A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

The DEAD box helicase, Dhh1p, functions in mRNA decapping and interacts with both the decapping and deadenylase complexes

A major pathway of mRNA turnover in eukaryotic cells initiates with deadenylation, leading to mRNA decapping and subsequent 5' to 3' exonuclease digestion. We show that a highly conserved member of the DEAD box family of helicases, Dhh1p, stimulates mRNA decapping in yeast. In dhh1delta mutants, mRNAs accumulate as deadenylated, capped species. Dhh1p's effects on decapping only occur on normal messages as nonsense-mediated decay still occurs in dhh1delta mutants. The role of Dhh1p in decapping appears to be direct, as Dhh1p physically interacts with several proteins involved in mRNA decapping including the decapping enzyme Dcp1p, as well as Lsm1p and Pat1p/Mrt1p, which function to enhance the decapping rate. Additional observations suggest Dhh1p functions to coordinate distinct steps in mRNA function and decay. Dhh1p also associates with Pop2p, a subunit of the mRNA deadenylase. In addition, genetic phenotypes suggest that Dhh1p also has a second biological function. Interestingly, Dhh1p homologs in others species function in maternal mRNA storage. This provides a novel link between the mechanisms of decapping and maternal mRNA translational repression.

Association and aggregation analysis using kin-cohort designs with applications to genotype and family history data from the Washington Ashkenazi Study

When a rare inherited mutation in a disease gene, such as BRCA1, is found through extensive study of high-risk families, it is critical to estimate not only age-specific penetrance of the disease associated with the mutation, but also the residual effect of family history once the mutation is taken into account. The kin-cohort design, a cross-sectional survey of a suitable population that collects DNA and family history data, provides an efficient alternative to cohort or case-control designs for estimating age-specific penetrance in a population not selected because of high familial risk. In this report, we develop a method for analyzing kin-cohort data that simultaneously estimate the age-specific cumulative risk of the disease among the carriers and non-carriers of the mutations and the gene-adjusted residual familial aggregation or correlation of the disease. We employ a semiparametric modeling approach, where the marginal cumulative risks corresponding to the carriers and non-carriers are treated non-parametrically and the residual familial aggregation is described parametrically by a class of bivariate failure time models known as copula models. A simple and robust two-stage method is developed for estimation. We apply the method to data from the Washington Ashkenazi Study [Struewing et al., 1997, N Engl J Med 336:1401-1408] to study the residual effect of family history on the risk of breast cancer among non-carriers and carriers of specific BRCA1/BRCA2 germline mutations. We find that positive history of a single first-degree relative significantly increases risk of the non-carriers (RR = 2.0, 95% CI = 1.6-2.6) but has little or no effect on the carriers.

Light microscopic and scanning electron microscopic retrieval analyses of implanted biomaterials retrieved from humans and experimental animals

This paper reports analysis obtained from 200 implant cases retrieved from humans and submitted to the American Academy of Implant Dentistry Research Foundation, Medical College of Georgia implant retrieval center. The samples that were not decalcified were embedded in polymethylmethacrylate and examined with scanning electron microscopy and routine light, polarized, or Nomarski microscopy. Cases included both orthopedic and dental implants, as well as entire mandibles and portions of maxillae obtained at autopsy. A significant number of submitted implants had substantial amounts of adhered bone, which permitted evaluation of human bone remodeling to osseointegrated implants. These implants failed because of implant fracture. As was observed with animal studies, healthy bone supported these implants, with the bone containing an interdigitating canaliculi network that provided communication between interfacial osteocytes and osteocytes deeper within the remodeled osteonal and trabecular bone. Early dental implants containing a coating of beads showed a connective tissue interface, which corresponded to the bead surface of specific orthopedic implants that underwent some degree of micromovement. This is in contrast with the excellent response reported for successful contemporary beaded implants. Significant numbers of osseointegrated fractured hydroxyapatite (HA)-coated dental implants demonstrated the adequate serviceability of these implants before biomaterial fracture. In contrast, the HA coating was dissociated from retrieved orthopedic implants, leading to extensive cup loosening and case failure. This study, therefore, underscores the need for evaluation of failed human dental and orthopedic implants. Correlations can be drawn between human retrieval and experimental animal studies.

Mechanisms and control of mRNA decapping in Saccharomyces cerevisiae

The process of mRNA turnover is a critical component of the regulation of gene expression. In the past few years a discrete set of pathways for the degradation of polyadenylated mRNAs in eukaryotic cells have been described. A major pathway of mRNA degradation in yeast occurs by deadenylation of the mRNA, which leads to a decapping reaction, thereby exposing the mRNA to rapid 5' to 3' exonucleolytic degradation. A critical step in this pathway is decapping, since it effectively terminates the existence of the mRNA and is the site of numerous control inputs. In this review, we discuss the properties of the decapping enzyme and how its activity is regulated to give rise to differential mRNA turnover. A key point is that decapping appears to be controlled by access of the enzyme to the cap structure in a competition with the translation initiation complex. Strikingly, several proteins required for mRNA decapping show interactions with the translation machinery and suggest possible mechanisms for the triggering of mRNA decapping.

The transcription factor associated Ccr4 and Caf1 proteins are components of the major cytoplasmic mRNA deadenylase in Saccharomyces cerevisiae

The major pathways of mRNA turnover in eukaryotes initiate with shortening of the poly(A) tail. We demonstrate by several criteria that CCR4 and CAF1 encode critical components of the major cytoplasmic deadenylase in yeast. First, both Ccr4p and Caf1p are required for normal mRNA deadenylation in vivo. Second, both proteins localize to the cytoplasm. Third, purification of Caf1p copurifies with a Ccr4p-dependent poly(A)-specific exonuclease activity. We also provide evidence that the Pan2p/Pan3p nuclease complex encodes the predominant alternative deadenylase. These results, and previous work on Pan2p/Pan3p, define the mRNA deadenylases in yeast. The strong conservation of Ccr4p, Caf1p, Pan2p, and Pan3p indicates that they will function as deadenylases in other eukaryotes. Interestingly, because Ccr4p and Caf1p interact with transcription factors, these results suggest an unexpected link between mRNA synthesis and turnover.

Use of soil and water protection practices among farmers in three midwest watersheds

Data were collected from 1011 farmers in three Midwestern watersheds (Ohio, Iowa, and Minnesota) to assess factors that influence the use of conservation production systems at the farm level. The "vested interests" perspective used to guide the investigation was derived from elements of social learning and social exchange theories. Respondents were asked to indicate their frequency of use for 18 agricultural production practices that could be adopted on Midwestern farms at the time of the study. Responses to the 18 items were summed to form a composite variable, termed "conservation production index," for use as the dependent variable in multivariate analysis. Eleven independent variables were identified from the theory as likely predictors of conservation adoption, including respondents' perceptions about production costs, output and risks, and perceived importance of access to subsidies, technical assistance, and informational/educational programs. Regression analysis was used to assess the performance of the independent variables in explaining variance in the conservation production index. Explained variance in the three regression models ranged from 2% in the Minnesota watershed to 19% in the Ohio watershed. The researchers concluded that the model had limited utility in predicting adoption of conservation production systems within the three study watersheds. Findings are discussed in the context of conservation programs within the three areas.

Why don't patients do their exercises? Understanding non-compliance with physiotherapy in patients with osteoarthritis of the knee

STUDY OBJECTIVES

To understand reasons for compliance and non-compliance with a home based exercise regimen by patients with osteoarthritis of the knee.

DESIGN

A qualitative study, nested within a randomised controlled trial, examining the effectiveness of physiotherapy in reducing pain and increasing mobility in knee osteoarthritis. In the intervention arm, participants undertook a series of simple exercises and repositioning of the kneecap using tape. In depth interviews were conducted with a subset of participants in the intervention arm using open ended questions, guided by a topic schedule, to encourage patients to describe their experiences and reflect on why they did or did not comply with the physiotherapy. Interviews were audiotaped, fully transcribed and analysed thematically according to the method of constant comparison. A model explaining factors influencing compliance was developed.

SETTING

Patients were interviewed at home. The study was nested within a pragmatic randomised controlled trial.

PARTICIPANTS

Twenty participants in the intervention arm of the randomised trial were interviewed three months after they had completed the physiotherapy programme. Eight were interviewed again one year later.

MAIN RESULTS

Initial compliance was high because of loyalty to the physiotherapist. Reasoning underpinning continued compliance was more complex, involving willingness and ability to accommodate exercises within everyday life, the perceived severity of symptoms, attitudes towards arthritis and comorbidity and previous experiences of osteoarthritis. A necessary precondition for continued compliance was the perception that the physiotherapy was effective in ameliorating unpleasant symptoms.

CONCLUSIONS

Non-compliance with physiotherapy, as with drug therapies, is common. From the patient's perspective, decisions about whether or not to comply are rational but often cannot be predicted by therapists or researchers. Ultimately, this study suggests that health professionals need to understand reasons for non-compliance if they are to provide supportive care and trialists should include qualitative research within trials whenever levels of compliance may have an impact on the effectiveness of the intervention.

Cancer in patients with ataxia-telangiectasia and in their relatives in the nordic countries

BACKGROUND

Epidemiologic studies of the families of patients with ataxia-telangiectasia (A-T), a recessive genetic neurologic disorder caused by mutation of the ATM gene, suggest that heterozygous carriers of an ATM mutation are at increased risk of cancer. A population-based study of cancer incidence in A-T families with unbiased selection and tracing of relatives would confirm this hypothesis.

METHODS

We conducted a study in the Nordic countries of 1218 blood relatives of 56 A-T patients from 50 families. The relatives were identified from population registries, and the occurrence of cancer was determined from cancer registry files in each country and compared with national incidence rates. All statistical tests were two-sided.

RESULTS

Among the 56 patients with A-T, we observed six cases of cancer (four leukemias and two non-Hodgkin's lymphomas) compared with 0.16 expected, yielding a standardized incidence ratio (SIR) of 37 (95% confidence interval [CI] = 13 to 80). Among the 1218 relatives, 150 cancers were recorded, with 126 expected (SIR = 1.19; 95% CI = 1.01 to 1.40). Invasive breast cancer occurred in 21 female relatives of A-T patients (SIR = 1.54; 95% CI = 0.95 to 2.36), including five of the 50 mothers (all of whom are obligate ATM mutation carriers) (SIR = 7.1; 95% CI = 2.3 to 17). Relatives who were less likely to be carriers of a mutant ATM allele had no increase or only a modest, statistically nonsignificant increase in the risk of breast cancer. There was no evidence of increased risk for cancer at any other site.

CONCLUSIONS

We confirmed the previously recognized high risk of lymphoma and leukemia in A-T patients. Our data are also consistent with an increased risk of breast cancer among blood relatives of A-T patients. The epidemiologic findings suggest, however, that, even if ATM mutations are responsible for some breast cancer cases, ATM is a relatively weak genetic risk factor for the disease.

Integration of radiographic images with an electronic medical record

Radiographic images are important and expensive diagnostic tests. However, the provider caring for the patient often does not review the images directly due to time constraints. Institutions can use picture archiving and communications systems to make images more available to the provider, but this may not be the best solution. We integrated radiographic image review into the Regenstrief Medical Record System in order to address this problem. To achieve adequate performance, we store JPEG compressed images directly in the RMRS. Currently, physicians review about 5% of all radiographic studies using the RMRS image review function.

Two related proteins, Edc1p and Edc2p, stimulate mRNA decapping in Saccharomyces cerevisiae

The major mRNA decay pathway in Saccharomyces cerevisiae occurs through deadenylation, decapping, and 5' to 3' degradation of the mRNA. Decapping is a critical control point in this decay pathway. Two proteins, Dcp1p and Dcp2p, are required for mRNA decapping in vivo and for the production of active decapping enzyme. To understand the relationship between Dcp1p and Dcp2p, a combination of both genetic and biochemical approaches were used. First, we demonstrated that when Dcp1p is biochemically separated from Dcp2p, Dcp1p was active for decapping. This observation confirmed that Dcp1p is the decapping enzyme and indicated that Dcp2p functions to allow the production of active Dcp1p. We also identified two related proteins that stimulate decapping, Edc1p and Edc2p (Enhancer of mRNA DeCapping). Overexpression of the EDC1 and EDC2 genes suppressed conditional alleles of dcp1 and dcp2, respectively. Moreover, when mRNA decapping was compromised, deletion of the EDC1 and/or EDC2 genes caused significant mRNA decay defects. The Edc1p also co-immunoprecipitated with Dcp1p and Dcp2p. These results indicated that Edc1p and Edc2p interact with the decapping proteins and function to enhance the decapping rate.

Micro-affordance: the potentiation of components of action by seen objects

It is suggested that seen objects potentiate a range of actions associated with them, irrespective of the intentions of the viewer. Evidence for this possibility is provided by the data from two experiments, both of which required a participant to make a binary motor response to an auditory stimulus. In the first experiment the response was a power or precision grip, which was performed whilst simultaneously viewing a real object which would normally be grasped using either a power or precision grip. A significant interaction of response and grip compatibility of the object was observed. Similar results were obtained in the second experiment when a wrist rotation of a given direction was used as a response, whilst viewing objects which would require wrist rotations if they were to be grasped. The effects of the seen objects on components of action are described as microaffordances which are said to be dispositional states of the viewer's nervous system.

Characterization of ATM mutations in 41 Nordic families with ataxia telangiectasia

The Ataxia Telangiectasia Mutation (ATM) gene is mutated in the rare recessive syndrome Ataxia Telangiectasia (AT), which is characterized by cerebellar degeneration, immunodeficiency, and cancer predisposition. In this study, 41 AT families from Denmark, Finland, Norway, and Sweden were screened for ATM mutations. The protein truncation test (PTT), fragment length and heteroduplex analyses of large (0.8-1.2 kb) cDNA fragments were used. In total, 67 of 82 (82%) of the disease-causing alleles were characterized. Thirty-seven unique mutations were detected of which 25 have not previously been reported. The mutations had five different consequences for the ATM transcript: mutations affecting splicing (43%); frameshift mutations (32%); nonsense mutations (16%); small in-frame deletions (5%); and one double substitution (3%). In 28 of the probands mutations were found in both alleles, in 11 of the probands only one mutated allele was detected, and no mutations were detected in two Finnish probands. One-third of the probands (13) were homozygous, whereas the majority of the probands (26) were compound heterozygote with at least one identified allele. Ten alleles were found more than once; one Norwegian founder mutation constituted 57% of the Norwegian alleles. Several sequence variants were identified, none of them likely to be disease-causing. Some of them even involved partial skipping of exons, leading to subsequent truncation of the ATM protein.

The Bristol 'OA500 study': progression and impact of the disease after 8 years

OBJECTIVE

To study the natural history of peripheral joint osteoarthritis (OA) and assess its impact over eight years in a prospective study of 500 patients.

METHODS

500 consecutive patients with peripheral joint OA were recruited from a hospital-based rheumatology clinic. All were invited for review 3 and 8 years after entry. Joint sites involved, pain severity, change in index joints, global change in the condition, use of medication, surgery and walking aids were all recorded at each visit, and after eight years disability was assessed by the health assessment questionnaire (HAQ) and anxiety and depression by the Hospital anxiety and depression scale (HAD).

RESULTS

At eight-year review, 349 patients were seen: 90% of those remaining alive. Outcome was heterogeneous. Sixty patients (17.2%) reported worsening in all three subjective parameters (pain, index joint and global change) compared with 22 (6.3%) who improved in all three parameters. Using this definition of worsening or improvement, strong baseline predictors of clinical outcome did not emerge. For further description, the group was split according to the index joint sites involved at entry to the study, there being 111 with knee OA alone, 87 with hand and knee OA, 72 with hand disease alone, and 29 with hip disease alone. Forty-four percent of those with lone hand disease at entry had acquired significant knee or hip OA 8 years later. The mean HAQ and HAD scores at 8 years were high, especially in those with knee disease, indicating significant disability as a result of the disease. Those with knee or knee and hand disease had the worst outcome in all parameters recorded. The data showed a general decrease in use of NSAIDs over the eight years, but an increase in utilization of analgesics, surgery (especially for hip disease) and walking aids.

CONCLUSIONS

Patients with peripheral joint OA of sufficient severity to lead to hospital referral have a heterogeneous, but generally bad outcome over 8 years, the disease resulting in high levels of physical disability, anxiety and depression, with a high level of utilization of healthcare resources, including joint replacement, drugs and walking aids. The results were consistent with previous suggestions that peripheral joint OA in older people is characterized by the slow acquisition of new joint sites. Progression and outcome may depend on a complex set of psychosocial factors, as well as biological ones.

[Culture of blastocysts using sequential media]

The advantages of cultivating human pre-embryos to the stage of blastocites, are well known. The use of media of culture sequential, without the backing of somatic cells, is new. The objective was to cultivate human pre-embryos to the stage of blastocyte to the determine the recuperation indexes, implantation index and pregnancy index in patients subjected to FIVT/TE or ICSI. Once obtained the ovules of patients were injected/inseminated to latter be cultivated for 72 hours using P1 medium at 10% of SSS under mineral oil for, latter, be transferred to a complex medium for blastocites culture for 48 hours, and finally be transferred. Thirteen were included (9 of FIV and 4 of ICSI) obtaining 205 ovules; fertilized 143 and 131 had cellular division. One hundred and twenty one pre-embryos were cultivated to blastocyst stage, from which, 53 reached that stage (43.8%); transferring 28 and freezing 25. In average, 2.1 blastocysts were transferred by patient. There were four pregnancies and one alive newborn, at term for an index of implantation of 14.2% and a pregnancy index of 30.7%. The study shows our initial experience, which demonstrated and acceptable idea of recuperation of blastocysts and pregnancies.