Loss of function mutations of the GnRH receptor: a new cause of hypogonadotropic hypogonadism

The association of hypogonadotropic hypogonadism with anosmia defines Kallmann's syndrome. The gene of the X-linked form of this syndrome has been cloned and several mutations described. However, the relatively small number of hypogonadotropic hypogonadic patients with Kallmann's gene defects supports the hypothesis that other genes may be involved. Idiopathic hypogonadotropic hypogonadism (IHH) is not associated with anosmia. The GnRH gene was excluded as a candidate gene in IHH since no abnormality was found in several patients. The action of the GnRH is mediated through a G-protein coupled receptor present in the cell membrane of gonadotropes. The GnRH receptor was thus another candidate gene. Recently, we described the first patient with partial hypogonadotropic hypogonadism without anosmia caused by loss of function mutations of the GnRH receptor. We compare this first family with a new family presenting complete hypogonadotropic hypogonadism and a variable degree of gonadotrope deficiency in the affected kindred, and discuss genotype-phenotype correlation.

Detection of telomerase activity in biopsy samples of colorectal cancer

BACKGROUND

Telomerase is a ribonucleoprotein that synthesizes telomeric DNA onto chromosomal ends. The expression of telomerase is thought to be required for cellular immortality and oncogenesis.

METHODS

To investigate the role of telomerase in the pathogenesis of colorectal cancer, we analysed telomerase activity in biopsy samples of colorectal cancer and colonic adenomas. Using a polymerase chain reaction-based assay, we examined telomerase activity in 52 samples of colorectal cancer, 12 colonic adenomas and 30 normal colonic mucosa samples obtained by endoscopic biopsy.

RESULTS

Telomerase activity was detectable in 88.5% (46/52) of colorectal carcinomas, in 50% (6/12) of colonic adenomas but not in normal colorectal mucosa. There was no correlation between telomerase activity and tumour location, type, size and differentiation (P > 0.05).

CONCLUSIONS

It was concluded that telomerase activation plays a role in the evolution of colorectal cancer, and that measurement of telomerase activity in biopsied colorectal mucosa samples may provide information both as a diagnostic marker to detect small numbers of cancer cells, and as a screening method for patients at high risk for colorectal carcinoma.

Effect of a physiotherapist-led training programme on attitudes of nurses caring for patients after stroke

BACKGROUND

A multidisciplinary project team developed a five-month physiotherapist-led training programme designed to enhance nurses' rehabilitation skills.

AIMS

Investigation of the effects of the training programme on nurses attitudes to patients with stroke.

METHOD

An attitude questionnaire was completed by the participating nurses before and after the training programme. In a complementary qualitative evaluation the nurses' expectations and views of the training programme were explored.

RESULTS

Analysis of the attitude questionnaire indicated that the programme was successful in positively influencing the nurses' attitudes (median of the change in score 2, p = 0.005). The qualitative interviews reflected a similar outcome.

CONCLUSIONS

Quantitative and qualitative evaluation indicates that the training programme had some effect in changing nurses' attitudes to treating patients after a stroke. Such a training programme could be a useful contribution to post-stroke care.

Systematic review of day hospital care for elderly people. The Day Hospital Group

OBJECTIVE

To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people.

DESIGN

Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials).

SUBJECTS

2867 elderly people.

MAIN OUTCOME MEASURES

Death, institutionalisation, disability, global "poor outcome," and use of resources.

RESULTS

Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or "poor" outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care.

CONCLUSIONS

Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable.

Gastroenteropancreatic neuroendocrine tumor metastases to the thyroid gland: differential diagnosis with medullary thyroid carcinoma

Neuroendocrine tumors (NET) of the thyroid gland are rare. Apart from medullary thyroid carcinoma (MTC), metastases of gastroenteropancreatic (GEP) NET may also occur. Features of six patients (five men, one female: age range, 39-67 years) with thyroid metastases from a GEP-NET are described. Thyroid metastases were bilateral in all patients and were associated with enlarged neck lymph nodes in five. In four cases, the thyroid tumor was either the first sign of the disease (n = 2) or was an isolated site of recurrence (n = 2). The tumors were well (n = 3) or poorly differentiated (n = 3). Five tumors for which the primary site could be determined corresponded to foregut-derived tumors (3 lungs, 1 thymus and 1 pancreatic NET). One tumor demonstrated calcitonin (CT) production as shown by immunohistochemistry and elevated plasma CT levels. However, the disease history and the clinical features strongly favored a metastasizing GEP-NET. No tumoral RET proto-oncogene mutation was found in this patient. The differential diagnosis between metastatic GEP-NET and MTC is crucial because prognosis, work-up, and treatment differ greatly.

Developing a mission, vision, and philosophy in the new context of cultural diversification

This article is about the blending of a mission, vision, and philosophy of care by two systems of health care that are both rich in history and vision. The unique qualities of each hospital are described. The diversified cultures of each organization are discussed in terms of reaching a final decision regarding the joint vision, philosophy of care, and mission of the system that has been redesigned.

Lorazepam given the night before surgery reduces preoperative anxiety in children undergoing reconstructive burn surgery

A high level of preoperative anxiety frequently occurs in children undergoing reconstructive burn surgery. Reduction of this anxiety may have a number of physiological and psychological benefits. Various pharmaceutical and nonpharmaceutical regimens to reduce preoperative anxiety have been devised; however, most regimens are not initiated until the period immediately before surgery. Many of the children in our institution report high levels of anxiety beginning the night before surgery. Therefore we hypothesized that sedation the night before surgery would be beneficial. Oral lorazepam 0.025 mg/kg or placebo was given the night before surgery to 45 patients in a prospective, randomized, double-blind fashion; in addition, all patients received preoperative sedation per protocol on the day of surgery. Immediately before induction of anesthesia, all patients (mean age 12.5 +/- 0.9 years, range 6 to 18 years) performed an anxiety self-rating with the use of a validated visual analog scale (VAS). Patient anxiety and quality of anesthesia induction was also rated by one of the investigators. Postoperatively, patients rated their recall of anxiety with the use of the VAS. When queried preoperatively, patients who received lorazepam the night before surgery self-reported significantly less anxiety than those receiving placebo. Investigator observations did not detect this difference; this reinforces the assertion that patient self-rating of anxiety may be the best tool for rating anxiety.

Prospective study of outcome in antenatally diagnosed renal pelvis dilatation

AIMS

To ascertain the outcome associated with antenatal renal pelvis dilatation; to recommend guidelines for postnatal investigation and determine an upper limit of normal for the anterioposterior dimensions of the fetal renal pelvis.

METHODS

Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated using postnatal renal tract ultrasound and a micturating cystogram. Isotope studies were also performed, where appropriate.

RESULTS

Vesicoureteric reflux (VUR), the most common diagnosis, was evident in 23/104 (22%). In 14 infants with VUR the postnatal ultrasound scan was normal. There was no evidence of renal scarring or dysplasia in any of the refluxing kidneys. Other diagnoses were pelviureteric junction obstruction, renal dysplasia, and idiopathic dilatation. Antenatal counselling and parental information facilitated postnatal assessment.

CONCLUSIONS

Infants with antenatal renal pelvis measurements of 5 mm or greater should be investigated postnatally, as a significant percentage will have VUR. A normal postnatal ultrasound scan does not preclude the presence of VUR.

Is a man's facial appearance predictive of how he will die?

The ability of a range of health professionals including an oncologist, a haematologist, a cardiologist, a general practitioner and a counsellor to predict the cause of death from facial appearance has been evaluated. Each participant was asked to predict the cause of death from facial photographs of 200 caucasian male doctors whose cause of death was known to be due to either arterial disease or neoplasia. Statistically significant concordance was found between the oncologist and both the GP and the counsellor in their predictions of cause of death, although the individual accuracy was no greater than would be expected by chance. This suggests that common judgments based on facial appearances may be shared among certain health professionals.

Expression of Bcl-2 protein is decreased in colorectal adenocarcinomas with microsatellite instability

Bcl-2 is known to inhibit apoptosis and is thought to play a role in colorectal tumour development. Studies of the promoter region of bcl-2 have indicated the presence of a p53 responsive element which downregulates bcl-2 expression. Since p53 is commonly mutated in colorectal cancers, but rarely in those tumours showing microsatellite instability (MSI), the aim of this study was to examine the relationship of bcl-2 protein expression to MSI, as well as to other clinicopathological and molecular variables, in colorectal adenocarcinomas. Expression of bcl-2 was analysed by immunohistochemistry in 71 colorectal cancers which had been previously assigned to three classes depending upon their levels of MSI. MSI-high tumours demonstrated instability in three or more of six microsatellite markers tested, MSI-low tumours in one or two of six, and MSI-null in none of six. Bcl-2 expression in tumours was quantified independently by two pathologists and assigned to one of five categories, with respect to the number of cells which showed positive staining: 0, up to 5%; 1, 6-25%; 2, 26-50%; 3, 51-75%; and 4, > or =76%. Bcl-2 negative tumours were defined as those with a score of 0. Bcl-2 protein expression was tested for association with clinicopathological stage, differentiation level, tumour site, age, sex, survival, evidence of p53 inactivation and MSI level. A significant association was found between bcl-2 expression and patient survival (P = 0.012, Gehan Wilcoxon test). Further, a significant reciprocal relationship was found between bcl-2 expression and the presence of MSI (P = 0.012, Wilcoxon rank sum test). We conclude that bcl-2 expressing colorectal cancers are more likely to be MSI-null, and to be associated with improved patient survival.

The same molecular defects of the gonadotropin-releasing hormone receptor determine a variable degree of hypogonadism in affected kindred

Detailed endocrinological studies were performed in the three affected kindred of a family carrying mutations of the GnRH receptor gene. All three were compound heterozygotes carrying on one allele the Arg262Gln mutation and on the other allele two mutations (Gln106Arg and Ser217Arg). When expressed in heterologous cells, both Gln106Arg and Ser217Arg mutations altered hormone binding, whereas the Arg262Gln mutation altered activation of phospholipase C. The propositus, a 30-yr-old man, displayed complete idiopathic hypogonadotropic hypogonadism with extremely low plasma levels of gonadotropins, absence of pulsatility of endogenous LH and alpha-subunit, absence of response to GnRH and GnRH agonist (triptorelin), and absence of effect of pulsatile administration of GnRH. The two sisters, 24 and 18 yr old, of the propositus displayed, on the contrary, only partial idiopathic hypogonadotropic hypogonadism. They both had primary amenorrhea, and the younger sister displayed retarded bone maturation and uterus development, but both sisters had normal breast development. Gonadotropin concentrations were normal or low, but in both cases were restored to normal levels by a single injection of GnRH. In the two sisters, there were no spontaneous pulses of LH, but pulsatile administration of GnRH provoked a pulsatile secretion of LH in the younger sister. The same mutations of the GnRH receptor gene may thus determine different degrees of alteration of gonadotropin function in affected kindred of the same family.

Antibody analysis of the localisation, expression and stability of HlyD, the MFP component of the E. coli haemolysin translocator

HlyD has a single transmembrane domain (residues 59-80) and a large periplasmic domain, and is essential for the secretion of haemolysin from Escherichia coli. Using an antibody raised against HlyD, the protein was localised to the cell envelope by immunofluorescence and to the cytoplasmic membrane by sucrose gradient analysis. We have examined the stability of this protein in the presence and absence of other putative components of the translocator, HlyB and TolC. HlyD is normally highly stable but in the absence of TolC, the steady-state level of HlyD is greatly reduced and the protein has a half-life at 37 degrees C of 36 min. In the absence of HlyB, HlyD is also unstable and specific degradation products are detected, which co-fractionate with the inner membrane, indicating in this case limited cleavage at specific sites. However, the effect of removing both HlyB and TolC is not additive. On the contrary, in the absence of both HlyB and TolC the half-life of HlyD is approximately 110 min. This result shows that in the presence of HlyB removal of TolC renders HlyD more unstable than it is in the absence of both HlyB and TolC. This suggests that the presence of HlyB induces a structural change in HlyD. In addition, HlyB itself appears to be less stable in the absence of HlyD. These results are consistent with an interaction between HlyD/TolC and HlyB/HlyD. A derivative of HlyD, HlyD22, lacking the 40 N-terminal residues of HlyD assembles into the inner membrane displaying the same stability with and without HlyB as wild type HlyD does. This N-terminal region therefore appears to play no role in stable localisation but is involved in secretion, since HlyD22 is completely secretion defective. Modification of the C-terminus on the other hand completely destabilised the molecule and HlyD was not detectable in the envelope. Secretion of active haemolysin is limited to a brief period during mid to late exponential phase. In contrast, HlyD is apparently synthesised constitutively throughout the growth phase, demonstrating that the production of this component of the translocator is not the limiting factor for growth phase-dependent secretion.

Functional hypothalamic amenorrhoea: a partial and reversible gonadotrophin deficiency of nutritional origin

OBJECTIVE

Functional hypothalamic amenorrhoea (FHA) is a consequence of low dietary intake as observed in two major pathophysiological conditions, anorexia nervosa and/or intensive physical exercise. The aim of the present study was to assess in women with FHA and normal body mass index (BMI) and apparently normal daily activities, the degree of impairment of GnRH secretion, its nutritional origin and its reversibility.

PATIENTS

Twelve women (22-35 years) with FHA not related with exercise and 12 age and BMI matched menstruating controls (NC) were studied. Six women with congenital hypothalamic hypogonadism (CHH), representative of complete gonadotrophin deficiency, were also enrolled for comparison.

DESIGN

Plasma oestradiol (E2) and androstenedione (A) levels were measured and the pulsatile profile of LH was studied. A GnRH agonist test, using 100 micrograms S/C of DTrp6 GnRH (Triptorelin) was performed (sampling every 2 h for 24 h). Dietary intake, body composition and nutritional markers (FT3, ferritin, retinol binding protein (RBP), SHBG, IGF-1 and leptin) were measured. All the women with FHA were advised to normalize their diet during four months. The same studies were performed if nutritional markers and body composition were normalized.

RESULTS

In FHA, mean plasma E2 and A levels were low. LH pulse frequency and amplitude were significantly reduced compared to NC (P < 0.005). FSH/LH ratio increased rapidly after triptorelin with a significant increase in plasma E2 levels between 18 and 24 h. In contrast, no response to triptorelin was observed in women with CHH. The fat body mass was lower and the lean body mass higher in FHA than in NC. Marked differences in nutritional intake were identified, with altered dietary composition. FHA consumed significantly less fat (P < 0.001) and less carbohydrate (P = NS) than the BMI-matched controls. Mean plasma levels of SHBG were increased whereas mean plasma levels of FT3, ferritin, RBP, IGF-1, and leptin were significantly decreased. Only three patients with FHA kept a balanced diet and improved their body composition after 4 months. LH pulsatile profile and response to triptorelin challenge were normalized in these patients.

CONCLUSION

Mild dieting, close to normal but prolonged and characterized by an important fat restriction, is able to interfere with gonadotrophin secretion. Assessment of nutritional markers allows recognition of mild nutritional insufficiency as a common cause of FHAs. The gonadotrophin deficiency is partial and may be reversible after improvement of nutritional intake and body composition.

Evidence-based guidelines for early stroke management

Stroke disease is the commonest neurological emergency encountered by the junior medical team. We have reviewed the literature to produce a series of substantiated guidelines to assist the admitting doctor in managing early stroke care optimally.

Strip grazing to control wool growth rate of sheep grazing green annual pastures

We compared strip grazing (SG) as a means of controlling wool growth rate, reducing variation in fibre diameter along the staple, and of carrying more Merino sheep through winter on green annual pastures, with set stocking (SS) in 3 experiments. In experiments 1 and 2, SG involved grazing to a residual feed on offer (FOO) of 400 kg DM/ha with an estimated intake of about 0.8 kg DM/day for each sheep. Treatments commenced after pasture establishment in autumn–winter, with both treatments stocked at 20 wethers/ha until late spring. During spring, average liveweight changes were lower (P<0.01) under SG than SS (55 v. 153 g/day experiment 1; –16 v. 217 g/day experiment 2). Strip grazing, compared with SS, reduced (P<0.01) the variation in wool growth rate and fibre diameter along the staple leading to lower (P<0.01) clean wool weights (3.54 v. 3.94 and 2.97 v. 4.12 kg), but finer (P<0.01) (20.9 v. 22.0 and 19.5 v. 21.5 mm), stronger (P<0.01) (28.6 v. 25.3 and 39.9 v. 35.5 N/ktex) wool. However, there was also an increase in vegetable matter content of the wool. The effects on annual pastures were to increase grass (79 v. 48 and 59 v. 25%) and reduce legume (12 v. 36 and 22 v. 54%) content at the end of spring. In experiment 3, two strip grazing treatments were used: SGl with a residual FOO of about 400 kg DM/ha and a stocking rate of 28 wethers/ha; and SGh with a residual FOO of about 800 kg DM/ha and stocking rate of 14 wethers/ha. The stocking rate for SS was 12 wethers/ha. SGl, following an autumn deferment, enabled a stocking rate of 28 wethers/ha to be sustained through winter without supplementary feeding. This is substantially higher than the district average stocking rate of about 7 sheep/ha. Strip grazing reduced (P<0.01) liveweights at the completion of treatments (SGl 41.9 v. SGh 47.9 v. SS 60.3 kg), reduced (P<0.01) clean wool weights (3.40 v. 3.72 v. 4.54 kg) and mean fibre diameter (19.1 v. 19.0 v. 20.9 m), but increased staple strength (21.3 v. 19.0 v. 16.9 N/ktex). These results are discussed in relation to opportunities to utilise strip grazing in sheep production systems on annual pastures in south-western Australia.

DNA microsatellite instability in hyperplastic polyps, serrated adenomas, and mixed polyps: a mild mutator pathway for colorectal cancer?

AIM

To investigate the distribution of DNA microsatellite instability (MSI) in a series of hyperplastic polyps, serrated adenomas, and mixed polyps of the colorectum.

METHODS

DNA was extracted from samples of 73 colorectal polyps comprising tubular adenomas (23), hyperplastic polyps (21), serrated adenomas (17), and mixed polyps (12). The presence of MSI was investigated at six loci: MYCL, D2S123, F13B, BAT-40, BAT-26, and c-myb T22, using polymerase chain reaction based methodology. MSI cases were classified as MSI-Low (MSI-L) and MSI-High (MSI-H), based on the number of affected loci.

RESULTS

The frequency of MSI increased in tubular adenomas (13%), hyperplastic polyps (29%), serrated adenomas (53%), and mixed polyps (83%) (Wilcoxon rank sum statistic, p < 0.001). Hyperplastic epithelium was present in nine of 12 mixed polyps and showed MSI in eight of these. MSI was mostly MSI-L. MSI-H occurred in two serrated adenomas and three mixed polyps. Clonal relations were demonstrated between hyperplastic and dysplastic epithelium in four of eight informative mixed polyps.

CONCLUSIONS

The findings support the view that hyperplastic polyps may be fundamentally neoplastic rather than hyperplastic. A proportion of hyperplastic polyps may serve as a precursor of a subset (10%) of colorectal cancers showing the MSI-L phenotype, albeit through the intermediate step of serrated dysplasia. This represents a novel and distinct morphogenetic pathway for colorectal cancer.

The prolonged hematologic effects of a single injection of PEG-rHuMGDF in normal and thrombocytopenic mice

A single injection of > or =10 microg/kg PEG-rHuMGDF in mice causes a dose-dependent increase in circulating platelets beginning on day 3 and peaking on days 5-6. The mean platelet volume and platelet distribution width at doses > or =100 microg/kg initially increase in a dose-dependent fashion and later decrease. However, the mean platelet volume does not change when platelets are incubated with PEG-rHuMGDF in vitro. The number of marrow megakaryocytes increases in a dose-dependent fashion as early as day 1 and peaks on day 3. Marrow megakaryocyte colony-forming units (CFU-Meg) do not increase on days 1-3 at a dose of 100 microg/kg (a dose that increases platelet numbers two- to threefold and may be clinically relevant), but the relative frequency of high ploidy megakaryocytes and the proportion of large marrow megakaryocytes (29-50 microm in diameter) increases. After a dose of 1,000 microg/kg the percentage of megakaryocytes in mitosis peaks at 24-48 hours and the percentage of megakaryocytes incorporating BrdU is maximal at 48 hours, the relatively delayed peak of BrdU incorporation most likely representing endomitosis. The relative frequency of type II and III megakaryocytes peaks on days 3 and 4, respectively. Pharmacokinetic analysis of PEG-rHuMGDF shows peak serum concentrations at 2-4 hours and a terminal half-life of 11.4+/-2.5 hours. A single injection of PEG-rHuMGDF ameliorates carboplatin-induced megakaryocytopenia and thrombocytopenia in a dose-response dependent fashion. In conclusion, a single injection of PEG-rHuMGDF increases megakaryocyte and platelet production in normal and myelo-suppressed mice.

Hypoglycemia in multiple trauma victims

The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.

Use of pulmonary rehabilitation strategies to wean a difficult-to-wean patient: case study

The primary purpose of this article is to describe the effectiveness of an interdisciplinary team and innovative interventions by a pulmonary rehabilitation specialist in addressing one patient's failure to wean from mechanical ventilation. This case study shows the importance of considering both physical and psychological factors that may hinder weaning. An interdisciplinary approach was used to address the patient's anxiety, sleep deprivation, lack of appetite, decreased communication, decreased activity, dyspnea, knowledge deficit about dyspnea and weaning, lack of self-confidence, and decreased verbalization. The pulmonary rehabilitation RCP effectively implemented the following strategies: biofeedback by using a flow-volume display, positive reinforcement, teaching about dyspnea and weaning, and use of the modified Borg scale. The patient's family participated in providing some of these interventions. With a concerted effort by all involved, the patient was successfully weaned from mechanical ventilation.

Use of pulmonary rehabilitation strategies to wean a difficult-to-wean patient: case study

The primary purpose of this article is to describe the effectiveness of an interdisciplinary team and innovative interventions by a pulmonary rehabilitation specialist in addressing one patient's failure to wean from mechanical ventilation. This case study shows the importance of considering both physical and psychological factors that may hinder weaning. An interdisciplinary approach was used to address the patient's anxiety, sleep deprivation, lack of appetite, decreased communication, decreased activity, dyspnea, knowledge deficit about dyspnea and weaning, lack of self-confidence, and decreased verbalization. The pulmonary rehabilitation RCP effectively implemented the following strategies: biofeedback by using a flow-volume display, positive reinforcement, teaching about dyspnea and weaning, and use of the modified Borg scale. The patient's family participated in providing some of these interventions. With a concerted effort by all involved, the patient was successfully weaned from mechanical ventilation.

Mutations in DPC4 (SMAD4) cause juvenile polyposis syndrome, but only account for a minority of cases

Juvenile polyps are present in a number of Mendelian disorders, sometimes in association only with gastrointestinal cancer [juvenile polyposis syndrome (JPS)] and sometimes as part of known syndromes (Cowden, Gorlin and Banayan-Zonana) in association with developmental abnormalities, dysmorphic features or extra-intestinal tumours. Recently, a gene for JPS was mapped to 18q21.1 and the candidate gene DPC4 (SMAD4) was shown to carry frameshift mutations in some JPS families. We have analysed eight JPS families for linkage to DPC4. Overall, there was no evidence for linkage to DPC4; linkage could be excluded in two of the eight pedigrees and was unlikely in two others. We then tested these eight families and a further 13 familial and sporadic JPS cases for germline mutations in DPC4. Just one germline DPC4 mutation was found (in a familial JPS patient from a pedigree unsuitable for linkage analysis). Like all three previously reported germline mutations, this variant occurred towards the C-terminus of the DPC4 protein. However, our patient's mutation is a missense change (R361C); somatic missense mutations in DPC4 have been reported previously in tumours. We therefore confirm DPC4 as a cause of JPS, but show that there is considerable remaining, uncharacterized genetic heterogeneity in this disease.

Training to enhance partnerships between mental health professionals and family caregivers: a comparative study

A training program for mental health staff was collaboratively developed and delivered by family caregivers and professionals. It addressed calls for less blaming attitudes toward families and increased contact between professionals and families. Two levels of training were compared. Twenty-seven staff members completed a 30-hour extended 12-week program. Eighty-two percent of all eligible staff from area teams attended a brief program involving three or six hours of training. Self-ratings of competence and attitudes toward families improved only for staff receiving extended training. Contacts with families increased for those in the extended program but not for all types of teams, suggesting that length of training and service type may limit the impact of training.