Understanding how organisational culture supports patient involvement in a national research agency

Background

The Belgian Health Care Knowledge Centre (KCE) formally involves stakeholders in its researches since 2012. Patients are treated as one stakeholder amongst others, but it is recognized that patient involvement (PI) requires a different approach. The success of implementing PI depends, however, on the organizational culture towards PI.

Objectives

The objective of this study was to map the PI culture at KCE in the context of the development of organization-wide supported position statements about PI.

Methods

A nominal group technique was used to measure the PI culture at KCE. Arguments for and against PI and conditions for PI in different phases of the research process were collected. A literature review and interviews fed the draft position statements, for which support was assessed by means of a two-round Delphi process.

Results

Arguments in favour of PI in research related to the relevance of the scope, expertise with data collection, bringing in fresh ideas for study design, access to survey participants, validation of data analyses, adherence to recommendations. Disadvantages and risks included the lack of scientific knowledge of involved patients, resources requirements, conflicts of interest, and heterogeneity within patient populations. Conditions for meaningful PI referred to measures mitigating the identified disadvantages. Eighteen position statements supported by KCE could be formulated.

Conclusions

The KCE culture seems predominantly positive towards PI, although attitudes vary between researchers. KCE recognizes the potential value of PI in research, but considers the level of involvement to be contingent on the topic and phase in the research process.

Key messages

• Organizational culture towards patient involvement is a driver of successful researches.

• 18 position statements supported implementation of patient involvement in a national health agency.

Aberrant Membrane Composition and Biophysical Properties Impair Erythrocyte Morphology and Functionality in Elliptocytosis

Red blood cell (RBC) deformability is altered in inherited RBC disorders but the mechanism behind this is poorly understood. Here, we explored the molecular, biophysical, morphological, and functional consequences of α-spectrin mutations in a patient with hereditary elliptocytosis (pEl) almost exclusively expressing the Pro260 variant of SPTA1 and her mother (pElm), heterozygous for this mutation. At the molecular level, the pEI RBC proteome was globally preserved but spectrin density at cell edges was increased. Decreased phosphatidylserine vs. increased lysophosphatidylserine species, and enhanced lipid peroxidation, methemoglobin, and plasma acid sphingomyelinase (aSMase) activity were observed. At the biophysical level, although membrane transversal asymmetry was preserved, curvature at RBC edges and rigidity were increased. Lipid domains were altered for membrane:cytoskeleton anchorage, cholesterol content and response to Ca²⁺ exchange stimulation. At the morphological and functional levels, pEl RBCs exhibited reduced size and circularity, increased fragility and impaired membrane Ca²⁺ exchanges. The contribution of increased membrane curvature to the pEl phenotype was shown by mechanistic experiments in healthy RBCs upon lysophosphatidylserine membrane insertion. The role of lipid domain defects was proved by cholesterol depletion and aSMase inhibition in pEl. The data indicate that aberrant membrane content and biophysical properties alter pEl RBC morphology and functionality.

Different Time Scales in the Dissociation Dynamics of Core-Excited CF_{4} by Two Internal Clocks

Fragmentation processes following C 1s→lowest unoccupied molecular orbital core excitations in CF_{4} have been analyzed on the ground of the angular distribution of the CF_{3}^{+} emitted fragments by means of Auger electron-photoion coincidences. Different time scales have been enlightened, which correspond to either ultrafast fragmentation, on the few-femtosecond scale, where the molecule has no time to rotate and the fragments are emitted according to the maintained orientation of the core-excited species, or dissociation after resonant Auger decay, where the molecule still keeps some memory of the excitation process before reassuming random orientation. Potential energy surfaces of the ground, core-excited, and final states have been calculated at the ab initio level, which show the dissociative nature of the neutral excited state, leading to ultrafast dissociation, as well as the also dissociative nature of some of the final ionic states reached after resonant Auger decay, yielding the same fragments on a much longer time scale.

α-Hederin Induces Apoptosis, Membrane Permeabilization and Morphologic Changes in Two Cancer Cell Lines Through a Cholesterol-Dependent Mechanism

In perspective of reducing the mortality of cancer, there is a high interest in compounds which act on multiple cellular targets and therefore prevent the appearance of cancer resistances. Saponins and α-hederin, an oleanane-type saponin, induce cancer cell death through different pathways, including apoptosis and membrane permeabilization. Unfortunately, the mechanism by which cell death is induced is unknown. We hypothesized that the activity of α-hederin mainly depends on its interaction with membrane cholesterol and therefore investigated the cholesterol and saponin-structure dependency of apoptosis and membrane permeabilization in two malignant monocytic cell lines. Apoptotic cell death and membrane permeabilization were significantly reduced in cholesterol-depleted cells. Permeabilization further depended upon the osidic side chain of α-hederin and led to extracellular calcium influx and nuclear fragmentation, with only the latter being susceptible to caspase inhibitors. Membrane order, measured by laurdan generalized polarization imaging, was neither reduced by α-hederin nor its aglycone hederagenin suggesting that their activity was not related to membrane cholesterol extraction. However, a radical change in morphology, including the disappearance of pseudopodes was observed upon incubation with α-hederin. Our results suggest that the different activities of α-hederin mainly depend on its interaction with membrane cholesterol and consequent pore formation.

Mg2H2: new insight on the Mg-Mg bonding and spectroscopic study

The six dimensional potential energy surface of the electronic ground state X̃(1)Σ(g)(+) of Mg(2)H(2) has been generated by the coupled-cluster approach with single, double and perturbative triple excitations [CCSD(T)] combined with the aug-cc-pCVTZ basis set for Mg atoms and the aug-cc-pVTZ basis set for the H atoms. The analytical representation of this surface was used in variational calculations of the rovibrational energies of Mg(2)H(2), Mg(2)D(2), and HMg(2)D for J = 0 and 1. For Mg(2)H(2), the rotational constant B(0) is computed to be 0.1438 cm(-1), and the fundamental anharmonic wavenumbers are calculated to be ν(1) = 1527.3 cm(-1) (Σ(g)(+)), ν(2) = 275.3 cm(-1) (Σ(g)(+)), ν(3) = 1503.6 cm(-1) (Σ(u)(+)), ν(4) = 312.9 cm(-1) (Π(g)), and ν(5) = 256.5 cm(-1) (Π(u)). In addition, the electronic ground states of Mg(2)H, MgH(2), Mg(2), and MgH have been investigated in order to compute the bonding energies of Mg(2)H(2) and to explain the strength of the Mg-Mg bond in this tetra-atomic molecule. The nature of the low-lying excited states of Mg(2)H(2) is also studied.

Ab initio study of HZnF

On the basis of highly correlated ab initio calculations, an accurate determination of the electronic structure and of the rovibrational spectroscopy has been performed for the electronic ground state of the HZnF system. Using effective core pseudopotentials for the Zn and F atoms and associated aug-cc-pVQZ basis sets, we have calculated, at the multireference configuration interaction level including the Davidson correction, the three-dimensional potential energy surface of the X(1)Sigma(+) ground state. The rovibrational energy levels have been obtained variationally, and the results have been discussed and compared with existing experimental data on the ground state of the close system HZnCl, which exhibits a complicated vibration-rotation spectrum. Our analysis shows that the nature of the H-ZnF bond is quite similar to that of the H-ZnCl bond, according to their bond lengths, harmonic frequencies of the H-Zn stretching mode, and dissociation energies into H and ZnF/ZnCl. The ab initio study of the electronic ground and excited states of ZnH and ZnH(+) are also presented using similar level of calculations. Characteristic constants are given for the first bounded electronic states correlating to the first two dissociation asymptotes of the neutral and ionic diatomics.

t(5;14)/HOX11L2-positive T-cell acute lymphoblastic leukemia. A collaborative study of the Groupe Français de Cytogénétique Hématologique (GFCH)

To accurately estimate the incidence of HOX11L2 expression, and determine the associated cytogenetic features, in T-cell acute lymphoblastic leukemia (T-ALL), the Groupe Français de Cytogénétique Hématologique (GFCH) carried out a retrospective study of both childhood and adult patients. In total, 364 patients were included (211 children </=15 years and 153 adults), and 67 (18.5%) [47 children (22.4%) and 20 adults (13.1%)] were shown to either harbor the t(5;14)q35;q32) translocation or express the HOX11L2 gene or both. Most of the common hematological parameters did not show significant differences within positive and negative populations, whereas the incidence of CD1a+/CD10+ and cytoplasmic CD3+ patients was significantly higher in positive than in negative children. Out of the 63 positive patients investigated by conventional cytogenetics, 32 exhibited normal karyotype, whereas the others 31 showed clonal chromosome abnormalities, which did not include classical T-ALL specific translocations. Involvement of the RANBP17/HOX11L2 locus was ascertained by fluorescence in situ hybridization in six variant or alternative (three-way translocation or cytogenetic partner other than 14q32) translocations out of the 223 patients. Our results also show that HOX11L2 expression essentially occurs as a result of a 5q35 rearrangement, but is not associated with another identified T-ALL specific recurrent genetic abnormality, such as SIL-TAL fusion or HOX11 expression.

Spurious monosomy 7 in leukemia due to centromeric heteromorphism

We report heteromorphism of the centrometric region of human chromosome 7, which was observed in the cytogenetic assessment of a complete remission of a pre-B acute lymphoblastic leukemia in the bone marrow cells of a 25-year-old woman. Classical cytogenetic study was performed, as well as metaphase and interphase fluorescence in situ hybridization (FISH) carried out with an alphoid DNA probe specific for the chromosome 7 centromere for detection of leukemic clones with monosomy 7 found at the initial diagnosis. We show an important centromeric heteromorphism of this chromosome detected by FISH and clearly visible on all metaphases and nuclei analyzed. This heteromorphism is observable as a fluorescent signal five- or sixfold larger than that on the homologue. To our knowledge, this heteromorphism of chromosome 7 has not been reported in the literature. However, with the use of FISH analysis, it could be easily mistaken for a mosaicism of monosomy 7, which can be misleading in the interpretation of the results.

IS elements as constituents of bacterial genomes

We provide here an overview of our present understanding of the distribution of different insertion sequences (ISs) within bacterial genomes (both chromosomes and plasmids). This is at present fragmentary and a significant effort is needed in the analysis of the increasing number of genomes whose sequence has been determined. We also consider some of the properties of ISs which are important in their role of assembling, reassorting, and transmitting groups of genes.

MIC231, a naturally occurring mobile insertion cassette from Bacillus cereus

Recent dissection of numerous plasmids and transposable elements has given more credence to the modular organization of these genetic and genomic entities. Although many variations on each theme exist, the number of basic functional cassettes is thought to be relatively limited. In this paper, a novel type of mobile cassette is described. A naturally occurring assemblage consisting of two left IS231 ends flanking a D-stereospecific endopeptidase (adp) gene was found in several natural isolates of Bacillus cereus. This 1.9 kb genetic entity was shown to transpose in the presence of IS231A transposase, not only in Escherichia coli but also in Bacillus. The acronym MIC231 is proposed for this mobile insertion cassette trans-activated (teletransposed) by IS231. Using (D-Phe)4 tetrapeptide as substrate, the endopeptidase activity of the MIC231 adp gene could be demonstrated in E. coli and B. subtilis. Interestingly, this D-stereospecific endopeptidase activity was not limited to the original B. cereus isolates but was also detected in all but one of the 69 B. cereus sensu lato strains tested, indicating its important, yet dispensable, biological function. However, inactivation of the MIC231 adp gene in two B. cereus strains did not result in any detectable variation of their activity on (D-Phe)4, suggesting the presence of other distantly related adp gene(s). Thus, although the exact role of MIC231 adp remains elusive, its presence inside a mobile cassette represents the archetype of a novel insertion sequence modular organization.

IS231A transposition: conservative versus replicative pathway

This paper describes a novel approach, based on suicide transposition, to addressing the question of whether IS231A can give rise to cointegrate molecules through replicative transposition, even at a very low frequency. Comparative analysis was carried out with IS 10, another member of the same IS4 family. The results indicate that transposition of both elements is exclusively conservative.

Integrated physical and genetic mapping of Bacillus cereus and other gram-positive bacteria based on IS231A transposition vectors

The genome structure of Bacillus cereus is relatively complex, its DNA being modulated between a size-varying chromosome and large plasmids. To study the genetic organization of the B. cereus type strain ATCC 14579, thermosensitive transposition vectors were designed on the basis of IS231A-derived cassettes containing uncommon restriction sites. A highly preferred insertion site for IS231A was detected in the chromosome by Southern blotting and pulsed-field gel electrophoresis (PFGE) analyses of independent insertion mutants. However, once this insertional hot spot was occupied, secondary IS231A insertions occurred randomly, as demonstrated by isolation of independent B. cereus auxotrophs at a frequency of approximately 0.6%. The hot-spot site, as well as several auxotrophic mutations, were mapped by using NotI, SfiI, and AscI PFGE restriction profiles. It was confirmed by sequencing that one of the insertions, generating an Ade- phenotype, had disrupted a gene of the purine synthesis pathway. These results showed that combined PFGE and sequencing analyses of mini-IS231A insertions enable the construction of integrated physical and genetic maps of B. cereus type strain. Moreover, the presence of the ultrarare I-SceI restriction site in the mini-IS231A allowed the isolation, in double-insertion mutants, of contiguous and nonoverlapping large chromosomal fragments, convenient for direct sequencing. The system detailed in this report is therefore a powerful tool for comparative genetic studies among members of the B. cereus group (i.e., B. cereus, B. thuringiensis, B. mycoides, and B. anthracis) and could also be applied to more distantly related gram-positive bacteria.

Diversity and differential distribution of IS231, IS232 and IS240 among Bacillus cereus, Bacillus thuringiensis and Bacillus mycoides

Bacillus cereus, Bacillus thuringiensis and Bacillus mycoides are very closely related bacteria, generally considered as subspecies of B. cereus sensu lato. Different transposable elements have been isolated from B. thuringiensis, including IS231, IS232 and IS240 and their variants. The distribution of these three insertion sequences (IS) within the B. cereus group has been investigated in 90 strains of B. thuringiensis (representing 61 serovars), in 30 reference strains of B. cereus and in 33 strains of B. mycoides. Since these IS elements are delimited by well-conserved and specific inverted repeats, the use of primers corresponding to these ends allowed their amplification by PCR. The results showed that IS231 is the most abundant element in the three taxa, whereas IS232 is apparently exclusively associated with B. thuringiensis. Hybridization and Dral RFLP analysis of the PCR products confirmed and extended knowledge of the heterogeneity previously observed among iso-IS231 elements. Moreover, a similar diversity was observed among iso-IS240 elements. This contrasted with the relative homogeneity displayed by iso-IS232 elements. No specific association appeared to exist between any particular iso-element and a specific strain or serotype.

Cloning and characterization of cspL and cspP, two cold-inducible genes from Lactobacillus plantarum

Two cold shock genes, cspL and cspP, have been cloned from two Lactobacillus plantarum strains. These genes, which are nonallelic, were present in all strains tested. The genes encode 66-amino-acid polypeptides related to each other and to the cold shock Csp family. Transcription of cspP rendered a single mRNA, while two cspL mRNAs were found with common 5' ends. The amounts of these transcripts increased moderately upon exposure of the cultures to cold.

New ultrarare restriction site-carrying transposons for bacterial genomics

Electrophoretic separation of macrorestriction fragments containing a particular genomic interval has until recently depended on fortuitously placed native rare restriction sites. We present new IS10-based transposons carrying the yeast intron-encoded I-SceI restriction site which is absent from most prokaryotic and eukaryotic genomes. Construction of the plasmid vectors containing them is described. Analysis by conventional or Pulsed Field gel electrophoresis of the DNA fragments generated by the I-SceI digestion reveals the physical distance between genomic insertions of these transposons: use of the same approach to subdivide the chromosome of Escherichia coli K-12 into equivalently sized contiguous/nonoverlapping I-SceI fragments is demonstrated. Because coordinates for the loci delimited by their insertions can be readily determined in different isolates by either physical or genetic manipulations, these transposons allow sufficient flexibility for species-wide bacterial genomics.

Additional translocation (9;12)(p13;q24.1) in newly diagnosed chronic myeloid leukemia: complete cytogenetic remission after interferon therapy

We report the case of a patient with chronic phase CML who exhibited, in the same cells, beside the Philadelphia chromosome, an additional translocation between the other chromosome 9 and one of the chromosomes 12 [t(9;12)(p13;q24.1)]. Complete cytogenetic remission with disappearance of both karyotypic abnormalities was achieved after 18 months treatment with low dose (1.4 x 10(6) U/m2/day) recombinant alpha-interferon and has been sustained with maintenance therapy for 68+ months (actual follow-up). Clonality at diagnosis and recovery of polyclonal hematopoiesis in complete cytogenetic remission were demonstrated using the polymorphism at the human androgen receptor gene (Humara) locus on chromosome X. The role of the additional translocation in the response to low dose alpha-interferon therapy remains hypothetical.

Monosomy 21q: two cases of del(21q) and review of the literature

We report on two cases of partial monosomy 21 and review cases with a partial or an apparently full monosomy 21. In situ hybridization and/or molecular studies appear to be necessary tools to study imbalance in such a small chromosome and to perform further genotype-phenotype correlations. The segregation mode in cases with a translocation is adjacent 1, adjacent 2, and 3:1 in about 1/4, 1/4 and 1/2 of the cases, respectively.

[Myelodysplastic syndromes in children]

Myelodysplastic syndromes are clonal haemopathies known to exist in elderly people where they are classified into 5 categories: refractory anaemia, acquired idiopathic sideroblastic anaemia, refractory anaemia with excess of blasts, refractory anaemia with excess of blasts undergoing acute transformation, and chronic myelomonocytic leukaemia. Transformation into acute leukaemia is frequent. These syndromes seem to be rarer in children, but they are often misdiagnosed. Some of their forms are particular to childhood. They include association with constitutional blood diseases predisposing to acute leukaemia, or with congenital or non-congenital malformative syndromes; there are hypoplastic forms, forms evolving towards stabilization of haematological abnormalities, and border forms with certain myeloproliferative syndromes. The diagnosis of myelodysplasia rests on morphological, functional, biochemical, isotopic data reflecting inefficient haematopoiesis, and on cytogenetic data. Studies of clonality and malignancy markers will in the near future enable us to distinguish between true preleukaemic states and polyclonal constitutional or virus-induced myelodysplasias, probably more frequent in children. The choice of treatment depends on the severity of the myelodysplastic syndrome, defined by the initial partial blastosis, the presence of cytogenetic anomaly and the certainty of clonality. In cases with poor prognosis, early bone marrow allograft is the only possible treatment.

Acute lymphoblastic leukemia with trisomy 21 constitutional mosaicism

Acute lymphoblastic leukemia was diagnosed in an 11-year-old girl with mild signs of Down's syndrome. She was known since birth to have a constitutional mosaicism (46,XX/47,XX,+21c). At initial diagnosis of acute leukemia, additional chromosome changes were found in bone marrow blasts: hyperdiploidy > 50, with a structural abnormality. She was treated with a standard chemotherapeutic protocol, and has remained in complete remission for more than 3 years. The constitutional mosaicism evolved toward normalization year after year in the blood and under the effect of chemotherapy in the bone marrow.

Trisomy 16p in a liveborn offspring due to maternal translocation t(16;21)(q11;p11) and review of the literature

We report on a case of dup(16p) and review previous cases. The triplicated chromosome region leading to this specific syndrome lies in 16p13.1 p13.3. Most of the cases are inherited and the mode of segregation was found to be 3:1 in half of the cases, but these observations might be due to biases. The other chromosomes involved in the translocations as well as the breakpoints in these chromosomes do not appear to be random.

Inactivated X chromosome fold in human leukemia and related clonal disorders

A disturbance of the X chromosome inactivation process has been demonstrated in some human tumors. In order to study this phenomenon in leukemia, the site of unusually frequent folding in Xq13-q21 was used as a morphological marker. A total of 858 GTG-banded mitoses from 61 women with different hematological malignancies were analyzed, 35 of them with normal karyotype and 26 with chromosome aberrations. The folding patterns and the fold percentage remained unchanged in our patients. Using this marker, X-inactivation could easily be verified in leukemia and related disorders on routine preparations.

[Genetic aspects of artificial insemination. Choice of donors]

Artificial insemination with donors has genetic repercussions which increase with its impact on demography. Genetic control of semen donors offers a possibility of preventing the main genetic handicaps. The French Federation of Human Semen Study and Preservation Centres (CECOS) is currently organizing such a control system. The reasons for this and the modalities of the system are given in this article.

A new method for automatic metaphase finding adaptable to different chromosome preparations

A FORTRAN computer program, running on a Digital PDP 11-34 minicomputer, has been developed for use in conjunction with a Cambridge Quantimet 720 image analyzer for the investigation of metaphase preparations in routine cytogenetics. During a short initiation phase the program is adapted to the type of metaphase being analyzed. The program is fast and its performance is good, even at low microscopic magnifications. It has other uses in biology for all investigations and characterizations of small distinct elements widely spread within a preparation (e.g., autoradiography, bacteriology).

[Partial monosomy due to long-arm deletion of chromosome 11 : del (11) (q23) (author's transl)]

A girl, who died at 25 days of age, was found to have a partial monosomy due to a 11q23 leads to 11qter deletion. The main clinical findings were trigonocephay, facial dysmorphia, and congenital heart disease. A review of developmental and dysmorphic features of the seventeen recognized cases is presented.

Male sterility associated with familial translocation heterozygosity: t(8;15) (q22;p11)

During the investigation of the family of a subject consulting for primary sterility, the same oligoteratospermia was found in two of his brothers. The three karyotypes of these subjects exhibited an equilibrated reciprocal autosomal translocation t(8;15) (q22;p11), which was also detected in their mother. The karyotypes of the remaining siblings, one brother and one sister, were normal. The semen analysis of the sterile subjects suggests that the block of gamete production occurs at the beginning of spermiogenesis. The chromosomal anomaly, which has no effect on the reproduction of the mother, leads to sterility of the male offspring bearing it.

An automatic system for chromosomal analysis applied to prenatal diagnosis

Computer-assisted metaphase analysis for prenatal diagnosis can be economically performed by a preexisting hardware-software system. The program can be run by technician-level (i.e. nonspecialist) personnel who can opt for the automatic operational mode for good quality metaphases or for the semimanual mode for problem metaphases (numerous superpositions, artifacts, etc.). The karyotype can be obtained in conversational mode. Hardcopy output is available for all modes.

[Measurement of the position and intensity of chromosomal denaturation bands by an automatic system]

The band density profile of a marked chromosome was obtained using a photodiode collector combined with a minicalculator, working with an ordinary photographic document. The measurement was carried out over 10 to 20 300-point lines oriented longitudinally along the chromosome. The profile obtained corresponds to the sum of the values of each of these lines. The proposed systems's originality resides in its ability to determine the position and intensity of a band over the entire thickness of the chromosome.

Association of pericentric inversion of chromosome 9 and reproductive failure in ten unrelated families

A pericentric inversion of chromosome 9 has been detected in 10 unrelated families. The break points are identical and the inversions involved the heterochromatic segment. The effects of inversion of chromosome 9 on different aspects of reproductive failure are discussed.