Engaging Australian men in disease prevention - priorities and opportunities from a national survey

Objective and importance of the study: In Australia, preventable causes of morbidity and mortality are common among men. The National Men's Health Strategy 2021-2030 highlights the need to successfully engage men in disease prevention; hence, we aimed to examine the prevention priorities, attitudes and information sources reported by Australian men.

STUDY TYPE

Population survey.

METHODS

Men aged 18 years and over were recruited from the nationally representative Life in Australia panel. Participants completed an online survey that measured the prevention issues of greatest concern, attitudes to prevention behaviours and services, and the health information sources considered most useful.

RESULTS

Among 1282 respondents, mental health issues, followed by those pertaining to chronic disease and relationships, were rated of highest concern. Weight management, physical activity, and fruit and vegetable consumption were most often considered as important for personal health. Being 65 years and older and having adequate health literacy were strongly associated with positive attitudes towards prevention practices. More than three-quarters of men rated their doctor as the most useful information source, followed by health websites, internet searching, and their partner.

CONCLUSIONS

Psychological and social issues are of high concern to men, and their attitudes toward preventive behaviours and services often do not align with public health recommendations. Understanding the topics of greatest concern to men and their preferred sources of information can inform communication and engagement strategies to improve health-related practices among men.

Biallelic loss-of-function variants in PLD1 cause congenital right-sided cardiac valve defects and neonatal cardiomyopathy

Congenital heart disease is the most common type of birth defect, accounting for one-third of all congenital anomalies. Using whole-exome sequencing of 2718 patients with congenital heart disease and a search in GeneMatcher, we identified 30 patients from 21 unrelated families of different ancestries with biallelic phospholipase D1 (PLD1) variants who presented predominantly with congenital cardiac valve defects. We also associated recessive PLD1 variants with isolated neonatal cardiomyopathy. Furthermore, we established that p.I668F is a founder variant among Ashkenazi Jews (allele frequency of ~2%) and describe the phenotypic spectrum of PLD1-associated congenital heart defects. PLD1 missense variants were overrepresented in regions of the protein critical for catalytic activity, and, correspondingly, we observed a strong reduction in enzymatic activity for most of the mutant proteins in an enzymatic assay. Finally, we demonstrate that PLD1 inhibition decreased endothelial-mesenchymal transition, an established pivotal early step in valvulogenesis. In conclusion, our study provides a more detailed understanding of disease mechanisms and phenotypic expression associated with PLD1 loss of function.

AB1321-HPR DEVELOPING A SELF-MANAGEMENT INTERVENTION TO MANAGE JOINT HYPERMOBILITY SYNDROME AND EHLERS-DANLOS SYNDROME HYPERMOBILITY TYPE: AN ANALYSIS INFORMED BY BEHAVIOUR CHANGE THEORY

Background:

Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos Syndrome Hypermobility Type (EDS-HT) are heritable disorders of connective tissue that can cause joint instability and pain and are associated with increased anxiety and depression. There is currently little UK guidance for supporting patients with JHS/EDS-HT1. The analysis presented here used the Behaviour Change Wheel (made up of the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation and Behaviour (COM-B) model2) to identify possible intervention options to improve self-management in people with JHS/EDS-HT.

Objectives:

To determine recommendations for the components of a behaviour change intervention for people with JHS or EDS-HT.

Methods:

Data from: 1) A systematic review and thematic synthesis of the literature examining adults’ lived experiences of JHS/EDS3and 2) A thematic analysis of interview data where UK adults with JHS/EDS-HT (n=17, 14 women, 3 men) discussed the psychosocial impact of the condition on their lives4, were mapped onto the TDF and COM-B in a behavioural analysis. A modified Nominal Group Technique focus group (n=9, all women) explored which interventions identified by the TDF/COM-B mapping exercise were most important to them.

Results:

Participants prioritised a range of potential self-management interventions, including:

Education: Participants wanted greater support to improve their knowledge of JHS/EDS-HT, including self-help strategies for coping with injury, fatigue and overexertion, and how to evaluate information about their condition.

Training: In activity pacing, assertiveness and communication skills, and what to expect during pregnancy, when symptoms of JHS/EDS-HT can worsen.

Environmental restructuring and enablement:Support from occupational therapists to maintain independence at home. Enablement of access to CBT, mindfulness and emotional support.

Modelled behaviour:Positive first-person narratives that address how other patients with JHS/EDS-HT have coped with anxiety, depression, distress, fear, frustration and feelings of loss.

Conclusion:

This study is the first to apply theoretically-informed approaches to the management of JHS/EDS-HT. Through a modified nominal group technique, potential behaviour change interventions for addressing barriers to self-management have been prioritised. Discussion with participants indicated poor access to psychological support, occupational therapy and a lack of knowledge of JHS/EDS-HT. Future research with healthcare professional and patient stakeholder groups will further evaluate which intervention options would be most acceptable and feasible for the management of JHS/EDS-HT.

References:

[1]Palmer, S., Terry, R. Rimes, K.A., Clark, C., Simmonds, J. & Horwood, J. (2016). Physiotherapy management of joint hypermobility syndrome – a focus group study of patient and health professional perspectives. Physiotherapy,http://dx.doi.org/10.1016/j.physio.2015.05.001.

[2]Michie, S., van Stralen, M.M. & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6(42).

[3]Bennett, S.E., Walsh, N., Moss, T. and Palmer, S. (2019a) “The lived experience of joint hypermobility and Ehlers-Danlos Syndromes: A systematic review and thematic synthesis.”Physical Therapy Reviews, 24 (1-2). pp. 12-28. ISSN 1083-3196

[4]Bennett, S.E., Walsh, N., Moss, T. and Palmer, S. (2019b) “Understanding the psychosocial impact of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome Hypermobility Type: A qualitative interview study.”Disability and Rehabilitation. ISSN 0963-8288

Disclosure of Interests:

None declared

Understanding the psychosocial impact of joint hypermobility syndrome and Ehlers-Danlos syndrome hypermobility type: a qualitative interview study

PURPOSE

Little attention has been paid to psychosocial factors in Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (hypermobility type). This study sought to identify the psychosocial impact by examining participants' lived experiences; and identify characteristics of effective coping.

MATERIALS AND METHODS

Adults with Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome (Hypermobility Type) were invited to discuss their own lived experiences and the impact of the condition. All met recognized criteria for clinically significant joint hypermobility, and had a self-confirmed diagnosis. The transcripts were coded and analyzed using inductive thematic analysis.

RESULTS

Seventeen participants (14 women, 3 men) purposively selected to broadly represent different genders, ages and ethnicities. Analysis identified five key themes: healthcare limitations, a lack of awareness of Joint Hypermobility, and Ehlers-Danlos Syndrome (Hypermobility Type) among healthcare professionals; a restricted life; social stigma; fear of the unknown; and ways of coping.

CONCLUSIONS

The results highlight the significant psychosocial impact on participants' lives. Coping approaches identified included acceptance, building social networks, learning about joint hypermobility, and adapting activities. Physiotherapists supported regular exercise. Further research should consider potential interventions to improve information provision, address psychological support, and increase awareness of hypermobility among healthcare professionals.Implications for rehabilitationParticipants who had help from family members to complete activities described guilt and shame, highlighting the need for a greater rehabilitation focus on maintaining independence.Difficulties with sexual relationships due to prolapse or erectile dysfunction, and associated anxieties have indicated a need for greater awareness of these issues within primary care.The provision of reliable information and materials is vital, both for healthcare professionals and patients, to reduce misinformation and fear.Physiotherapists with knowledge of Joint Hypermobility Syndrome and Ehlers-Danlos Syndrome hypermobility type were cited as sources of support and hope, which helped people to cope with and manage their condition.

Primary care clinicians' views of paediatric respiratory infection surveillance information to inform clinical decision-making: a qualitative study

AIM

To investigate primary care clinicians' views of a prototype locally relevant, real-time viral surveillance system to assist diagnostic decision-making and antibiotic prescribing for paediatric respiratory tract infections (RTI). Clinicians' perspectives on the content, anticipated use and impact were explored to inform intervention development.

BACKGROUND

Children with RTIs are overprescribed antibiotics. Pressures on primary care and diagnostic uncertainty can lead to decisional biases towards prescribing. We hypothesise that real-time paediatric RTI surveillance data could reduce diagnostic uncertainty and help reduce unnecessary antibiotic prescribing.

METHODOLOGY

Semistructured one-to-one interviews with 21 clinicians from a range of urban general practitioner surgeries explored the clinical context and views of the prototype system. Transcripts were analysed using thematic analysis.

RESULTS

Though clinicians self-identified as rational (not over)prescribers, cognitive biases influenced antibiotic prescribing decisions. Clinicians sought to avoid 'anticipated regret' around not prescribing for a child who then deteriorated. Clinicians were not aware of formal infection surveillance information sources (tending to assume many viruses are around), perceiving the information as novel and potentially useful. Perceptions of surveillance information as presented included: not relevant to decision-making/management; useful to confirm decisions post hoc; and increasing risks of missing sick children. Clinicians expressed wariness of using population-level data to influence individual patient decision-making and expressed preference for threat (high-risk) information identified by surveillance, rather than reassuring information about viral RTIs.

CONCLUSIONS

More work is needed to develop a surveillance intervention if it is to beneficially influence decision-making and antibiotic prescribing in primary care. Key challenges for developing interventions are how to address cognitive biases and how to communicate reassuring information to risk-oriented clinicians.

Understandings and experiences of visible difference and romantic relationships: A qualitative exploration

The association between disfigurement ('visible difference') and romantic relationships has received relatively little consideration in the research literature. This qualitative research, conducted in the United Kingdom, explored participants' accounts of their visible difference and romantic life. Semi-structured interviews were conducted with 22 participants who had a variety of visible differences. Inductive thematic analysis demonstrated that participants understood their difference as having a pervasive and enduring impact. These encompassed challenges that must be negotiated in the formation of romantic relationships, including feeling unattractive to others and feeling personally devalued. Relevant physical and sexual sequelae were comprised of anxieties regarding informing partners of a difference, impacted sexual activity, and concerns about heritability. Finally, the potential for partner support and acceptance to positively impact romantic relationships was recognised. This research highlighted the need to extend our understanding of visible difference and intimate relationships and to develop effective interventions to ameliorate appearance-related concern.

Patient Decisions to Receive Secondary Pharmacogenomic Findings and Development of a Multidisciplinary Practice Model to Integrate Results Into Patient Care

Whole exome sequencing (WES) has the potential of identifying secondary findings that are predictive of poor pharmacotherapy outcomes. The purpose of this study was to investigate patients’ wishes regarding the reporting of secondary pharmacogenomic findings. WES results (n = 106 patients) were retrospectively reviewed to determine the number of patients electing to receive secondary pharmacogenomic results. Phenotypes were assigned based on Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. The percent of patients with a predicted phenotype associated with a gene‐based CPIC dosing recommendation was determined. Ninety‐nine patients (93.4%) elected to receive secondary pharmacogenomic findings. For each gene–drug pair analyzed, the number of patients with an actionable phenotype ranged from two (2%) to 43 patients (43.4%). Combining all gene–drug pairs, 84 unique patients (84.8%) had an actionable phenotype. A prospective multidisciplinary practice model was developed for integrating secondary pharmacogenomic findings into clinical practice. Our model highlights a unique collaboration between physician‐geneticists, pharmacists, and genetic counselors.

A randomized phase 2 study of MK-2206 versus everolimus in refractory renal cell carcinoma

Background

Activation of the phosphoinisitide-3 kinase (PI3K) pathway through mutation and constitutive upregulation has been described in renal cell carcinoma (RCC), making it an attractive target for therapeutic intervention. We performed a randomized phase II study in vascular endothelial growth factor (VEGF) therapy refractory patients to determine whether MK-2206, an allosteric inhibitor of AKT, was more efficacious than the mammalian target of rapamycin inhibitor everolimus.

Patients and methods

A total of 43 patients were randomized in a 2:1 distribution, with 29 patients assigned to the MK-2206 arm and 14 to the everolimus arm. Progression-free survival (PFS) was the primary endpoint.

Results

The trial was closed at the first futility analysis with an observed PFS of 3.68 months in the MK-2206 arm and 5.98 months in the everolimus arm. Dichotomous response rate profiles were seen in the MK-2206 arm with one complete response and three partial responses in the MK-2206 arm versus none in the everolimus arm. On the other hand, progressive disease was best response in 44.8% of MK2206 versus 14.3% of everolimus-treated patients. MK-2206 induced significantly more rash and pruritis than everolimus, and dose reduction occurred in 37.9% of MK-2206 versus 21.4% of everolimus-treated patients. Genomic analysis revealed that 57.1% of the patients in the PD group had either deleterious TP53 mutations or ATM mutations or deletions. In contrast, none of the patients in the non-PD group had TP53 or ATM defects. No predictive marker for response was observed in this small dataset.

Conclusions

Dichotomous outcomes are observed when VEGF therapy refractory patients are treated with MK-2206, and MK-2206 does not demonstrate superiority to everolimus. Additionally, mutations in DNA repair genes are associated with early disease progression, indicating that dysregulation of DNA repair is associated with a more aggressive tumor phenotype in RCC.

Discarded surrogates, modified traditions, welcome complements: The chequered careers of alternative technologies in Berlin's infrastructure systems

This article takes an historical perspective on current attempts to 'open up' established, centralized systems of urban infrastructure to alternative technologies designed to minimize resource use and environmental pollution. The process of introducing alternative technologies into, or alongside, centralized urban infrastructures is not a novel phenomenon, as is often assumed. The physical and institutional entrenchment of large technical systems for urban energy, water or sanitation services in industrialized countries in the late 19th and early 20th centuries did not close the door completely on alternatives. I investigate a number of alternative technologies used in Berlin in the interwar period (1920-1939), in order to reveal the rationales developed around each technology and the ways in which each emerged, disappeared and re-emerged or survived across highly diverse political regimes. The selection of cases is guided by the desire to illustrate three different phenomena of alternative technology diffusion (and exclusion) experienced in Berlin: (1) technologies promoted by early pioneers and discarded by their successors (waste-to-energy), (2) technologies modifying traditional practices that were at odds with modernized systems (wastewater reuse for agriculture) and (3) technologies co-existing alongside the dominant centralized system throughout the 20th century (cogeneration). The empirical findings are interpreted with reference to their contribution to scholarship on urban socio-technical transitions.

De novo mutations in PURA are associated with hypotonia and developmental delay

PURA is the leading candidate gene responsible for the developmental phenotype in the 5q31.3 microdeletion syndrome. De novo mutations in PURA were recently reported in 15 individuals with developmental features similar to the 5q31.3 microdeletion syndrome. Here we describe six unrelated children who were identified by clinical whole-exome sequencing (WES) to have novel de novo variants in PURA with a similar phenotype of hypotonia and developmental delay and frequently associated with seizures. The protein Purα (encoded by PURA) is involved in neuronal proliferation, dendrite maturation, and the transport of mRNA to translation sites during neuronal development. Mutations in PURA may alter normal brain development and impair neuronal function, leading to developmental delay and the seizures observed in patients with mutations in PURA.

Psychosocial Outcomes of Quadrantectomy Versus Mastectomy in a Southern Italian Sample: Development and Needs of the Italian Derriford Appearance Scale 24

BACKGROUND/AIM

Breast cancer is associated with appearance concerns and issues of appearance identity, that require an appropriate and independent assessment. The Derriford Appearance Scale (DAS) has been widely used to this end, as has been shown in UK and other international samples. The aim of this study was to determine the extent to which an Italian translation of DAS24 is valid, reliable, and culturally appropriate, while remaining user friendly. The extent to which the statistical robustness of the scale is maintained was also assessed.

PATIENTS AND METHODS

Ninety-three female participants were recruited at a Breast Cancer Department in Southern Italy. According to the protocol designed by the original authors of the questionnaire, a booklet containing the DAS24ita and other scale was completed anonymously by participants.

CONCLUSION

The results of the statistical analysis confirmed the validity and reliability of the DAS24ita. The DAS24ita demonstrated significant correlations with the other measures of appearance sensitivity and quality of life. The translated scale was able to differentiate among patients with differential diagnoses, and was more sensitive to these differences than generic quality-of-life scales.

The expanding clinical phenotype of Bosch-Boonstra-Schaaf optic atrophy syndrome: 20 new cases and possible genotype-phenotype correlations

PURPOSE

Bosch-Boonstra-Schaaf optic atrophy syndrome (BBSOAS) is an autosomal-dominant disorder characterized by optic atrophy and intellectual disability caused by loss-of-function mutations in NR2F1. We report 20 new individuals with BBSOAS, exploring the spectrum of clinical phenotypes and assessing potential genotype-phenotype correlations.

METHODS

Clinical features of individuals with pathogenic NR2F1 variants were evaluated by review of medical records. The functional relevance of coding nonsynonymous NR2F1 variants was assessed with a luciferase assay measuring the impact on transcriptional activity. The effects of two start codon variants on protein expression were evaluated by western blot analysis.

RESULTS

We recruited 20 individuals with novel pathogenic NR2F1 variants (seven missense variants, five translation initiation variants, two frameshifting insertions/deletions, one nonframeshifting insertion/deletion, and five whole-gene deletions). All the missense variants were found to impair transcriptional activity. In addition to visual and cognitive deficits, individuals with BBSOAS manifested hypotonia (75%), seizures (40%), autism spectrum disorder (35%), oromotor dysfunction (60%), thinning of the corpus callosum (53%), and hearing defects (20%).

CONCLUSION

BBSOAS encompasses a broad range of clinical phenotypes. Functional studies help determine the severity of novel NR2F1 variants. Some genotype-phenotype correlations seem to exist, with missense mutations in the DNA-binding domain causing the most severe phenotypes.Genet Med 18 11, 1143-1150.

The persistence of long-term potentiation in the projection from ventral hippocampus to medial prefrontal cortex in awake rats

A potentially vital pathway in the processing of spatial memory is the pathway from ventral hippocampus to medial prefrontal cortex (vHPC-mPFC). To assess long-term potentiation (LTP) induction and maintenance across days in this pathway, the effects of several induction paradigms were compared in awake, freely moving rats. Two different high-frequency stimulation (HFS) protocols generated LTP lasting no longer than 1 week. However, after delivering HFS on three consecutive days, LTP lasted an average of 20 days, due mainly to the greater initial induction. Thus the pathway does not require extensive multi-day stimulation to induce LTP, as for other intra-neocortical pathways, but also it does not exhibit the extremely long-lasting and stable LTP previously observed in area CA1 and the dentate gyrus. By using bilaterally placed stimulating and recording electrodes, we found that HFS in one vHPC generated responses and LTP in the contralateral mPFC, even when the ipsilateral mPFC was inactivated by CNQX. We attribute this crossed response to a polysynaptic pathway from the vHPC to the contralateral mPFC. Finally, we found that repeated overnight exposure to an enriched environment also potentiated the vHPC-mPFC response, but this too was a transient effect lasting < 9 days, declining to baseline even before the enriched environment treatment was completed. Overall, these findings are consistent with the view that potentiation of vHPC-mPFC pathway may play a key role in promoting the hippocampus-mPFC interplay that, over days, leads to long-term storage in the frontal cortex of memories that are independent of the hippocampus.

Pathogenic mechanism of recurrent mutations of SCN8A in epileptic encephalopathy

Objective

The early infantile epileptic encephalopathy type 13 (EIEE13, OMIM #614558) results from de novo missense mutations of SCN8A encoding the voltage‐gated sodium channel Na_v1.6. More than 20% of patients have recurrent mutations in residues Arg1617 or Arg1872. Our goal was to determine the functional effects of these mutations on channel properties.

Methods

Clinical exome sequencing was carried out on patients with early‐onset seizures, developmental delay, and cognitive impairment. Two mutations identified here, p.Arg1872Leu and p.Arg1872Gln, and two previously identified mutations, p.Arg1872Trp and p.Arg1617Gln, were introduced into Na_v1.6 cDNA, and effects on electrophysiological properties were characterized in transfected ND7/23 cells. Interactions with FGF14, G‐protein subunit Gβγ, and sodium channel subunit β1 were assessed by coimmunoprecipitation.

Results

We identified two patients with the novel mutation p.Arg1872Leu and one patient with the recurrent mutation p.Arg1872Gln. The three mutations of Arg1872 and the mutation of Arg1617 all impaired the sodium channel transition from open state to inactivated state, resulting in channel hyperactivity. Other observed abnormalities contributing to elevated channel activity were increased persistent current, increased peak current density, hyperpolarizing shift in voltage dependence of activation, and depolarizing shift in steady‐state inactivation. Protein interactions were not affected.

Interpretation

Recurrent mutations at Arg1617 and Arg1872 lead to elevated Na_v1.6 channel activity by impairing channel inactivation. Channel hyperactivity is the major pathogenic mechanism for gain‐of‐function mutations of SCN8A. EIEE13 differs mechanistically from Dravet syndrome, which is caused by loss‐of‐function mutations of SCN1A. This distinction has important consequences for selection of antiepileptic drugs and the development of gene‐ and mutation‐specific treatments.

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study

Aims

To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation.

Methods

This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression.

Results

The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression.

Conclusions

Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed.

Heterozygous de novo and inherited mutations in the smooth muscle actin (ACTG2) gene underlie megacystis-microcolon-intestinal hypoperistalsis syndrome

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is a rare disorder of enteric smooth muscle function affecting the intestine and bladder. Patients with this severe phenotype are dependent on total parenteral nutrition and urinary catheterization. The cause of this syndrome has remained a mystery since Berdon's initial description in 1976. No genes have been clearly linked to MMIHS. We used whole-exome sequencing for gene discovery followed by targeted Sanger sequencing in a cohort of patients with MMIHS and intestinal pseudo-obstruction. We identified heterozygous ACTG2 missense variants in 15 unrelated subjects, ten being apparent de novo mutations. Ten unique variants were detected, of which six affected CpG dinucleotides and resulted in missense mutations at arginine residues, perhaps related to biased usage of CpG containing codons within actin genes. We also found some of the same heterozygous mutations that we observed as apparent de novo mutations in MMIHS segregating in families with intestinal pseudo-obstruction, suggesting that ACTG2 is responsible for a spectrum of smooth muscle disease. ACTG2 encodes γ2 enteric actin and is the first gene to be clearly associated with MMIHS, suggesting an important role for contractile proteins in enteric smooth muscle disease.

Existence of benefit finding and posttraumatic growth in people treated for head and neck cancer: a systematic review

Background. The impact of head and neck cancer (HNC) in long-term survivors differs widely among individuals, and a significant number of them suffer from the negative effects of disease, whereas others report significant positive effect. This systematic review investigated the evidence the implications of treatment for HNC and subsequent development of Benefit Finding (BF) or Posttraumatic Growth (PTG). Purpose. To understand how differing medical, psychological and social characteristics of HNC may lead to BF/PTG and subsequently inform post-treatment interventions to encourage positive outcomes. Method. In February 2012, five databases including Pubmed, and Psych Info, were searched, for peer-reviewed English-language publications. Search strings included key words pertaining to HNC, BF, and PTG. One thousand three hundred and sixty three publications were identified, reviewed, and reduced following Cochrane guidelines and inclusion/exclusion criteria specified by a group of maxillofacial consultants and psychologists. Publications were then quality assessed using the CASP Cohort Critical Appraisal tool. Findings. Five manuscripts met the search and selection criteria, and were sourced for review. All studies were identified as being level IIb evidence which is a medium level of quality. The majority of studies investigated benefit finding (80%) and were split between recruiting participant via cancer clinics and postal survey. They focused on the medical, psychological and social characteristics of the patient following completion of treatment for HNC. Conclusion. Demographic factors across the papers showed similar patterns of relationships across BF and PTG; that higher education/qualification and cohabitation/marriage are associated with increased BF/PTG. Similarly, overlap with disease characteristics and psychosocial factors where hope and optimism were both positively correlated with increased reported BF/PTG.

Early Onset and Severe Clinical Course Associated with the m.5540G>A Mutation in MT-TW

We report a patient harboring a de novo m.5540G>A mutation affecting the MT-TW gene coding for the mitochondrial tryptophan-transfer RNA. This patient presented with atonic-myoclonic epilepsy, bilateral sensorineural hearing loss, ataxia, motor regression, ptosis, and pigmentary retinopathy. Our proband had an earlier onset and more severe phenotype than the first reported patient harboring the same mutation. We discuss her clinical presentation and compare it with the only previously published case.

Electrochemotherapy for large cutaneous recurrence of breast cancer: a phase II clinical trial

BACKGROUND

Cutaneous recurrences of breast cancer may cause considerable discomfort due to ulceration, oozing, and pain and can also be difficult to treat. Electrochemotherapy is a localised anticancer treatment using electric pulses to make cell membranes permeable, augmenting uptake of chemotherapeutic drugs, and thus enabling highly efficient tumour cell kill. This is the first systematic investigation of electrochemotherapy for larger cutaneous recurrences of breast cancer.

PATIENTS AND METHODS

We conducted a phase II trial for patients with cutaneous recurrences where no further treatment options were available. Primary endpoint was objective response evaluated by clinical examination. Secondary endpoints included response evaluated by PET/CT, change in lung diffusion capacity, patient reported symptoms, and distress related to bodily appearance. Treatment consisted of bleomycin injection followed by application of electric pulses.

RESULTS

Seventeen heavily pre-treated patients received electrochemotherapy. Twelve patients were evaluable (follow-up > 8 weeks). CT showed four (33%) patients achieving over 50% tumour volume reduction, clinical examination showed one CR and one PR (OR 17%). Symptomatic relief included decreasing exudates, odour, and bleeding. Treatment was well tolerated; the main side effect was post-treatment pain.

CONCLUSION

This first phase II study indicates that electrochemotherapy is a promising treatment alternative for cutaneous recurrences of breast cancer.

The DAS24: A short form of the Derriford Appearance Scale DAS59 to measure individual responses to living with problems of appearance

OBJECTIVES

To develop a psychometrically robust and widely applicable short form of the Derriford Appearance Scale, (DAS59), which (1) will reliably and validly assess the distress and difficulties experienced in living with problems of appearance, (2) is acceptable to clinical and non-clinical populations, and (3) facilitates research and clinical decision-making through good standardization and sensitivity.

DESIGN

Cross-sectional survey designs using clinical (out-patient and in-patient) and general population samples.

METHOD

Twenty-five items were selected initially from the 59 items of the original DAS59. These were refined to 24 through item analyses and the scale was standardized on 535 patients with a range of problems of appearance and on a representative general population sample (N=1, 107).

RESULTS

All 24 items contributed well to the total score and internal consistency was high (alpha=.92). Test-retest reliability (6 months) was good (0.82), and criterion validity, with the DAS59, was excellent (0.88). Good construct validity was demonstrated in differences between (1) patient and general population samples, (2) members of the general population concerned and not concerned about their appearance, and (3) in patterns of convergent and divergent correlations with a range of established scales. The general population data revealed widespread concerns about appearance.

CONCLUSION

The DAS24 provides a widely applicable and acceptable short form of the original DAS59. It is psychometrically robust and discriminates well between patient groups, between clinical and non-clinical populations, and within the general population between those concerned, and those not concerned, about their appearance.

Multilevel water governance and problems of scale: setting the stage for a broader debate

Environmental governance and management are facing a multiplicity of challenges related to spatial scales and multiple levels of governance. Water management is a field particularly sensitive to issues of scale because the hydrological system with its different scalar levels from small catchments to large river basins plays such a prominent role. It thus exemplifies fundamental issues and dilemmas of scale in modern environmental management and governance. In this introductory article to an Environmental Management special feature on "Multilevel Water Governance: Coping with Problems of Scale," we delineate our understanding of problems of scale and the dimensions of scalar politics that are central to water resource management. We provide an overview of the contributions to this special feature, concluding with a discussion of how scalar research can usefully challenge conventional wisdom on water resource management. We hope that this discussion of water governance stimulates a broader debate and inquiry relating to the scalar dimensions of environmental governance and management in general.

A new paradigm for the regulation of the mammalian ribosomal RNA genes

Ribosome assembly occurs co-transcriptionally on the rRNA genes. This process requires the co-ordinated expression and assembly of many hundreds of proteins and is finely tuned to cell and organism growth. Co-ordinate regulation of the rRNA genes and the ribosomal protein genes is therefore essential for high-fidelity ribosome assembly. Recent work shows that rRNA gene transcription is regulated at the level of elongation via the mitogen-activated protein kinase pathway. We argue that this may provide an explanation for the high fidelity of ribosome assembly.

Immunization information systems progress - United States, 2005

Immunization registries are confidential, computerized information systems that collect and consolidate vaccination data from multiple health-care providers, generate reminder and recall notifications, and assess vaccination coverage within a defined geographic area. A registry with added capabilities, such as vaccine management, adverse event reporting, lifespan vaccination histories, and linkages with electronic data sources, is called an immunization information system (IIS). This report summarizes data from CDC's 2005 Immunization Information System Annual Report (IISAR), a survey of grantees in 50 states, five cities, and the District of Columbia (DC) that receive funding under section 317b of the Public Health Service Act. These data indicated that approximately 56% of U.S. children aged <6 years participated in an IIS, an increase from 48% in 2004. Moreover, 75% percent of public vaccination provider sites and 44% of private vaccination provider sites submitted vaccination data to an IIS during July-December 2005. These findings underscore the need to increase the number of participating children, from the current 13 million to approximately 21 million, to assure 95% participation of children aged <6 years and improve the effectiveness of U.S. immunization programs.

A housekeeper with power of attorney: the rRNA genes in ribosome biogenesis

Ribosome biogenesis centres both physically and functionally on the activity of the ribosomal RNA (rRNA) genes. Ribosome assembly occurs co-transcriptionally on these genes, requires the coordinated expression and assembly of many hundreds of proteins and is finely tuned to cell and organism growth. This review presents contemporary understanding of the mode and the means of rRNA gene transcription and how growth factors, oncogenes and tumour suppressors regulate this transcription. It is argued that transcription elongation is a key mechanism regulating rRNA gene transcription. This unorthodox view provides a logical framework to explain the co-transcriptional phase of ribosome biogenesis.

Malignant transformation of posterior fossa epidermoid cyst

The authors report the case of a 45-year-old man who presented with a short duration of a painful ophthalmoparesis. Initial magnetic resonance imaging revealed an extraaxial petroclival mass characteristic of an epidermoid cyst, with the exception of a contiguous contrast-enhancing lobule. A subtotal resection was performed with the histopathological diagnosis revealing malignant transformation of an epidermoid cyst. Despite aggressive postoperative adjuvant therapy, the patient developed leptomeningeal metastasis and died shortly thereafter. The presence of contrast enhancement at the site of an epidermoid cyst combined with an acute, progressive neurological deficit should alert the treating physician to the possibility of a malignant transformation. When transformation does occur, the clinical and radiological course is quite aggressive as compared with the indolent growth of epidermoid cysts. Treatment options include surgery with adjuvant chemotherapy or radiotherapy. We review the pertinent features of this case along with the relevant literature regarding primary intracranial squamous cell carcinomas.

Cellular senescence in naevi and immortalisation in melanoma: a role for p16?

Cellular senescence, the irreversible proliferative arrest seen in somatic cells after a limited number of divisions, is considered a crucial barrier to cancer, but direct evidence for this in vivo was lacking until recently. The best-known form of human cell senescence is attributed to telomere shortening and a DNA-damage response through p53 and p21. There is also a more rapid form of senescence, dependent on the p16-retinoblastoma pathway. p16 (CDKN2A) is a known melanoma susceptibility gene. Here, we use retrovirally mediated gene transfer to confirm that the normal form of senescence in cultured human melanocytes involves p16, since disruption of the p16/retinoblastoma pathway is required as well as telomerase activation for immortalisation. Expression (immunostaining) patterns of senescence mediators and markers in melanocytic lesions provide strong evidence that cell senescence occurs in benign melanocytic naevi (moles) in vivo and does not involve p53 or p21 upregulation, although p16 is widely expressed. In comparison, dysplastic naevi and early (radial growth-phase, RGP) melanomas show less p16 and some p53 and p21 immunostaining. All RGP melanomas expressed p21, suggesting areas of p53-mediated senescence, while most areas of advanced (vertical growth-phase) melanomas lacked both p16 and p21, implying escape from both forms of senescence (immortalisation). Moreover, nuclear p16 but not p21 expression can be induced in human melanocytes by oncogenic BRAF, as found in around 80% of naevi. We conclude that cell senescence can form a barrier to melanoma development. This also provides a potential explanation of why p16 is a melanoma suppressor gene.

Dexamethasone can stimulate G1-S phase transition in human airway fibroblasts in asthma

Corticosteroids are the first line of therapy for asthma. Whether they alter the progression of airway remodelling in asthma is, as yet, unknown. To determine whether corticosteroids could alter the fibroblast cell cycle the current authors studied the effect of dexamethasone on cultured airway fibroblasts obtained from nine mild-to-moderate, steroid-naïve asthmatics (forced expiratory volume in one second 78+/-4% predicted), and seven normal controls. Fibroblasts were cultured from endobronchial biopsies obtained via bronchoscopy. Cells were exposed to dexamethasone (10(-9)-10(-7) M) and studied at 72 h to determine differences in progression through the cell cycle. In asthmatic fibroblasts, dexamethasone, at concentrations of 10(-8)M and 10(-7)M, nearly doubled the number of cells in the S phase (17.8+/-3.0% and 18.4+/-3.1%, respectively) compared with untreated fibroblasts (10.3+/-1.4%). There was no significant effect in normal control fibroblasts. Dexamethasone induced hyperphosphorylation of the tumour suppressor, retinoblastoma (RB) in asthmatic fibroblasts; fibroblasts from normal controls had significantly less hyperphosphorylation of RB. No difference in protein expression of the CCAAT/enhancer binding protein alpha between the two groups was detected. This study suggests that dexamethasone can stimulate G1-S phase cell cycle transition in human airway fibroblasts obtained from asthmatics. Whether this leads to enhanced airway remodelling in some individuals remains to be determined.

Disease progression in heterosexual patients infected with closely related subtype B strains of HIV type 1 with differing coreceptor usage properties

Previously we described a heterosexual outbreak of HIV-1 subtype B in a town in the north of England (Doncaster) where 11 of 13 infections were shown to be linked by phylogenetic analysis of the env gp120 region. The 11 infections were related to a putative index case, Don1, and further divided into two groups based on the patients' disease status, their viral sequences, and other epidemiological information. Here we describe two further findings. First, we found that viral isolates and gp120 recombinant viruses derived from patients from one group used the CCR5 coreceptor, whereas viruses from the other group could use both the CCR5 and CXCR4 coreceptors. Patients with the X4/R5 dual tropic strains were symptomatic when diagnosed and progressed rapidly, in contrast to the other patient group that has remained asymptomatic, implying a link between the tropism of the strains and disease outcome. Second, we present additional sequence data derived from the index case, demonstrating the presence of sequences from both clades, with an average interclade distance of 9.56%, providing direct evidence of a genetic link between these two groups. This new study shows that Don1 harbored both strains, implying he was either dually infected or that over time intrahost diversification from the R5 to R5/X4 phenotype occurred. These events may account for/have led to the spread of two genetically related strains with different pathogenic properties within the same heterosexual community.

Investigating the structural basis of purine specificity in the structures of MS2 coat protein RNA translational operator hairpins

We have determined the structures of complexes between the phage MS2 coat protein and variants of the replicase translational operator in order to explore the sequence specificity of the RNA-protein interaction. The 19-nt RNA hairpins studied have substitutions at two positions that have been shown to be important for specific binding. At one of these positions, -10, which is a bulged adenosine (A) in the stem of the wild-type operator hairpin, substitutions were made with guanosine (G), cytidine (C) and two non-native bases, 2-aminopurine (2AP) and inosine (I). At the other position, -7 in the hairpin loop, the native adenine was substituted with a cytidine. Of these, only the G-10, C-10 and C-7 variants showed interpretable density for the RNA hairpin. In spite of large differences in binding affinities, the structures of the variant complexes are very similar to the wild-type operator complex. For G-10 substitutions in hairpin variants that can form bulges at alternative places in the stem, the binding affinity is low and a partly disordered conformation is seen in the electron density maps. The affinity is similar to that of wild-type when the base pairs adjacent to the bulged nucleotide are selected to avoid alternative conformations. Both purines bind in a very similar way in a pocket in the protein. In the C-10 variant, which has very low affinity, the cytidine is partly inserted in the protein pocket rather than intercalated in the RNA stem. Substitution of the wild-type adenosine at position -7 by pyrimidines gives strongly reduced affinities, but the structure of the C-7 complex shows that the base occupies the same position as the A-7 in the wild-type RNA. It is stacked in the RNA and makes no direct contact with the protein.

An MRI and neuropathological study of a case of fatal status epilepticus

We report a case of fatal status epilepticus of unknown origin resulting in acute neuropathological changes in the hippocampus and claustrum. The case history, brain magnetic resonance images, and results of neuropathological study of the whole brain were obtained. The subject was a 35 year old male with no significant previous medical history who presented with generalized epileptic seizures progressing to status epilepticus. He died 6 days after developing status epilepticus. Magnetic resonance imaging (MRI) brain scans were performed before and four days after developing status epilepticus. The first scan was normal and the second showed high signal lesions on T2 weighted images in the medial aspects of both temporal lobes and in the right claustrum. Neuropathological studies showed severe neuronal loss in the Sommer section of both hippocampi with early glial reactive changes. Similar changes were seen in the claustrum on both sides. There was no evidence of other causes of brain injury such as infectious encephalitis or global hypoxic-ischaemic change. The patient died of status epilepticus for which no underlying cause was found despite extensive investigation. In this case the radiological and pathological changes found bilaterally in the claustrum and hippocampus appear to be the direct result of the status epilepticus.

Structural basis of pyrimidine specificity in the MS2 RNA hairpin-coat-protein complex

We have determined the X-ray structures of six MS2 RNA hairpin-coat-protein complexes having five different substitutions at the hairpin loop base -5. This is a uracil in the wild-type hairpin and contacts the coat protein both by stacking on to a tyrosine side chain and by hydrogen bonding to an asparagine side chain. The RNA consensus sequence derived from coat protein binding studies with natural sequence variants suggested that the -5 base needs to be a pyrimidine for strong binding. The five -5 substituents used in this study were 5-bromouracil, pyrimidin-2-one, 2-thiouracil, adenine, and guanine. The structure of the 5-bromouracil complex was determined to 2.2 A resolution, which is the highest to date for any MS2 RNA-protein complex. All the complexes presented here show very similar conformations, despite variation in affinity in solution. The results suggest that the stacking of the -5 base on to the tyrosine side chain is the most important driving force for complex formation. A number of hydrogen bonds that are present in the wild-type complex are not crucial for binding, as they are missing in one or more of the complexes. The results also reveal the flexibility of this RNA-protein interface, with respect to functional group variation, and may be generally applicable to other RNA-protein complexes.

An immediate response of ribosomal transcription to growth factor stimulation in mammals is mediated by ERK phosphorylation of UBF

Ribosomal transcription in mammals is regulated in response to growth, differentiation, disease, and aging, but the mechanisms of this regulation have remained unresolved. We show that epidermal growth factor induces immediate, ERK1/2-dependent activation of endogenous ribosomal transcription, while inactivation of ERK1/2 causes an equally immediate reversion to the basal transcription level. ERK1/2 was found to phosphorylate the architectural transcription factor UBF at amino acids 117 and 201 within HMG boxes 1 and 2, preventing their interaction with DNA. Mutation of these sites inhibited transcription activation and abrogated the transcriptional response to ERK1/2. Thus, growth factor regulation of ribosomal transcription likely acts by a cyclic modulation of DNA architecture. The data suggest a central role for ribosome biogenesis in growth regulation.

DNA looping in the RNA polymerase I enhancesome is the result of non-cooperative in-phase bending by two UBF molecules

The so-called upstream binding factor (UBF) is required for the initial step in formation of an RNA polymerase I initiation complex. This function of UBF correlates with its ability to induce the ribosomal enhancesome, a structure which resembles in its mass and DNA content the nucleosome of chromatin. DNA looping in the enhancesome is probably the result of six in-phase bends induced by the HMG boxes of a UBF dimer. Here we show that insertion/deletion mutations in the basic peptide linker lying between the N-terminal dimerisation domain and the first HMG box of Xenopus UBF prevent the DNA looping characteristic of the enhancesome. Using these mutants we demonstrate that (i) the enhancesome structure does not depend on tethering of the entering and exiting DNA duplexes, (ii) UBF monomers induce hemi-enhancesomes, bending the DNA by 175 +/- 24 degrees and (iii) two hemi-enhancesomes are precisely phased by UBF dimerisation. We use this and previous data to refine the existing enhancesome model and show that HMG boxes 1 and 2 of UBF lie head-to-head along the DNA.

Phylogenetic analysis of multiple heterosexual transmission events involving subtype b of HIV type 1

Between 1996 and 1999 thirteen cases of HIV infection were detected in Doncaster, a small town in the north of England (population approximately 250,000). A complex network of shared sexual histories involving local nightclubs linked these cases, with the only known risk factor being heterosexual intercourse. A series of frozen blood samples was collected in 1998-1999 and amplified by PCR to generate full-length gp120 clones. Sequencing demonstrated that all the transmission events in this heterosexual group involved the B subtype of HIV-1. When relationships between the samples were assessed it became clear that these 13 cases represented at least three separate strains of HIV-1, indicating that HIV is well established in this community. Eleven of the 13 cases were related, forming two distinct groups. Further investigation revealed that one group contained five patients whose general health was good and who were not receiving HAART. In contrast, the second group of six patients, including the putative index case, were symptomatic, receiving HAART, and may have been infected with a CXCR-4-utilizing virus. Several of the cases that were linked by genetic criteria were not linked by contact tracing, implying that further undiagnosed cases may exist in this community. To our knowledge, this is the largest outbreak of HIV studied within the heterosexual community in the United Kingdom to date, suggesting that this route of infection is becoming more common within the United Kingdom.

Probing the kinetics of formation of the bacteriophage MS2 translational operator complex: identification of a protein conformer unable to bind RNA

We have investigated the kinetics of complex formation between bacteriophage MS2 coat protein subunits and synthetic RNA fragments encompassing the natural translational operator site, or the consensus sequences of three distinct RNA aptamer families, which are known to bind to the same site on the protein. Reactions were assayed using stopped-flow fluorescence spectroscopy and either the intrinsic tryptophan fluorescence of the protein or the signals from RNA fragments site-specifically substituted with the fluorescent adenosine analogue 2'-deoxy, 2-aminopurine. The kinetics observed were independent of the fluorophore being monitored or its position within the complex, indicating that the data report global events occurring during complex formation. Competition assays show that the complex being formed consists of a single coat protein dimer and one RNA molecule. The binding reaction is at least biphasic. The faster phase, constituting 80-85 % of the amplitude, is a largely diffusion driven RNA-protein interaction (k1 approximately 2x10(9) M(-1) s(-1)). The salt dependence of the forward reaction and the similarities of the on-rates of lower-affinity RNA fragments are consistent with a diffusion-controlled step dominated by electrostatic steering. The slower phase is independent of reactant concentration, and appears to correspond to isomerisation of the coat protein subunit(s) prior to RNA binding (k(iso) approximately 0.23 s(-1)). Measurements with a coat protein mutant (Pro78Asn) show that this phase is not due to cis-trans isomerisation at this residue. The conformational changes in the protein ligand during formation of an RNA-protein complex might play a role in the triggering of capsid self-assembly and a model for this is discussed.

Competitive recruitment of CBP and Rb-HDAC regulates UBF acetylation and ribosomal transcription

RNA polymerase I (PolI) transcription is activated by the HMG box architectural factor UBF, which loops approximately 140 bp of DNA into the enhancesome, necessitating major chromatin remodeling. Here we show that the acetyltransferase CBP is recruited to and acetylates UBF both in vitro and in vivo. CBP activates PolI transcription in vivo through its acetyltransferase domain and acetylation of UBF facilitates transcription derepression and activation in vitro. CBP activation and Rb suppression of ribosomal transcription by recruitment to UBF are mutually exclusive, regulating in vivo PolI transcription through an acetylation-deacetylation "flip-flop." Thus, PolI transcription is regulated by protein acetylation, and the competitive recruitment of CBP and Rb.

The effect of neuraxial steroids on weight and bone mass density: a prospective evaluation

The deleterious effects of corticosteroids utilized in neural blockade are a commonly discussed and contentious issue. Corticosteroids are considered to have widespread effects on almost all body systems, with suppression of the release of corticotropin (ACTH) from the pituitary suppressing the secretion of endogenous corticosteroids, thus producing a secondary adrenocortical insufficiency. Even though a multitude of complications of neuraxial steroids have been popularized, the more practical complications of corticosteroid administration are twofold - those resulting from withdrawal and those resulting from continued use of large doses. These mainly include suppression of the pituitary-adrenal axis, weight gain, osteopenia, osteoporosis, and a variety of other minor complications. This prospective evaluation was undertaken to evaluate the effect of corticosteroids and the dose relationship on weight gain, bone-mass density (BMD), and other deleterious effects of steroids. The study population consisted of 204 patients; however, complete data were available on only 123 patients. These patients were divided into two groups, with group I receiving neural blockade without any steroids, and, Group II consisting of patients receiving neuraxial steroids. The results of serial determination of weight and BMD showed no significant change at any interval or at the end of 1 year in all 123 patients with or without steroid administration. In addition, this study also showed some improvement in BMD, as well as weight reduction indicating improvement in functional status. It is concluded that low-dose administration of neuraxial steroids is safe in patients suffering with chronic pain who have failed to respond to conservative modalities of treatment with a favorable risk-benefit ratio. This study also showed no deleterious effect on weight or BMD.