

In conclusion, compliance increased by 11% with the “Big Six”, however, not to the defined standards identified in the SHFA. Further long-lasting interventions have now been made to ensure that compliance rates continue to improve along with our standard of care.

Barriers and Facilitators That Influence Providers' Ability to Educate, Monitor, and Treat Substance Use in First-Episode Psychosis Programs Using the Theoretical Domains Framework

In this qualitative study, we explore providers' experiences with addressing substance use among individuals with first-episode psychosis (FEP) enrolled in coordinated specialty care (CSC) programs. Three focus groups were conducted with 24 providers from CSC programs for FEP in Washington. Questions were focused on barriers and facilitators to addressing substance use using the Theoretical Domains Framework (TDF) as a guide. Thematic analysis was used to code all transcripts. Identified TDF domains were then mapped onto the COM-B (Capability, Opportunity, Motivation, Behavior) intervention functions and behavior change techniques. Seven theoretical domains were identified as the most relevant to addressing substance use: "Knowledge," "Skills," "Environmental Context and Resources," "Social Influences," "Social and Professional Role and Identity," "Beliefs about Capabilities," and "Reinforcement." The use of the TDF provides a framework to explore barriers and facilitators for targeting substance use and suggestions for behavior change techniques when considering implementation of evidence-based strategies to enhance CSC models.

Geographic Disparities in Access to Specialty Care Programs for Early Psychosis in Washington State

Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural-Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods.

Family Experiences Prior to the Initiation of Care for First-Episode Psychosis: A Meta-Synthesis of Qualitative Studies

OBJECTIVES

This study systematically reviewed existing qualitative evidence of family members' experiences prior to the initiation of mental health services for a loved one experiencing their first episode of psychosis (FEP).

METHODS

A meta-synthesis review of published peer-reviewed qualitative studies conducted between 2010 and 2019 were included. Keyword searches were performed in four electronic databases and the reference lists of primary manuscripts. Two independent reviewers used the Critical Appraisal Skills Programme (CASP) qualitative checklist to assess methodological quality of each study.

RESULTS

A total of 365 articles were initially identified and 9 were articles identified in a secondary review and literature search. A total of 21 met inclusion criteria. Of those included in this review 169, mothers were the primary family to recall experiences. The meta-synthesis identified four major themes related to family member experiences prior to the initiation of mental health services for FEP: the misinterpretation of signs, the emotional impact of FEP on family members, the effect of stigma on family members, and engaging with resources prior to mental health services for FEP.

CONCLUSIONS

Additional research is needed to develop healthy communication strategies that effectively deliver educational information about psychosis. This meta-synthesis also identified the need to understand help-seeking behaviors among families of those with FEP in effort to reduce the duration of untreated psychosis and improve pathways to care often initiated by a family member.

Habit-based workplace physical activity intervention: a pilot study

BACKGROUND

Increasing workplace physical activity has important implications for workers' health and well-being. However, few interventions targeting physical activity in the workplace are grounded in behavioural theory.

AIMS

The aim of this study was to develop and pilot a 6-week habit-based intervention designed to promote the development of workplace physical activity habits and increase average weekly step counts. Changes in the strength of workplace physical activity habit and weekly step counts were assessed at 1 and 6 weeks following the intervention.

METHODS

The study was a prospective three-wave within-subjects single-arm intervention study that ran for 12 weeks (baseline, 7 weeks, 12 weeks). During the 6-week intervention, participants received information regarding 10 top tips (10TT) to increase and promote habit formation and wore a pedometer during work hours. Differences in workplace physical activity habit and weekly step counts were compared across baseline (T1), 1 (T2) and 6 weeks (T3) post-intervention using repeated measures analyses of variance.

RESULTS

Data from 20 sedentary office workers at a large Australian University were included. The average strength of workplace physical activity habits significantly increased from baseline (M = 3.90) to 1 week post-intervention (M = 4.45), and these effects were maintained 6 weeks later (M = 4.72). No significant increase in step counts were observed across any of the time points (all P > 0.05).

CONCLUSIONS

The results of this pilot study reveal that workplace physical activity habits can be strengthened via a habit-based intervention. Further research is needed to replicate these findings in larger cohorts of office workers.

Elevating MAST-Data Publications with Digital Object Identifiers (DOIs)

The use of digital object identifiers (DOIs) to identify data sets used in original research allows peer reviewers and journal editors to more easily validate research methods and verify results. Fellow astronomers can duplicate results or expand on initial findings when the precise data used in a research project are identified. Precise identification of data may allow archives and observatories to better understand how the community is accessing and combining its data to reach new scientific conclusions. Earlier studies have suggested that papers with linked data are more highly cited in the literature, providing motivation for authors to adopt more stringent and thorough data citation practices.

A selective chemical probe for exploring the role of CDK8 and CDK19 in human disease

There is unmet need for chemical tools to explore the role of the Mediator complex in human pathologies ranging from cancer to cardiovascular disease. Here we determine that CCT251545, a small-molecule inhibitor of the WNT pathway discovered through cell-based screening, is a potent and selective chemical probe for the human Mediator complex-associated protein kinases CDK8 and CDK19 with >100-fold selectivity over 291 other kinases. X-ray crystallography demonstrates a type 1 binding mode involving insertion of the CDK8 C terminus into the ligand binding site. In contrast to type II inhibitors of CDK8 and CDK19, CCT251545 displays potent cell-based activity. We show that CCT251545 and close analogs alter WNT pathway-regulated gene expression and other on-target effects of modulating CDK8 and CDK19, including expression of genes regulated by STAT1. Consistent with this, we find that phosphorylation of STAT1(SER727) is a biomarker of CDK8 kinase activity in vitro and in vivo. Finally, we demonstrate in vivo activity of CCT251545 in WNT-dependent tumors.

Journeys of adjustment: the experiences of adolescents living with juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is one of the most common diseases of childhood causing pain, swelling of joints and reduced mobility. Previous research has focused on the challenges and psychosocial impact of JIA, but there has been limited attention given to how young people adjust and adapt to living with a long-term condition such as JIA. The aim of this qualitative study was therefore to explore adolescents' experiences of living with JIA, with particular focus on the process of adjustment.

METHODS

Ten adolescents (7 female, 3 male) aged 13-17 years with good treatment adherence were recruited from an adolescent arthritis clinic. In-depth interviews were conducted, and data were analysed by two researchers independently using interpretative phenomenological analysis.

RESULTS

These adolescents described the physical and psychosocial 'burden of living with JIA' and the challenges faced by an underlying preoccupation 'to be a normal teenager'. However, their accounts also revealed ways in which they regained agency and developed 'resilience through taking control' over their lives. This resilience helped the adolescents re-establish a sense of well-being through an ongoing process of 'acceptance and self-growth'.

CONCLUSIONS

Although much research has adopted a deficit model that focuses on adjustment problems, the current study highlights the resourcefulness of young people in managing the challenges of living with a long-term condition. These experiences of successful adjustment can be used as the basis of positive, strength-based intervention approaches for adolescents with arthritis to enhance resilience and well-being.

Amyloid-associated nucleic acid hybridisation

Nucleic acids promote amyloid formation in diseases including Alzheimer's and Creutzfeldt-Jakob disease. However, it remains unclear whether the close interactions between amyloid and nucleic acid allow nucleic acid secondary structure to play a role in modulating amyloid structure and function. Here we have used a simplified system of short basic peptides with alternating hydrophobic and hydrophilic amino acid residues to study nucleic acid - amyloid interactions. Employing biophysical techniques including X-ray fibre diffraction, circular dichroism spectroscopy and electron microscopy we show that the polymerized charges of nucleic acids concentrate and enhance the formation of amyloid from short basic peptides, many of which would not otherwise form fibres. In turn, the amyloid component binds nucleic acids and promotes their hybridisation at concentrations below their solution K(d), as shown by time-resolved FRET studies. The self-reinforcing interactions between peptides and nucleic acids lead to the formation of amyloid nucleic acid (ANA) fibres whose properties are distinct from their component polymers. In addition to their importance in disease and potential in engineering, ANA fibres formed from prebiotically-produced peptides and nucleic acids may have played a role in early evolution, constituting the first entities subject to Darwinian evolution.

Young people's satisfaction with residential care: identifying strengths and weaknesses in service delivery

This paper presents findings from a landmark Australian study investigating the experiences and perspectives of young people in residential care. Data from a representative sample are analyzed to identify young people's satisfaction with various aspects of their residential care experience: their sense of safety, normality, support, comfort in general living environment, participation in decision-making, and improvements in well-being. Findings point to strengths and weaknesses in current service delivery. The vast majority of respondents felt safe and well-treated and satisfied with the care and support provided by staff. Respondents were less commonly satisfied with the care and support provided by caseworkers, their participation in higher order decision-making, their sense of normality, and the amount of contact with their families. Compared with older respondents, younger respondents less commonly expressed satisfaction with various aspects of their care. Similarly, those reporting more placements were less satisfied with their care and support than those reporting fewer placements.

Factors associated with radiation exposure in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) patients undergo multiple radiological evaluations.

AIM

To estimate total and abdominal radiation exposure from diagnostic X-ray investigations in IBD patients and the associated risk factors.

METHODS

Patients with Crohn's disease (CD) or ulcerative colitis (UC) treated in the IBD clinic were recruited. Clinical data were extracted from patient files and radiological data were obtained from the central HMO computer data base.

RESULTS

A total of 199 CD and 125 UC patients were included. The mean cumulative estimated doses (CED) for CD and UC were 21.1 19.5 and 15.1 20.4 millisieverts (mSv) respectively (P < 0.001). Twenty-three patients (7.1%) had an estimated CED of > or =50 mSv. In multivariate analyses, predictors of increased CED were: surgery (OR 5.68, 95% CI: 2.73-11.8, P < 0.001), CD (OR 2.56, 95% CI: 1.29-5.07, P = 0.007), prednisone use (OR 2.0, 95% CI: 1.11-3.67, P = 0.02), first year of disease (OR 6.4, 95% CI: 1.3-32, P = 0.02) and age in the upper quartile(OR 3.26, 95% CI: 1.68-6.3, P = 0.001).

CONCLUSIONS

Diagnosis of CD, IBD-related surgery, prednisone use, first year of diagnosis and age on the upper quartile are independent predictors of increased exposure in IBD patients. Alternative investigations which do not require radiation exposure should be considered for patients at risk for increased radiation exposure.

Two functionally distinct Axin-like proteins regulate canonical Wnt signaling in C. elegans

Axin is a central component of the canonical Wnt signaling pathway that interacts with the adenomatous polyposis coli protein APC and the kinase GSK3beta to downregulate the effector beta-catenin. In the nematode Caenorhabditis elegans, canonical Wnt signaling is negatively regulated by the highly divergent Axin ortholog PRY-1. Mutation of pry-1 leads to constitutive activation of BAR-1/beta-catenin-dependent Wnt signaling and results in a range of developmental defects. The pry-1 null phenotype is however not fully penetrant, indicating that additional factors may partially compensate for PRY-1 function. Here, we report the cloning and functional analysis of a second Axin-like protein, which we named AXL-1. We show that despite considerable sequence divergence with PRY-1 and other Axin family members, AXL-1 is a functional Axin ortholog. AXL-1 functions redundantly with PRY-1 in negatively regulating BAR-1/beta-catenin signaling in the developing vulva and the Q neuroblast lineage. In addition, AXL-1 functions independently of PRY-1 in negatively regulating canonical Wnt signaling during excretory cell development. In contrast to vertebrate Axin and the related protein Conductin, AXL-1 and PRY-1 are not functionally equivalent. We conclude that Axin function in C. elegans is divided over two different Axin orthologs that have specific functions in negatively regulating canonical Wnt signaling.

Neuronal and astrocytic responses involving the serotonergic system in human spongiform encephalopathies

The relationships between the degree of cortical prion protein (PrP) deposition, tissue vacuolation and astrocytosis were studied in the frontal cortex of 27 cases of human spongiform encephalopathy, encompassing 13 cases of sporadic Creutzfeldt-Jakob disease (sCJD), four cases of familial CJD (fCJD) (one owing to E200K mutation, one owing to 144 bp insertion, one owing to P102L mutation and one owing to A117V mutation), five cases of iatrogenic CJD (iCJD) owing to growth hormone therapy and five cases of variant CJD (vCJD). The size and number of tryptophan hydroxylase (TPH) positive cells in the dorsal raphe were determined as an index of the function of the brain's serotonergic system. The amount of PrP deposited in frontal cortex in vCJD was significantly greater than that in both sCJD and iCJD, which did not differ significantly from each other. The extent of grey matter deposition of PrP correlated with that of white matter deposition. Deposition of PrP as plaques was greater in cases of sCJD bearing valine at codon 129 of PrP gene, especially when homozygous. However, all cases of vCJD displayed florid plaque formation yet these were homozygous for methionine at codon 129. Prion protein deposition as plaques was greater in cases of sCJD with 2A PrP isotype than those with 1 PrP isotype, similar to that seen in cases of vCJD all of which are 2B PrP isotype. There were no significant differences in the extent of astrocytosis between the different aetiological groups, in either grey or white matter, as visualized with glial fibrillary acidic protein (GFAP) or 5HT-2A receptor (5HT-2AR) immunostaining, although there was a strong correlation between the severity of 5HT-2AR and GFAP reactions within both grey and white matter. The extent of PrP deposition within the grey, but not white, matter correlated with the degree of astrocytosis for both GFAP and 5HT-2AR and the extent of tissue vacuolation in grey and white matter, although the latter did not correlate with degree of astrocytosis for either GFAP or 5HT-2AR. Astrocytes may be responding directly to the presence of PrP within the tissue, rather than the vacuolar damage to neurones. Although S100beta immunoreactivity was present in astrocytes in control cases, no S100beta staining was seen in astrocytes in either grey or white matter in most CJD cases. There were no differences in the number of TPH-positive cells between CJD and control cases, although the mean TPH-positive cell size was significantly greater, and cells were more intensely stained, in CJD compared to controls, suggesting a pathological overactivity of the brain's serotonergic system in CJD. This may result in excessive release of 5HT within the brain triggering increased 5HT-2AR expression within activated astrocytes leading to release and depletion of S100beta protein from such cells. The clinical symptoms of fluctuating attention and arousal could be mediated, at least in part, by such alterations in function of the serotonergic system.

Structural basis for recruitment of glycogen synthase kinase 3beta to the axin-APC scaffold complex

Glycogen synthase kinase 3beta (GSK3beta) is a serine/threonine kinase involved in insulin, growth factor and Wnt signalling. In Wnt signalling, GSK3beta is recruited to a multiprotein complex via interaction with axin, where it hyperphosphorylates beta-catenin, marking it for ubiquitylation and destruction. We have now determined the crystal structure of GSK3beta in complex with a minimal GSK3beta-binding segment of axin, at 2.4 A resolution. The structure confirms the co-localization of the binding sites for axin and FRAT in the C-terminal domain of GSK3beta, but reveals significant differences in the interactions made by axin and FRAT, mediated by conformational plasticity of the 285-299 loop in GSK3beta. Detailed comparison of the axin and FRAT GSK3beta complexes allows the generation of highly specific mutations, which abrogate binding of one or the other. Quantitative analysis suggests that the interaction of GSK3beta with the axin scaffold enhances phosphorylation of beta-catenin by >20 000-fold.

The regulation of glycogen synthase kinase-3 nuclear export by Frat/GBP

Previous studies have shown that nuclear levels of glycogen synthase kinase-3 (GSK-3) are dynamically regulated and may affect access of GSK-3 to its substrates. In this study we show that the GSK-3-binding protein Frat/GBP regulates the nuclear export of GSK-3. We show that Frat/GBP contains a nuclear export sequence that promotes its own nuclear export and that of associated GSK-3. Treating cells with leptomycin B increased nuclear levels of endogenous GSK-3 suggesting that an endogenous process targets GSK-3 for nuclear export. To investigate this further, we used two approaches to disrupt the interaction between GSK-3 and endogenous Frat. First we isolated mutants of GSK-3 that selectively interfered with Frat binding and found that these mutants were poorly exported. Second we expressed a peptide that competes with Frat for GSK-3 binding and found that it caused endogenous GSK-3 to accumulate in the nucleus. Together these data suggest that Frat may be the endogenous factor that targets GSK-3 for nuclear export. The dynamic expression patterns of Frat mRNAs together with the role of Frat in mediating GSK-3 nuclear export have important implications for the control of the substrate access of GSK-3 in several signaling pathways.

Identification of the Axin and Frat binding region of glycogen synthase kinase-3

Glycogen synthase kinase-3 (GSK-3) is a key component of several signaling pathways including those regulated by Wnt and insulin ligands. Specificity in GSK-3 signaling is thought to involve interactions with scaffold proteins that localize GSK-3 regulators and substrates. This report shows that GSK-3 forms a low affinity homodimer that is disrupted by binding to Axin and Frat. Based on the crystal structure of GSK-3, we have used surface-scanning mutagenesis to identify residues that differentially affect GSK-3 interactions. Mutations that disrupt Frat and Axin cluster at the dimer interface explaining their effect on homodimer formation. Loss of the Axin binding site blocks the ability of dominant negative GSK-3 to cause axis duplication in Xenopus embryos. The Axin binding site is conserved within all GSK-3 proteins, and its loss affects both cell motility and gene expression in the nonmetazoan, Dictyostelium. Surprisingly, we find no genetic interaction between a non-Axin-binding GSK-3 mutant and T-cell factor activity, arguing that Axin interactions alone cannot explain the regulation of T-cell factor-mediated gene expression.

Crystal structure of glycogen synthase kinase 3 beta: structural basis for phosphate-primed substrate specificity and autoinhibition

Glycogen synthase kinase 3 beta (GSK3 beta) plays a key role in insulin and Wnt signaling, phosphorylating downstream targets by default, and becoming inhibited following the extracellular signaling event. The crystal structure of human GSK3 beta shows a catalytically active conformation in the absence of activation-segment phosphorylation, with the sulphonate of a buffer molecule bridging the activation-segment and N-terminal domain in the same way as the phosphate group of the activation-segment phospho-Ser/Thr in other kinases. The location of this oxyanion binding site in the substrate binding cleft indicates direct coupling of P+4 phosphate-primed substrate binding and catalytic activation, explains the ability of GSK3 beta to processively hyperphosphorylate substrates with Ser/Thr pentad-repeats, and suggests a mechanism for autoinhibition in which the phosphorylated N terminus binds as a competitive pseudosubstrate with phospho-Ser 9 occupying the P+4 site.

Refined linkage disequilibrium and physical mapping of the gene locus for X-linked dystonia-parkinsonism (DYT3)

X-linked dystonia-parkinsonism (XDP) is a recessive disorder characterized by generalized dystonia with some patients exhibiting parkinsonism. The disease gene, DYT3, is located between DXS453 (DXS993) and DXS559, and strongest linkage disequilibrium is found distal to DXS7117 and proximal to DXS559. We have isolated and analyzed four novel polymorphic markers between DXS7117 and DXS559 and, by haplotype analysis, have narrowed the candidate interval to <350 kb. A sequence-ready contig of 700 kb has been constructed spanning DXS7117 to DXS559 and is composed of 35 PACs, BACs, and cosmids. Nine genes and novel ESTs have been mapped into this contig, and mutations in the coding regions and intron-exon borders of two genes have been excluded as the cause of XDP. Several of the other genes and ESTs located within the contig code for proteins implicated in normal brain development and function and are candidates for DYT3.

Health promotion in the Scottish workplace: a case for moving the goalposts

The workplace provides an important opportunity for health promotion, both in terms of allowing access to a large proportion of the adult population and encouraging developments within the workplace structure to improve health. This paper reports on the findings of a survey of Scottish workplaces carried out in 1996 for the Health Education Board for Scotland to assess the state of health promotion activity in the Scottish workplace setting. The results echo those from previous surveys in that most health promotion effort was centred around health and safety, smoking, and alcohol issues, particularly for the smaller and less well-resourced businesses. Under one-fifth of businesses surveyed addressed areas such as stress and mental health, which are being seen as increasingly important in terms of their contribution to the well-being of the employee and the organization. The main implication of these findings is that it is smaller businesses who potentially have the most to gain from workplace health promotion. In this context, the construction of relevant and sustainable health promotion programmes requires an organizational development perspective in order to encourage such businesses to regard workplace health promotion as part of good business practice.

Effectiveness of antismoking telephone helpline: follow up survey

OBJECTIVE

To evaluate the effectiveness of an antismoking campaign conducted by the Health Education Board for Scotland.

DESIGN

Descriptive survey of adult callers to a telephone helpline (Smokeline) for stopping smoking; panel study of a random sample of adult callers; assessment of changes in prevalence of smoking in Scotland before and after introduction of the helpline.

SETTING

Telephone helpline.

SUBJECTS

Callers to Smokeline over the initial one year period. Detailed information was collected on a 10% sample (n = 8547). A cohort of adult smokers who called Smokeline (total n = 848) was followed up by telephone interview three weeks, six months, and one year after the initial call.

MAIN OUTCOME MEASURES

Numbers of adult smokers calling helpline; changes in smoking behaviour, especially stopping smoking among cohort members; and changes in prevalence of smoking in the general population.

RESULTS

An estimated 82782 regular adult smokers made genuine contact with Smokeline over the year, representing about 5.9% of all adult smokers in Scotland. At one year 143 of the cohort of 848 callers (23.6%; 95% confidence interval 20.2% to 27.0%) reported that they had stopped smoking and 534 (88.0%; 85.4% to 90.6%) reported having made some change. About 19500 (16700 to 22350) adult smokers, equivalent to 1.4% (1.2% to 1.6%) of the mean adult smoking population, stopped smoking with direct help from Smokeling. During the second year of the campaign (1994) smoking prevalence among 25-65 year olds in Scotland was 6% (2.0% to 10.0%) lower than it had been before the start of the campaign.

CONCLUSION

The Health Education Board for Scotland's antismoking campaign reached a high number of adult smokers, was associated with a highly acceptable quit rate among adults given direct help through Smokeline, and contributed considerably to an accelerated decline in smoking prevalence in Scotland.

Moratorium-achievement (MAMA) cycles in lifespan identity development: value orientations and reasoning system correlates

Three important questions emerging in identity research are: Why do only some persons with Foreclosed identities move on to Identity Achievement? Why do some Identity Achievement persons move "back" to Foreclosure? How can life-span identity re-formulation be accounted for? This study proposes that individual's positions on two variables, "instrumental vs. experiential orientation" and formistic vs. dialectrical thinking, may be important in answering these questions. Among 60 university students, 23 males and 37 females, those in an identity status characterized by formation and maintenance of structure (Foreclosure) were instrumentally-oriented while those characterized by openness to change and revision (Moratorium) were experientially-oriented. Similarly, more Moratoriums than other statuses were high in dialectic thinking. These results are discussed in terms of their theoretical implications for life-span identity development.

Isolation of a major human placental substrate for the epidermal growth factor (urogastrone) receptor kinase: immunological cross-reactivity with transducin and sequence homology with lipocortin

Using as a starting material either a detergent extract or a protein fraction eluted from membranes with ethylene glycol bis (beta-aminoethyl ether)-N,N'-tetraacetic acid, we have isolated from human placental membranes a major substrate for the epidermal growth factor (urogastrone) receptor kinase (EGF kinase). The substrate was isolated both in an intact form, having a molecular mass of approximately 38-kDa (p38), and in a 35-kDa form (p35) representing a proteolytic cleavage product of p38. Both p38 and p35 cross-reacted with antibodies directed against bovine retinal transducin, but did not cross-react with antibodies directed against the 35-kDa beta subunit of human placental G-protein. Antisera directed against the placental EGF kinase substrate failed to react with either bovine or human placental src kinase substrate, p36. Conversely, antisera directed against p36 reacted only poorly with placental p38 or p35. Although p38 had a blocked amino terminus that precluded sequence analysis, p35 yielded an N-terminal sequence that was identical with residues 13-36 of human lipocortin. Our data clearly distinguish p38 from the previously described intestinal calcium binding protein calpactin I or p36 that is also a tyrosine kinase substrate, and our work points to a close relationship (if not identity) between p35 and a 35-kDa EGF receptor kinase substrate previously characterized in A431 cells. We conclude that p38 and p35, which very likely represent human placental lipocortin, may share only limited epitope homology with transducin alpha subunit; however, the possibility that p38, along with intestinal p36 and with a family of related calcium binding proteins, may, like transducin, play a role in receptor-mediated transmembrane signaling is discussed.

A combination of oral diazepam and droperidol for premedication. A double blind comparison with diazepam alone

Oral diazepam is commonly used as a premedicant. For a given dose there is considerable between patient variation in clinical effect and plasma levels. The addition of droperidol may improve consistency and contribute antiemesis whilst avoiding the undesirable effects of droperidol alone. Ninety patients undergoing minor gynecological or minor urological surgery were given as an oral premedicant either diazepam (0.185 mg/kg) or one of two combinations of diazepam and droperidol (diazepam, 0.185 mg/kg plus droperidol, 0.09 mg/kg; or diazepam, 0.135 mg/kg plus droperidol, 0.09 mg/kg). There was no significant difference between the groups in altering mean anxiety measurements or improving consistency of action as judged by the number of patients having reduced anxiety measurements. Side effects, including nausea and vomiting, were not significantly different between the three groups. In the doses used there was no practical advantage in adding droperidol to diazepam for oral premedication.

Rare occurrence of Addison's disease and diabetes mellitus in children

We report on two children with both Addison's disease and diabetes mellitus, a rare occurrence in children. One of the children first developed Addison's disease and later developed diabetes mellitus, while the other had the onset of diabetes mellitus first and later Addison's disease. In the latter patient a direct relationship was shown between the insulin dose and adrenal cortical hormone. Organ-specific antibody studies are reported and the diagnosis and management of these combined endocrinopathies are discussed.