A critical evaluation of the EU-virtual consultation platform (CPMS) within the European Reference Network on Rare Endocrine Conditions

In 2017, the European Commission installed 24 European Reference Networks (ERNs) for different categories of rare and complex conditions to facilitate cross-border health care via virtual case consultations in a secure Clinical Patient Management System (CPMS). The ERN for rare endocrine conditions (Endo-ERN) previously reviewed the CPMS, in which they detailed the difficulties physicians encountered with the system and proposed solutions to these that should enable the system to be used to a greater extent. This paper will further the endeavor of the first by performing a critical evaluation of the CPMS, assessing how these suggested improvements have been implemented, and if these have affected the usage of the system. The evaluation involves an assessment of CPMS usage statistics since its conception that takes into consideration the technical updates and the external factors that may have affected these, including data from a review survey following a training workshop for our new healthcare providers (HCPs) added in January 2022. It appears that the improvements made to the system since the first review, in particular the implementation of the Operational Helpdesk, have had a positive effect in increasing CPMS membership; however, the regular usage of the system continues to fluctuate. Several suggestions are made on how to further facilitate the use of CPMS by our members both individually and network-wide, by integrating CPMS activities with other network initiatives and further integrating these into national health care systems as well as looking for ways to measure patient satisfaction from the CPMS discussions outcomes.

Z-score neurofeedback, heart rate variability biofeedback, and brain coaching for older adults with memory concerns

BACKGROUND

The three-month, multi-domain Memory Boot Camp program incorporates z-score neurofeedback (NFB), heart rate variability (HRV) biofeedback, and one-on-one coaching to teach memory skills and encourage behavior change in diet, sleep, physical fitness, and stress reduction.

OBJECTIVE

This prospective trial evaluates the Memory Boot Camp program for adults ages 55 to 85 with symptoms of Mild Cognitive Impairment (MCI) and subjective memory complaints.

METHODS

Participants were evaluated via the Montreal Cognitive Assessment (MoCA), NeuroTrax Global Cognitive Score, measures of anxiety, depression, sleep, quality of life, quantitative electroencephalography (QEEG), and HRV parameters at four timepoints: baseline, pre-program, post-program, and follow-up. The trial included a three-month waiting period between baseline and pre-program, such that each participant acted as their own control, and follow-up took place six months after completion of the program.

RESULTS

Participants' MoCA scores and self-reported measures of anxiety, depression, sleep quality, and quality of life improved after treatment, and these changes were maintained at follow-up. Physiological changes in HRV parameters after treatment were not significant, however, breathing rate and QEEG parameters were improved at post-program and maintained at follow-up. Finally, participants' improvement in MoCA score over the treatment period was correlated with their improvement in two brain oscillation parameters targeted by the z-score NFB protocol: relative power of delta and relative power of theta.

CONCLUSIONS

Trial results suggest that the Memory Boot Camp program is a promising treatment strategy for older adults with symptoms of MCI and subjective memory complaints.

Z-Score Neurofeedback and Heart Rate Variability Training for Adults and Children with Symptoms of Attention-Deficit/Hyperactivity Disorder: A Retrospective Study

ADHD is a common condition that causes suffering for those affected and economic loss for society at large. The current standard treatment for ADHD includes stimulant medications, which are not effective for all patients, may include side effects, and can be non-medically misused. Z-score neurofeedback (NFB) and heart rate variability (HRV) biofeedback are alternative treatment strategies that have been associated with Attention-Deficit/Hyperactivity Disorder (ADHD) symptom improvement. We utilized a retrospective pre-post study design to quantify the change in clients' ADHD symptoms after combined NFB + HRV treatment (which included simultaneous z-score training at four sites). We also assessed whether relevant physiological measures changed in accordance with the protocol, which would be consistent with effective NFB + HRV training. Adults (n = 39) and children (n = 100) with Borderline or Clinical ADHD classifications by the Achenbach System of Empirically Based Assessment (ASEBA) received 30 sessions of NFB + HRV training. Measures were compared before and after treatment for the ASEBA, the Integrated Visual and Auditory Continuous Performance Test (IVA), ADHD medication use, HRV and breathing parameters, and quantitative electroencephalogram (QEEG) parameters. Average ASEBA Attention-Deficit/Hyperactive Problems score improved after treatment for adults and children (p < 0.0001), with Cohen effect sizes (dz) of -1.21 and -1.17, respectively. 87.2% of adults and 80.0% of children experienced improvements of a magnitude greater than or equal to the Minimal Clinically Important Difference. After treatment, 70.8% of adults and 52.8% of children who began in the ASEBA Clinical range, and 80.0% of adults and 63.8% of children who began in the ASEBA Borderline range, were classified in the Normal range. IVA scores also improved after treatment. Changes in HRV and breathing pattern after treatment were consistent with the protocol. QEEG parameters after treatment were closer to the age-based normative mean, which is consistent with effective z-score NFB training.

Seeing past the appendix: the role of ultrasound in right iliac fossa pain

Acute right iliac fossa pain is a common surgical presentation. The presentation is often non-specific and encompasses a wide differential, which creates a diagnostic challenge. Ultrasound is commonly the initial cross-sectional imaging modality and can be used as a tool to triage patients appropriately; assessing for appendicitis and other salient findings, which may indicate an alternative condition. Additionally, the dynamic nature of this imaging modality enables patient interaction. Following a systematic assessment of the abdomen and pelvis, a more focused interrogation of the right iliac fossa is performed. In this pictorial review, we illustrate the sonographic features of appendicitis and other conditions that can mimic appendicitis in its presentation. This highlights that through a systematic approach, it is possible to distinguish between these different pathologies, enabling clinicians to optimally manage the patient.

Oxysterols regulate expression of the steroidogenic acute regulatory protein

The steroidogenic acute regulatory (StAR) protein promotes intramitochondrial delivery of cholesterol to the cholesterol side-chain cleavage system, which catalyzes the first enzymatic step in all steroid synthesis. Intriguingly, substrate cholesterol derived from lipoprotein can upregulate StAR gene expression. Moreover, substrate oxysterols have been suggested to also play a role. To investigate whether oxysterols can regulate StAR expression, two steroidogenic cell lines, mouse Y1 adrenocortical and MA-10 Leydig tumor cells, were treated with various oxysterols and steroids, including 25-hydroxycholesterol (25 OHC), 22(R)OHC and 20alphaOHC. The majority of these compounds rapidly increased StAR protein levels within as little as 1 h. The most potent oxysterols were 20alphaOHC for Y1 and 25 OHC for MA-10 cells. After 8 h, StAR mRNA abundance also increased whereas there were no detected changes in promoter activity. Thus, in contrast to lipoprotein, oxysterols acutely increase StAR protein levels independently of mRNA abundance, and later increase mRNA levels independently of new gene transcription. Therefore, we propose that oxysterols modulate steroidogenesis at two levels. First, oxysterols may be important in post-transcriptional regulation of StAR activity and production of steroids for paracrine action. Secondly, through direct conversion to steroid, oxysterols may account in part for StAR-independent steroid production in the body.

PUM2, a novel murine puf protein, and its consensus RNA-binding site

Members of the Puf family of RNA-binding proteins from Drosophila, Caenorhabditis elegans, and Dictyostelium are known to function as translational repressors. To identify mammalian proteins that might regulate posttranscriptional gene expression, we have characterized a novel murine Puf protein, PUM2. Pum2 transcripts were expressed in all murine tissues examined, suggesting the gene influences processes common to many cell types. Like all Puf family members, PUM2 contains a C-terminal RNA-binding domain related to the Drosophila Pumilio homology domain (PUM-HD). Two features found in the amino-terminus of PUM2, regions rich in serine and glutamine/alanine-rich regions, were also identified in most Puf family members. RNA sequences capable of binding with high affinity (6.5 nM) to a 48-kDa recombinant protein containing the PUM2 PUM-HD were isolated by using an iterative amplification-selection protocol (SELEX). The consensus sequence [UGUANAUARNNNNBBBBSCCS] of the PUM2 binding element (PBE) is related to, but distinct from, the 3' end of the Drosophila Nanos response element. The characterization of PUM2 and potential RNA-binding site will assist efforts to assess the extent and mechanism by which mammalian genes are regulated at a posttranscriptional level.

Lipoproteins regulate expression of the steroidogenic acute regulatory protein (StAR) in mouse adrenocortical cells

The steroidogenic acute regulatory protein (StAR) is required for the movement of cholesterol from the outer to the inner mitochondrial membrane, the site of cholesterol side chain cleavage. Here we describe a novel form of regulation of StAR gene expression in steroidogenic cells. Treatment of Y-1 BS1 adrenocortical cells with either low density lipoprotein (LDL) or high density lipoprotein (HDL) increases expression of endogenous StAR mRNA and protein in a dose-dependent manner. Induction of StAR mRNA by lipoprotein requires basal cAMP-dependent protein kinase, since the inhibitor, R(p)-8-Br-cAMP, inhibited induction of StAR protein by LDL. Likewise, basal StAR expression or LDL induction of StAR protein was not detectable in Y-1 kin-8 cells which are deficient in cAMP-dependent protein kinase. Aminoglutethimide and ketoconazole were used to determine if side chain cleavage of lipoprotein-derived cholesterol is required for induction of StAR mRNA. Treatment with either drug alone induced StAR mRNA expression 1.5-3-fold, while induction of StAR in cells treated with either drug plus LDL, was equal to, or greater than, induction seen with either agent alone, suggesting that lipoprotein does not regulate StAR via generation of an oxysterol intermediate. Both LDL and HDL increased expression of a mouse -966 StAR promoter-reporter construct 1.5-2.5-fold, indicating that regulation occurs at the level of transcription. In contrast, neither lipoprotein was able to induce transcription from a -966 StAR promoter in which the steroidogenic factor-1 site at -135 was abolished, indicating that regulation of StAR transcription by lipoproteins requires steroidogenic factor-1. The regulation of StAR gene expression by lipoproteins may represent a positive feedback circuit which links cholesterol availability with steroidogenic output.

Fus deficiency in mice results in defective B-lymphocyte development and activation, high levels of chromosomal instability and perinatal death

The gene FUS (also known as TLS (for translocated in liposarcoma) and hnRNP P2) is translocated with the gene encoding the transcription factor ERG-1 in human myeloid leukaemias. Although the functions of wild-type FUS are unknown, the protein contains an RNA-recognition motif and is a component of nuclear riboprotein complexes. FUS resembles a transcription factor in that it binds DNA, contributes a transcriptional activation domain to the FUS-ERG oncoprotein and interacts with several transcription factors in vitro. To better understand FUS function in vivo, we examined the consequences of disrupting Fus in mice. Our results indicate that Fus is essential for viability of neonatal animals, influences lymphocyte development in a non-cell-intrinsic manner, has an intrinsic role in the proliferative responses of B cells to specific mitogenic stimuli and is required for the maintenance of genomic stability. The involvement of a nuclear riboprotein in these processes in vivo indicates that Fus is important in genome maintenance.

Inducible expression of protein kinase Calpha suppresses steroidogenesis in Y-1 adrenocortical cells

We have previously shown that protein kinase C (PKC) suppresses steroidogenesis in Y-1 adrenocortical cells. To ask directly if the PKCalpha isoform mediates this suppression, we have developed Y-1 cell lines in which PKCalpha is expressed from a tetracycline-regulated promoter. Induction of PKCalpha expression in these cell lines results in decreased P450 cholesterol side-chain cleavage enzyme (P450-SCC) activity as judged by the conversion of hydroxycholesterol to pregnenolone. Transcription of a P450-SCC promoter-luciferase construct is also reduced when PKCalpha expression is increased. However, expression of PKCalpha has no effect on 8-bromo-cAMP induction of steroidogenesis, indicating that these pathways function independently to regulate steroidogenesis. To determine the relationship between endogenous PKC activity and steroidogenesis, we examined 12 Y-1 subclones that were isolated by limited dilution cloning. In each of these subclones, steroid production correlates inversely with total PKC activity and with the expression of PKCalpha but not PKCepsilon or PKCzeta. These studies define for the first time the role of a specific PKC isoform (PKCalpha) in regulating steroidogenesis and P450-SCC activity in adrenocortical cells.

Peripheral astigmatic asymmetry and angle alpha

The association between peripheral astigmatic asymmetry and angle alpha was tested in the present study. Measurements were made in 34 eyes. Peripheral astigmatism was measured over the horizontal meridian using a Zeiss (Jena) Hartinger coincidence optometer and a Canon R-1 autorefractometer. Curves were fitted to the measured data of each eye and the minima determined by differentiation. Angle alpha was estimated by alignment of Purkinje images I (anterior cornea) and IV (posterior crystalline lens). Peripheral astigmatism was found to be symmetrical about a point on the nasal retina. This point departed from the visual axis by 8.8 +/- 7.0 degrees (Hartinger) and 9.4 +/- 9.8 degrees (Canon). Both values were found to be significantly higher than angle alpha 5.0 +/- 1.2 degrees. The results indicate that either peripheral astigmatic asymmetry is due to additional factors such as lack of symmetry in the peripheral curvature of individual optical surfaces, or that there is further misalignment of optical surfaces away from an optical axis.